United States Government Accountability Office Report to Congressional Committees NURSE CORPS September 2021 LOAN REPAYMENT PROGRAM Too Early to Determine Effects of Allowing Recipients to Serve at For-Profit Facilities GAO-21-104379 September 2021 NURSE CORPS LOAN REPAYMENT PROGRAM Too Early to Determine Effects of Allowing Recipients to Serve at For-Profit Facilities Highlights of GAO-21-104379, a report to congressional committees Why GAO Did This Study What GAO Found The supply and retention of registered The Health Resources and Services Administration (HRSA), within the nurses is uneven across the country, Department of Health and Human Services, manages the Nurse Corps Loan with shortages in rural and other Repayment Program (LRP). The program provides educational loan repayments underserved areas. These shortages for registered nurses and other nursing professionals in exchange for their are exacerbated by other challenges, service in a critical shortage facility (CSF)—a facility that is located in or such as lower numbers of nursing designated as a health professional shortage area. From October 2007 to March students who want to work in rural or 2020, recipients of the Nurse Corps LRP could not fulfill their required program other underserved areas. service by working at for-profit CSFs. The CARES Act eliminated this restriction To help address this problem, HRSA’s in March 2020, allowing recipients of the LRP to serve in either nonprofit or for- Nurse Corps LRP provides nursing profit CSFs. school loan repayments for registered nurses and other nursing professionals To manage the program, HRSA has processes in place to communicate program who work in underserved areas. From information to applicants and to verify information, such as an applicant’s fiscal year 2016 through fiscal year eligibility, loan information, and proof of employment in an eligible CSF. HRSA 2020, 4,156 Nurse Corps LRP awards also conducts annual evaluations to monitor the effects of the program and were distributed. issues an annual report to Congress. These reports describe the program’s results, such as the number of applications, number of recipients and loan Congress included a provision in the repayments, number and placement locations of the Nurse Corps LRP recipients, CARES Act for GAO to review the and recipients’ demographics. Nurse Corps LRP. This report describes (1) how HRSA manages the It is too early to determine the effects of allowing loan recipients to fulfill their program, and (2) what is known about service commitment at a for-profit CSF. Funding decisions for the first group of the effect on CSFs of eliminating the applicants that may serve in for-profit CSFs will not be completed until for-profit restriction. September 30, 2021. Selected applicants will begin their 2 years of service and GAO reviewed the CARES Act and start working in designated CSFs in late 2021. According to HRSA officials, they other related statutory provisions, as plan to examine the effects of allowing service in for-profit facilities in future well as HRSA documents, including annual program evaluations, with the first set of results expected in fiscal year application and guidance information, 2022. information verification, annual reports Officials associated with for-profit and nonprofit CSFs had opposing views about to Congress, and other program- the possible effects of the elimination of the for-profit restriction. Officials from an related documents. association representing for-profit CSFs stated that eliminating the restriction GAO also interviewed HRSA officials could provide an incentive for nurses to work in areas with the greatest need, about their management of the regardless of whether a CSF is for-profit or nonprofit. Officials from a nonprofit program, and officials from two critical access hospital and its associated nonprofit rural health clinic told GAO nonprofit CSFs and one stakeholder they were concerned that for-profit CSFs may have financial advantages over group that represented for-profit nonprofit CSFs. They stated that these financial advantages, such as a higher hospitals that are CSFs to obtain a wage rate, could make for-profit CSFs more attractive to program participants, variety of perspectives on the resulting in fewer nurses willing to work at nonprofit CSFs in rural or other elimination of the for-profit restriction. underserved areas. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate. View GAO-21-104379. For more information, contact Michelle B. Rosenberg at (202) 512- 7114 or RosenbergM@gao.gov United States Government Accountability Office Contents Letter 1 Background 3 HRSA Communicates Program Information, Verifies Applications, Targets Funds for Emerging Health Needs, and Evaluates the Effects of the Nurse Corps LRP 7 Too Soon to Determine Effects of Eliminating the For-Profit Restriction in the Nurse Corps Loan Repayment Program 10 Agency Comments 11 Appendix I: GAO Contact and Staff Acknowledgments 12 Tables Table 1: Funding Preference Tiers for the Nurse Corps Loan Repayment Program Applicants who will be Serving at CSFs 5 Table 2: Nurse Corps Loan Repayment Program Applications and Awards, Fiscal Years 2016 through 