♪ ♪ ♪ ♪ Sierra Artemus> Welcome to " Palmetto Perspectives," I'm Sierra Artemus.

Who cares for you?

Yes, you.

That's the question we're asking tonight, as we look at the future of health care in our state.

The landscape is changing, and many South Carolinians are already beginning to feel the effects.

Fueling that change is lack of doctors.

The Department of Health and Human Services reports the state could be short 3000 doctors.

And that number is growing.

To help us understand the shortage and give us insight on how accurate that number is we've invited Director of Area Health Education Consortium or A.H.E.C., Dr.

Ann Lefebvre, Dr.

Vicki Young, the C.E.O.

of the South Carolina Primary Health Care Association, State senator from the district of 46, that's Jasper and Beaufort Counties, Tom Davis, CEO of the South Carolina Office of Rural Health Dr.

Graham Davis... Adams, excuse me, and Executive Director of the Good Samaritan Clinic, Mike Young.

Thank you all so much for joining us today.

I want us to start, we're gonna jump right in it.

Now I'll also say this, many of you are already very familiar with each other.

You worked together at some point, so there's no stranger on this stage, with an exception of myself.

But I'll make sure to make myself fit in somehow.

But I want to start things off by asking you, Dr.

Lefebvre, is there really a shortage in our physicians, or is that just the access to care that we have the shortage in?

Dr.

Lefebvre> Well, so the term shortage is a bit of a general term.

So when we're talking about physicians in particular, there's a lot of things to take into consideration when we're talking about the need for physicians.

So you could have specialties, you know, whether they specialize in neurosurgery or whether they specialize in primary care.

So really, when we're looking at the number of physicians to support communities across the state, we really want to drill down into the distribution of physicians.

And so that brings us to a much better count, a much better look at things at the community level so that we're understanding how are the physicians that we have distributed And then what is the distribution we need for that going forward, in order for everyone across the state to have access to the physicians that they'd like to see.

And so there's a big difference between how we calculate a shortage and how we look at distributions.

And, you know, our state we're fortunate, our state is a growth state.

That's a great place for South Carolina to be in.

But that also means that more population is coming into our state.

And so that does a lot of great things for our state, but they're not coming into every community, and they're not coming into every community equally.

And so I think we really have specific communities, maybe 13 to 15 counties across the state that we're particularly very concerned about when we're talking about access to health care, access to physicians.

And that's when I'm talking about distribution.

There's really some communities that we have to be very targeted to see what their needs are, because the whole state is growing when we look at general population, but certain communities are hurting right now and those are not the communities that are growing.

Sierra> Thank you so much.

And speaking of those communities that are not growing, I had a chance to speak with you earlier today about the rural communities.

Tell us more about how that growth may impact the rural communities.

Dr.

Adams> Sure.

So, the state put out some data in the spring of 2024 showing expected population growth and decline through 2042.

And as a lot of people might know, South Carolina has been one of the fastest growing states in the country the last handful of years.

And when you look at the data, at least what is projected is that as a state, we will continue to grow.

But when you look as Dr.

Lefebvre spoke of, that growth is not equal.

So if you're in a county on the coast or if you're in a metropolitan area or adjacent to one, you are expected to see some growth, especially like the Rock Hill, Charlotte area, for instance.

But we have 23 of our 46 counties that are expected to lose population by 2042.

And for some, it's just a couple percent here and there.

But for some, you know, Allendale and Fairfield, for instance, they're drastic changes that are projected that they'll lose.

And when you lose population, you lose the tax base that those communities use to support so many essential functions, be it, pay for the public school system, pay for EMS, so many different resources that we rely on from the community that we live in.

It becomes more and more difficult for communities that have a dwindling population and a dwindling tax base.

So, that's one of the things that, you know, I'm concerned about as we move forward as a state.

Let's, let's celebrate, let's take advantage of all the growth we have in our state, but again, it's not equal to each community and let's really figure out how we provide the services that are needed to you in your community, no matter where you live.

Sierra> Mr.

Young?

Mike> Absolutely.

And I want to mention that the Latino community is the, South Carolina has the third fastest growing Latino community nationwide.

