Title VII Programs: Critical to the UAMS Mission, in Jeopardy

Dr. Billy Thomas
Billy Thomas, MD, MPH
Vice Chancellor for Diversity and Inclusion
Professor, College of Medicine

By Billy Thomas, MD, MPH
Vice Chancellor for Diversity and Inclusion
Professor, College of Medicine

Given the current political climate, the ongoing congressional struggles with the federal debt and the mandate to cut several trillion dollars from the annual federal budget, it is appropriate to take a look at Title VII programs, which have been historically targeted in most attempts to bring about a budget reduction.

Title VII programs, an extremely small percentage of the federal budget, are critical to Arkansas’ ability to provide primary care for its growing and increasingly diverse population, especially in medically underserved areas, which take in much of the state’s geographic area.

The University of Arkansas for Medical Sciences is dependent on Title VII funding to accomplish one of its strategic goals, the education and training of a diverse and culturally competent health care workforce. Title VII-funded programs at UAMS include an array of outreach programs administered through the Center for Diversity Affairs targeting under-represented minority and disadvantaged students, kindergarten through college, as well as training programs for medical students, residents and staff of the UAMS system. This funding includes a current grant for three year totaling $1.2 million.

One such program, “Innovative Methods to Train Residents in Cultural Competence and in Serving the Underserved,” is housed in the Department of Preventive and Family Medicine and is supported by a three-year grant totaling $500,000. Another Title VII grant enables the department to recruit medical students to family medicine.

Another beneficiary of Title VII funds for many years has been the UAMS Area Health Education Centers (AHEC) program. Most recently, the AHEC program received a one-year, $600,774 grant extension to support a variety of activities critical to its mission of delivering quality health care to rural areas, such as continuing education and health literacy training for staff and faculty and the provision of field learning opportunities for students and residents.

Critical Role of Title VII Programs in the U.S. Health System

A historical summary of the role of Title VII programs in the restructuring of the U.S. health care system provides some context for appreciating their importance to academic health centers and why they must be preserved.

Title VII programs were developed and implemented in three phases, each in response to an identified need within the health care system and in an attempt to provide a much needed and illusive public service: equitable, quality health care.

The driving force behind the Title VII programs has been a chronic national shortage of health care professionals during a time when population growth has consistently outpaced the ability of the health care system to identify, recruit and train enough health care providers. The shortage has been compounded by over-specialization and a very uneven geographical distribution of health care workers concentrated in urban communities. As a result, the population with the most need – those in rural, medically underserved areas – has no to minimal access to primary care.

In response to the Flexner Report of 1910 (1), the number of medical schools in the United States and Canada was reduced from a high of 155 to 76 by 1929 (2). Simultaneously, the dental profession took a similar approach to upgrade and reduce the number of professional schools during the 1920s. What occurred was an extremely important shift from for-profit professional schools to the development of medical and dental schools that were tied to larger university systems and used laboratories and hospitals to train students in the basic sciences and direct patient care. This provided the foundation and structure of our current health professions schools.

Between 1925 and 1950 and simultaneous with the restructuring and reduction of the number of health professional schools, the U.S. population increased by 35 million, leaving too few physicians, dentists and other health care worker to meet the needs of a growing population (2). In response to this shortage, efforts were put in motion to expand the health care workforce – resulting in the advent of Title VII programs, the purpose of which is to provide federal assistance for health professions training.

Phase 1, 1963-1975

Funding focus: 50% increase in the numbers of physicians, dentist and other health care workers by 1975

The primary goal was to increase the number of family physicians and students from diverse socioeconomic backgrounds. This period was highlighted by the construction of new training facilities for medicine, dentistry, osteopathy, public health, optometry, nursing, and pharmacy (2). In addition federal funds were used for school loans to students from disadvantaged backgrounds. Forty new medical schools opened between 1960 and 1980, raising the total to 126 – up from 76 in 1929 (2).