2020 6 Abbreviations APRN advanced practice registered nurse CSF critical shortage facility HPSA health professional shortage area HRSA Health Research and Services Administration LRP loan repayment program RN registered nurse This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page i GAO-21-104379 Nurse Corps Loan Repayment Program Letter 441 G St. N.W. Washington, DC 20548 September 8, 2021 The Honorable Patty Murray Chairman The Honorable Richard Burr Ranking Member Committee on Health, Education, Labor, and Pensions United States Senate The Honorable Frank Pallone, Jr. Chairman The Honorable Cathy McMorris Rodgers Republican Leader Committee on Energy and Commerce House of Representatives The supply and retention of registered nurses (RN) is uneven across the country, with shortages in rural and other underserved areas. 1 This uneven distribution of RNs is exacerbated by other challenges, such as the aging and retirement of the nursing workforce, and lower numbers of nursing students who want to work in rural or other underserved areas. 2 To help address this problem, the Nurse Corps Loan Repayment Program (LRP), which is a component of the Nurse Corps Loan Repayment and Scholarship Programs, provides loan repayments for RNs and advanced practice registered nurses (APRN) in exchange for service in a health care facility with a critical shortage of nurses, referred 1Department of Health and Human Services, Health Resources and Services Administration, Report to Congress: Nursing Workforce Fiscal Year 2020 (Rockville, Md.). 2E.H.Larson, C.H.A. Andrilla, and L.A. Garberson, Supply and Distribution of the Primary Care Workforce in Rural America: 2019, Policy Brief no.167, University of Washington (June 2020). Page 1 GAO-21-104379 Nurse Corps Loan Repayment Program to as a critical shortage facility (CSF). 3 From fiscal year 2016 through fiscal year 2020, 4,156 Nurse Corps LRP awards were distributed. The Health Resources and Services Administration (HRSA), within the Department of Health and Human Services, manages the Nurse Corps LRP. From October 2007 until enactment of the CARES Act in March 2020, recipients of the Nurse Corps LRP could not fulfill their required program service by working at for-profit CSFs. 4 The CARES Act eliminated this for-profit restriction, allowing recipients of the loan repayment program to serve in either nonprofit or for-profit CSFs. 5 The CARES Act also included a provision for us to review the Nurse Corps LRP. 6 In this report we describe 1. how HRSA manages the Nurse Corps LRP, and 2. what is known about the effects on CSFs of eliminating the for-profit restriction. To describe how HRSA manages the Nurse Corps LRP, we reviewed the CARES Act and other related statutory provisions, as well as HRSA’s Nurse Corps LRP application and guidance documents from fiscal years 2016 through 2021 that include information about the eligibility requirements for applicants, among other things. We reviewed HRSA’s website to learn how HRSA communicates information to prospective Nurse Corps LRP applicants. To learn how HRSA verifies information 342 U.S.C. § 297n. The Nurse Corps LRP also has a faculty component where repayment of nursing school loans is awarded to nursing school teachers in exchange for service at eligible educational institutions. In addition, the Nurse Corps Scholarship Program pays for the nursing school education, including tuition, required fees, and a stipend while the recipient is in nursing school in return for the recipient working at an eligible CSF upon graduation. This report focuses on the loan repayment program for nurses serving at CSFs; it does not cover the faculty component of the Nurse Corps LRP, nor the Nurse Corps Scholarship Program. Funds appropriated for the Nurse Corps LRP are used to make awards to qualified applicants, which includes RNs and APRNs, such as certified nurse midwives, clinical nurse specialists, nurse practitioners, and certified registered nurse anesthetists. 4The Nurse Reinvestment Act of 2002 amended the program to prohibit placement of nurses in private, for-profit entities after fiscal year 2007. Pub. L. 107-205, § 103(a), 116 Stat. 811, 813. 5CARES Act, Pub. L. No. 116-136, div. A, tit. III, § 3404(a), 134 Stat. 281, 394 (2020). 6Pub. L. No. 116-136, div. A, tit. III, § 3404(b), 134 Stat. at 396. Page 2 GAO-21-104379 Nurse Corps Loan Repayment Program obtained from applicants, we reviewed HRSA’s verification forms, as well as the agency’s standard operating procedures for new application loan verification and continuing loan verification. Additionally, we interviewed HRSA officials about how they verify information submitted by applicants and evaluate participants’ compliance with the requirements of the Nurse Corps LRP. To describe what is known about the effects on CSFs of eliminating the for-profit restriction, we interviewed HRSA officials. We also interviewed officials from two nonprofit CSFs and one association that represented for-profit hospitals that are CSFs about their views on how the elimination of the for-profit restriction may affect for-profit and nonprofit CSFs. 7 We conducted this performance audit from June 2020 to September 2021 