3
Costs and Financing of Health Professions Education

The costs associated with health professions education pose a considerable barrier for many underrepresented minority (URM) students, whose economic resources are, on average, more limited compared to their majority counterparts. URM students, in particular, may be discouraged from entering health professions training programs when faced with the prospect of high debt. Some health professions leaders have therefore called for a reexamination of the costs and financing of health professions training to significantly reduce or eliminate many training costs, particularly for those students whose service in the public sector is likely to increase access to care for medically underserved populations.

While URM students are more likely than non-URM students to come from low-income families, most low-income students are white. Policies that solely target financial support to low-income students may or may not successfully help URM students to access and succeed in health professions training programs. Therefore, it is important for financial strategies to be implemented in conjunction with other “race-conscious” interventions targeting, for example, admissions and accreditation policies.

A number of public and private initiatives have been established to assist URM students finance the costs of their education and training. Some provide direct financial assistance to students and others indirectly support URM students through funding provided to institutions for diversity activities. All, however, provide support to increase URM participation in health professions and reduce financial barriers, directly or indirectly, for students who experience difficulty financing their training. This chapter will provide



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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 3 Costs and Financing of Health Professions Education The costs associated with health professions education pose a considerable barrier for many underrepresented minority (URM) students, whose economic resources are, on average, more limited compared to their majority counterparts. URM students, in particular, may be discouraged from entering health professions training programs when faced with the prospect of high debt. Some health professions leaders have therefore called for a reexamination of the costs and financing of health professions training to significantly reduce or eliminate many training costs, particularly for those students whose service in the public sector is likely to increase access to care for medically underserved populations. While URM students are more likely than non-URM students to come from low-income families, most low-income students are white. Policies that solely target financial support to low-income students may or may not successfully help URM students to access and succeed in health professions training programs. Therefore, it is important for financial strategies to be implemented in conjunction with other “race-conscious” interventions targeting, for example, admissions and accreditation policies. A number of public and private initiatives have been established to assist URM students finance the costs of their education and training. Some provide direct financial assistance to students and others indirectly support URM students through funding provided to institutions for diversity activities. All, however, provide support to increase URM participation in health professions and reduce financial barriers, directly or indirectly, for students who experience difficulty financing their training. This chapter will provide

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce an overview of the financial status of URM families, assess the costs of training, and show the negative impact of these costs on URM students’ pursuit of education. In addition, the chapter will assess the role of private and public sources of funding for health professions students, and examine issues regarding the financing of education. For a detailed review of publicly funded health professions programs that support URM students, the reader is referred to the commissioned paper, Public Financing of the Health Professions: Levers for Change, prepared by Karen Matherlee, which appears as an appendix of this report. For purposes of this report, the study committee defines health professions educational costs as a formulation involving total educational and living expenses: including tuition and fees (which vary considerably across institutions, particularly between public and private health professions education institutions [HPEIs]); other educational expenses (including books, equipment, supplies, etc.); the number of years to degree completion; living costs (including rent, utilities, and other living expenses); and the costs of any specialized, prerequisite post-high school or post-baccalaureate preparation. The other side of this equation—financing of health professions training—can be described as a student’s financial resources (both personally and nonpersonally derived), as well as scholarships, loans, and other forms of financial assistance. Unmet financial need is therefore total health professions educational costs, minus student financial resources. This chapter attempts to describe educational costs, sources of financing of training, and unmet financial need, and how these factors affect URM participation in health professions education. This analysis is severely limited, however, by a lack of data regarding these factors, particularly in disciplines other than medical education, where financing issues are more thoroughly documented. This absence of data prevents a comparison of financing issues across health professions disciplines, because the factors identified above, such as tuition, fees, number of years to degree completion, and sources of financial aid, vary considerably across disciplines. The most useful perspective is therefore to examine the financial obstacles within each profession, rather than across professions. FINANCIAL STATUS OF UNDERREPRESENTED MINORITY FAMILIES Census figures indicate a large disparity in family income among various racial and ethnic groups in the United States (Figure 3-1) (U.S. Census Bureau, 2002a). Households headed by black and Hispanic individuals earn significantly less than either white non-Hispanic or Asian and Pacific Islander householders. In 2001, the median income for black and Hispanic families was approximately $34,000 and $35,000, respectively. In com-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-1 Race and Hispanic origin of householder: families by median income, 1990–2001. SOURCE. U.S. Census Bureau, Historical Income Tables—Families, 2002. parison, white families had a median income of $57,000 and Asian/Pacific Islander families had a median income of $60,000. American Indian and Alaska Native families were not included in these census figures; however other census data indicate that the three-year average median income for 1999–2001 was $32,116 for American Indian and Alaska Native households, which was higher than the median income of black households and similar to the median income of Hispanic households during this time period (U.S. Census Bureau, 2002b). Thus, as URM students prepare for higher education, they are more likely to face difficulties financing their education. In addition to disparities in household income, data indicate large racial and ethnic differences in wealth (Figure 3-2). On average, white families are wealthier than black or Hispanic households, even after controlling for income and demographic variables (Choudhury, 2002). Housing equity is fairly equally distributed across racial and ethnic groups, although rates of homeownership are greater for whites. Nonhousing equity (e.g., liquid assets, stocks, bonds, IRAs, vehicle and business equity) varies more widely between racial and ethnic groups as income increases, with whites holding larger sums of nonhousing equity. COSTS OF UNDERGRADUATE EDUCATION: EFFECTS ON ACCESS AND COMPLETION Much of the available data regarding the impact of the high costs of education relates to college access and degree attainment. These findings have implications for health professions education and strategies that may be employed to reduce financial barriers for URM students entering these fields.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-2 Mean net worth for households by race, ethnicity, and income quar-tile. NOTE: Cutoff points for income quartiles, in 1992 dollars: $23,460; $41,900; $66,900. SOURCE: Health and Retirement Study Wave 1 (1992) as cited in Choudhury, 2002. The Advisory Committee on Student Financial Assistance reports that “… financial barriers to a college education have risen sharply due to shifts in policies and priorities at the federal, state, and institutional levels, resulting in a shortage of student aid, and in particular need-based grant aid, as well as rising college tuition” (Advisory Committee on Student Financial Assistance, 2002, p. v). The Advisory Committee estimated that these financial barriers prohibit 48 percent of low-income students who are academically qualified for college from attending a four-year institution. The lowest achieving, highest socioeconomic status (SES) students attend college at approximately the same rate as the highest achieving, lowest SES students, at 77 percent and 78 percent, respectively (Advisory Committee on Student Financial Assistance, 2002). Because URM families earn less, on average, than their white or Asian/Pacific Islander counterparts, they may face greater difficulty in financing their children’s undergraduate education. Estimates from the 1999–2000 academic year indicate that among full-time undergraduate students who were financially dependant on their families, black, Hispanic, Asian, and those students who indicated more than one race were more likely to be from low-income families (Figure 3-3; U.S. Department of Education, 2003b). White, Pacific Islander, and American Indian students were more likely to come from high-income families. While rates of tuition have climbed steadily, sources of grant aid have

