Ritter, health groups back bill to address crisis in rural care

A bill proposed for the next legislative session would improve a state loan-repayment program for rural health professionals with the aim of attracting more providers to rural areas.

Dr. Fisher's Office (Flickr; Bluegrass Annie)
Dr. Fisher's Office (Flickr; Bluegrass Annie)

The Colorado Rural Health Center (CRHC), the Colorado Community Health Network (CCHN) and the Governor’s office are jointly proposing the bill, according to Terri Hurst, policy analyst at CRHC. She expected it to be sponsored by Representative Sara Gagliardi, D-Arvada, and Senator John Morse D-Colorado Springs.

According to CRHC and CCHN, Colorado has a significant shortage of health care outside its metro regions. Fifty-seven of sixty-four Colorado counties are currently designated as primary-care shortage areas by the U.S. Secretary of Health and Human Services.

To meet its needs, the state would have to add at least 182 primary care physicians, 71 dentists, and 54 licensed mental health professionals, according to the federal Health Resources and Services Administration.

Of Colorado’s counties, said Clint Cresawn, program director for Colorado STRIDES (Sustainable Towns: Rural Innovation, Development, Expansion, and Success) eight have only one full-time primary-care physician, and four of those are not accepting new Medicaid patients.

Six additional counties lack even one full-time rural-care doctor, he said. One has none at all—Crowley County, on the eastern plains. Cresawn added that 14 rural counties have no dentist accepting Medicaid, and seven have no dentist at all.

“If you thought about a land mass as large as Rhode Island without one physician, that wouldn’t stand,” said Cresawn. “But we have counties bigger than that which are struggling to find a provider.”

Cresawn noted that a number of factors contribute to providers’ unwillingness to practice in rural areas. Among them, he counts professional and social isolation and the scary possibility that a provider may have to handle emergencies outside his or her specialty area. CCHN and CRHC add distance to major cities and low reimbursement rates as reasons that health professionals shy away from rural practice.

But Cresawn, CCHN and CRHC also argue that doctors choosing an area of practice are strongly influenced by a need to repay loans. According to the groups, graduating physicians in 2008 reported an average debt load of $142,000.

“High loan debt strongly influences health care professionals to opt out of primary care in favor of higher-paying sub-specialties that typically do not serve the uninsured and underinsured,” argues CCHN/CRHC. “Loan forgiveness significantly incentivizes primary care service in rural and medically underserved areas, increasing access to primary care for medically underserved populations.”

The new bill, said the CRHC’s Hurst, would raise or eliminate the annual repayment cap—currently set at $35,000. It would also include dentists and dental hygienists among those eligible for loan repayment. And among other administrative changes, it would rename the program as the Colorado Health Services Corps—to align its branding more closely with the federal loan repayment program, known as the National Health Services Corps.

Hurst said the bill is not expected to cost the state any more. She explained that the Primary Care Office at the Colorado Office of Health and the Environment, which administers the loan repayment program, received several grants this year to help fund the loan repayments, including American Reinvestment and Recovery Act funds.

“So they have a bigger pot of money than they usually do,” she said.

She also did not expect the bill to have any major opponents: “I’m not sure who would oppose it or why they would,” she said. “Then again, as soon as you say that, someone will come out of the woodwork.”

She did expect that providers not eligible for loan repayment might ask to be included in the loan repayment program. Currently the program covers doctors of allopathic and osteopathic medicine, primary care-certified nurse practitioners, certified nurse-midwives, primary care physician assistants, clinical or counseling psychologists, licensed clinical social workers, psychiatric nurse specialists, licensed professional counselors and marriage and family therapists, according to the website.

The loan repayment program began in the fall of 2007, a product of SB07-232 legislation, said Hurst. Last session, House Bill 09-1111 transferred administration of the loan repayment program to the Primary Care Office at the Colorado Office of Health and the Environment. It also adjusted the program requirements to attract private gifts, grants and donations.

The loan repayment program bill is the only rural health care bill that Hurst was aware of for Colorado’s next legislative session. However, U.S. Senator Mark Udall recently successfully introduced two rural health care amendments into the Senate health care bill passed on December 24.

Udall’s Rural Physicians Pipeline Amendment would establish a grant program to help expand rural training programs at medical schools.

Another Udall amendment would ensure that the Community Transformation Grants already in the Senate bill would be equally distributed between both rural and urban areas. The grants are designed to help prevent and reduce chronic disease in communities across the country by funding programs that combat obesity, tobacco use, diabetes and other health conditions or unhealthy lifestyle choices.

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