By Joel Teitelbaum

Background

Strengthening and modernizing the health care workforce was a major goal of the Affordable Care Act (ACA). The law contains dozens of provisions related to health care workforce issues, including national workforce policy development (what the law refers to as workforce “innovations”), increasing the supply of primary care physicians and nurses, strengthening the dental health workforce, education and training of the workforce, and expanding teaching health centers. This Implementation Brief focuses on the provisions of the ACA dealing with the education, training, and support of public health and allied health care workers; previous Briefs have focused on the other topics.

Public health and allied health care professionals directly influence the cost and quality of care. Thus training a high-performing health workforce will increase the likelihood of success of other ACA reforms, including policies aimed at expanding insurance coverage, increasing access to care, and controlling costs.^[1] Improving both the quality of training programs and providing federal support for expanding programs for workforce training and distribution will create a more efficient system.^[2] Targeting education and training can relieve workforce problems such as lack of racial and cultural diversity, healthcare geographic and specialty distribution, and promotion of interdisciplinary care.^[3]

Changes Made by the Health Reform Law (P.L. 111- 148, §§ 5201 – 5210; 5302-5307; 5313 -5315; 5401; 5403; 5507)

The ACA included a number of reforms aimed at making education in public and allied health fields more accessible and desirable, in addition to supporting the existing health workforce. Of primary importance was expanding training programs, incentivizing individuals to choose careers in which shortages exist or loom on the horizon and to practice in underserved areas, and improving the quality of health professions education. The reforms can be classified into four areas:

1) Grant Programs

The ACA authorizes the Secretary of Health and Human Services (Secretary) to make contracts and/or grant awards under a number of different public and allied health programs. The following provides a brief description of the purpose and structure of each program.

• Direct Care Training: This program authorizes the Secretary to make grants to educational institutions to aid students entering new training programs for direct care workers who are employed in long-term care settings.^[4] The educational institutions must use the grants to provide financial assistance to individuals entering the programs.
• Training for Low-Income Individuals: This is a demonstration program which gives grants to entities to aid low-income individuals with education and training to help them prepare to enter and advance in health care careers.^[5] Entities receiving grants can provide eligible individuals with financial aid, child care, case management, and other supportive services. Individuals are eligible to receive aid if they are receiving financial assistance from a state TANF program.
• Personal and Home Care Aide Training: Another program provides grants to states to conduct demonstration projects for purposes of developing core training competencies and certification programs for personal or home care aides.^[6]
• Geriatric Training: This program provides grants or contracts to geriatric education centers for the purposes of providing short-term intensive courses on geriatrics, long-term care, and chronic care management.^[7] The courses are expected to act as a supplement to the training of faculty at health professional schools. The education centers must also provide courses to family caregivers and direct care providers that include training for supporting frail elders and individuals with disabilities. The Secretary also can award grants/contracts to advanced practice nurses, clinical social workers, pharmacists, or students of psychology who are pursuing a doctorate or other advanced degree in geriatrics in order to create more interest in the field of geriatrics, long-term care, and chronic care management.^[8]
• Mental and Behavioral Health Training: The Secretary is authorized to make grants to educational institutions to support recruitment, education, and clinical experiences in graduate social work and psychology programs and field placement programs in child and adolescent mental health.^[9]
• Cultural Competency, Prevention, Public Health Proficiency, and Individuals with Disabilities Training: The ACA expands the authority of the Secretary to award grants, contracts, or cooperative agreements to public and non-profit entities to develop curricula to be used in health professions training programs.^[10] The curricula should provide training in cultural competency, prevention, public health proficiency, reducing health disparities, and training for working with disabled individuals.
• Allied Health Advancement: The ACA authorizes the Secretary of HHS to make grants to educational institutions offering studies in public or allied health for the purpose of providing scholarships to mid-career public or allied health professionals seeking to advance their education in their field.^[11] Individuals eligible to receive scholarships are those employed in public or allied health positions with the federal, state, tribal or local government who are looking to upgrade their education.
• Public Health Training: This program requires the Centers for Disease Control and Prevention (CDC), along with the HHS Secretary, to award grants to entities to train community health workers and develop outreach programs aimed at educating underserved medical communities about positive health behaviors.^[12] The Secretary is also permitted to expand CDC fellowship programs that provide training in applied public health epidemiology, public health laboratory science, public health informatics, and epidemic intelligence services.^[13]
• Center for Excellence: The ACA reauthorized the Centers for Excellence grant program, which provides grants to health professional schools for supporting programs for underrepresented minorities.^[14] Depending on the appropriations granted for this program, certain grant amounts must be available for health professional schools that have Hispanic and Native-American Centers (i.e., schools with an above-average enrollment of those minorities).
• Improving Existing Area Health Education Center Program: Two grants are available under this program.^[15] First, the Secretary is authorized to make awards to entities to enable them to create workforce educational programs or to continue to carry out comparable programs already operating. The Secretary is also authorized to make grants to maintain and improve the effectiveness and capabilities of an existing area health education center program. Eligible entities are responsible for using the grants to develop and implement strategies to recruit underrepresented minorities into health professions, to provide community-based education and training to individuals seeking health care careers within underserved areas, conduct interdisciplinary training, and deliver continuing education, among other things.