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-3 Percentage distribution of full-time, full-year dependent undergraduates according to family income, 1999–2000, by race and ethnicity. SOURCE: U.S. Department of Education, National Center for Education Statistics, 2003b. decreased. At the federal level, the maximum awards provided by Pell grants, awarded to help low-income students attend college, have decreased significantly relative to the cost of attendance. The maximum award decreased from 84 percent of public 4-year costs during the 1975–1976 academic year to 39 percent of costs during the 1999–2000 academic year (College Board, 2000, and U.S. Department of Education, 2000b, as cited in Advisory Committee on Student Financial Assistance, 2001). At the state level, more new grants are merit-based rather than need-based. In 1982, 9.6 percent of grants were merit-based compared to 18.6 percent in 1998 (Heller, in press, as cited in Advisory Committee on Student Financial Assistance, 2001). Similarly, higher education institutions are increasing merit-based awards. At private institutions, grants for middle-income students have exceeded grants for low-income students (McPherson and Shapiro, in press, as cited in Advisory Committee on Student Financial Assistance, 2001). Increased tuition costs and decreased need-based aid have resulted in higher levels of unmet need for lower income students (Figure 3-4). Unmet financial need is calculated as the total cost of education minus expected family contribution minus aid (U.S. Department of Education, 2003a). In 1995–1996, students from the lowest income families faced $3,800 in unmet need for a public 4-year college and $6,200 for private 4-year colleges. For middle-income students, whose family income was between $25,000 and $49,000, average unmet need was $3,000 for public and $4,900 for private college. In comparison, those students from the highest SES level faced $400 in need for public college and $3,000 for private institutions (U.S.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-4 Average annual unmet need of high school graduates, by family income and type of institution. SOURCE: Advisory Committee on Student Financial Assistance, 2002. Department of Education, 1999). Between 1992 and 1999, average annual borrowing by low-income students with high unmet need increased from $1,812 to $2,982 at public 4-year colleges (Advisory Committee on Student Financial Assistance, 2002). At private colleges borrowing increased from $2,935 to $4,130 (Advisory Committee on Student Financial Assistance, 2002). Thus, a 4-year baccalaureate degree can result in over $16,000 of debt for low-income students. The impact of high unmet need can be considerable on low-income students, even those who are academically prepared for the challenges of higher education. Low-income students with high unmet need are significantly less likely than high-income students with low unmet need to expect to finish college; plan to attend a 4-year college after graduating from high school; take entrance exams; and apply, enroll, and persist to degree completion (Figure 3-5) (Advisory Committee on Student Financial Assistance, 2002). Students who have sufficient funds for college enjoy enhanced academic performance and social integration on campus and are more likely to persist to graduation (Nora and Cabrera, 1996). In an investigation of the influence of race and gender on the awarding of financial aid, Heller (2000), using data from the National Postsecondary Student Aid Studies, found that while there were variations in financial aid by geographic region and type of institution, in general, African American students were more likely to receive nonneed grants (based on merit or other circumstance not related to financial need, such as academic, artistic, or athletic merit), particularly those students attending public institutions. Hispanic students were less likely to receive nonneed grants. The author

