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State Experience with Dental Loan Repayment Programs

September 2005

ISBN-1-58024-425-4

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"While private dental practices in the state flourish, it is extremely difficult to attract providers to dental safety net facilities.  The growing recognition of this crisis among professionals and policy makers has elicited a slow but steady legislative and programmatic response."                                                                                            - Center for California Health Workforce Studies,                                                                                           "Evaluation of Strategies to Recruit Oral Health Care Providers                                                                                            to Underserved Areas of California," 2004.

States are struggling with dentist shortages, particularly among low-income, medically uninsured and underserved populations. In 2002, the National Conference of State Legislatures (NCSL) interviewed state advocates for Medicaid recipients, maternal and child health coalitions, advocates for people with disabilities, and oral health directors in five states. From these interviews came a consistent message: there is a shortage of dentists—especially pediatric dentists—and it is most acute in rural areas. Although some disagree that there is an overall shortage of dentists, there appears to be widespread agreement that there are geographic maldistributions of dentists and that the shortfalls are worse in rural and underserved areas.

The need is great in the country’s 2,477 dental health professional shortage areas, which encompass more than 41 million people. According to the U.S. Health Resources and Services Administration, approximately 8,500 additional dentists are needed to achieve a ratio of 3,000 patients per dentist in those areas alone.

Even in areas where dentists are practicing, many people struggle to gain access to services. For the uninsured, obtaining the oral health care they need is a challenge because they may not be able to afford the cost of care or may have trouble locating a provider who will provide services at a reduced fee. Children in families that lack dental insurance are three times more likely to have unmet dental needs than are children in families that have public or private insurance. Nationally, 138 million Americans, including 39 million children, lack private dental insurance.¹ According to the Centers for Disease Control and Prevention, for every child who does not have medical insurance, there are 2.6 children who lack dental insurance; among adults, three lack dental insurance for every one who lacks medical insurance.²

Dental Health Professional Shortage Area (DHPSA) Defined Communities with shortages of dental professionals may apply for the federal designation.  Becoming a DHPSA enables the community to participate in state and federal funding programs, such as the National Health Service Corps and state loan repayment programs.  According to HRSA's Bureau of Health Professions, in order to receive DHPSA status, the area must meet the following three requirements to receive DHPSA status: The area must be a rational area for the delivery of dental services. The dentist-to-population ratio must be at least 5,000-to-1 (i.e., 5,000 people for every full-time equivalent dentist) or less  if the area has "unusually high needs for dental services or insufficient capacity of existing dental providers." Dental professionals in neighboring areas are "overutilized, excessively distant, or inaccessible."

Among children and adults who rely on public programs such as Medicaid or the state’s children’s health insurance plan, many struggle to obtain the care they need because providers are unable or unwilling to see these individuals. One in five children who were eligible for preventive dental care received services in 1998.³

The burden of oral diseases falls disproportionately on low-income and some racial/ethnic minority groups, according to the Centers for Disease Control and Prevention. Despite the fact that it is preventable, oral disease, including both decayed and filled teeth, remains the number one chronic childhood disease—five times more common than childhood asthma.⁴ Poor children in every racial and ethnic group are more likely than their non-poor peers to have untreated, decayed primary teeth. Moreover, 25 percent of poor children have not seen a dentist before they attend kindergarten.⁵

To fill the gaps, states are implementing a broad spectrum of strategies to alleviate dentist shortages and encourage dentists to treat underserved patients. In addition to increasing the supply of dentists who practice in and serve underserved populations, states are considering strategies to diversify the workforce and improve the distribution of providers to address the most profound gaps in access to care.

Background: State Loan Repayment Programs

Loan repayment programs are a targeted approach to recruiting dentists into the most underserved communities. Various types of loan repayment programs are available to a range of providers (see box). The goals of these programs, however, are the same: increase access to primary and preventive care in medically and dentally underserved areas by recruiting providers to work in those communities. In exchange for service in a shortage area, the program funder—which could include the federal government, states, localities, private entities or providers—repay all or a portion of the provider’s student loans.

Loan Repayment Programs Defined NHSC-LRP.  The National Health Service Corps operates its own loan repayment program.  Primary care providers from various fields-physicians, nurse practitioners, dentists and others-must work full-time in a public or nonprofit site within a federally designated health professional shortage area to be eligible. NHSC-SLRP.  Beginning in 1987, the NHSC established its state loan repayment program in which the NHSC grants dollar-for-dollar matching funds directly to participating states to operate their own loan repayment program for eligible provider types. The NHSC grants provide 50 percent of the loan repayment funds, while states and/or communities must provide the other half, and states pay administrative costs.  Under the program, states must require that recipients work full-time in a public or nonprofit site located in a federally designated health professional shortage area.  According to the Bureau of Health Professions, 38 states participate. SLRPs.  Several states create and fund their own loan repayment programs for dentists and other providers-sometimes in addition to the NHSC-SLRP.  These state programs have their own eligibility requirements, and many allow providers to work part-time or allow recipients to work in private practice as long as they help underserved patients.

More than two dozen states have established loan repayment programs. By promising to pay a portion of student loans in exchange for service in a shortage area, these programs remove some financial barriers that otherwise might discourage dentists from practicing in a rural health center or other setting. Loan repayment removes—or minimizes—the overwhelming student debt that average nearly $120,000 per dental graduate.⁶ This debt burden influences a new dentist’s choices about where to practice; private practice promises to compensate at a much higher rate—and thus allow more rapid debt repayment—than public health locations. In other words, loan repayment programs broaden options for graduating dentists, especially those who desire to practice in an underserved area but who, because of financial reasons, may pursue a more lucrative career path.

The model is considered by many to be a winning solution for all involved: communities gain access to oral health services and providers receive help to pay their often hefty student loans. States model their programs after the National Health Service Corps (NHSC)—a national loan repayment program that is available to various health care providers who work in an underserved community for a minimum of two years. Since 1972, when the first NHSC clinicians were assigned to communities, more than 24,000 providers—including physicians, dentists, dental hygienists, nurses and others—have provided care to millions of underserved patients.⁷

States that have their own loan repayment programs may also have a National Health Service Corps state loan repayment program for dentists. States that design their own programs have more flexibility in determining where providers may practice, for how long and various other program elements. By developing their own programs, states can tailor their programs to the state’s needs and modify rules to attract a certain niche of providers. Specifically, states can use criteria other than the federal health professional shortage area designation to identify eligible communities and can allow part-time and private practice work—as long as the provider fulfills his or her duty to provide care to underserved populations.

