ADDRESSING HEALTH INEQUITIES THROUGH LOAN FORGIVENESS
BY STEPHEN SULKES, MD
Access to high quality, sensitive health care for people with Intellectual and Developmental Disabilities (IDD) remains a challenge nationwide.
Interest in serving this population continues to grow gratifyingly among medical students, including the growing numbers of members of the student chapters of the American Academy of Developmental Medicine and Dentistry (AADMD), encouraged by more and more medical schools incorporating disability-specific curriculum. However, there are multiple factors that work against these idealistic young professionals being able to continue to focus on this population.
Medicaid, the most common payor for health care for people with IDD, typically reimburses health providers at substantially lower levels than commercial insurance. Appropriate care for people with IDD takes extra time; office settings that are physically accessible and support communication and sensory challenges; and providers with special knowledge and skills – all of these are potential disincentives to serving this population. Beyond this, young health providers often graduate from training with hundreds of thousands of dollars in educational loan debt. Serving a population that is high in needs, requires special skills and potentially extra years of training, no matter how rewarding, cannot compete with practice options that provide more family-friendly hours and levels of pay high enough to reduce their large loan burdens.
The issue in Developmental-Behavioral Pediatrics (the subspecialty of Pediatrics mainly focusing on children with IDD) is a big one now, but it is likely to get worse. Much of the workforce in this subspecialty is over age 50. Given the financial disincentives, young physicians are simply not signing up for the extra three years of training needed for Board certification. For the past several years, the number of available training slots has exceeded the number of applicants for fellowship training by one-third or more.
Fortunately, government officials in Washington, DC, and some states have begun to recognize this issue. For many years, health providers electing to work with Medically Underserved Populations, like low-income patients served in urban or rural health clinics, have been eligible for loan repayment or forgiveness. Recently, Congress authorized the Pediatric Subspecialty Loan Repayment Program, which will offer loan repayment for pediatric subspecialists who serve children in underserved areas. Advocacy is now underway to encourage Congress to allocate funds to this initiative. An analysis by the American Academy of Pediatrics in each state estimated driving distances for children to reach providers in 17 pediatric subspecialties. Nationwide, families needed to travel an average of 27 miles to see a Developmental-Behavioral Pediatrician. In many states, particularly those with widely distributed rural populations, distances were over 50 miles. The barriers present in the pediatric range are compounded for those serving adults with IDD. Planning for an approved subspecialty of Developmental Medicine is underway, and there are a handful of programs training physicians in the special health needs of adults with IDD, but there is no formal certification process yet in place, and no promise of extra support for physicians who pursue such training.
A bipartisan group of legislators in the House of Representatives sponsored a bill in 2019 called the "Healthcare Extension and Accessibility for Developmentally disabled and Underserved Population" (HEADs UP) Act. This bill would have designated people with IDD nationwide as a Special Medically Underserved Population. If passed, this legislation would, among other benefits, support educational loan repayment or forgiveness for health providers primarily serving people with IDD. There is hope that the bill will be re-introduced in the current Congress, or that educational loan forgiveness for health providers serving people with IDD across the lifespan will be included in other upcoming legislation to support workforce development.
For people with IDD to achieve health equity, they need equal access to knowledgeable, caring providers. Until financial disincentives to serve this population are eliminated, the best training will have limited impact. Loan forgiveness is an easy and cost-effective way for the government to reduce these barriers, and with enough people speaking out in favor of it, Congress might be ready to open the door for it. •
ABOUT THE AUTHOR:
Stephen Sulkes, MD, Professor of Pediatrics at Golisano Children's Hospital in Rochester, NY, is former Director of the University of Rochester Leadership Education in Neurodevelopmental and Related Disabilities (UR LEND) Program, and Pediatric Discipline Coordinator, and CoDirector of the Strong Center for Developmental Disabilities (SCDD), Rochester's UCEDD. In the latter role, he is a member of the New York State Developmental Disabilities Planning Council. He is Board Certified in Developmental-Behavioral Pediatrics and Neuro-developmental Disabilities. He is a Fellow of the American Academy of Pediatrics (AAP), and of the Society for Developmental-Behavioral Pediatrics. He is a past President of the American Academy of Developmental Medicine and Dentistry (AADMD), and he has been Treasurer of AUCD, and a board member of the Society for Developmental Pediatrics. Among other honors, he was named Golisano Health Leadership Award winner for North America by Special Olympics International in 2017.