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-5 College access process for high- and low-income college-qualified high school graduates. SOURCE: Advisory Committee on Student Financial Assistance, 2002. speculates that since academic achievement and other institutional and student characteristics served as controls, the effect of race on receiving nonneed aid was the result of institutional financial aid policies and that African American students were specifically targeted for financial aid compared with white students (Heller, 2000). Several studies have examined the impact of financial barriers and the effect of financial aid on student enrollment. An investigation of racial differences in high school students’ access to postsecondary education found that low-income, black, and Hispanic high school graduates were less likely to be academically prepared for a 4-year college and that among those who were prepared, low-income and Hispanic students were less likely to take entrance exams and apply for admissions (U.S. Department of Education, 1997). However, differences in enrollment rates between college-qualified low- and middle-income students were eliminated among those students who took college entrance exams and completed the admissions application. Similarly, differences in enrollment between college-qualified students of varying race and ethnicity (black, Hispanic, Asian, and white) were also eliminated among those who took entrance exams and completed an application. This study also found that “the more sources of information they had obtained, and the more people with whom they had discussed financial aid, the more likely college-qualified low- and middle-income, black, and Hispanic students were to take college entrance exams and apply for admis-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce sion to a four-year college” (U.S. Department of Education, 1997, p. 60). However, a causal relationship between college attendance and information-seeking could not be established. It may be that students who intended to attend sought more information. The type of aid received by students also may influence college attendance. In a review of evidence of financial aid’s impact on college entry and retention, Grumbach et al. (2002) reported that grants had a large effect on increasing attendance for students in the lowest income category. In contrast, loans were not associated with enrollment rates for this group of students. For middle-income students, both grants and loans were associated with increased attendance (St. John, 1994; Grumbach et al., 2002). Grumbach and colleagues also noted that differences in how far low-income students advance in their education are not only a function of the ability to pay. Low socioeconomic status is associated with a range of factors that may affect college access and success, including attendance at primary and secondary schools with few resources and having few family members who have attended college (and therefore know what the experience is like and can help navigate the application process). As mentioned in the outset of this chapter, providing financial aid alone is unlikely to remove all barriers to higher education for URM students. In light of trends in tuition costs, educational organizations have called for changes in policies for the provision of financial aid to low-income students. Recently, the College Board urged the government to raise the maximum awards for Pell Grants to cover the average cost of tuition, fees, room, and board, which was estimated to be $9,000 for the 2002–2003 academic year, and to expand loan forgiveness for students who enter and stay in occupations that serve high-need areas (College Board, 2003). In addition, the Board urged the federal government to partner with states, colleges, universities, and the private sector and to take the lead in developing programs to encourage investment in need-based aid. Specific recommendations included: “… Loan forgiveness for students who enter and remain in certain key occupations and those who serve in high-need areas should be supported and expanded…” (College Board, 2003, p. 6). “… The federal government should also increase its level of support directly to institutions that serve large percentages of high-need students…” (College Board, 2003, p. 7). “… Colleges and universities should reaffirm their commitment to need-based aid, striving to enroll larger numbers of students from low-income and underrepresented backgrounds” (College Board, 2003, p. 7). “The federal government and the states should explore ways of more closely linking increases in tuition to increases in need-based aid, to insulate

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce financially needy student from effects of economic downturns…” (College Board, 2003, p. 8). In summary, the financial burdens imposed by undergraduate education are a significant factor for low-income students who wish to attend college. A student’s ability or academic readiness does not make them immune to these difficulties. These impediments may continue for those who continue their studies at the graduate level. COSTS OF HEALTH PROFESSIONS EDUCATION: TUITION AND STUDENT DEBT By the time students with high unmet need complete college, they may have debts of $10,000 to $15,000 or more. As students consider obtaining degrees in one of the health professions, they must contemplate the even higher costs of these degrees. There is some evidence to suggest that low-income students who graduate from college are less likely than their higher income peers to continue on to graduate education (Grumbach et al., 2002). This section will review trends in costs of health professions education and debt incurred by students. Dental Education In 1999, the average first-year resident tuition for dentistry schools was $15,653 (Figure 3-6), compared to $7,086 in 1985 (Valachovic et al., 2001). The fees at public schools were $9,354 while private school tuition and fees totaled $30,208, resulting in costs ranging from $37,000 to $120,000 at the end of four years. Moreover, the average debt of dental students has significantly increased in the past 20 years (see Figure 3-7) (Hardigan, 1999). The average rate of increase for all schools between 1991–1992 and 1997–1998 was 84.6 percent. The increase was greatest at public schools (94.5 percent). Medical Education For medical students, average tuition and debt are similarly high. During the 2001–2002 academic year, mean tuition and fees for residents at public medical schools were $12,970. Fees for nonresidents were more than double this figure (Figure 3-8) (AAMC, 2003). In 2001, approximately 75 percent of URM graduates had received scholarships during medical school, with average scholarship awards of $46,383 for private school graduates and $25,184 for public school graduates (AAMC, 2002). By comparison, nearly 50 percent of non-URM stu-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-7 Average debt of senior dental students, 1991–1992, 1997–1998. SOURCE: Hardigan, 1999. Reprinted, with permission, from the American Dental Education Association, 2004. Copyright 2004 by ADEA. FIGURE 3-6 Average first year resident tuition and fees at U.S. dental schools, 1999. SOURCE: Valachovic et al., 2001. Reprinted, with permission, from the American Dental Education Association, 2004. Copyright 2004 by ADEA.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce FIGURE 3-8 Tuition and fees for first year students at U.S. medical schools, 2001–2002. SOURCE: AAMC, 2003. dents received scholarship aid, averaging $40,197 for private school graduates and $18,134 for public school graduates. Like dental students, medical graduates face high levels of debt, which have increased six-fold in the past 20 years. Among students who incur debt, URM and non-URM students face similar levels of total debt. However, URM graduates are twice as likely to carry some educational debt. Among 2001 private school graduates, 20.3 percent of non-URMs had no debt, as compared to 8.1 percent of URMs (AAMC, 2002). For public school graduates, 16.8 percent of non-URM students completed with no educational debt, while only 8.4 percent of URM student graduated debt free. However, for those that had debt, approximately 50 percent of all students owed more than $100,000 (AAMC, 2002). Professional Psychology Education The average cost of education for students in schools of psychology is less, on average, than for students in other health professions. However, these students tend to earn less once in practice than some other health professionals. During the 2001–2002 academic year, the average cost of tuition at public institutions offering graduate degree programs in psychology was $3,380 for state residents and $8,858 for state nonresidents (Figure 3-9; APA, 2003). Tuition at private institutions was approximately $17,000. Debt for clinical and other psychology health-service areas has, like other health professions, increased in recent years (Murray, 1999). A larger