Although much is known about the National Health Service Corps loan repayment program, there has, to date, been little analysis of how state programs operate. To fill this gap, NCSL conducted state legislative research and a 50-state survey of state loan repayment program administrators to describe how states administer, fund and evaluate their programs. Appendix A contains a list of states from which administrators responded that there was a state loan repayment program. The information on state programs is from a 2004 NCSL survey of program administrators and is based on state self-reporting. Somewhat different findings might result from a different data-gathering methodology.

This report summarizes state loan repayment programs, including the legislation that establishes loan repayment programs; how programs operate; and what is known about program outcomes. The report provides data from the NHSC loan repayment programs to supplement findings from state programs when state data are lacking. (Appendix B contains the study methodology.)

Legislative Characteristics

State loan repayment programs often are established through legislation and typically this legislation outlines various program components, from the agency in charge to the penalties for defaulters. (Appendix C summarizes state laws in 23 states that have SLRPs for dentists and one additional state—Florida—that maintains a scholarship program for dentists.) State laws typically address the following.

• Establish the program and identify the agency in charge of administering the program. This often includes the health department, the state dental board, or a finance or higher education assistance authority. In some cases, the law directs the agency to work with other advisory councils or boards to develop rules and administer the program.

• Define roles and responsibilities for the entities administering the program. For example, the law may direct the agency to develop eligibility rules for program recipients and develop a process for identifying dentally underserved communities.

• Define conditions for eligibility. Some states require recipients to be state residents, work full-time, or complete a short probationary period before they begin to receive loan repayment. New Jersey, Ohio and Wisconsin, for example, prohibit recipients from simultaneously receiving loan repayment benefits from the state and from the National Health Service Corps. In addition, many laws specify priorities for participation; for example, the law may direct the administering agency to give priority to applicants who come from a disadvantaged background, speak another language, or demonstrate a high level of commitment to working in an underserved area. In addition to defining specific conditions that the recipient must meet to qualify for the program, some states also require that the population served meet certain criteria. For example, some states require that providers accept patients regardless of their ability to pay. In Arizona, for example, the law dictates that the dentist must provide "organized, discounted, sliding-fee scale services for medically uninsured individuals from families with annual incomes below 200 percent of the federal poverty level."

• Describe how—and how much—to fund the program. In California, for example, the statute authorizes $3 million from the state dentistry fund to create a Dentally Underserved Account that will support the loan repayment program. Colorado law provides that the program receive $200,000 annually, subject to available appropriations. Many laws state that the program’s operations are contingent upon state appropriations. South Dakota and Wyoming require a community match—of between 25 percent and 75 percent of the loan repayment amount—to help repay the recipient’s loans. Some states encourage or require the program to seek grants and revenues from other sources. California law directs the Office of Statewide Health Planning and Development to establish a fund and seek matching funds from foundations and private sources.

• Establish parameters for program operations. Many state laws identify minimum years of service and maximum number of years for participation. Some states also identify other limits on the program size and budget. South Dakota law specifies that no more than five dentists may participate in the program at any one time. Most states identify a maximum amount of loan repayment annually (typically ranging from $10,000 to $30,000), and some specify an overall cap on how much a recipient can receive during his or her tenure. For example, California law authorizes the state dental board to provide up to $25,000 after the first year, $35,000 after the second year and $45,000 after the third year—or a maximum of $105,000.

• Define penalties for noncompliance and a process for enforcing contract provisions. States that have loan repayment programs levy penalties for recipients who fail to meet the terms of their agreement with the state. In many states—such as Minnesota—defaulters must repay the loan repayment amount with interest. In Arizona, recipients must repay twice the total uncredited amount, and in Maine, recipients are required to repay the entire principal amount of the loan, plus interest. In addition to repaying the loan, Maine law also requires recipients to pay an unserved obligation penalty, which equals the number of unserved months multiplied by $1,000.

• Require program evaluation and monitoring. Many states require the agency that administers the program to submit program information to the legislature, including such information as number of applicants, number of loan recipients, number of defaulters, and reasons recipients did not fulfill their obligations. California requires an evaluation of the program’s effectiveness and recommendations for improving the program. Colorado law requires the Department of Public Health to report to the legislature on the number of recipients, cost-effectiveness and impact on the underserved population. Maine law establishes an advisory committee to help the Finance Authority evaluate and improve the program. New Mexico requires the Commission on Higher Education to submit annual reports to the Legislature, with information such as names and locations of recipients.

State loan repayment programs share similar goals: policymakers and administrators design them to recruit in-demand health professionals to medically underserved communities and improve access to quality health care within those communities. Although the goals are often the same from state to state, the way that states implement these programs varies considerably. To better understand how states administer their programs, NCSL conducted a survey of state loan repayment program administrators in 2004, and 27 states provided information on their programs—when and why they started, who is eligible, how the state disburses awards and other program characteristics. The following section summarizes the survey findings and provides detail about how states organize and operate their loan repayment programs.

SLRP History. States began awarding loan repayments to dentists as early as 1990, according to the NCSL survey. Of the 27 states that responded, nearly 90 percent began a program before 2002, and three states established programs in 2003 and 2004. In some states, dentists were added as an eligible recipient of the state program after the loan repayment program was established. In 1994, for example, Arizona lawmakers authorized the state’s loan repayment program and provided state funds to match federal loan repayment grant funds. The program required that recipients practice in a public or nonprofit setting located in a federally designated health professional shortage area. In 1997, the state authorized funds from the Medically Needy Account—funded through the tobacco tax—to provide loan repayments for providers who serve in rural, private practices located in medically underserved areas. Dentists were included as eligible providers in 1999.

When asked about the top two priorities for loan repayment programs, the largest percentage of SLRP administrators ranked among the top two priorities recruitment of dentists to underserved areas of the state and increasing access to dentists among low-income populations. Retention also is a priority for programs; however, it appears that the top priority is to encourage greater numbers of dentists to practice in low-income areas.

These goals are similar to the National Health Service Corps, which defines its mission as improving the health of the underserved by "uniting communities in need with caring health professionals" and "supporting communities’ efforts to build better systems of care."⁸ In other words, programs at the federal and state levels alike strive to connect underserved communities with high-demand providers and, by so doing, increase the level of care.

Paying for Loan Repayment Programs. When asked to identify all of funding sources for their state loan repayment programs, 90 percent of the 27 responding administrators said they receive state funding, and half said they receive some type of federal funding. Lesser numbers of states receive funding from local, foundation and other sources. Figure 1 illustrates state loan repayment programs funding sources.

States fund loan repayment programs through various mechanisms, including general fund appropriations and tobacco settlement funds. In Colorado, for example, state law provides that the program receive $200,000 annually from tobacco settlement funds, subject to available appropriations. Although the program received full funding in 2002, its first year of operation, the General Assembly appropriated less in the two subsequent years.⁹ Texas law states that each dental school must set aside 2 percent of tuition charges, which will be transferred to the state treasury to repay dentist student loans.