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background Nurse Corps Loan The goal of the Nurse Corps LRP is to improve the distribution of nursing Repayment Program professionals by encouraging them to work in underserved communities. It is a financial incentive program in which RNs and APRNs are repaid 60 percent of their outstanding balance of qualified educational loans in exchange for a commitment to work full time for 2 years at a CSF while in the LRP. Qualifying recipients may receive an additional 25 percent of their original total outstanding balance of qualified educational loans repaid for an additional third year of work at an eligible CSF. To be eligible for the Nurse Corps LRP, applicants must • be a U.S. citizen, U.S. national, or lawful permanent resident; 7We contacted 18 CSFs, including both for-profit and nonprofit CSFs, to obtain their perspectives on the effect of the policy change, but were only able to reach officials from two nonprofit CSFs who were willing to be interviewed. We also interviewed two officials from an association representing for-profit hospitals to learn of their views on the elimination of the for-profit restriction. Page 3 GAO-21-104379 Nurse Corps Loan Repayment Program • have earned a diploma, associate, baccalaureate, graduate, or doctorate degree in nursing, and have an outstanding balance of qualified educational loans; • be employed as a full time RN or APRN working at least 32 hours per week at a CSF before the end of the application cycle; • have completed the nursing program for which the loans apply; and • have a current, full, permanent, unencumbered, unrestricted license to practice as an RN or an APRN, if applicable. HRSA has an online portal for RN and APRN applicants to complete and submit their applications for the Nurse Corps LRP, including documentation for determining eligibility. If applicants meet all of the criteria, they are deemed eligible and enter the applicant pool. Funding Allocation For fiscal year 2021, the Nurse Corps LRP and Scholarship Programs received funding of about $88.6 million, the same amount the programs received in fiscal year 2020. According to HRSA officials, about two-thirds of the total funding is usually provided to the LRP, with the remaining one- third going to the Nurse Corps Scholarship Program. 8 The Nurse Corps LRP fiscal year 2021 funding includes specific allocations for identified emerging health needs, psychiatric and other nurse practitioners, and RNs and APRNs working in certain types of CSFs. 9 Awardee Selection RNs and APRNs selected for the Nurse Corps LRP must work full time at Process an eligible CSF while receiving loan repayments from the program. An eligible CSF is a health care facility that is located in, designated as, or serving a primary medical care or mental health care health professional shortage area (HPSA). HPSAs are used to identify geographic areas, 8The American Rescue Plan Act of 2021 appropriated an additional $200 million specifically for the Nurse Corps Loan Repayment and Scholarship Programs. Pub. L. No. 117-2, § 2603, 135 Stat. 4, 44. The funds are available until expended. HRSA officials told us that they will use 50 percent of the funding in fiscal year 2021 and the remaining 50 percent in fiscal year 2022. These officials indicated they intend to divide the funding the way they divide annual appropriations for the programs: two-thirds for the Nurse Corps LRP and one-third for the Nurse Corps Scholarship Program. 9Specifically, after the allocation for emerging health needs, up to 50 percent of the remaining funds were to be allocated to nurse practitioners, with about 20 percent allocated to psychiatric nurse practitioners and about 30 percent allocated to all other nurse practitioners. The other 50 percent of the remaining funds is divided so that 15 percent is allocated to RNs and APRNs working in disproportionate share hospitals/public hospitals, a type of CSF, and about 25 percent is allocated to those working in all other types of CSFs. The remaining 10 percent is allocated to nurse faculty. Page 4 GAO-21-104379 Nurse Corps Loan Repayment Program population groups, or facilities that are experiencing a shortage of health care professionals. 10 To help determine which applicants will be awarded LRP funds, HRSA uses a scoring system for HPSAs that differentiates areas of greatest need. Specifically, HRSA calculates a score for each HPSA that ranges from 0 to 25; the higher the HPSA score, the greater the level of need for health care professionals. 