Right.

And that's the predominant population that our clinic serves.

I'm on the board of the Free Clinic Association, and that's the predominant community that we serve as a whole with free clinics.

And, with that, there's additional barriers to the access, right?

We're talking language, but intimidation and fear and we're lucky that we have interpreters.

We've fully provided the equity to have all those pieces put into place.

We even have one of our providers, Dr.

Perez, in the audience here.

He's served with us for, like, 15, 20 years.

We're sad to see him go, but he's moving on to bigger things in Spain.

But he has, you know... that's priceless.

Having a doctor that could speak the language with your patient, you see the fear and the ease just melt away, right?

I mean, we have clinics that are houses that were retrofit into clinics.

So, it already has that, like welcoming space and we put the extra effort in with the smile and the compassion to really make people feel welcome.

But yeah, that's one of the uneven, you know, growths in our state, is the Latino community is growing rapidly and we just got to make sure we have the infrastructure in place because, you know, they are contributing to our economy and the tax, you know, funds and everything like that, so.

Sierra> Thank you.

And, Senator, you've introduced a few bills to ensure that there is access to health care.

So, could you elaborate on what everyone else has said?

Senator Davis> Sure.

I mean, I'm gonna give a little perspective here.

When we talk about access to health care, it's really a supply and demand issue.

And so I first became really interested in this about 7 or 8 years ago.

I chair a standing subcommittee of Medical Affairs, on scope of practice, what medical professionals are able to provide the public.

And in 2017, I believe it was, I learned that nurse practitioners, for instance, were only allowed by statute to do about 65 or 70% of what they're trained to do in school.

We have never, you know, synced up what the statute said nurse practitioners could do with what schools were actually teaching them to do.

So I filed legislation so that they were able to provide services commensurate with their abilities.

And we got that passed.

What we also did is remove from the code a requirement that a nurse practitioner even practicing within their scope, they couldn't do it outside of where a 45 miles of a physician was, a 45-mile radius.

And since most physicians were in urban areas, if you draw that 45-mile radius, they couldn't get into rural areas.

And so we started this access issue by allowing nurse practitioners to practice to the full scope of competency.

We removed that 45-mile radius requirement and as a result, you started to see primary care being provided by nurse practitioners in rural areas exponentially greater than before.

And so, when we talk about access to health care, I think it's extremely important that we look at the physician shortage, because obviously physicians are critical to health care delivery.

But the broader question is, if we have a lower number of physicians not keeping pace with the people coming into South Carolina, we have to look at our non M.D.

providers like nurse practitioners, physician's assistants, pharmacists, you know, these can help address that access issue.

Now, we don't want any of those professionals providing services beyond their training, but we want them to practice to their full extent of their training.

And there's a lot we can do in that area still.

Sierra> Wonderful.

And Dr.

Young, you all offer support for workforce and also training for physicians, as well.

Could you elaborate more?

Dr.

Vicki Young> Yeah and I'd actually like to tag on to what Senator Davis had just mentioned.

Our membership is community health centers, or F.Q.H.C.s, as some may have them referred to, and their model of providing care actually uses physicians and non-physician providers, as well as a broader set of individuals who are part of the health care team.

So, for us, that's a good model where we're able to allow people to practice at the top of their licensure and help stand in the gap, as you will, for what is occurring with the access to care issues.

I agree that distribution has a lot to do with where there are shortages, but overall, there's a shortage that having the providers of all type be a part of the expanded health care team is going to go a long way in addressing access to care, preventive and primary care.

Sierra> Let's jump back a second and talk about why we are having the shortage in physicians, in primary care physicians.

What impacts that?

Dr.

Lefebvre> I'll jump into some of those and then others can add to it.

So there's a lot to becoming a physician.

I think we mentioned that, you know, you know, it really takes, you know, a lot of time.

Physicians do four years of undergraduate college, and then they do four years of medical schools, and then they have to do 3 to 5 years of a residency training before they can go out and practice independently.

And so, it's an investment on their part, but also, you know, on the state and federal government's part too to support that training and education.

And so with that, in medical school, in about the third year of medical school, medical students go out and do what's called clinical rotations.

