Why the VT Legislature Needs to Invest
in Loan Repayment Now!
On behalf of the 2,600 members of the Vermont Medical Society, American Academy of Pediatrics Vermont Chapter, Vermont Academy of Family Physicians, and the Vermont Psychiatric Association, we urge the legislature to devote $793,000 to restore the existing AHEC primary care loan repayment program to 2009 funding levels.
As your committee considers the FY23 Budget please consider not only creating new loan repayment/forgiveness programs, but also restoring the funding for AHEC’s existing educational loan repayment (ELR) program for primary care. This vital program can help build back Vermont's primary care workforce, including primary care physicians, psychiatrists, dentists, APRNs, LPNs, RNs and PAs.Click here for the VMS Loan Repayment Memo
Please read our members comments on loan repayment benefits:
In the late 1990’s I was a beneficiary of the AHEC Loan Repayment Program. I had accumulated about $100,000 in education debt by the time I was ready to move back to Vermont and start practicing. Today the average medical student graduates with over $240,000 dollars of debt. Despite being in rural primary care which is woefully undercompensated compared to urban areas and other specialties, I was able to pay my educational loans back in about 5 years. This helped my husband and I obtain a home and start a family while I provided primary care in the underserved Lamoille region. I have been providing medical services through Lamoille Health Partners (and its previous iterations) for 22 years and have no plans to leave. Our family is firmly embedded in the community.
As the Chief Medical Officer of the Lamoille region’s federally qualified health center, I am responsible for recruiting more physicians, nurse practitioners, physician assistants, and dentists to the area to carry our mission forward. We have two senior physicians retiring this year, another two leaving Vermont this summer, and a remaining physician workforce that is in their 40’s and 50’s. Recruitment is our biggest existential challenge. Failure to recruit threatens our very existence.
Candidates always ask me about loan repayment. I cannot guarantee AHEC funds will be available. We provide matching funds but cannot reassure candidates that their applications will be accepted. Already this prospect of coming here and not being funding discourages my applicants. The more you reduce funding and whittle away the number of applicants who will be supported, the harder it is for me to attract and retain candidates. My practice lost a dentist due to lack of loan repayment. Burlington’s Community Health Center lost a family physician who was providing obstetrical care to the Somali refugee population due to lack of loan repayment. Even if a candidate accepts a position without certain loan repayment (doubtful), once they do not attain it they will not stay. There are precious few primary care graduates coming out of medical training and they have many other options for their employment. We will never prevail in bringing them here without a robust loan repayment program.
I am now in my mid 50’s and I wonder who is coming to take my place? Who will care for my patients when I no longer can? Who will take of me?
Please do not underestimate the critical value of AHEC’s program to continue our rural healthcare system and sustain Vermont’s communities. We cannot do it without you.
Melissa Volansky, MD
Physician, Chief Medical Officer
office: (802) 253-9174
I have provided information to the legislature in the past about loan repayment for physicians and other primary care clinicians, and testified at a Senate hearing 2 plus years ago about this, but want to be sure current legislators understand just how important it is to fund this program.
Not only did I stay in Vermont instead of moving 2p plus years ago, as a direct consequence of obtaining loan repayment, but I also saw the direct effect it had on our ability to attract and retain my new younger partner about 6 years ago.
Primary care providers who are well trained are CRUCIAL to the functioning of our health care system, and recruiting and retaining them should be one of the TOP priorities of this and every budget going forward, if we want to have the best access and outcomes for Vermonters. As a member of the Primary Cared Advisory Group to the GMCB, I can tell you that this has been one of our top priorities as we discuss ways to ensure access to healthcare. It is so important that this is funded consistently, s that we can tell new recruits, as well as established providers that in addition to enjoying quality of life in Vermont, they can also afford to live and practice here.
Valerie A Rooney MD FAAP
Brattleboro Memorial Hospital
I am a family medicine physician practicing in central VT. When I graduated from medical
school, I had approximately $400,000 in educational debt. This is higher than average as I
attended a post-baccalaureate pre-medical program and had significant undergraduate debt.
However, I attended a “state” medical school and did receive some state funding to supplant my
education costs and decrease my debt burden. I graduated from a residency program with a
significant focus on full-spectrum family medicine and rural practice in 2019. Each of the 10
graduates in my residency class cited loan repayment as of significant importance in choosing
employment after residency. In comparing several options for loan repayment, having done
research projects on rural primary care education and retention, and benefiting from the VT
AHEC LRP, I have several thoughts on the essential priority of loan repayment in Vermont.
As noted above, the median medical graduate educational debt is $200,000 based on 2019
data included in the "AAMC Physician Education Debt and the Cost to Attend Medical School
Report 2020". Of those reporting, 73% of medical graduates have educational debt.