11 In addition, HRSA officials said the agency tries to respond to emerging health needs identified by the agency with specific allocations and administrative set-asides from the Nurse Corps LRP funds. In awarding LRP funds, HRSA also considers applicants’ financial need. HRSA determines which applicants have the greatest financial need based on the ratios of applicants’ outstanding balance of qualified educational loan debt to their base salaries (referred to as a debt-to-base salary ratio). The applicants are then placed into funding preference tiers based on their financial need and the HPSA score of the CSF where they work. (See table 1.) Table 1: Funding Preference Tiers for the Nurse Corps Loan Repayment Program Applicants Who Will Be Serving at CSFs Applicant’s outstanding qualified educational loans HPSA score for Funding preference tier debt-to-base salary ratio applicant’s chosen CSF Tier 1 ≥ 100 percent 25 - 14 Tier 2 < 100 percent 25 - 14 Tier 3 ≥ 100 percent 13 - 0 Tier 4 < 100 percent 13 - 0 Legend: HPSA = health professional shortage area; CSF = critical shortage facility Source: Health Resources and Services Administration. I GAO-21-104379 10State and territorial primary care offices conduct health care workforce and shortage designation analysis, provide technical assistance, and work with federal, state, and local partners. Each office assesses the need for primary care services and providers, and if needed, submits an application to HRSA for a HPSA designation. HRSA reviews the application and may issue a HPSA designation if criteria are met. 11HPSA scores range from 0 to 25 for primary care and mental health HPSAs, and 0 to 26 for dental health HPSAs. The Nurse Corps LRP uses only primary care and mental health HPSAs. Page 5 GAO-21-104379 Nurse Corps Loan Repayment Program Selection of award recipients starts at tier 1, where the applicants have the highest debt-to-salary ratio and the CSFs have the highest HPSA scores. Within a tier, awards are made in order of decreasing debt-to- base salary ratios until all funds are expended. 12 According to HRSA, the Nurse Corps LRP is highly competitive; in prior years, program funds for RNs and APRNs have only been sufficient to fund applicants primarily in tier 1. Award payments are made to the recipients over 24 months and recipients must use all payments to pay lenders or holders of their outstanding balance of qualified educational loans. Numbers of Applications The number of total applications to the Nurse Corps LRP greatly and Awardees exceeded the number of total awards given in fiscal years 2016 through 2020. (See table 2.) The average number of applications for fiscal years 2016 through 2020 was about 7,156, and the average number of awards distributed for those years was about 831 (about 12 percent). Table 2: Nurse Corps Loan Repayment Program Applications and Awards, Fiscal Years 2016 through 2020 Applications Awards Number of Number of applications for Number of Fiscal applications for continuation Number of initial continuation year initial funding funding Total year recipients awards recipients Total 2016 7,715 403 8,118 518 365 883 2017 8,629 362 8,991 501 340 841 2018 7,461 330 7,791 544 279 823 2019a 4,572 322 4,894 561 292 853 2020 5,672 316 5,988 465 291 756 Source: Health Resources and Services Administration. I GAO-21-104379 Note: Initial applications for the Nurse Corps Loan Repayment Program are to receive funds to repay 60 percent of their outstanding balance of qualified educational loans in exchange for a 2-year service commitment. Qualifying recipients may receive an additional 25 percent of their outstanding balance of qualified educational loans repaid for an additional third year of service, referred to as a continuation application and award. a According to Health Resources and Services Administration officials, the fiscal year 2019 Nurse Corps Loan Repayment Program application cycle for new awards was open 35 days, 9 days less than the average award cycle, resulting in fewer applications submitted for initial funding. 12For example, RNs and APRNs in tier 1 whose practice area will address the emerging needs identified by HRSA will be funded first, in order of their debt-to-salary ratio, followed by those nurses falling into each of the categories allocated program funding. Page 6 GAO-21-104379 Nurse Corps Loan Repayment Program HRSA’s management of the Nurse Corps LRP includes communicating HRSA Communicates the program information to potential applicants, verifying applicants’ Program Information, information, and identifying emerging health needs to use as a basis for targeting funding. Further, HRSA conducts annual evaluations of the Verifies Applications, effectiveness of the program and reports the results to Congress. Targets Funds for HRSA communicates program information to applicants. A key Emerging Health aspect of HRSA’s management of the Nurse Corps LRP is Needs, and Evaluates communicating information about the program to potential applicants. This information includes (1) annual application guidance and program the Effects of the guidance documents, (2) contact information for technical assistance, and Nurse Corps LRP (3) webinars about the application process. HRSA officials told us agency staff develop and implement media strategies for application rollouts and post current information about the Nurse Corps LRP on the agency’s website. Additionally, HRSA provides multiple ways potential applicants can contact the agency to get support with the application process, such as through email, a customer call center, and a customer service portal, which houses program information and an online application. HRSA verifies applicants’ information. HRSA reviews and verifies applicants’ information to ensure applicants meet the requirements of the Nurse Corps LRP. This information includes • citizenship or residency status, verified by a U.S. birth certificate, a state enhanced driver’s license, or a permanent resident card; • transcripts from each college, university, or school of nursing that include the coursework directly related to the nursing degree; • loan information, including loan type, original loan amount, applicant’s name, and account numbers; 13 • employment information submitted by an applicant’s supervisor at a CSF; and • whether the CSF is for-profit or nonprofit. HRSA officials said the application process begins in January and typically runs for about 6 weeks each year. Agency officials told us recipients selected for awards are notified on a rolling basis. 