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce could be monitored and evaluated. Subsequently, an evaluation of COE awardees between 1993 and 1999 was conducted by Carline and colleagues (1999). Again, a meaningful assessment was not possible because of inconsistent data collection. To address this deficiency, Carline and colleagues developed a data collection system, including narrative and other objective evidence, such as number of applicants, enrollees, and graduates; demographic characteristics of students; sponsored faculty; amount and dispersment of funding; and research and other activities and experiences of COE faculty and students. While a rigorous evaluation was prohibited by the lack of baseline data and comparison groups, results suggested that many of the COE objectives had been met. While this chapter has focused on HRSA programs that target minority and disadvantaged students, HRSA’s Title VII, Section 747 programs, which focus on the education and training of the primary care provider workforce more generally, have increased the number of graduates who practice in underserved communities and who are members of racial and ethnic minority groups (Advisory Committee on Training in Primary Care Medicine and Dentistry, 2001). In a report to the Department of Health and Human Services (HHS) and Congress, the Advisory Committee reported that graduates of these programs (in family medicine residency, general dentistry, physician assistant, and general internal medicine/pediatric residency programs) are three to ten times more likely to practice in medically underserved communities. In addition, these programs graduate two to five times the number of minority and disadvantaged students than other programs. The BHPr also employs funding factors that increase the likelihood that its grants will be awarded to programs that enroll significant numbers of students from minority and disadvantaged backgrounds. While these are not direct strategies to increase diversity, they may indirectly achieve this goal. As with other BHPr activities, it is difficult to assess the impact of such strategies. Grumbach and colleagues (2002) speculate that these strategies may be less effective for increasing the overall pool of URMs in health professions when employed for funding of residency training, since these programs are competing for a finite pool of URM students already enrolled in schools. Rather, funding factors may be more effective for predoctoral education, but the authors note that the amount of funding is not large enough to make a substantial change. It has also been suggested that while requirements for BHPr programs to collect data on race and ethnicity of students and trainees are important in measuring efforts to increase diversity, there is no evidence that collecting this data encourages institutions to improve recruitment efforts (Matherlee, this volume). The General Accounting Office (GAO) provided an assessment of Titles VII and VIII programs and provided testimony for congressional reauthori-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce zation of the programs in 1997 (GAO, 1997). The office concurred with other assessments that the effectiveness of these programs is difficult to evaluate. The GAO found that Titles VII and VIII supported a wide range of objectives without common goals, outcome measures, and reporting requirements and noted that HHS was not required to evaluate their programs. Furthermore, GAO noted that the programs were not linked to improvements in the supply, distribution, and minority of health professionals. Evaluations of some of the programs measured outcomes for particular institutions as opposed to the national impact. Some institutions receiving grants reported on program process as opposed to outcomes (for example, a report was provided on how the institution established recruitment strategies and not the number of students recruited through the activity). The GAO report concluded by stating that “if these programs are to specifically improve supply, distribution, and minority representation for health professionals, federal efforts need to be directed to activities that clearly support those goals and whose results can be measured and reported in terms of those goals…. [O]nce goals are defined, performance measures and targets are critical to determine when federal intervention is no longer required, or when federal strategies are not successful and should be redirected” (GAO, 1997, pp. 6–7). Another concern critics have raised regarding some of the BHPr’s programs is that program payback requirements often “track” students into specialty areas without the flexibility to expand or change these areas. This may dissuade some students from participating in these programs. It may be beneficial to explore potential options for increasing flexibility of HRSA programs to allow students to explore more specialty options. In summary, little is known about the efficacy of financial aid programs in increasing URM participation in health professions. Evidence suggests that components of BHPr activities may meet program goals. However, comparisons of programs and knowledge of best practices are lacking. Policy makers have a substantial need to obtain data to evaluate how well various programs that provide financial assistance to students succeed in recruiting and retaining URM students. The National Center for Health Workforce Analysis and its regional centers, which collect and analyze health profession data and evaluate health professions training programs, among other efforts, have made a significant step toward collecting data at the state level (Matherlee, this volume). Recommendation 3-1: HRSA’s health professions programs should be evaluated to assess their effectiveness in increasing numbers of URM students enrolling and graduating from HPEIs to ensure that they maximize URM participation.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce THREATS TO HEALTH PROFESSIONS FINANCING In the current environment of federal, state, and local budget deficits and reduced endowments of many foundations, programs that support URM access to and success in health professions education programs may be threatened. Matherlee (this volume) cites seven factors that may impede public efforts to increase diversity in the workforce via financing of training and education at the institutional and policy level: Much of the emphasis of programs and funding of educational efforts is on increasing the pipeline of URM students, rather than supporting students in higher education. Most federal health professions training funds rely on discretionary funding, making them vulnerable to cuts. Discretionary funds are “siloed” in various agencies and division within the government, making coordination of funding and communication about the shared goal more difficult. This may also reduce the ability of students to become familiar with career options and paths across disciplines and limit student awareness of varied funding opportunities. The Medicare GME program lacks workforce goals regarding URM participation. There is considerable variation among states in the use of funds to increase URM participation in the workforce. High debt incurred by health professions students may disproportionately hurt URM participation. Policy makers are reluctant to fund new URM initiatives because of federal and state budget deficits. Several avenues have been discussed for using financial incentives to increase URM participation in health professions education, including the collection of data on various programs and efforts, the use of Medicare GME to develop new policy approaches, and expansion of the NHSC. Evidence from undergraduate education suggests that students may benefit from increased knowledge about the various sources of financial assistance and the provision of grant-based aid rather than loans. Recommendation 3-2: Congress should increase levels of funding for diversity programs and strategies shown to be effective in ensuring diversity within the National Health Service Corps and Titles VII and VIII of the Public Health Service Act. Furthermore, Congress should develop other financial mechanisms to enhance the diversity of the health-care workforce. This may include exploring changes in Medicare GME to increase URM participation in medicine, psychology, dentistry, and nursing.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce RETHINKING THE FINANCING OF HEALTH PROFESSION EDUCATION The large variety and scope of public and private efforts for funding URM students in health profession education programs make it difficult to assess if and how well funding programs work together and complement one another to expand opportunities for URM participation. While there are many programs targeting URM students who are entering graduate education, many of these same programs as well as a host of others also engage in pipeline enhancement efforts. Grumbach and colleagues note that the result of this compilation of programs is “a discontinuity of interventions across regions and across stages of the educational pipeline, making it difficult to sustain gains from one educational stage to the next” (Grumbach et al., 2002, p. 71). They conclude that coordination and communication among various programs will assist funders to better plan their own efforts and determine additional needs, and that the formation of coalitions of funders may facilitate these goals. Another area of need identified by Grumbach et al. (2002) is the relative amounts of funding for various health professions disciplines. For example, in FY 2003, Title VII programs received $308.4 million and Title VIII programs received $112.8 million. As discussed in Chapter 1, the nursing profession has reached a critical shortage in its workforce. An area in need of further exploration in terms of URM student participation in health profession education is the impact of institutional funding programs, policies, and perspectives dealing with URM access. At the institutional level, many students are funded based on need alone and many URM students are funded based on need and ethnicity. The effect of these funding policies on URM student access is an important area that should be investigated further. While there are barriers for financial aid programs due to larger scale funding or political priorities, some public and private entities have developed innovative ways of using financing as a lever to increase the number of URMs in health professions programs. One new model for education funding is through a unique public–private partnership. The University of Colorado Health Sciences School of Dentistry has partnered with the Orthodontic Education Company (OEC) to establish a new dental center that they hope will address the shortage of orthodontists and provide low-cost care to children in underserved areas (see Box 3-1). The OEC provides scholarships and stipends in exchange for service in OEC private or group practices following graduation. The University of Colorado will establish and administer the program, which will involve the investment of almost $100 million by the OEC. This type of partnership may be an innovative way to deal with an anticipated shortage of orthodontists as well as a variety of