As shown in figure 2, NCSL’s 2004 survey found that, on average, states spent nearly $94,000 in the program’s first year; by the year the administrators completed the survey (2004), the mean state investment rose by 71 percent to more than $161,000. State funding nearly doubled in New Jersey and North Carolina, and the increases were even more significant in Minnesota, North Dakota and Texas.

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Although the overall trend is an increase in how much money states spent on these programs between the first year and 2004, a closer look shows that several states invested the same amount or less than when the program began. For example, funding decreased or remained the same between the first and current year in Arizona, Iowa, Vermont and Wisconsin.

Although states are an important source of funding, the figure 2 illustrates that funding levels typically are not on a large scale; half the states that responded to these questions reported investments of less than $100,000.

Implementing State Loan Repayment Programs. State loan repayment programs are administered by a state agency, such as the department of health, department of community affairs, or a state finance or higher education agency. Every state has a method for determining underserved geographic areas that are eligible to receive an SLRP provider. According to NCSL’s survey, the majority of states—22 of the 27 responding states—use the federal definition of health professional shortage area (HPSA) for placement purposes. Five states—Colorado, Minnesota, Nebraska, New Jersey and Vermont—place recipients in shortage areas based on another definition. States struggle with determining the best method for identifying shortage areas, and the dental HPSA—though heavily used—is not universally accepted as the most effective indicator of unmet dental needs. Specifically, the federal definition’s emphasis on the dentist-to-population ratio (although not its only criteria) may not adequately reflect pockets of unmet needs in otherwise well-served locations, for example.

The number of dentists who receive loan repayment varies from year to year in each state, depending on a number of factors such as amount of funds available and the number of dentists who apply. As shown in figure 3, of the 24 states that answered the question, 17 states—or 70 percent of respondents—awarded loan repayment to between one and 10 recipients in the current year. Five states reported that they did not award loan repayment to any dentists, and two states awarded loan repayment to more than 10 dentists in that year.

Respondents were asked to identify how loans are distributed and, in some cases, identified more than one method. In short, states vary widely on how they distribute repayment money; however, the norm is to distribute over time, rather than in a lump-sum amount. Distributing funds in installments gives the program administrators more oversight to ensure that recipients are meeting their obligations over time. In addition, more frequent payments may help the recipients repay their loans over time, whereas a lump-sum payment at the end of their obligation may present a burden for many providers who have large debts.

As shown in figure 4, nine states reported distributing the loan directly to the recipient, and six distribute it to a loan servicing organization. States distribute funds at various intervals, including quarterly, biannually and annually. One state reported distributing a lump-sum payment at the end of the service obligation, and two reported providing a lump-sum payment at the beginning of service. In Colorado, for example, the state modified its payment method from a lump-sum payment to payment in installments. This change in how funds are distributed was intended to ensure that the recipient meets quarterly requirements to serve a certain number of patients.¹⁰

Just as states differ on how they distribute funds, they also on how much they give out to recipients, although certain amounts are more common than others. The majority of states that responded to the question—71 percent—provide between $10,000 and $20,000 per year to recipients, as shown in figure 5.

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The majority of states require recipients to use funds to repay school loans. According to 60 percent of administrators who responded to the question, funds must be used to repay recipients’ school loans. Fewer than 30 percent of states that responded to the question allow recipients to use funds for such things as living expenses related to the recipients’ education.

In 23 of 25 responding states, loan repayment awards are taxed. In two states, they are tax exempt. This differs from the National Health Service Corps’ State Loan Repayment Program, which exempts repayment awards from gross income and employment taxes.

Most states do not allow recipients to concurrently receive loan repayment through the state’s National Health Service Corps loan repayment program. Among the 25 states that responded to this question, 22 prohibit recipients from simultaneously receiving state and national loan repayment dollars.

Eligibility Requirements. States identify certain preferences for loan repayment recipients. By infusing certain public policy goals—for example, practice in a rural setting—the program helps to influence where providers are placed. Arizona law directs the department to "give priority" to applicants who intend to practice in rural areas "most in need of primary care services." Arizona also established a rural private primary care provider loan repayment program to open eligibility to providers in private practice who serve medically uninsured, low-income populations.

The majority of states report that loan repayment recipients do not need to be state residents to qualify for the program; in other words, recipients can participate in the program even if they move from another state, as long as they are licensed to practice in the state. As shown in figure 6, more than two-thirds of the states that responded to the question do not have a residency requirement; the rest require recipients to be state residents.

Survey respondents also were asked if dentists are required to work at the site before they receive a guarantee of loan repayment. As shown in figure 7, among the 27 states that responded, nearly 60 percent require recipients to work on site before they receive a guarantee of loan repayment; 44 percent do not have such a requirement.

Every state requires loan recipients to commit to a minimum number of years in order to be eligible for loan repayment. This requirement ensures continuity in the providers available to serve the community. In almost 60 percent of states (16 of the 27 responding states), recipients are required to commit to practicing a minimum of two years to be eligible for loan repayment (figure 8). Recipients are required to commit to practicing a minimum of three years in seven states.

In addition, many states allow recipients to receive loan repayment for longer than the required length of service. By extending the length of time recipients can participate, the program and the site benefit by retaining an experienced professional who is committed to serving a low-income population. According to the survey findings, more than half the states that responded to the survey allow recipients to receive loan repayment for up to four years, and five states allow recipients to receive awards for five years or more.

Two-thirds of the states reported that they require recipients to work full-time as a condition of eligibility. As shown in figure 9, nine states allow part-time service, and 18 do not.

Some states allow recipients to work part-time to allow them to work in private practice in addition to their placement. In these cases, the amount they receive for loan repayment is prorated according to their work load. By allowing recipients to work part-time in another setting, the program might attract a broader field of candidates—such as those individuals who seek private practice work to either pay off student loans sooner or build up a practice in the local community. The part-time option also appeals to working parents and others who have family responsibilities.

All states penalize recipients who default on their obligation. In addition to repaying an amount equal to that received, many states also require that defaulters pay a penalty fee, which can include doubling or tripling the amount the defaulter is required to repay. Nebraska, for example, requires defaulters to repay the entire amount received plus a one-time, 25 percent penalty. In Arizona, a defaulter is required to repay twice the total amount of the loan on a prorated monthly basis. The Department of Health Services may prescribe additional conditions consistent with the National Health Service Corps’ loan repayment program. Iowa also requires the defaulter to repay two times the amount received. In Pennsylvania, a recipient who defaults is required to repay three times the amount received at the time of default.