While it is true that "comparing a variety of potential repayment scenarios across various specialties,
including primary care, leads to the conclusion that any physician can repay any amount
borrowed regardless of specialty or where they live", repayment can take 20-25 years in many
scenarios. A few other important pieces of data are that the average medical residency salary is
about $60,000 for 3-7 years depending on residency. For residency, income-based repayment
plans often result in payments less than the accruing monthly interest and lead to negative
amortization. Many leave residency with more debt than when they started. Based on 2021
data, the average salary for an employed (hospital group or academic setting) family practice
physician with 1-7 years experience is $174,000. However, in the Northeast, that average is
$154,000 ($179k for men; $140k for women). Vermont is in the bottom third of physician
payment across states.
While PSLF was an admirable goal, prior to 2021 <0.3% of loans for eligible borrowers were
forgiven. It is too soon to see what happens with the recent overhaul but PSLF is primarily
designed for those with lower incomes - and generally lower average loans - than medical
graduates. The program is exceedingly complex and, as we have seen, at the whim of federal
bureaucracy. Sadly, we have very minimal financial education in medical school or residency so
most of my physician friends have missed their window to participate in PSLF or get maximum
PSLF through one error or another. Perhaps the most pertinent fact is that PSLF requires trust
in the system that the program has not, in my opinion, earned. Personally, I do not feel
comfortable paying minimally on my loans, accruing interest for 10 years, and hoping that a) the
program will still be in existence when I complete my service and b) I will have avoided any
errors that void my acceptance. This alone is a huge emotional burden to weather over 10 years
while sitting on debt twice my annual salary. If I had pursued PSLF only to be denied at 10
years, I would have paid approximately ~$250,000 and still had over $400,000 in debt. I hope
you can see how terrifying that prospect can feel.
I am grateful to have received one year of VT AHEC LRP and am fortunate that I do not yet
have a family to support and have been able to live frugally for many years. This funding was
incredible and allowed me to focus on paying many of my highest interest private loans. With
the sharp rise in cost of living in VT, my husband and I have been able to buy a house with a
mortgage payment much lower than what we were paying in rent. However, this was solely
possible because my husband had personal savings from prior to our marriage. I have minimal
retirement and personal savings as my focus has been to pay my debt. Please keep in mind
that not only are medical graduates paying debt but we also have a minimum of a 7-year delay
in significant retirement savings. Unfortunately, I have not been able to access more state loan
repayment - at a time when it would be most valuable with 0% interest on federal loans - as I
needed to leave my employer in 2021 and could not commit to a year or service and there was
not enough funding in 2022. If I had received money this year, my $4000/month payments plus
the AHEC funding would change the total time to pay-off my federal loans (I still have
outstanding private educational loans) from 27 months with $6500 interest to 19 months with
$3000 interest. This is a huge difference as we consider settling in our new community, funding
our retirement plans, and potentially starting a family.
While there is a high density of primary care in Central VT, I am in an 8-provider practice with 6
current providers, two of whom are trying to retire. We are constantly juggling poor access and
caring for several thousand “extra” patients within the practice. Some providers’ panels have
ballooned to around 2000 patients which is untenable. I typically work four 11-hour days with
one day of off-site administrative work and am on-call 24/7 for a week about every 6 weeks
which is frankly not sustainable. We have had several potential recruits express concern about
lower than average salaries and loan burdens and have been unable to attract new providers.
My colleagues are fantastic but it is devastating to know that every day we are providing care
differently than we would if we had full staff. The absence of loan repayment will not deter me
from this work but its presence would go a long way in making me feel valued for the time and
money I have put into my work and community.
In exploring loan repayment options, I have come across some features of loan repayment,
aside from adequate funding, that make certain programs more appealing than others.
1. Rolling applications: This may seem minor but it is extremely important. Most residents
have signed contracts by early spring and graduate at the end of June. Applications for
VT AHEC LRP are submitted in September and funded in February/March of the
following year. This means that most new graduates have to wait 8-9 months before
entering a loan repayment cycle. At 6% interest on $200,000, you can see what an
impact that makes. A rolling application cycle or cycle better aligned with medical
graduates’ transitions significantly mitigates this concern and makes positions more
attractive as applicants do not have to wait a year to know if they received funding.
2. Employer match not required: Although I would hope that most employers would be
willing and able to support primary care by offering a match, this is not a reality and the
flexibility to choose a position based on fit may afford better retention and avoid some of
the short tenures that are inherent when recruits seek loan repayment.
3. Flexible commitment: Allowing for review of practice transitions within Vermont under the
LRP. Personally, I was in a practice situation that was seriously impacting my work
satisfaction, mental health, and general burn-out. I anticipated a move within Vermont
but was unable to accept loan repayment funds in 2021 due to the 1-year commitment.
My options were to accept the money and commit to a very difficult situation or to turn
away from $20,000. This was an extremely difficult position and, while I am much
happier in my new position, I worry greatly about the financial impact this had especially
in light of the pandemic and not receiving funding in 2022. The pressure to remain in
negative situations is an undue burden on providers who are already balancing
numerous stressors. While I recognize it is not possible for employer match funds to
follow a provider, the option of a panel review and independent transition plan if a
provider plans to leave a position but remain in VT would be yet another way to
recognize the challenges we face. Similarly, allowing a little more individual flexibility in
terms of leave (ie parental leave) would be appreciated. I agonized over the possibility
that a pregnancy and delivery may have complications requiring more leave than allotted
in the terms of repayment.