2) Public Health Sciences Track

The ACA also establishes the United States Public Health Sciences Track (Track) to train physicians, dentists, nurses, physician assistants, mental and behavioral health specialists, and public health professionals by emphasizing team-based service, public health, epidemiology, and emergency preparedness and response.^[16] Students admitted to the Track at affiliated institutions receive tuition remission and a stipend in exchange for two years of service as a Commissioned Corps Officer for each year of school covered. Programs offering the Track are primarily located in health professions shortage areas in order to train students to practice in underserved areas.

3) Loan Repayment Programs

The ACA also attempts to increase the supply of health care professionals by authorizing the Secretary of HHS to make educational loan repayments on behalf of eligible individuals in various programs. One such program is aimed at increasing recruitment for pediatric specialties.^[17] This program authorizes the Secretary to make payments of up to $35,000 per year for up to 3 years on educational loans for health professionals that agree to provide “pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care in an area with a shortage of the specified pediatric subspecialty . . . .”^[18] Health professionals that qualify for this program include non-physician mental health professionals that have received specialized training or have clinical experience with respect to child and adolescent mental health.^[19] The Secretary is required to give preference to applicants who:

• are or willing to work in a school or educational setting;
• have familiarly with evidence-based methods and cultural and linguistic competence health care services; and
• demonstrate financial need.

Another program authorizes the Secretary to create and implement a Public Health Workforce Loan Repayment Program targeted at shortages of public health officials in federal, state, tribal, and local agencies.^[20] Similar to the pediatric specialists program, the Secretary can contract with eligible individuals and agree to pay up to $35,000 per year in exchange for at least 3 years of service in a public health agency. Eligible individuals include:

• students in their final year of attaining a degree or certificate in a public health or health profession; or
• employees of a public health agency that have graduated during the preceding 10 year period and received a public health or health professions degree or certificate.

Eligible individuals must also be a U.S. citizen, submit an application to the program, and enter into a contract with HHS.

The ACA also expands the Loan Forgiveness^[21] provision of the Federal Family Education Loan Program^[22] for individuals working in areas of national need by expanding the type of professions eligible in the program to include allied health professionals.

4) Amendments to the Commissioned Corps

Finally, the ACA amends the Commissioned Corps program in two ways to increase the supply of health professionals. First, it eliminates the 2,800-person cap on the number of commissioned officers.^[23] Second, it establishes the Ready Reserve Corps, which will be available to aid the Commission Corps in national or public health emergencies and which can be called to duty by the Surgeon General.^[24] The Ready Reserve Corps duties include:

• participating in routine training;
• being available for involuntary calls to active duty;
• being available for backfilling critical positions left open during deployment of Commissioned Corps members; and
• being available for service in medically underserved communities.

Implementation

Agency

HRSA is the fiscal and administrative agent for the loan and grant programs, with the exception of the Community Health Worker Training Grant, which is administered by the CDC. The Surgeon General is the administrative agent for the Public Health Sciences Track.

Key Dates

None.

Process

The health reform law does not provide specific direction to HHS regarding the administrative process used to implement the law. The agency therefore has the discretion to use a range of tools to implement the statute, such as publishing regulations in the Federal Register with a public notice and comment period, or using other types of approaches such as posted policy instructions, funding availability announcements (where applicable), official letters to affected entities (such as letters to state Medicaid agencies), and posted rulings and notices. Agency websites can be checked regularly for updates.

Key Issues

General:  Will these initiatives expand health care access, improve health care quality, and/or lower health care costs?