Program Challenges. States encounter challenges in administering loan repayment programs, as do the sites where recipients work. In the SLRP survey, NCSL asked administrators to identify such challenges. Among the challenges facing administrators is the availability of sustained funding over time, administrative requirements (e.g., contracting with recipients and ensuring that recipients meet obligations) and collecting the data needed for state program evaluations.

In addition, the program sites sometimes struggle to satisfy program requirements. Although sites within the designated shortage areas benefit from receiving a SLRP provider, they must satisfy various requirements to be eligible. Among the challenges facing sites are becoming designated as an eligible site, recruiting providers, paying for the dentist, supervising a new graduate and providing mentoring in small practice sites, supporting a full-time dentist and meeting the program’s reporting requirements.¹¹ In small and struggling dental clinics, meeting these requirements may pose a significant burden.

Several states require the agency that is administering a loan repayment program to submit a program evaluation to the legislature to demonstrate how well the programs are achieving their desired outcomes, including enhanced access to oral health services and improved oral health in underserved communities. NCSL examined state evaluations and summarizes below how some states evaluate their programs and the indicators they use to measure program success. In addition to a general summary of state evaluation methods, this section also highlights state examples to illustrate specific ways in which states have measured their program results. (NCSL has not verified that these results are accurate; they are included here to provide examples of how states can—and are—measuring program activities.)

Despite program differences, states generally share the same objectives—recruiting and retaining providers and improving access to care in underserved communities. Table 1 provides a synopsis of existing state evaluations, and describes the various ways states are measuring program achievements. Among the small number of states that have evaluated their programs, the majority appear to focus on tracking the program’s achievements in recruitment, retention, effect on access to care and program expenditures; a few examine cost-effectiveness.

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States often track the number of participating providers to measure recruitment, as well as the effect on access to care. Since each provider treats many underserved patients, a greater number of participating providers suggests that more underserved patients in more communities are receiving care that they otherwise may not have received.

In its 2004 survey of SLRP program administrators, NCSL found that more than half of state loan repayment program administrators—13 of the 22 who responded—reported they had fewer than 10 participating dentists since the program began. As shown in figure 10, four program administrators responded that their programs have not thus far admitted any dentists. An equal number—from Michigan, Minnesota, New Jersey and Vermont—have supported more than 30 dentists.

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In other words, in most states, state loan programs for dentists still are operating on a small scale. Although the availability of funds limits the size of programs, one SLRP administrator told us that the program also is limited by the number of applicants who qualify for the program and have an interest in participating.

Effect on Access to Care. Although the number of participating providers is a significant measure, states also are concerned about the effect that the participating providers have on access to care in underserved communities. Two states—California and Colorado—measure the effect on access to care by the number of patient visits to a state loan repayment program dentist. By examining the number of patients served by participating providers, states are seeking to show how many people receive care as a result of the program. However, this number may be inflated because some individuals may have received care even if the program did not exist.

In California, the 51 oral health providers—mostly dentists—who are meeting their obligations under the state’s scholarship and loan forgiveness programs are providing an estimated 130,050 visits per year for nearly 40,000 underserved patients, according to a 2004 evaluation by the Center for California Health Workforce Studies.¹²

A Colorado program assessment broke down the specific populations that benefited from a participating provider, as shown in table 2. The Oral, Rural and Primary Care Section of the Prevention Services Division at the Department of Health and Environment oversees the state loan repayment program. Participating dentists and hygienists provided care to more than 10,000 Medicaid enrollees, 2,200 enrollees in the Child Health Plan Plus and 22,200 sliding fee patients—or a total of more than 35,000 underserved patients (table 2).

Provider Retention. States with loan repayment programs have not produced significant data about provider retention. State programs are relatively new, and in some states there have as yet been no program graduates to follow (since the recipients are still under contract with the state).

Pennsylvania’s Office of Rural Health conducts an annual evaluation of its loan repayment program. The survey’s primary goal is to identify the practice location of providers who have completed their service, to ascertain how many remained at their service delivery location, and to determine how many continued to provide service for the underserved population at another site.

Although the Pennsylvania study includes all providers—not only dentists—the data illustrates the course of provider careers after their loan repayment obligations are met. Almost half (48 percent) of the 132 providers who completed their service between 1993 and 2004 still were at their original work site. On average, the service locations retained participants for slightly more than two years after their commitment to serve ended. Among those who left their original work site, nearly 80 percent stayed in the Commonwealth and almost 60 percent were practicing in a health professional shortage area.

The 2003 survey found that nearly all the 69 providers surveyed (94 percent) found the program helpful in recruiting them to—or retaining them in—their practice site. In addition, 96 percent of respondents would recommend the program to colleagues.

Program Costs. In addition to examining the number of patient visits, states also want to know how much was spent to administer and support the program. Evaluating program expenditures, however, is not enough. In addition to information about what was spent, policymakers want to know what the state received in exchange for its investment. The two states summarized below examine program costs in relation to the effects—number of patients seen, for example—on access to care. An evaluation in California examined program costs and benefits, and a Colorado state audit examined program and administrative costs.

A 2004 evaluation of the California state loan repayment program¹³ examined costs in relation to patient visits to determine the amount the state paid for each SLRP patient visit. According to the evaluation, most state loan repayment programs provide dentists with $25,000 to $35,000 annually for several years. In total, the cost for each provider can exceed $100,000, as demonstrated in table 3.

These clinicians typically provide at least 10,000 patient visits over a four-year period. As a result, the subsidized cost per patient—that is, the amount the state is paying for each visit—averages $10. The subsidized cost per patient visit illustrates the value of retention: when doctors continue to practice in these communities after the program ends, the subsidized cost per patient visit drops. If half the providers continue to practice in an underserved community after five years, the subsidized cost per visit drops to $6, and after 10 years it drops even further to $4.50. In other words, the longer the provider remains, the better the state’s return on its investment.

In 2004, the Colorado Office of the State Auditor evaluated the dental loan repayment program; the program’s revenue and expenditures are summarized in table 4. The program, funded by the tobacco Master Settlement Agreement (which the state is scheduled to receive for 25 years),¹⁴ was authorized by statute to spend up to $36,000 in administrative expenditures during fiscal year 2002. Administrative costs for the first year of the program totaled $22,870, well below the authorized $36,000.

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Following the first year, the program was authorized to spend no more than 10 percent on administrative costs. Any unspent funds remain in the state dental loan repayment fund. The program spent half of the amount allowed in statute on administrative costs—5 percent of overall expenditures in 2003.

The program awarded a total of $154,800 in its first year to six dentists and two dental hygienists. These eight providers treated nearly 15,000 underserved individuals. Six of the eight providers worked at federally qualified health centers and reported treating an average of more than 140 patients per month.

