40-plus Years of Primary Care: Public Health Implications from an Alumni Perspective
Established in 1970, the NHSC has grown to 10,400 clinicians providing primary care to an estimated 11 million people at more than 5,000 sites in underserved communities. Over the last 40-plus years, more than 50,000 providers have participated in the program and been on the front lines for key public health events and significant changes to the health care system that affected and may continue to affect the way they practice medicine. Events such as the breakout of HIV/AIDS, Hurricane Katrina, and key changes to the NHSC program not only impacted the communities that were served, but the providers serving in those communities.
The establishment of the NHSC had a tremendous effect on public health and access to care in underserved areas. For those first clinicians who participated 40 years ago, the creation of the NHSC has a much more personal impact. Donald Weaver, MD, is one of our Corps’ most passionate pioneers. He completed his NHSC service in Tooele, Utah in 1975. “At that time, NHSC clinicians were considered volunteers who worked as federal employees as a civilian or an officer in the U.S. Public Health Service Commissioned Corps,” explains Dr. Weaver. “It was an exciting time for me and my colleagues, because it was a time clinicians were willing to serve in areas where others would not go. There were certainly many challenges, but it was an amazing time and we were well-received by our community.”
In the 1980s, the discovery of HIV/AIDS completely changed the conversation about safe sex and contraception. There was fear of this new, deadly disease among the public and a lack of understanding among the medical community. As a new provider in Tuba City, AZ, Ellen King recalls that there was not much talk among the medical community about the disease and very little was known about testing and treatment methods. It wasn’t until after she completed her service in Arizona then moved to Washington, DC to work at St. Elizabeth’s Hospital that she began to see more HIV cases among her mental health patients. “Staff were frightened to treat patients with HIV and by law, they could not divulge a patient’s HIV status to another patient, regardless of what activities they were engaged in. The disease was truly considered a taboo.” Today, we have more knowledge about the disease and medications to more effectively treat people so they can live longer but there is still much to be done in the area of prevention. “HIV is a very complicated disease and we have to do better with our prevention strategy in underserved communities.”
In the early 1990s, the attitude about mental and behavioral health was changing among the medical community, and these disciplines became part of the primary care conversation – and the NHSC program. Hope Phelon, LCSW was one of the first mental health professionals to become an NHSC member. She began her service commitment with the NHSC at Lincoln County Mental Health Services in Kemmerer, WY, a town with less than 3,000 people and an hour away from the nearest fast food restaurant or Walmart. She and her supervisor were the only mental health clinicians in the county, and there were a host of issues among her patients due to harsh weather conditions and living in such a rural, isolated and desolate area. Her experiences highlighted the importance of adding mental and behavioral health to the NHSC. “It was very necessary, especially in a health professional shortage area. We have to treat the whole person, and we can’t do that without the mental and behavioral health component,” says Hope.
In August of 2005, New Orleans was hit by a hurricane that forever changed the city. Dr. Corey Hebert was in service at the time of the hurricane and said “It was one of the worst situations I’ve ever been in. There was no power, no police force and the entire city was totally flooded.” Many hospitals and clinics were impacted, but Dr. Hebert’s practice was untouched. While this was good news for the community, it meant he and his partner were the only pediatricians in New Orleans for several months. As people made their way back to the city, Dr. Hebert worked 16-hour days seven days a week, but his biggest challenge was trying to provide care to people who were already poor and did not have access to the basic necessities of life in the aftermath of the hurricane. Hurricane Katrina brought the disparities between the rich and the poor front and center for the entire nation. According to Dr. Hebert, the same is true among the medical community. “As a whole, health care providers across the country will now be more cognizant of underserved populations across the U.S. and hopefully more aware of the impact of NHSC.”
Hurricane Katrina showed the tremendous need for increased access to care among the underserved, and the Affordable Care Act of 2010 did something to address it. Dr. Adrian Billings began his service as a NHSC scholar in August of 2007 in Alpine, TX. Working in such a rural environment made simple things like getting epidurals for his pregnant patients a struggle. However, as a direct result of the enactment of the Affordable Care Act, which provided the NHSC with $1.5 billion of support over 5 years, Dr. Billings’ practice now functions as a federally qualified health center (FQHC) under an $11 million expansion. He also operates under a higher health professional shortage area (HPSA) score and receives a higher percentage in Medicare/Medicaid reimbursement compared to when he started his practice in 2007. Without the Affordable Care Act, Dr. Billings’ feels that his practice would not have been sustainable. For Dr. Billings, a sustainable practice means nothing without knowing he has helped his patients. “What matters most to me as a provider – and as a person – is that I can give my patients a better quality of life. I am here to serve them.”
Though many events and programmatic changes have taken place over the last 40 years that has impacted the delivery of primary care, the passion and dedication of the NHSC providers remains the same. The NHSC has made great advances over the years but also faced many challenges. Yet 40 years later, there still remains a compassion for the underserved and a desire to keep providing quality care to communities in need. As Dr. Donald Weaver puts it, “Our work is not done until everyone in this country has primary and preventative health care.”