Financial Incentives:  Will the grant programs create sufficient financial incentives to boost the number of students choosing certain health professions, the number of teachers for those health professions, or the number of public and allied health professionals choosing health careers where there is shortage or other need?

Quality:  Will the grant programs increase the quality of training by promoting the development of new curricula?

Appropriations for grants:  How much money will Congress actually appropriate for the grant programs where money has only been authorized previously?

Recent Agency Action

On August 5, 2010, the Secretary of HHS announced $159.1 million in grant funds to support health care workforce training. Read the press release here. Funds included:

• $29.5 million in grants were awarded to promote Interdisciplinary Geriatric Education and Training, of which $17.2 million went to Geriatric Education Centers, $8.1 million went to geriatric training of health professionals, and $4.2 million went to the Comprehensive Geriatric Education Program.
• $23.5 million to support Centers of Excellence Programs.

On September 13, 2010, the Secretary of HHS announced that $16.8 million is available for support for 27 Public Health Training Centers. Read the press release here.

On September 27, 2010, the Secretary of HHS announced that $320 million is available for grants to improve and expand the health care workforce. The grants are awarded under six health professions programs administered by HRSA and are designed to build the primary care workforce and provide community-based prevention services. For a complete listing of how the money will be spent, read the press release here.

Authorized Funding Levels

For the education loan programs, the changes are regulatory in nature and therefore do not directly include the award of federal funds.

For the Direct Care Training Grants: Ten million dollars is authorized to be appropriated for fiscal years 2010 through 2013.

For the Demonstration Projects to Provide Low-Income Individuals with opportunities for Education, Training, and Career Advancement: $85 million is appropriated for each of the fiscal years 2010 through 2014. Of that amount, $5 million is to be used for grants under the Demonstration Project to Develop Training and Certification Programs for Personal or Home Care Aides for each fiscal year 2010 through 2012.

For the Geriatric Training Grants: Congress authorized to be appropriated $10.8 million for the fiscal years 2011 through 2014.

For the Mental and Behavioral Health Education Grants: For the fiscal years 2010 through 2013, Congress authorized to be appropriated $8 million for training in social work, $12 million for training in graduate psychology, $10 million for training in professional child and adolescent mental health, and $5 million for training in para-professional child and adolescent work.

For the Cultural Competency, Prevention, Public Health Proficiency, Individuals with Disabilities Training Grants: Congress authorized to be appropriated such sums as necessary for the fiscal years 2010 through 2015.

For the Mid-Career Public and Allied Health Professional Grants: Congress authorized to be appropriated $60 million for fiscal year 2010, and such sums as necessary for the years 2011 through 2015. For each fiscal year, 50 percent of the grant funds must go to mid-career public health professionals and 50 percent to mid-career allied health professionals.

For the Community Health Worker Grants: Congress authorized such sums as necessary to be appropriated for the years 2010 through 2014.

For the CDC Fellowship Program Expansion: Thirty-nine million dollars were authorized to be appropriated for each of fiscal years 2010 through 2013, of which $5 million is for the epidemiology fellowship training program, $5 million is for laboratory fellowship training programs, $5 million is for the Public Health Informatics Fellowship Program, and $24.5 million is for the Epidemic Intelligence Service under subsection.

For the Centers for Excellence Programs: Fifty million dollars were authorized to be appropriated for 2010, and such sums as needed for the years 2011 through 2015.

For Continuing Education Support: Congress authorized to be appropriated $125 million for each of the fiscal years 2010 through 2014.

For the Public Health Sciences Track Program: Congress authorized the Secretary to transfer such sums as necessary from the Public Health and Social Services Emergency Fund for the purposes of funding the program.

For the Pediatric Healthcare Workforce Loan Repayment program: Twenty million dollars was authorized to be appropriated for each of the fiscal years 2010 through 2013 for loan repayments of child and adolescent mental and behavioral health specialists.

For the Public Health Workforce Loan Repayment program: Congress authorized to be appropriated $195 million for fiscal year 2010 and such sums as necessary for the fiscal years 2011 through 2015.

For the Commissioned Corps: Five million dollars was authorized to be appropriated for each fiscal year 2010 through 2014 for carrying out the duties that are imposed by the ACA, and $12.5 million per year 2010 through 2014 was authorized to be appropriated for recruitment and training of the Ready Reserve.