The above examples illustrate ways states are measuring their programs. Given the relative newness of state programs, however, many states have yet to produce program evaluations. As a result, a shortage of outcome information exists from the state level. Given the lack of available data from states and the similarities between the state and national programs, the longer-running national repayment program provides useful information to state policymakers about how the loan repayment model has worked nationally. The following section summarizes lessons learned from the national program, specifically those that may inform policymakers about the effect of these programs on recruitment, retention and access to care.

To maximize the public investment, loan repayment program administrators and policymakers are concerned about retaining providers in underserved areas after their service obligation has ended. The return on investment increases when providers continue to work at their service site—as do continuity and access to care in the community. In addition to monitoring how many providers remain in the same location, loan repayment programs want to know how many providers continue to treat underserved populations after they leave the program. In other words, if the provider left the site for private practice, the program still achieved some measure of success if the provider continues to help underserved individuals. However, to truly understand the program’s effectiveness, it is critical to ascertain whether these providers would have worked in an underserved area or served a low-income population even if the program did not exist.

Created in 1970, the National Health Service Corps (NHSC) was established to extend primary health care services in underserved areas of the country. The program recruits qualified health care professionals, including medical, dental and mental health providers, to serve in needy communities. In exchange for a minimum two-year commitment, health service providers are awarded loan repayment scholarships of up to $25,000 per year. Since the program’s inception, more than 24,000 health care professionals have participated. According to the NHSC administration, at least 50 percent of NHSC clinicians remain in service to the underserved after they fulfill their service obligations.¹⁵

NHSC Program Evaluation. In 2000, the Cecil G. Sheps Center for Health Services Research and Mathematica Policy Research, Inc. evaluated the National Health Service Corps.¹⁶ When comparing the retention rates of scholarship versus repayment recipients, the researchers found that "participants in the loan repayment program generally exhibit equivalent or better outcomes than clinicians in the scholarship program."¹⁷ A higher percentage of loan recipient program alumni continued to work at the same site or another underserved area one month after their service obligation ended than did scholarship recipients (79 percent and 62 percent, respectively).

Current clinicians also were interviewed in the same study and, when projecting their future plans, 82 percent of loan repayment recipients planned to stay at the same site for one year or longer, 66 percent for two years or longer, and 46 percent for four or more years. When the question is broadened to ask how many current loan repayment recipients plan to work in any underserved area for four years or longer, the number jumps to 85 percent. In other words, NHSC providers intend to continue serving in underserved areas for years after they complete their obligations.

Loan repayment program achievements are due to several factors; among them, loan repayment programs appeal to professionals who are further along in their clinical training. As a result, these individuals tend to have more well-defined career goals. In addition, the study concludes that loan repayment program recipients exhibit higher satisfaction levels because they have more options for placement sites than scholarship recipients.

NCSL Survey. NCSL distributed a questionnaire to current and past NHSC loan repayment recipients and received 80 completed surveys. NCSL found that almost all the responding dentists remained at their placement site for a period of time after fulfilling their service obligation, and most NHSC recipients continue to treat underserved patients even after their obligation ends. Specifically:

• Nine of 10 dentists who responded to NCSL’s survey currently treat Medicaid patients and nearly half treat SCHIP patients.
• Eight of 10 respondents accept patients with special needs.
• Nearly three-quarters offer a sliding fee scale, and nearly two-thirds offer payment plans.
• Of those who left their placement site after fulfilling their duties, the most common reasons for leaving included needing a higher income and job dissatisfaction.
• Of those who left their placement site, 53 percent described their current practice site as private practice (including group practice), 27 percent as a community or rural health center, 13 percent as other public site, and 7 percent as other.

In short, NHSC graduates tend to have a high retention rate, particularly when the broader definition is applied—that providers continue to treat underserved populations even if they have left their NHSC placement site.

The NCSL survey also sought to measure recipient satisfaction with the program. Recipient perceptions of the program’s strengths and weaknesses help policymakers know what characteristics draw—or potentially drive away—applicants and recipients. Table 5 lists the top three strengths and weaknesses of the program’s administration, according to survey respondents.

In short, recipients believe that the program excels with many of the administrative procedures once they are in the program—including timely payment and convenient and reliable loan repayment, for example. On the other hand, getting "into" the program—filling out the application, receiving word about notification, and other communication with repayment officials—receives lower marks. Of 67 dentists who responded, the average amount of time it took for a dentist to find a loan repayment eligible site was 6.7 months.

The majority of dentists report that they did not encounter problems fulfilling loan repayment eligibility requirements. Only 12 percent of the responding dentists reported difficulties, which included management issues, medical leave, fund availability, lost money with Medicaid reimbursement levels, lost paperwork and heavy patient load.

Program recipients responded to a number of other questions about their experiences. Some findings include the following:

• Nearly 40 percent of all dentists surveyed had to accept a lower salary to work at their placement site relative to their salary at a previous place of employment.
• Approximately half of respondents (53 percent) said they were required to agree to their placement site before their loan repayment was guaranteed; 9 percent could not recall.
• Almost all the respondents—97 percent—would recommend the NHSC loan repayment program to newly graduated dentists.

Finally, NCSL inquired about ways to improve the program. The recommendations that follow reflect survey respondents’ attitudes about how the program could be designed to better meet their needs. Although some of these suggestions are specific to the national program, others contain useful information for state programs.

Improving the National Health Service Corps: Suggestions from Program Graduates Simplify application process. Provide interest-free student loans during service obligation. Site should provide average salary or more competitive salaries. Provide online data application. More carefully monitor NHSC sites. Use current and former LRP recipients for recruitment purposes at dental schools. Open program to non-citizens. Provide better communication and customer service. Increase funding to allow more people to participate. Program should have greater understanding about family obligations: e.g. spousal employment, good schools for children, etc. Address site eligibility prior to employment; don’t require a contract before applying. NHSC should pay the loan directly. Provide mentoring programs. Implement national standards.  Source:  NCSL Survey of NHSC providers, 2004.

States have established loan repayment programs as one of many public policy approaches to improve access to dental care among underserved communities. States typically use legislation to establish program parameters—such as who is eligible and how the program is funded—and entrust a public agency with designing the fine details of the program. Although programs vary across states, several common program characteristics are shared by most or all states.

Most states:

• Have legislation establishing the program;
• Share similar goals: recruitment, improving access in underserved areas, and retention;
• Invest state resources, although amounts vary;
• Use the federal HPSA definition for placement purposes;
• Award repayment to between one and 10 dentist recipients annually;
• Provide up to $20,000 per year in loan repayment;
• Distribute funds in installments;
• Require recipients to use funds to repay school loans (and not other expenses);
• Tax loan repayment awards;
• Prohibit recipients from receiving NHSC loan repayment at the same time;
• Do not require applicants to be state residents;
• Require recipients to commit to a minimum of two years, and many allow participation for longer;
• Require full-time work; and
• Penalize recipients for failing to meet contract obligations.