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce other health professionals in the next decade and finance education while reducing the burden on taxpayers, students, and parents. A second program at the University of Colorado, legislated by the state, provides community-based learning experiences for students. The Advanced Clinical Training and Service Program, treats the oral health needs of disadvantaged citizens of Colorado (Box 3-2). The program may help to increase diversity by not only generating, among youth served, interest in dental careers, but drawing prospective health professions students through the availability of community-based learning. As an example from the field of pharmacy, CVS provides a Scholarship of Excellence, a program in which CVS interns apply to receive $5,000 per academic year for a maximum of 4 years. For each year the scholarship is received, students commit to work full-time for 1 year as a CVS registered pharmacist. In other efforts, New York State has initiated the Minority Participation in Medical Education Grant Program, which provides funds to institutions to enhance minority recruitment and retention, develop minority student mentoring programs, develop medical career pathways for minority BOX 3-1 University of Colorado Dental School and Orthodontic Education Company Partnership In January 2003, the School of Dentistry at the University of Colorado and the Orthodontic Education Company (OEC) initiated a 30-year business partnership with a $3 million gift and $92.7 million commitment from OEC to build the Lazzara Center for Oral–Facial Health and establish a training program in orthodontia. The partnership will help to address the anticipated shortage of orthodontists and help to provide low-cost care for low-income, minority, and underserved children in the state of Colorado. It is hoped that qualified students from diverse and economically disadvantaged backgrounds, for whom costs of dental education may be prohibitive, will consider dental specialties as a result of the scholarships. It is also hoped the program will have an indirect benefit of increasing diversity in dentistry by exposing underserved children to the profession through the program’s services. Each year, the OEC will sponsor 12 of the 16 students that the Center will train. These students will receive a $30,000 salary, benefits, malpractice insurance, tuition, and additional funds for instruments and computers. In exchange for sponsorship the students will commit to practice for 7 years postgraduation at OEC sites throughout the country, earning a salary of $150,000 per year. The school will establish admission criteria, curriculum, and academic standards for graduation. Selected residents will have to meet criteria established by the admissions and chair of orthodontics. In addition, the school will follow accreditation procedures set for by the Commission on Dental Accreditation for a specialty program in orthodontics (Landesman, 2003).