13As a part of the loan verification process, HRSA officials told us that loan verification analysts review all loan documentation and match applicants’ loan information with their transcripts. Page 7 GAO-21-104379 Nurse Corps Loan Repayment Program HRSA officials said that during application review, HRSA program analysts will verify loan documents submitted by the applicant. Additionally, they said that HRSA verifies that the recipients are working full time at a CSF when they begin the program and every 6 months thereafter. 14 According to HRSA officials, at the end of the second year, if a recipient wishes to continue with the optional third year of funding, the recipient must account for all funds received during the initial 2 years by submitting a history of payments made to lenders; loan payments made during the 2 years must be equal to or greater than the funds provided by the Nurse Corps LRP. HRSA targets funding for emerging health needs. HRSA officials said the agency has discretion in allocating funding, and this flexibility allows the program to respond to emerging health needs identified by the agency. For example, in fiscal year 2021, HRSA identified women’s health issues as an emerging health need and allocated up to $5 million for nurses with expertise in this area. Specifically, the funding was provided to APRNs with certifications in women’s health, and RNs certified in obstetrics and gynecology. This allocation was an increase over the $750,000 set aside for women’s health issues in fiscal year 2020. HRSA conducts annual program evaluations of the Nurse Corps LRP. As required by statute, HRSA submits an annual report to Congress describing the Nurse Corps LRP. This includes program results and evaluation of overall costs and benefits. To evaluate the overall costs and benefits of the Nurse Corps LRP, HRSA officials said the agency developed a clinician dashboard to track program effects and analyze field strength—the number of nurses who are actively serving at CSFs. HRSA officials told us that the Nurse Corps LRP recipients saw approximately 1.8 million patients across more than 900 unique sites in fiscal year 2019. The field strength data includes the percentage of awards going to recipients in rural and non-rural areas. HRSA officials told us that information from the clinician dashboard is 14Award recipients must not miss more than 35 workdays per service year; therefore, HRSA monitors the number of days missed from work. Any workdays missed greater than 35 per service year will be added to the current contract end date, extending the service completion date proportionately by the number of workdays missed greater than 35. HRSA officials said they perform in-service verifications through the recipient’s CSF point of contact and verify the total number of workdays. Page 8 GAO-21-104379 Nurse Corps Loan Repayment Program used by HRSA for prioritizing policies and funding amounts for future emerging health needs. HRSA also monitors the annual rate at which Nurse Corps LRP recipients default on their loans and includes that information in its annual report to Congress. 15 Reasons for LRP defaults include nurses who resigned or left their CSFs before their service obligation was completed, voluntarily defaulted, or worked less than full time. 16 HRSA officials told us that there were no defaults in fiscal year 2019, and that between fiscal year 2017 and fiscal year 2019 the default rate averaged about 1.5 percent, which they said demonstrated that the program recruits nurses suitable for and with a clear commitment to service in underserved areas. HRSA has consistently issued the Nurse Corps LRP annual report to Congress in a timely manner. The annual report describes the program’s results, such as the number of applications, number of recipients and loan repayments, number and placement locations of the Nurse Corps LRP recipients, and recipients’ demographics. According to HRSA’s reports to Congress, between fiscal years 2014 and 2019, on average, approximately 84 percent of Nurse Corps LRP recipients remained at their designated CSF for one or more years beyond completion of their service commitment. 