And they rotate to really kind of try on different specialties, if you will.

They try on family medicine.

They try on surgery.

And really that's where they start to develop and get a feel for what type of medicine do they want to practice.

And then in their fourth year, that's when they go out and they interview with different residency programs you know, in the specialty of their choosing.

So with that, the physicians as medical students choose their specialty.

So when we're talking about primary care, and we do need more physicians or more medical students to choose primary care, you know, it's really at that critical stage in medical school that they're making that choice.

And it really, you know, at A.H.E.C., we work with our partners across the state to try to get medical students to do those rotations out in rural communities, out in federally qualified health centers and others, so that their experiences with primary care, are out in those communities where we need them the most.

You know, again, it's that medical student and then for the physicians choice as to what specialty they work in.

But again, I think that's where we're looking at when we start to look at distribution.

It's not just a geographic distribution.

It's also distributions within those specialties.

Family medicine is really what we need out to serve rural communities.

We need all types of primary care, internal medicine, pediatric medicine, obstetrics medicine.

We need all types of primary care.

But in rural communities, it's very hard for a pediatrician, per se, to provide only pediatric care in a rural community because of the age of the population there.

So family medicine is really, we need a growth in family medicine in the state so that they're out there providing care in our rural and medically underserved communities and can provide that cradle-to-grave care that they're looking at a full broad scope of family medicine.

Mike> I like this, thinking about in terms of the workforce development, right.

Because I see us playing a big role in that as well, like F.Q.H.C.s and us being tied to the university and volunteerism.

Free clinics, like, it almost seems like a rite of passage that like a lot of our medical workforce have spent time in the Good Samaritan Clinic, like, [speaking Spanish], right?

They work their way up, but that was just a badge that they wore through medical school, volunteering.

And they get to practice and have hands on experience, right?

So that seems to be like part of the pipeline, which I think is really, really neat how it gets interconnected that way.

And then also, like, students and interns and community health workers, also, is another piece, that's where I come from.

I come from the community health worker workforce.

So that's like looking at whole person care, like you were saying, you know, and really drilling down on what are the other things that are making you sick, right.

Which is education, nutrition, transportation, all the variables, right?

So I think, yeah, a free clinic space, you know I'm gonna champion that, right?

But there's so much that can come with it, right?

So many ways to lift up people in all the aspects of their lives.

Dr.

Young> Excuse me, with that similar model.

of course, that's the model that community health centers follow.

It's not just the care that is provided in the actual clinic or practice, but those other determinants of health care outcomes that the community health centers provide services around.

To your question about workforce, another area beyond once they've chosen to go to medical school or in some of the other areas of professional education, is looking at growing your own.

So I heard you mention that, and I wanted to really, tout that.

There are programs that actually speak to the pathways to careers.

We've seen in some of the community health centers where they have staff who may have started at one level and in one area, but they expressed an interest, and then they were supported in their education to move forward to then become another type of provider in the health system.

So it grows them as they come along.

Because one of the things that we've seen is that if people have a tie to the community, they tend to stay.

Dr.

Lefebvre> There's strong evidence out there to support that individuals who grew up in a rural community are much more likely to want to practice in a rural community.

Individuals who, even if they didn't grow up in a rural community, if they did a clinical rotation out in a, in a rural community and had a positive experience during that rotation, are more likely to go back and practice in a rural community.

So growing our own is a really important piece.

A.H.E.C.

has programs where we work with rural high schools, rural high school students across the state exposing them to health care careers.

In a lot of our rural communities health care is the largest employer, and so it's really important to be there.

But we also need in our state to make sure that we have the primary and secondary education out in our rural communities so that they have the, you know, the competition of getting into an undergraduate, you know, into a four year college is steep.

We need to make sure that they have as much exposure to everything that they need as we get provided in our urban communities, so that we have a chance to grow our own, out in these rural communities so that they come back there to practice, as well.

Sen.

Davis> I want to make a final point on something, and these are all great ideas.

And over a long term of time, it may change the needle a little bit, but we're about to hit a cliff, okay.

