The program unjustly excludes certain physicians in California and Texas, harming patient access to care in already underserved communities

Recently, the U.S. Department of Education proposed sweeping changes to overhaul the broken Public Service Loan Forgiveness (PSLF) Program that was intended to provide loan forgiveness to individuals who commit to community service for 10 years by working in non-profit organizations. 

The California Medical Association (CMA), the California Hospital Association (CHA), the Texas Medical Association (TMA) and the Texas Hospital Association (THA) applaud these long overdue improvements. These organizations are, however, urging the Department to address a significant problem that unfairly prevents certain otherwise qualifying physicians in California and Texas from participating in the program because of conflicting state laws.

Congress enacted the Public Service Loan Forgiveness Program in 2007 to encourage careers serving the public good and to improve access to health care by making it easier for physicians to pursue careers working in nonprofit community hospital/clinic settings. Unfortunately, when the U.S. Department of Education wrote the implementing regulations, the regulations were narrowed to require physicians to be “directly employed.” Because state laws in California and Texas prohibit most hospital employment of physicians, physicians in our nation’s two largest states were unintentionally excluded from the program, in which physicians from all other 48 states participate.

“This unjust denial limits California’s and Texas’ ability to recruit and retain physicians because they cannot receive the same loan forgiveness as the other 48 other states,” said CMA President Robert E. Wailes, MD. “If not corrected, it will lead to an exodus of doctors from California and Texas, harming patient access to care in our underserved regions and exacerbating health care disparities in our minority and marginalized communities.”

“The PSLF program also was intended to help low-income, minority students pursue careers in medicine. Often these students return to serve in their communities when they become physicians. Fixing PSLF would provide more equitable access to medical school and medical care in underserved communities in Texas and California,” said Gary W. Floyd, MD, Texas Medical Association President.  “We urge the Department to ensure Texas and California physicians, who are dedicated to serving their patients and the public good, have access to this national loan forgiveness program.”

With an average $200,000 in medical school debt, physicians are discouraged from practicing in California and Texas because they cannot get their loans forgiven, as they can in other states. California and Texas are projected to have the two largest physician shortages over the next decade due to growing and aging populations, and an aging physician workforce (roughly one-third of physicians are over age 60, and half are over age 50).

“If physicians are lured away to other states where they can have their loans forgiven, Texas and California simply won’t be able to sustain a physician workforce capable of meeting the growing needs of patients in community hospitals, children’s hospitals and rural hospitals,” said Carmela Coyle, President & CEO of the California Hospital Association. “The PSLF Program was intended to bring racial equity to health care professions and to reduce health care disparities for underserved patients. Failure to fix the inadvertent exclusion of our physicians from the PSLF Program will accelerate our worsening physician shortages and harm hospitals’ ability to fully care for our most vulnerable, marginalized patients.”   

“Rural non-profit hospitals in Texas have long experienced physician shortages, and the COVID-19 pandemic has only exacerbated access to care issues,” said John Hawkins, President & CEO of the Texas Hospital Association. “Texas and California physicians must be allowed to participate in PSLF Program to ensure rural hospitals can continue to serve their communities.”

“We need more doctors in the Central Valley, it's as simple as that," said Representative Josh Harder. "We can bring more doctors to our communities by fixing the Public Service Loan Forgiveness Program and the time to act is now. If we fix the exclusion of our doctors from this program, this will mean more accessible and more affordable care for everyone who needs it."

Earlier this year, the California and Texas congressional delegations wrote to Education Secretary Miguel Cardona and told him that Congress never contemplated excluding physicians in the nation’s two largest states when they created the program. CMA, CHA, TMA and THA thank Congressman Harder, Senator Feinstein, and Senator Cornyn for their leadership.

CMA, CHA, TMA and THA are calling on Secretary Cardona to provide parity for physicians and patients in all 50 states. Our organizations have proposed a solution that provides a rigorous California and Texas equivalent to direct hospital employment, which we believe meets the intention of the original statute and the Department’s standards.

(Please note the proposed solution is in the link above and below.)