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce BOX 3-2 University of Colorado Dental School Advanced Clinical Training and Service Program The Advanced Clinical Training and Service (ACTS) program at the University of Colorado School of Dentistry is a community-based service learning program. This program was legislated by the state of Colorado. Students perform the equivalent of one academic year of direct service, under supervision, to underserved communities in Colorado. Training sites include community health clinics, hospital-based practices, and private practices. Supervision is provided by community dentists who are also faculty members (Landesman, 2003). There are two required rotations for the program. The first, Integrated Care Clinics, provides treatment for older adults and those with HIV or who are mentally and physically challenged. The second rotation involves service provision in rural dental practices. Students choose other rotations in clinics for underserved populations across the state (University of Colorado School of Dentistry, 2003). These experiences in underserved communities help students to increase self-confidence in their clinical skills, promote greater independence, and enhance students’ sense of personal responsibility. As with the university’s business partnership with OEC, it is hoped that ACTS will help to promote diversity in the health professions by drawing students who are interested in serving disadvantaged populations and exposing those who receive the services to the field of dentistry. students, and develop minority faculty role models (New York State Office of the Governor, 2002; Stoll, 2003). Funds were provided to seven institutions across the state. There have been no published reports assessing the program’s results or whether certain approaches have been successful in recruiting and retaining minority students. However, the state announced in 2002 that over 155 minority students participated in medical school and residency programs sponsored by the programs in the previous year. Programs such as the ones outlined in this section may serve as models for ways to use public and private funds to increase diversity of the healthcare workforce. While much of the funding for health profession education is from public sources, private sources can also contribute and have much to gain by investing in diversity. Joint investments made by business, states, the federal government, foundations, and institutions will be crucial in this effort. Recommendation 3-3: State and local entities, working where appropriate with HPEIs, should increase support for diversity efforts. This may be accomplished via a variety of mechanisms in programs committed to diversity, such as loan forgiveness, tuition reimbursement, loan repayment, GME, and supportive affiliations with community-based providers.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Recommendation 3-4: Private entities should be encouraged to collaborate through business partnerships and other entrepreneurial relationships with HPEIs to support the common goal of developing a more diverse health-care workforce. SUMMARY URM students may face sizeable financial barriers as they consider health professions education. The disparity between URM and non-URM family incomes is significant, leaving minority students with fewer financial resources to attend college and health profession schools. The costs of both college and health professions education have increased sharply, while the availability of sufficient need-based aid has decreased, leaving students with higher unmet need and record levels of debt. College tuition trends have prompted the College Board to call for colleges and universities to reaffirm their commitment to need-based aid and for the federal government to increase support to institutions that serve large percentages of high-need students. While the impact of financial barriers has not been well studied among health professions students, evidence from undergraduate education reveals that low-income students and some URM students may be less likely to apply to college and that aid, particularly grants, may be associated with increased attendance for low-income students. There are a variety of public and private sources of financial assistance for health professions students, through the provision of scholarships, loans, and loan repayment programs. Most provide funds to institutions that, in turn, make awards to students. The distribution of these funds vary across disciplines, with nursing Title VIII programs receiving significantly less funding than Title VII programs. In addition, these federal programs are funded via discretionary funding and are vulnerable to cuts. It is difficult to assess the impact of these programs on increasing diversity in the health professions workforce, as the scopes of the programs are broad, outcome measures are not clearly specified, and evaluation is not required. The primary source of funding, provided for with mandatory funds, is Medicare Graduate Medical Education (GME). GME dollars have not been tied to efforts to increase the representation of URMs in the health-care workforce. The high debt incurred by health professions students, reliance on discretionary funding for minority programs, lack of coordination and communication among funding sources, and lack of workforce goals in Medicare GME are among the barriers for the use of financing to increase diversity in the health professions workforce. In addition to a reexamination of existing programs, new and innovative strategies are necessary. Recent efforts have included, for example, partnerships between institu-