With these steep Medicaid cuts that are going to come, and they are coming, it is going to be a crisis situation here in South Carolina, and it's gonna be all hands on deck in regard to increasing access to health care.

When you talk about the number of physicians, I mean, we've talked already about how proportionately to the population coming in, it's falling short.

Two other things to remember about that, more and more of those physicians are staying in urban areas for lifestyle choices, for other choices.

That's just empirically true.

We may wish it were otherwise, but it's true.

It's also true that more and more physicians are moving into specialties and away from primary care.

So you combine the fact that we don't have the number of physicians keeping pace with the population.

You couple that with the fact that they're staying in urban areas, and you couple that with that they're moving away from primary care to more specialty, you've got to do something in the near term to address this critical access in rural communities.

And what you can do is look at very competent medical professionals.

You can look at physician's assistants, pharmacists, nurse practitioners, certified medical assistants, making sure that they're all practicing to the ultimate full scope of competency.

Because, look, this is a supply and demand problem.

Demands going up, populations going up and older populations going up, prices are going up.

The way you resolve that is by increasing the supply and you increase the supply by letting all these providers practice to the full scope of competency.

And let's, let's be frank, here in South Carolina, that's been a hard thing to do.

I talked to you before about 7 or 8 years ago, I passed legislation I got legislation passed to allow nurse practitioners to practice to their full scope of competency and to allow them to practice outside the 45-mile radius of physicians.

Physicians fought that tooth and nail, okay?

They fought it tooth and nail.

So let's just be frank about this, okay?

We just saw a video, our documentary talking about how it's all about money.

Everybody is acting in their own economic self-interest.

But if you're interested in increasing access to health care, it's all hands on deck.

Let these non-medical professionals practice to their full degree of competency and let's realize the dynamic that's making this a necessity, both the Medicaid cuts and the preference physicians have to be in urban areas and to practice specialties.

Dr.

Young> To add to what you- Sierra> This is a hot topic.

Look, everybody's ready.

Dr.

Young> To add to what you just said Senator Davis, if those barriers are taken away, there'll still be the issue of the reimbursement based on them providing the additional services.

And let's be realistic, in order for certain practices or other businesses to stay open, the reimbursement will have to change that goes along with the added scope of practice that is available to them.

Sen.

Davis> Fair enough.

Dr.

Adams> Yeah, I'll jump in here as well.

So the, the H.R.

1 Bill often referred to as the Big Beautiful Bill, does include about a trillion dollars worth of cuts to the health care system throughout the next ten years nationally.

It, I feel, is going to have a disproportionate effect on rural communities.

And so often rural providers and rural communities rely on Medicaid and Medicare encounters more than the urban provider counterparts.

So, as those cuts occur, we're going to see those providers kind of retracting the services that they offer.

It's gonna be harder for them to meet payroll and do the things that they need to do to serve their patients well.

And I think that, part of the thing that we have a challenge with is the incentives aren't aligned either.

Senator, you mentioned that they aren't incentivized to kind of all work towards the same end.

Currently, they're not.

You know, different pieces of the health care system have different metrics that they're held to, different milestones that they have to achieve, they have different reimbursement.

And as a result, you end up with a very fragmented system that isn't always working as best it can for the patient.

So, there are some models that have been explored nationally, where you're looking at trying to kind of bundle a payment around a patient and have all the providers working towards the same end, sharing that reimbursement, as needed.

Now, that's hard to do in practice, and it's not really the way providers are reimbursed at the moment.

But until we get the incentives aligned, I think that we're gonna continue to see a really disjointed result.

And again, I think the Medicaid cuts specifically are kind of... that's the 800 pound gorilla.

I mean, those are gonna have a drastic impact on, again, not just our rural providers, but every provider in the state.

And I think rural communities, again, that rely more and more on Medicaid and Medicare patients are, it's gonna be harder and harder for them to meet those needs.

So, I know our state can't solve the problem for the whole country, but I do think, you know, when you look at the federal A.C.A., the marketplace that has been available for folks a lot of the benefits of that have been stripped away throughout recent years.

And it really is taking away a viable resource for folks that don't get health insurance through their employer and who need insurance in some way.

