APHON Supports Title VIII Reauthorization

November 15th, 2018

The Honorable Lamar Alexander
Health, Education, Labor and Pensions
United States Senate
455 Dirksen Senate Office Building
Washington, DC 20510

The Honorable Patty Murray
Ranking Member
Health, Education, Labor and Pensions
United States Senate
154 Russell Senate Office Building
Washington, DC 20510

Dear Chairman Alexander and Ranking Member Murray,

On behalf of the 55 undersigned Nursing Community Coalition member organizations, we write with urgency to express our continued commitment to work with you and the Senate HELP Committee to pass Title VIII Nursing Workforce Reauthorization this Congress. Passing Title VIII Reauthorization is the cornerstone of the coalition’s advocacy work and remains our number one priority in the 115th Congress.

It is our understanding that there is a new request to add a provision that includes all hospitals, regardless of tax status, in the Title VIII Loan Repayment program. While we appreciate the desire to provide as many opportunities as possible to expand the nursing workforce in underserved areas, we are concerned that the impact of the proposed expansion on current grantees and applicants has not been adequately assessed. Our coalition – representing a profession that includes nearly four million Registered Nurses and Advanced Practice Registered Nurses – respectfully requests such a provision be time-limited and a study be required to validate its benefit to a program that is already oversubscribed.

In conversations with officials at the Health Resources and Services Administration (HRSA), we know that, on average, the agency receives between 8,000 to 10,000 applications for the Loan Repayment Program per year. Of those applications, approximately 2,000 are completed and can be considered for funding. Of those completed, HRSA has the resources to fund around 700-800 awards in total (approximately 500 new awards and 200 continuing awards) each year. That breaks down to funding approximately 25% of the completed applications they receive. Because of the demand for the loan and the interest to fund those with the greatest need, HRSA bases its funding decisions on debt-to-salary ratio. HRSA has historically supported those with the highest debt who work in facilities where salaries are low and in communities that need care the most.

Another priority consideration HRSA uses when awarding these grants is the Health Professional Shortage Area (HPSA) score of the facility. HRSA funds are used only to award those that are working in a HPSA where the designation is 14 or higher, an indication of highest need. HPSAs have a scale of 0-25 for primary care. The designation considers geography, population, and facilities. In our analysis of the for-profit hospitals, only approximately one-quarter would meet this criterion.

This program was created to assist those nurses who are willing to work in the areas with critical staffing needs and depressed salaries. Currently, this program supports 1,204 students from over 770 nonprofit, public, and government owned facilities across 48 states and DC.1 It is important that the intent of the loan repayment program remains centered on nurses with greatest need to help the communities they serve.

Our request is based on questions we have from when a similar for-profit provision was included, for a five-year period, in the 2002 reauthorization of the Title VIII programs. The analysis by the Government Accountability Office (GAO) report noted that, “most Nursing Education Loan Repayment Program (NELRP) awardees were working in not-for-profit facilities and in facilities located in the South and West.”2 The GAO report also illustrated a decline in awards going to for-profit facilities in 2005, with the majority of the funding (60%) awarded to non-profit facilities.3

The GAO did not suggest a reason for the decline or whether these facilities and their nurses continued to qualify based on HRSA’s requirements. Adding to our questions regarding the need for this provision, there has been no attempt to ensure its reinstatement despite the fact that the Title VIII programs were reauthorized in 2010, reauthorization bills were introduced in the 114th and 115th Congresses, and the Senate held hearings and roundtables on the programs. To this end, and to ensure we are addressing a rapidly changing healthcare environment, our coalition wants to be diligent that the demand and need is there by adding a time limit to this provision with a study. In future years, we hope to work as genuine partners with for-profit facilities to ensure all Title VIII programs are authorized and adequately funded.

We remain steadfast in the need to pass Title VIII Reauthorization in this session of Congress. Without a current authorization Title VIII Nursing Workforce Development programs are in jeopardy in future Congresses, as is the sustainability for these vital programs. If the Nursing Community Coalition can be of any assistance to you or your staff, please do not hesitate to contact the coalition’s Executive Director, Rachel Stevenson, at rstevenson@aacnnursing.org or 202-463-6930, ext. 271.


Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Association of Colleges of Nursing
American Association of Critical-Care Nurses
American Association of Heart Failure Nurses
American Association of Neuroscience Nurses
American Association of Nurse Anesthetists
American Association of Nurse Practitioners
American Association of Post-Acute Care Nursing
American College of Nurse-Midwives
American Nephrology Nurses Association
American Nurses Association
American Organization of Nurse Executives
American Pediatric Surgical Nurses Association
American Public Health Association, Public Health Nursing Section
American Psychiatric Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association for Radiologic and Imaging Nursing
Association of Community Health Nursing Educators
Association of Pediatric Hematology/Oncology Nurses
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Rehabilitation Nurses
Association of Veterans Affairs Nurse Anesthetists
Association of Women’s Health, Obstetric and Neonatal Nurses
Chi Eta Phi Sorority
Commissioned Officers Association of the U.S. Public Health Service
Dermatology Nurses’ Association
Emergency Nurses Association
Friends of the National Institute of Nursing Research
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
International Association of Forensic Nurses
International Society of Psychiatric-Mental Health Nurses
National Association of Clinical Nurse Specialists
National Association of Hispanic Nurses
National Association of Neonatal Nurse Practitioners
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women’s Health
National Association of Pediatric Nurse Practitioners
National Association of School Nurses
National Council of State Boards of Nursing
National Forum of State Nursing Workforce Centers
National League for Nursing
National Nurse-Led Care Consortium
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Oncology Nursing Society
Organization for Associate Degree Nursing
Pediatric Endocrinology Nursing Society
Preventive Cardiovascular Nurses Association
Society of Pediatric Nurses
Wound, Ostomy and Continence Nurses Society

The Honorable Michael Enzi
The Honorable Richard Burr
The Honorable Johnny Isakson
The Honorable Rand Paul
The Honorable Susan Collins
The Honorable Bill Cassidy
The Honorable Todd Young
The Honorable Orrin Hatch
The Honorable Pat Roberts
The Honorable Lisa Murkowski
The Honorable Tim Scott
The Honorable Bernie Sanders
The Honorable Robert Casey
The Honorable Michael Bennet
The Honorable Tammy Baldwin
The Honorable Christopher Murphy
The Honorable Elizabeth Warren
The Honorable Tim Kaine
The Honorable Maggie Hassan
The Honorable Tina Smith
The Honorable Doug Jones

1 Health Resources and Services Administration, Data Downloads – Scholarship and Loans: NURSE Corps Loan Repayors. https://data.hrsa.gov/data/download.
2 GAO, Nursing Workforce: HHS needs Methodology to Identify Facilities with a Critical Shortage of Nurses, GAO-07-492R (Washington, D.C.: April 30, 2007), 15-16.
3 Ibid

Promoting America’s Health Through Nursing Care www.thenursingcommunity.org · 202-463-6930 ext. 271

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