Phase 2, 1976-1991

Funding focus: Primary care and dental care for underserved populations

Primary care was defined as internal medicine, pediatrics, family medicine, and obstetrics-gynecology. The lack of primary care physicians and dentists in medically underserved areas intensified the focus on the critical need for programs that recruited significant numbers of minorities and disadvantaged students (and faculty) into the health professions, including physician assistants and dental auxiliaries (2). As a result, numbers of residency spots, fellowships, and faculty positions increased.

Phase 3, 1992-present

Funding focus: Activities that improve health care access and delivery by increasing the training of providers of primary care services, particularly to the medically underserved (2):

This phase marked the beginning of federal support for diversity pipeline programs – Health Career Opportunity Programs (HCOP) and the Center of Excellence (COE) program. A primary aim of these programs is to increase the number of health care providers in Health Profession Shortage Areas (HPSA) and Medically Underserved Communities (MUC). Very convincing outcome data from these programs indicate that individuals that graduate from Title VII funded programs are three to 10 times more likely to practice in MUCs (2).

As an incentive, these programs began to offer scholarships for the financially disadvantaged and those who agreed to go into primary care or general dentistry resulting in a slight increase in the number of health care providers moving into medical underserved areas. In addition and just as important was the establishment of family medicine departments at all medical schools. In 1998 family medicine departments, the scholarship program and rural health loans were consolidated into the Training in Primary Care Medicine and Dentistry grant program. As a result, the number of training programs increased for family medicine residents, physician assistants, general internal medicine, pediatrics, and general dentistry (2).

In sum, Title VII funding has made possible the preservation – and growth – of vitally important educational programs for pediatrics, dentistry, PAs, family medicine, and internal medicine. Title VII programs have been at the heart of ALL three phases of health care restructuring and expansion and to this day are at the core of national efforts to provide equitable, quality care.

National Health Care Reform: Uncertainties and New Pressures on Primary Care

In nature and in life most activities are cyclical. In 2012, we face the same dilemma as in 1929: a critical shortage of physicians to serve a rapidly growing and increasingly diverse population in a time of economic crisis. If health care reform goes forward, by 2014, an already over-taxed pool of primary care providers will be expected to care for an even larger number of underserved and underinsured patients.

The shortage of health care workers especially in primary care in the past 50 years has exacerbated health disparities and poor population health. Historically, women and underrepresented minorities have gone into primary care and have served the underserved at a much higher rate than their male or white counterparts.

The patient-centered family home model, a centerpiece of health care reform, is designed to alleviate the burden on primary care physicians via a team approach that brings together multiple providers (physician, dentist, PA, pharmacist, social worker, nutritionist) in the delivery of care. The likelihood that this model will improve access and quality of care in medically underserved areas is untested and unknown, but optimistically viewed as part of a possible solution to the current health care crisis.

Given the political climate in Washington, we may be in the last phase of the Title VII programs. The proven effectiveness of these programs to produce a health care workforce ready to serve a diverse patient population is a good argument for their continuation.

Title VII programs have wrongly been termed “entitlement programs.” However, given their very real, measurable and permanent effects on the health care system they should be regarded as “an essential component of America’s health care safety net.” (3)

Academic health centers have a moral, social and professional obligation to provide a health care system that is accessible, equitable and of high quality to the entire population. To do so, we must not only understand who we serve, but also how to best serve. Our mission is to ensure health equity and improve the health of the population through service – “for the public good.”

1. Flexner A. Medical Education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4 Boston, Mass: D.B. Updyke, The Merrymount Press; 1910.

2. Reynolds P. Preston. A Legislative History of Federal Assistance for Health Professions Training in Primary Care Medicine and Dentistry in the United States, 1963-2008. Acad. Med. 2008; 83 1004-1014.

3. 2011 State Physician Workforce Data Book. Center for Workforce Studies. Association of American Medical Colleges.

4. Reynolds P. Preston. Title VII Innovations in American Medical and Dental Education: Responding to 21st Century Priorities for the Health of the American Public. Acad. Med. 2008; 83:1015-1020.