Data shows that folks that have health insurance tend to be healthier, they have better health outcomes, they live longer.

And so many folks in rural communities and in urban underserved areas don't have that health insurance.

So they really struggle to make sure that they can get the care when they need it.

So often, a lot of the things that, that turn into a... a lifelong illness or challenge, if those were really addressed on the front end with timely preventative care, could have been avoided.

So I think that, it's better for us all.

A rising tide lifts all boats.

It's better for us all if everybody can get access to that basic care because it just doesn't impact the person who's uninsured, it impacts all of us in that the cost is shifted to us.

So our premiums are more, even though... our health might be good, we're sharing the cost of what the health system encounters for those that are uninsured.

Dr.

Lefebvre> Just to put some numbers behind it.

I absolutely agree.

And just to put some numbers behind what Senator Davis was talking about.

So since 2012, we've seen an increase in nurse practitioners in our state of over 200%.

So, we do have growing workforce in the state, we really do.

The policies that are in place, you know, stand.

But, we do see the physician assistant and nurse practitioner workforce are growing, you know, as is the physician workforce, but the physician workforce is not growing at the same rate that the advanced practice providers are growing at.

Sierra> You know, there's an effect that health care has on everyone, regardless of who can afford it and who cannot.

Senator, I want to direct this question to you.

When people can't afford health care or even have access to primary physicians, many of these people end up in the emergency room.

Tell our viewers in our audience here today how that impacts the South Carolina tax dollars or taxpayer.

Sen.

Tom Davis> I mean, a tremendous impact.

I mean, you know, to the extent that people aren't getting primary care, to the extent you're not having them avoid, you know, conditions and they go to the emergency room, it's exponentially higher in terms of cost.

And ultimately that cost gets passed on to other people and other practice lines.

So, you know, it's a hard thing to crack.

And I want to say this, I respect physicians.

We need more physicians, so we need to do whatever we can to increase the number of residencies, have people stay here.

I've got legislation pending to allow internationally trained and qualified doctors if they pass certain standard tests, to have them come in here, to try to address that supply problem.

But I think, you know, and you mentioned something earlier, I don't think we need to emphasize, it's not just the Medicaid cuts that are gonna cause this crisis.

It's the Affordable Care Act premium subsidies are going away and the ability to access.

So this is all happening all at the same time.

And it's also happening at a time when the federal government is 40 trillion dollars in debt, it's got annual structural deficits in the budget of about a trillion dollars a year.

There's gonna come a point in time when those transfer payments backed down to the state from Medicare for Medicaid for a number of things are going to dry up.

And so we need to start being creative and bold and imaginative down here.

And so, look, I mean, I believe in supply and demand.

I believe any time you increase supply and have competition and anytime you empower demand to give them choices, you usually end up with a better product at a lower cost.

That's a basic economic equation.

I think it can be applied to the health care context.

Now, it's not that simple.

But I think as a premise, it's a great point of departure.

And so, I'm optimistic.

I had a meeting earlier today with the South Carolina Medical Association.

They recognized this particular issue.

They are working with me and other legislators to try to address this access issue.

So there are no villains in this.

We all want the same thing.

We all want to increase the amount of health care.

And so there's a very good dialogue going on right now among nurse practitioners and physicians and physician's assistants.

And how can they all practice to the full scope of competency?

How can they work together?

How can patient safety be maintained?

So I don't want people to think that we just have these warring camps out there.

Everybody has the same objective.

We want to have better access to better quality health care, and I think we can get there if we all work with that objective in mind.

Sierra> I saw a study that came out recently, not a study, but a report that the Coalition for Access to Health Care, they're planning to refile their full practice authority bill in the 2027 legislative session.

That's for nurse practitioners to treat patients.

<Right> Let's talk about that.

Sen.

Davis> Yeah, I'm gonna refile that legislation.

It's a bill that was in Medical Affairs Committee last year.

We had 4 or 5 subcommittee hearings on it, and we ran out of time before session ended, to take it up.

I want to bring that back up.

I want to do the same thing with physician's assistants with the same objectives in mind.

And pharmacists, we haven't talked about that yet.