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce tions and private business, which reduce the burden on taxpayers and families. Reexamining the structure of financing programs, systematically measuring outcomes, and exploring new ways to help URM students finance their education will be crucial in increasing diversity in the health professions workforce. REFERENCES Advisory Committee on Student Financial Assistance. 2001. Access Denied: Restoring the Nation’s Commitment to Equal Educational Opportunity. Washington, DC: Advisory Committee on Student Financial Assistance. Advisory Committee on Student Financial Assistance. 2002. Empty Promises: The Myth of College Access in America. Washington, DC: Advisory Committee on Student Financial Assistance. Advisory Committee on Training in Primary Care Medicine and Dentistry. 2001. Comprehensive Review and Recommendations: Title VII, Section 747 of the Public Health Service Act. Report to Secretary of the U.S. Department of Health and Human Services and Congress. [Online]. Available: http://bhpr.hrsa.gov/medicine-dentistry/actpcmd1.htm [accessed October 1, 2002]. American Psychological Association (APA) Research Office. 2001. Analysis of Data from Graduate Study in Psychology: 1999–2000. By WE Pate II. [Online]. Available: http://research.apa.org/grad00contents.html [accessed August 5, 2003]. Association of American Medical Colleges (AAMC). 2002. Minority Students in Medical Education: Facts and Figures XII. Washington, DC: Association of American Medical Colleges Division of Community and Minority Programs. Association of American Medical Colleges (AAMC). 2003. Tuition and Student Fees Reports. [Online]. Available: https://services.aamc.org/tsf/TSF_Report/report_intro.cfm [accessed August 5, 2003]. Baker LC, Barker DC. 1997. Factors associated with the perception that debt influences physician’s specialty choices. Academic Medicine 72(12):1088–1096. Baum S, O’Malley M. 2002. College on Credit: How Borrowers Perceive Their Education Debt. Results of the 2002 National Student Loan Survey. Braintree, MA: Nellie Mae Corporation. Brotherton SE. 1995. The relationship of indebtedness, race, and gender to the choice of general or subspecialty pediatrics. Academic Medicine 70(2):149–151. Carline JD, Patterson D, Mandel L. 1999. Methodology Development and Assessment of the Impact of the Centers of Excellence Program. Prepared for the Division of Disadvantaged Assistance, Bureau of Health Professions, Health Resources and Services Administration, Public Health Service, HRSA 240-91-0045. Choudhury S. 2002. Racial and Ethnic Differences in Wealth and Asset Choices. Social Security Bulletin 64(4). [Online]. Available: http://www.ssa.gov/policy/docs/ssb/v64n4/v64n4p1.pdf [accessed October 2, 2003]. College Board. 2000. Trends in College Pricing. Washington, DC: College Board. College Board. 2003. Challenging Times, Clear Choices: An Action Agenda for College Access and Success. Investing More Equitably and Efficiently in Higher Education, Creating Value for America. Washington, DC: College Board. Colquitt WL, Zeh MC, Killian CD, Cultice JM. 1996. Effect of debt on U.S. medical school graduates’ preferences for family medicine, general internal medicine, and general pediatrics. Academic Medicine 71(4):400–411.

OCR for page 88
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce DeAngelis SL. 2000. Tuition, financial aid, debt, and dental student attrition. Journal of Student Financial Aid 30(2):7–21. General Accounting Office (GAO). 1997. Health Professions Education: Clarifying the Role of Title VII and VIII Programs Could Improve Accountability. Testimony by Bernice Steinhardt, Director Health Services Quality and Public Health Issues Health, Education, and Human Services Division before the Subcommittee on Public Health and Safety, Committee on Labor and Human Resources, U.S. Senate. GAO/T-HEHS-97-117. [Online]. Available: http://www.gao.gov/archive/1997/he97117t.pdf [accessed September 5, 2003]. Georges A. 1999. Keeping what we’ve got: The impact of financial aid on minority retention in engineering. National Action Council for Minorities in Engineering Research Letter 9(1):1–20. Grumbach K, Coffman J, Muñoz C, Rosenoff E, Gándara P, Sepulveda E. 2002. Strategies for Improving the Diversity of the Health Professions. University of California, San Francisco: Center for California Health Workforce Studies. Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB. 1992. Young physicians most and least likely to have second thoughts about a career in medicine. Academic Medicine 67(3):180–190. Hardigan, J. 1999. The costs and financing of dental education. Journal of Dental Education 63(12):873–881. Heller D. 2000. The Role of Race and Gender in the Awarding of Institutional Financial Aid. Paper presented at the Annual Meeting of the American Educational Research Association. New Orleans. Heller D. 2001. Debts and decisions: Student loans and their relationship to graduate school and career choice. Lumina Foundation for Education. New Agenda Series 3(4):2–50. Heller DE. In press. State Student Aid. The Condition of Access. Washington, DC: Advisory Committee on Student Financial Assistance. Houston Associates. 1994. Evaluation of the Health Careers Opportunity Program Summer Programs Final Report. Silver Spring, MD: Health Resources and Services Administration, Division of Disadvantaged Assistance. Johnson L. 2002a. Financial planning for residency: Part 2. Journal for Minority Medical Students 14(3):17–20. Johnson L. 2002b. Planning for residency: First do no harm. Journal for Minority Medical Students 14(2):40–46. Knapp RM. 2002. Complexity and uncertainty in financing graduate medical education. Academic Medicine 77(11):1076–1083. Landesman HM. 2003. Potential of Three Colorado Programs to Increase Access to and Interest in Dental Careers among Underrepresented Minorities. Presentation to Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce, June 30, Washington, DC. Lofton K. 2002. How med students’ indebtedness influences career choices. Journal for Minority Medical Students 14(2):47–48. McPherson MS, Schapiro MO. In press. Institutional Student Aid: The Condition of Access. Washington, DC: Advisory Committee on Student Financial Assistance. Millet C, MacKenzie S. 1995. An Exploratory Study of the Role of Financial Aid in Minority Doctoral Education. Paper presented at the Annual Meeting of the Association for the Study of Higher Education, Orlando, FL. Mullan F. 1997. The National Health Service Corps and inner-city hospitals. Health Affairs 336(22):1601–1603.