Although state experience with loan repayment programs is relatively new and the programs still are operating on a small scale, the examples highlighted in this report suggest that loan repayment is cost effective, is increasing the number of providers in underserved areas, and is enhancing access to oral health in those communities.

• A limited number of states have analyzed program costs, specifically how much was spent on administration and loan repayment. State experiences with their loan repayment programs will continue to benefit from examining program costs and, specifically, whether the benefits outweigh costs.
• Retention of providers after the program ends is good in at least one state (Pennsylvania) and in the National Health Service Corps program. Among the providers who leave their location, many continue to treat underserved populations at their new location.
• NHSC program recipients are satisfied with the program and would recommend it to others. The national and state programs are removing significant financial burdens that face new dentists and thus are enabling dentists who wish to work in underserved areas to do so.

Early findings suggest that state loan repayment programs are a cost-effective way to improve access to oral health services in underserved communities. These programs result in more providers treating more patients who otherwise would not have received dental care. Although they are making progress, the demand for services far exceeds the capacity of these programs to reach every individual in need. In short, although they are making inroads, these programs often are not operated on a large enough scale to close the gap in underserved communities. According to the Center for California Health Workforce Studies, " … the programs…have a strong impact on the communities they serve. However, so great is the gulf between what these efforts are able to produce and the growing need for care, that a new, expanded model of addressing this growing public health crisis needs to be considered. Such a strategy should be an amalgam of educational, loan repayment, practice reform, and finance of care."

Appendix A: States that Responded to NCSL Survey

The following states responded to NCSL’s survey and reported that they have a state-created loan repayment program. Their responses are summarized in the "Up Close" section. (Other states have SLRPs but did not respond affirmatively to the survey.)

NCSL used the following data collection methods:

• Disseminated a 50-state survey to state loan repayment program administrators and follow-up with respondents to ensure accuracy and a robust sample size.
• Disseminated a 50-state survey to National Health Service Corps program administrators. Although the focus of this report is on state loan repayment programs, the experience of NHSC loan repayment programs is instructive, given the many similarities in program goals and administration.
• Disseminated surveys to current and past state loan recipients. NCSL wanted to hear program recipients describe what works, what doesn’t, and how the program can be strengthened to reach a broader pool of potential recipients.
• Analyzed national and state-level data collected from organizations such as the National Health Service Corps, state agencies and other organizations to provide context about the policy environment in which loan repayment programs are created and maintained. For example, some states have conducted evaluations of their state loan repayment programs that provide useful information about the costs and benefits of these programs.
• Conducted in-depth legislative research to identify and summarize relevant state legislation.
• Reviewed guidance from a small, expert advisory panel comprised of state rural oral health experts.

Appendix C. Legislative Actions

Alabama

Ala. Code §16-47-79

Scholarship loans awarded to dental students must be repaid after graduation either in cash or through service in a needy area. Recipients who repay their scholarship loans contract with the Board of Dental Scholarship Awards. They may work in a variety of settings, including one in a remote, rural and underserved population, or in a public health or state institution. For any amount that is not repaid through service, recipients must repay the award balance plus 6 percent interest.

Arizona

Ariz. Rev. Stat. Ann. §36-2172

Establishes the primary care provider loan repayment program for dentists, primary care physicians and mid-level providers. The law states that application and eligibility requirements are consistent with the National Health Service Corps program. The law further directs the Department of Health Services to give priority to applicants "who intend to practice in rural areas most in need of primary care services." The funds are subject to legislative appropriations, and dentists and physicians are eligible to receive up to $20,000 per year of service for up to four years. The penalty for not meeting obligations equals twice the total uncredited amount of the loan repayment contract.

Ariz. Rev. Stat. Ann. §36-2174

Establishes the rural private primary care provider loan repayment program for dentists, physicians and mid-level providers who work in a rural area designated as medically underserved. The recipient must provide " … organized, discounted, sliding-fee scale services for medically uninsured individuals from families with annual incomes below 200 percent of the federal poverty level."

Cal. Business and Professions Code §1970

Establishes the California Dental Corps Loan Repayment Program of 2002. Directs the Dental Board of California to develop guidelines for selecting and placing applicants and directs the board to give priority to those who "are best suited to meet the cultural and linguistic needs and demands of dentally underserved populations" and who meet other criteria, such as having worked in an underserved community for three years, coming from a disadvantaged background, or speaking another language. The law requires the board to establish practice guidelines; at a minimum, the recipient must work in a practice in an underserved area and serve at least 50 percent dentally underserved population and the board must ensure geographic distribution of recipients. Recipients must work full-time for a minimum of three years. The statute authorizes $3 million from the state dentistry fund to create a Dentally Underserved Account. After serving one full year, the board is authorized to provide up to $25,000 for loan repayment, $35,000 after the second year and $45,000 after the third year, for a total of up to $105,000 in loan repayment. The statute requires the board to submit an evaluation of the program’s effectiveness to the Legislature and recommendations.

Cal. Health and Safety Code §127925

Establishes the California Medical and Dental Student Loan Repayment Program of 2002. The law directs the Office of Statewide Health Planning and Development to administer the program and provide a conditional warrant for loan repayment to medical and dental students in participating institutions. To be eligible, students must possess "outstanding ability" and agree to work in a medically underserved area, with preference given to those who, for example, speak another language, have experience working in an underserved area or come from an economically disadvantaged area. The statute directs the office to establish a fund and seek matching funds from foundations and private sources.

Colorado

Colo. Rev. Stat. §25-23-101

Directs the Department of Public Health to develop the Dental Loan Repayment Program subject to available appropriations. To be eligible, recipients must meet one of three requirements, including works in a federally qualified health center, owns or works in a practice that accepts clients enrolled in Medicaid or children’s basic health plan, or owns or works in a practice that provides "a significant level of service" to underserved populations. The recipient must enter into a contract to provide care to the underserved population for a minimum of two years, and the statute directs the department to develop penalties for noncompliance. The department is required to report to the legislature on the number of recipients, the cost-effectiveness and the effect on the underserved population.

Colo. Rev. Stat. § 24-75-1104.5

Specifies that the state dental loan repayment fund shall receive $200,000 in appropriations each year beginning in 2004, funded through tobacco settlement funds.

Connecticut

Conn. Gen. Stat. §19A-7D

Authorizes the commissioner of Public Health to establish, "within available appropriations," a program to provide three-year grants to community-based primary care providers—including dentists—with the goal of expanding access for the uninsured. The grants may be used to subsidize salaries or loan repayment for primary care providers. Recipients must provide services to the uninsured based on a sliding-fee schedule, provide free care if necessary, and accept Medicare and Medicaid-dependent clients.