I mean, all of these rural communities, most of them have pharmacies and these pharmacists just like nurse practitioners and physician's assistants, they're taught to do different things now, than they did 30, 40 years ago.

But we still have a statutory code that limits them to do the things that they were trained to do 30, 40 years ago.

I mean, we really need to focus in on how are they being trained and making sure our statutes allow them to provide that care.

So pharmacists is another area.

So again, this is an all hands on deck.

The physicians are always gonna be at the top and the most qualified and I don't want to minimize that.

But we have a plethora, it was just mentioned, that while physicians aren't keeping up with the growth and population, the number of nurse practitioners the last five years has doubled.

I mean, it is going up at an exponential rate.

And so why not take full advantage of that expanding workforce, especially when a lot of them can provide a lot of the primary care that those people in rural communities are going without?

I mean, would you rather have nobody in a rural area or would you rather have some nurse practitioners providing some primary care, even admitting that they might not be able to do all the things physicians can?

You'd rather have them there than nothing.

And then the alternative is only going to the emergency room.

Sierra> Especially for an emergency situation.

We're gonna take some questions from the audience.

And then I want to come to you, I see you writing some things down.

And we are also gonna talk about free health care.

Is there anyone in the audience that may have something they'd like to share or add?

Any questions?

Yes, ma'am.

Can we get a mic?

Renee> Hi, I'm Renee Miller.

I'm originally from Allendale County.

I have been in Columbia since going to Carolina in '82, 40 years ago.

How do we prepare our rural counties for the shortcoming or the continued shortcoming in Medicare, Medicaid?

What do we do, legislatively?

Sen.

Davis> I have one thing that I think we can do is start bringing care out to those communities, like, mobile centers and increasing the use of telemedicine and facilitating, you know, how they can access telemedicine.

We learned a lot about that during COVID, when people by necessity, were in their homes and they couldn't get access to health care.

And so we made great strides in regard to how to utilize that medium.

How can physicians and other medical professionals communicate with patients through telemedicine?

And so I think, you know, in terms of reaching out to rural areas, you send out these mobile clinics, you try to increase access to telehealth.

You try to do those things.

And again, there's no one single thing that's going to solve that problem.

But I think an all of the above approach like that and getting health care access out to those areas, is our objective.

And look, one of the great things about living in the United States is, is we got 50 states, 50 laboratories of democracy, so to speak.

We can look at what other states have done and what's worked.

I mean, they're also facing the same things we're facing, and we can look at what initiatives have worked in terms of increasing physicians, what has worked in terms of trying to increase access to health care and learn from their mistakes.

That's what I do when I'm drafting legislation.

I first look at other states that have adopted things a few years ago, look at the results and look at the benchmarks and see whether or not what they expected to occur has occurred.

And if it hasn't, how can we do things differently to make sure it does occur?

So, there's no one single answer, ma'am, but I think all those things together can make a big dent.

Dr.

Young> And I'd like to add to what the senator has said and talk about then what you as community partners can do.

So community health centers, many of them have mobile units that can go out too, and I'm sure some of the free clinics and others as well, but they have mobile units that can go out, they're utilizing telehealth.

Sometimes it's getting the word out.

They do as much with their outreach workers and community health workers, but having a partner in the community who is an advocate for the services and making sure they're helping to connect people will go a long way, as well.

Dr.

Adams> I'll add that, you know, I think that, telehealth and mobile units are great tools in the toolbox, and they can augment local providers that can be there to provide that service.

Sometimes I worry a little bit that people think that telehealth can be a substitution for a local provider.

It can break down transportation issues.

It can offer increased access to subspecialists, all kinds of benefits, but it's best coupled with local providers.

I do think that telemedicine, you know, during COVID, one of the things we saw was that reimbursement was made available to both the Federally Qualified Health Centers and the 118 rural health clinics in our state.

And that benefit has been extended through time, but it may go away.

And our state does not have parity for telehealth so that if a provider gets paid, to do something in person, he or she wouldn't get paid the same amount to do it via telehealth.

And I think we've seen where states, I think we're only one of about ten states that does not have that parity.