15HRSA officials stated that when a recipient is found to be in default they will refer the recipient to the Department of Health and Human Services’ collections division. They said any debt owed to the federal government is due within 3 years of the breach of contract. Also, the debt amount is subject to interest starting the date of the breach. According to HRSA officials, not paying this debt will result in delinquency and will be reported to credit agencies and collection agencies. The debt may also be reported to the Department of Justice for collection, or may be collected by a tax refund offset or administrative wage garnishment, or both. 16Voluntary default occurs when a recipient contacts the Nurse Corps LRP and requests a default. Any funds that are returned to HRSA because participants breached their contracts are available and remain available until distributed. These recovered funds are used to make new awards, continuations, and modifications to the existing contracts. Page 9 GAO-21-104379 Nurse Corps Loan Repayment Program It is too soon to determine the effects on CSFs from eliminating the for- Too Soon to profit restriction in the Nurse Corps LRP. Funding decisions for the first Determine Effects of group of applicants that will have for-profit CSFs as workplace options will not be completed until September 30, 2021. These recipients will begin Eliminating the For- their 2 years of service in a designated CSF in late 2021. According to Profit Restriction in HRSA officials, measuring the effect of this change in policy will begin when the fiscal year 2021 application cycle is over, and be conducted the Nurse Corps Loan annually with the first set of results expected in fiscal year 2022. Repayment Program While HRSA officials said it is too early to assess the actual effects of the policy change, they told us that removing the for-profit restriction will expand the number of eligible CSFs, thereby giving the Nurse Corps LRP recipients more choices and allowing for greater mobility. However, HRSA officials also expressed concern about including for-profit CSFs in the program, noting that for-profit CSFs may have more financial resources than nonprofit CSFs to recruit and retain RNs and APRNs. Officials of for-profit CSFs and nonprofit CSFs we spoke to also commented on the possible effects of the elimination of the for-profit restriction in the Nurse Corps LRP, offering opposing views. While for- profit CSF officials stated that adding for-profit CSFs to the list of eligible CSFs will result in equal treatment of all underserved areas, nonprofit CSF officials stated that they cannot compete with the higher wages offered by for-profit CSFs. • Officials from an association representing for-profit hospitals, including CSFs, said the elimination of the restriction could incentivize RNs and APRNs to work in areas with the greatest need, regardless of the CSFs’ profit status. Officials told us that all underserved areas should be treated equally and allow access to the Nurse Corps LRP by RNs and APRNs who work in any CSFs—both for-profit and nonprofit. Additionally, since Nurse Corps LRP payments go to RNs and APRNs, and not the CSFs, officials told us that whether or not a CSF is for-profit should not matter. When asked, officials said that the potential effect of the change on nonprofit CSFs remains to be seen. • Officials from nonprofit CSFs expressed concerns about possible negative consequences due to the elimination of the for-profit restriction. Officials from a nonprofit critical access hospital and its associated nonprofit rural health clinic said for-profit CSFs have financial advantages over nonprofit CSFs, and noted that for-profit CSFs can afford to raise wages or offer bonuses, which make it easier to recruit and retain RNs and APRNs. For example, the officials said that a for-profit competitor offered RNs a $4 per hour wage increase Page 10 GAO-21-104379 Nurse Corps Loan Repayment Program as an enticement to work at their facility. They told us that their nonprofit facilities cannot compete with that wage increase. Officials also noted that there is unmet need in rural areas. They are concerned that adding for-profit CSFs to the list of eligible CSFs could result in fewer Nurse Corps LRP recipients serving at nonprofit CSFs located in rural areas, because they might choose to serve at for-profit CSFs in non-rural areas. We provided a draft of this report to the Department of Health and Human Agency Comments Services for review. The Department of Health and Human Services provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Health and Human Services, and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at RosenbergM@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix I. Michelle B. Rosenberg Director, Health Care Page 11 GAO-21-104379 Nurse Corps Loan Repayment Program Appendix I:GAO Contact and Staff Appendix I:GAO Contact and Staff Acknowledgments Acknowledgments Michelle B. Rosenberg at (202) 512-7114 or RosenbergM@gao.gov GAO Contacts In addition to the contact name above, Kristi Peterson (Assistant Staff Director), Deborah J. Miller (Analyst in Charge), Sauravi Chakrabarty, Acknowledgments James Cosgrove, Martin T. Gahart, Virginia Lefever, and Drew Long made key contributions to this report. (104379) Page 12 GAO-21-104379 Nurse Corps Loan Repayment Program The Government Accountability Office, the audit, evaluation, and investigative GAO’s Mission arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. 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