Delaware

Del. Code. Ann. tit. 16, §9943

Develops the Board of Directors for the Delaware Institute for Dental Education and Research and lists development of loan repayment program as one of its duties.

Florida

Fla. Stat. Ann. §381.0302

The law establishes the Florida Health Services Corps and specifies that students of dentistry and other health professions are eligible for scholarships and relocation expenses in exchange for service in a public health care program or in an underserved area. The Department of Health is responsible for placing students and requiring recipients to treat low-income patients and Medicaid enrollees. (Note, this is a scholarship program for dentists; not a loan repayment program. The law specifies that the department may provide loan repayment for allopathic and osteopathic medical residents with primary care specialties.) The statute specifies that appropriated funds will be deposited in the Florida Health Services Corps Trust Fund, which is administered by the department.

Indiana

Ind. Code §16-46-5-8

Establishes the Indiana Health Care Professional Recruitment and Retention Fund to repay student loans and encourage full-time practice in a shortage area. The fund is comprised of appropriations, gifts, grants and other sources. The statute specifies that administrative costs may not exceed $30,000 annually. To be eligible, recipients must be licensed and must have completed one year of practice in a shortage area or in a community or migrant health center or maternal and health clinic in a shortage area. The state department is responsible for submitting annual reports to the General Assembly on program funds, number of applications, and number and type of loans awarded.

Maine

Me. Rev. Stat. Ann. tit. 20-A, §12302

Establishes the Maine Dental Education Loan Program. The finance authority administers the program, which is open to Maine residents who are enrolled in dental school or an individual eligible for dental licensure and who has outstanding debt. Priority is given to applicants who express an interest in practicing in an underserved area. Recipients are eligible to receive up to $20,000 each year for up to four years. The penalty for not meeting obligations is repayment of the entire principal amount of the loan plus interest. Recipients must provide care to all patients, "regardless of ability to pay through insurance or other payment source."

Me. Rev. Stat. Ann. tit. 20-A, §12304

Establishes an advisory committee to help the finance authority’s chief executive officer evaluate and improve the program.

Minnesota

Minn. Stat. Ann. §144.1502

Establishes a dentist education account in the general fund, and authorizes the commissioner of health to use money to establish a loan forgiveness program for dentists who agree to care for "substantial numbers" of individuals participating in state public programs and other low- to moderate-income uninsured patients. Preference may be given to Minnesota residents who are attending a Minnesota school and to applicants who are close to completing their training. The penalty for not fulfilling the terms is repayment of the entire amount plus interest.

Mississippi

Miss. Code Ann. §37-143-7

Establishes the Dental Loan or Scholarship Program. The program aims to provide assistance to recipients who obtain a four-year degree of dentistry at the University of Mississippi School of Dentistry. In lieu of repaying the loan, the recipient may work in a public health setting in a state institution, community health center, or in an area outside a metropolitan area that ranks between 1 and 54 on the relative needs index of four factors for dentists.

Missouri

Miss. Code Ann. §191.600

Establishes the Health Professional Student Loan Repayment Program for dentists and other providers who agree to practice in areas of defined need. Creates the Health Professional Student Loan Repayment Program Fund in the state treasury.

Nebraska

Neb. Rev. Stat. §71-5652

Establishes the Rural Health Systems and Professional Incentive Act, which has as one of its purposes the creation of a loan repayment program that will require community matching funds for eligible providers who practice in a rural area. To be eligible, recipients must be enrolled in a medical or dental school in Nebraska and enter into practice in a shortage area in Nebraska. Recipients may receive up to $10,000 per year of full-time practice in an underserved area and may not exceed $30,000.

New Jersey

N.J. Stat. Ann. §18A:71C-32

Establishes a Primary Care and Dentist Loan Redemption Program available in the Higher Education Student Assistance Authority. To be eligible, recipients must be state residents, graduates of an approved medical or dental school, with a recommendation from the school’s staff. Participants must complete a six-month probationary period at the beginning of their placement, and the statute prohibits recipients of National Health Service Corps loan repayment programs from simultaneously participating in the state program.

New Mexico

N.M. Stat. Ann. §21-22D-1 (1978)

The Health Professional Loan Repayment Act authorizes the Commission on Higher Education to administer loan repayment to primary care physicians, dentists and other providers. Among the eligibility requirements, recipients must be licensed to practice in the state, be residents of the state, and declare their intent to practice in a health professional shortage area in the state. Preference may be given to applicants who graduated from a New Mexico public post-secondary institution and who are among the most in-demand provider types. ·The statute creates the health professional loan repayment fund in the state treasury and specifies that appropriations for the program will be credited in this account. In addition, the statute requires the commission to make annual reports to the Legislature, with information such as the names and locations of grantees.

N.D. Cent. Code §43-28.1-01

Directs the State Health Council to administer a dentists’ loan repayment program to up to three dentists each year (or more if the council receives funding from other sources). The law states that recipients may receive funds for up to four years, with a maximum amount of $80,000. The council is charged with responsibilities, such as determining eligibility criteria and enforcing contract provisions. Among the eligibility criteria are the following: commitment to serving in an underserved community, competence and professional conduct, compatibility with the selected community, and willingness to accept Medicare and Medicaid enrollees. Recipients must be residents of, and licensed to practice in the state, and must contract to provide care in an underserved community for a minimum of four years. Recipients must provide care in the selected community for six months prior to receiving loan repayment awards.

Ohio

Ohio Rev. Code Ann. §3702.85

Creates the dentist state loan repayment program, administered by the Department of Health in cooperation with the board of regents and the dentist loan repayment advisory board (which also was created in the statute). The awards may be used for tuition, room and board and other educational expenses (e.g., fees and books). The Department of Health’s responsibilities include defining dental health resource shortage areas. Among the eligibility requirements are the following: the applicant is a dental student or resident in the final year of training, or has been in practice less than three years, and is not also receiving National Health Service Corps loan repayment. The maximum annual amount of loan repayment is $20,000, with a total cap of $80,000. The Department of Health is required to submit an annual report to the legislature describing the program operations, such as number of applications, number of awardees, the dental shortage areas that have not been matched with a recipient, and the number of dentists who failed to meet their obligations under the program.

Rhode Island

R.I. Gen. Laws §23-14.1-1 (1956)

Establishes the Health Professional Loan Repayment Program in the Higher Education Assistance Authority, and a health professional loan repayment board that is charged with determining geographic areas of need, reviewing applications for the program, and submitting a list of eligible applicants to the director of the Higher Education Assistance Authority. As a condition for eligibility, recipients must be licensed and agree to practice for a minimum of two years. In addition, the recipient must accept all patients, regardless of their ability to pay, and accept all forms of insurance. The penalty for noncompliance includes repayment and an unserved obligation penalty, which amounts to the number of unserved months multiplied by $1,000. The law states that the general assembly will appropriate $100,000 annually for the loan repayment program. The funds will be taken from the Department of Health’s appropriations for the children’s health initiative (RIte Track program).