OCR for page 88
In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce Murray B. 1999. Some clinical psychology students’ growing debt burden triggers response from training programs. American Psychological Association Monitor Online 30(2). [Online]. Available: http://www.apa.org/monitor/feb99/debt.html [accessed August 18, 2003]. Myers DR, Zwemer JD. 1998. Cost of dental education and student debt. Journal of Dental Education 62(5):354–360. National Science Foundation (NSF). 2000. Psychology Doctorate Recipients: How Much Financial Debt at Graduation? By AI Rapoport, J Kohout, M Wicherski. [Online]. Available: http://www.nsf.gov/sbe/srs/issuebrf/sib00321.htm [accessed August 18, 2003]. Nettles M. 1990. Black, Hispanic, and White Doctoral Students: Before, During and After Enrolling in Graduate School. Princeton, NJ: Educational Testing Service. New York State Office of the Governor. 2002. Nearly $1 Million to Boost Minority Physician Training. Press Release April 19, 2002. [Online]. Available: http://www.state.ny.us/governor/press/year02/april19_1_02.htm [accessed January 16, 2004]. Nora A, Cabrera AF. 1996. The role of perceptions in prejudice and discrimination and the adjustment of minority students to college. Journal of Higher Education 67(2):119–148. Rico M, Stagnaro-Green A. 1997. Debt and career choices of underrepresented minorities. Academic Medicine 72(8):657–658. Rosenthal MP, Marquette PA, Diamond JJ. 1996. Trends along the debt-income axis: Implications for medical students’ selections of family practice careers. Academic Medicine 71(6):675–677. St. John EP. 1994. Prices, productivity, and investment: Assessing financial strategies in higher education. ERIC Digest. EDO-HE-94-3. Stoll B. 2003. Overview of the New York State Council on Graduate Medical Education. Boston, MA: Community Catalyst. University of Colorado School of Dentistry. 2003. Advanced Clinical Training and Service Program. [Online]. Available: http://www.uchsc.edu/sd/sd/advanced.html [accessed September 5, 2003]. U.S. Census Bureau. 2002a. Historical Income Tables—Families. [Online]. Available: http://www.census.gov/hhes/income/histinc/f05.html [accessed August 14, 2003]. U.S. Census Bureau. 2002b. Money Income in the United States: 2001. Current Population Reports, P60-218. Washington, DC: U.S. Government Printing Office. [Online]. Available: http://www.census.gov/prod/2002pubs/p60-218.pdf [accessed September 3, 2001]. U.S. Department of Education. National Center for Education Statistics. 1997. Access to Postsecondary Education for the 1992 High School Graduates. NCES 98-105. By L Berkner, L Chavez. Project Officer CD Carroll. Washington, DC: U.S. Department of Education. U.S. Department of Education, National Center for Education Statistics. 1999. College Access and Affordability. Findings from The Condition of Education 1998. NCES 1999-108. Washington, DC: U.S. Department of Education. U.S. Department of Education, National Center for Education Statistics. 2000a. 1999–2000 National Postsecondary Student Aid Study (NPSAS: 2000). Washington, DC: U.S. Department of Education. U.S. Department of Education, National Center for Education Statistics. 2000b. Digest of Education Statistics, 1999. NCES 2000-031. Washington, DC: U.S. Department of Education. U.S. Department of Education, National Center for Education Statistics. 2002. Student Financing of Graduate and First-Professional Education, 1999–2000. Profiles of Students in Selected Degree Programs and Their Use of Assistantships. NCES 2002-166. By SP Choy, S Geis. Project Officer: AG Malizio. Washington, DC: U.S. Department of Education.

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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce U.S. Department of Education, National Center for Education Statistics. 2003a. Characteristics of Undergraduate Borrowers: 1999–2000. NCES 2003-155. By ME Clinedinst, AF Cunningham, JP Merisotis. Project Officer: CD Carroll. Washington, DC: U.S. Department of Education. U.S. Department of Education, National Center for Education Statistics. 2003b. How Families of Low-and Middle-Income Undergraduates Pay for College: Full-Time Dependent Students in 1999–2000. NCES 2003-162. By SP Choy, AM Berker. Project Officer: CD Carroll. Washington, DC: U.S. Department of Education. Valachovic RW, Weaver RG, Sinkford JC, Haden NK. 2001. Trends in dentistry and dental education. Journal of Dental Education 65(6):539–561. Zeigler J. 2003. As tuitions rise, medical students struggle with excessive loans. New Physician 52(6):15–23.