4. Employer match tax exempt: This, again, is the difference between thousands of dollars
in student loan reduction and I applaud you for allowing the employer match to be
funneled in such a way to provide this protection.
5. Transparency: I strongly urge you to develop more transparency in the process of
awarding funds. There are numerous definitions of “underserved” and the lack of clear
metric for awards means potential awardees are less likely to feel confident about the
process. This, in turn, harms recruitment as well as feelings of inequities amongst
participants. In another vein, priority should be given to those who teach upcoming
generations of physicians and are promoting a long-term recruitment model for the state
as data repeatedly indicates that medical education models that support primary care
drive the return of medical graduates to rural regions. Medical graduate surveys
consistently show around a third of graduates practicing in the state in which they went
to medical school. The value of teaching cannot be understated.
4. Address wage gap: While I recognize this is outside the scope of loan repayment per se,
starting salary must be considered part of the equation for recruitment and retention.
Men earn 27% more than women in primary care yet 50-60% of primary care physicians
are women (pediatrics, family medicine, OB/gyn, internal medicine). Although I do not
have the data, I suspect accounting for APPs exacerbates the gap. This is to say that
addressing the wage gap and loan repayment needs to go hand-in-hand to support state
recruitment and retention.
I appreciate being given the opportunity to express my thoughts on loan repayment programs. I
am passionate about rural healthcare and family medicine, in particular, and am very excited to
be involved in progressing both. Please do not hesitate to contact me with questions.
Rachel La Rocca, MD ABFM
Kane, Leslie. “Medscape Physician Compensation Report 2021.” April 2021. Accessed 29
March 2022. https://www.medscape.com/slideshow/2021-compensation-overview-6013761#1.
Youngclaus, James and Fresne, Julie. “Physician Education Debt and the Cost to Attend
Medical School.” AAMC, October 2020. Accessed 29 March 2022.
The Power of Primary Care - Fay Homan, M.D., Little Rivers Health Care
Little Rivers Healthcare in northeastern Vermont serves a cluster of remote towns that exemplify the Vermont adage that “you can’t get there from here.” These are small, economically stressed towns that have been hit hard by the opiate crisis. People from more populated areas might be surprised at the scope of healthcare that is provided at Little Rivers: complete health care from birth to geriatrics, including complex chronic medical problems and mental health. You can get all your prenatal care here and have your delivery with your family doctor. Skin biopsies, ultrasounds, joint injections, and substance abuse treatment are all part of our usual office days. My husband even had his chainsaw injury stitched up here last summer. Click to read more
This commentary is by Judy K. Orton, M.D., whose practice is at Green Mountain Pediatrics in Bennington.
"I was planning on working into my late 60s but will likely call it quits in five years, as will the practice I have built. I sincerely hope that the state will make a financial commitment to sustain primary care, so that Vermont patients and their families will have independent practices available to help them live their healthiest lives."
I have been a solo, independent pediatrician for 32 years at Green Mountain Pediatrics, located in Bennington. I have always strived to use best practices with some healthy common sense in the care of my kids.
I love being a part of these children’s growth and maturity, helping their families navigate parenthood. I am into a second generation, taking care of my “kids’” kids. There is a certain satisfaction and pride when they attend school, college, take a job, celebrating the next generation when they call and say they are pregnant and ask if I would be the pediatrician for the new baby. Click here to read the full VTDigger Commentary.
VMS 2022 Primary Care Platform: Let's Make Primary Care A Vermont Priority, A Vermont Value
Ashley Miller, pediatrician and owner of South Royalton Health Center - The Doctor is in for Kids in the Middle of the Night
I am originally from southern NH, moved to VT in 2004 and never looked back. I left a large multispecialty practice affiliated with an academic medical center in 2014, where I often had never seen the patient or family I was providing care for while on call, or in the office, to be able to provide more connected care to a smaller group of patients at South Royalton Health Center. Now, as a small business owner I am thrilled with my choice. At SRHC we work very hard to embody the patient-centered medical home, we feel strongly that it improves the health of our children and their communities, which is why I am highlighting why Vermont needs to invest in primary care now. Click to read more.
Katie Marvin, M.D., FAAP, Stowe Family Practice, "A day in family medicine, 8am-5pm:"
(just to be clear, these are not actual patients, just a common representation of a typical day, clearly with respect to HIPAA and patient privacy):
1). A 4-day old baby boy, to check on his weight, color (jaundice) and how the family is doing. We’ll see him and mom back in a few weeks.
2). A 12-year old with a broken foot. We take some x-rays and get her in a walking boot. One week follow up. Click here for the full story