South Dakota

S.D. Codified Laws Ann. §1-16A-73.26

Specifies that dentists are eligible for the dentist tuition reimbursement program if they are licensed and agree to practice in an eligible community—as determined by the Department of Health—for a minimum of three years. No more than five dentists may participate at any one time. Recipients are eligible to receive twice the University of South Dakota resident tuition that a physician would have paid if the physician had attended the University of South Dakota School of Medicine during the four most recently completed years—but does not include interest paid during that period. Communities are required to pay a percentage of the tuition reimbursement, ranging from 25 percent to 75 percent of the reimbursement amount.

Texas

Tex. Education Code Ann. §61.901

Specifies that the Texas Higher Education Coordinating Board may repay loans for dentists who qualify. To be eligible, recipients must have worked one year in an underserved area. The statute permits the board to assemble an advisory board to assist in implementing the program. The statute also directs the governing board of each dental school to set aside 2 percent of tuition charges, which will be transferred to the state treasury to repay dentist student loans.

Virginia

Va. Code §32.1-122.9:1

With funds appropriated, the Board of Health is directed to establish a dentist loan repayment program for graduates of accredited dental schools, with preference given to graduates from within Virginia Commonwealth’s School of Dentistry. Recipients must agree to practice in an underserved area or dental health professional shortage area and participate in, and not limit the number of clients in the medical assistance services program.

Washington

Wash. Rev. Code Ann. §28B.115.060

Authorizes the board to establish loan repayments for dentists, nurses and physicians, and specifies that the amount may not exceed $15,000 per year for a maximum of five years. Recipients must practice at least three years in a shortage area.

Wisconsin

Wis. Stat. Ann. §560.183

Authorizes the department to repay up to $50,000 in student loans for physicians and dentists who attended a public or private institution. Individuals participating in the National Health Service Corps are not eligible for the program. The dentist must enter into an agreement to practice at least 32 hours per week for a minimum of three years in a dental health shortage area in the state. The dentist also must agree to accept patients whose benefits are payable under Medicare, medical assistance or any other government program. The department may pay up to $20,000, or 40 percent of the loan principal, in the first year; another $20,000 or 40 percent in the second year; and $10,000 or 10 percent in the third year. The department’s obligation to make funds available depends upon the appropriations.

Wyoming

Wyo. Stat. §9-1-118 (1977)

Authorizes the department to enter into agreement with physicians and dentists who have graduated from accredited residency programs in the state. To be eligible, recipients must agree to work in an underserved area of the state and accept clients who are enrolled in public programs, such as Medicare and the child health insurance program. Recipients are eligible to receive up to 100 percent of loan repayment, but no more than $30,000 each year, in exchange for practicing in an underserved area for three years. ·The statute specifies that no state money will be used unless 25 percent of the money is matched from other sources—e.g., county, city, school district, health care facility or health care association.

Notes

1. National Governors Association, State Efforts to Improve Children’s Oral Health, (Washington, D.C.: NGA, 2002).
2. U.S. Department of Health and Human Services, Office of the Surgeon General, "Oral Health 2000: Facts and Figures," May 2000, http://www.cdc.gov/OralHealth/factsheets/sgr2000-fs1.htm.
3. Shelly Gehshan, Paetra Hauck and Julie Scales, Increasing Dentists’ Participation in Medicaid and SCHIP, (Washington D.C.: National Conference of State Legislatures, 2001).
4. National Center for Health Statistics, Third National Health and Nutrition Examination Survey (NHANES III) reference manuals and reports [CDROM]. (Hyattsville, Md: NCHS, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, 1996.)
5. U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General (Rockville, Md: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000).
6. American Dental Education Association, "Dental Education At-a-Glance," 2004, http://www.adea.org/DEPR/2004_Dental_Ed_At_A_Glance.pdf.
7. U.S. Health Resources and Services Administration, National Health Service Corps, "Help-Wanted: NHSC Tips and Tools for Successful Recruitment," 2003, http://nhsc.bhpr.hrsa.gov/site_toolkit/program_factsheet.asp
8. U.S. Health Resources and Services Administration, National Health Service Corps, National Health Service Corps, "The NHSC Mission," 2003, http://nhsc.bhpr.hrsa.gov/about/mission.asp.
9. Colorado Office of the State Auditor, Evaluation of the Dental Loan Repayment Program (memorandum to members of the Legislative Audit Committee)(Denver, Colo.: Office of the State Auditor, Denver, April 30, 2004).
10. Ibid, 6.
11. Elizabeth Mertz, Center for California Health Workforce Studies, e-mail conversation with author, July 2004.
12. Ibid.
13. Elizabeth Mertz, Gena Anderson, Kevin Grumbach and Edward O’Neil, Evaluation of Strategies to Recruit Oral Health Providers to Underserved Areas in California (San Francisco: Center for California Health Workforce Studies, July 2004).
14. Colorado Office of the State Auditor, Evaluation of the Dental Loan Repayment Program.
15. U.S. Health Resources and Services Administration, National Health Service Corps, "Frequently Asked Questions," 2004, ftp://ftp.hrsa.gov/nhsc/faq/FAQ-LRP-05-ver01.pdf.
16. Thomas Konrad and Carol Irvin et al., Evaluation of the Effectiveness of the National Health Service Corps: Final Report to HRSA (Chapel Hill, NC: Cecil G. Sheps Center for Health Services Research and Mathematica Policy Research, May 31, 2000). HRSA Contract No. 240-95-0038.
17. Ibid, xii.

This report was prepared by the NCSL Forum for State Health Policy Leadership with assistance from Kristine Goodwin, an independent consultant.  This report was made possible by a grant from the Office of Rural Health Policy in the U.S. Health Resources Services Administration, U.S. Department of Health and Human Services, HRSA03-091.  The author wishes to thank the Office of Rural Health Policy for supporting this project.  In addition, the author is grateful to Elizabeth Mertz at the California Center for Health Workforce Studies, Diane Brunson at the Colorado Department of Public Health and Environment, and Shelly Gehshan at the National Academy for State Health Policy for reviewing the document and providing feedback and direction.  Finally, the author wishes to thank NCSL staff Tara Lubin and Faith Chang for assisting with research, survey analysis and formatting, as well as Donna Folkemer, Group Director at NCSL, and Leann Stelzer, NCSL editor, for their careful review and guidance.

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