We've seen in states like Georgia, for instance, that has had it for years and years, the access has really been improved for rural patients, providers have access to subspecialists, and it really does open a lot of the opportunities that I think, we have so much expertise in the state, it's a barrier to getting it to the people where they are.

Sierra> Wonderful, and I think we have another question from the audience.

>> Hi.

Deborah Billings.

Thank you so much for all of these insights.

I think...I'm at the University of South Carolina.

I am engaged with students all the time.

Many of them are pre-med.

And I think about the cost, right?

The, the sometimes crushing debt that they're put into to become the health care providers that we need.

So I wonder if you could comment on that.

How do we do this differently?

Other countries do it differently.

It's not sustainable for young people, given all of the other challenges that they're looking at facing, you know, in the near future.

Dr.

Ann Lefebvre> So I'll jump in and I'm sure others can add to it as well.

So, so thank you for your question.

But, let me speak first to how we do it now.

And then, this too is also in the, H.R.

1 or one big beautiful bill, as well that I think we need to pay attention to.

So, the cost of higher education, in general, is very high.

The cost of medical school is high.

The cost of dental school is even higher.

You know, I mean, so these are exorbitant costs, that young people have to incur as they're deciding to, you know, what they want to do for the rest of their lives.

And so, it is a, is a big hill to climb.

That's for sure.

And they come out with an enormous amount of debt.

There are programs, both federal and then the state of South Carolina has programs to help them address that, that really stand out in the nation.

And I think that those are important.

Do I know, do I feel that they're enough?

Which is what I think you're getting at?

I think that can be something I go to next.

But we do.

We have done a lot in our state to address that.

There are National Health Service Corps funds that can help with loan repayment.

Especially, that guides them to working in these rural and underserved communities.

And then, the state has appropriated funds to A.H.E.C., as well.

That, allows for four additional years of contracted payment, to incentivize, those, you know, physicians to go work in rural communities, for an extended period of time.

And it's been a very successful program.

And actually, with the Rural Health Transformation program, other states are calling us to find out how we're doing this, because it really is seen as, advantageous for, for these programs.

Now, one of the things that's in the, one big, beautiful bill is also caps as to what students can borrow from federal lenders.

And so, that is concerning.

And so it's capped at, you know, $100,000 for some students and then $200,000 for medical students.

And so whether you're a nurse practitioner or whether you're a physician assistant or, a physician, you're, you're going to go in debt over those amounts.

That's just, you know, a reality of it.

And so, I think it's challenging now.

I think if, if it continues the way it is, we're going to see even greater challenge to it.

I do think that, you know, I think more we'll see more students using, you know, two years of technical college, you know, more students utilizing an associate's degree, before they go into, you know, a four year college and those types of things.

But I don't think those are necessarily going to be, you know, as much help as, as what we need.

So, it's yet another cliff that I think that we're facing and that young people are going to have to make hard decisions on because, you know, they're going to have to go to private lending to, to be able to meet these loans.

And that can be pretty predatory, as well.

So, it's, you know, it's a very, it's already a challenge.

I think it's facing a cliff.

Dr.

Young> And I would also say that that also directs them in what direction they go in as far as specialty, so that either actual or forecasted debt does weigh in on their decision of what specialty to go into, whether they go to specialty or family medicine or primary care.

Sierra> And I think we have another question from the audience.

And then I want to make sure we get back to you, Mr... Yes, sir.

>> Thank you so much.

My name is Dr.

Allen Simmons.

I'm the vice president of partnerships for American University College of Antigua, College of Medicine.

My question, senator, I'm so glad you brought up the point that you brought up, concerning the educational component and how we are expanding, educational efforts to help people in that training aspect.

My question directly, as we look at this shortage, the A.M.A.

is projecting you, you mentioned South Carolina and the shortage here nationally.

There's a shortage of 86,000 physicians by 2036.

That's a large number.

So what are we doing right now in terms of K through 12 programs, How we are helping to educate the next generation of physicians?

Sen.

Tom Davis> You know, in terms of having more individuals decide to become physicians and helping them financially get through the process.

Is that what the question is?

And how do we do that?

Dr.

Simmons> Are we creating pathways in terms of bringing more ideas, more knowledge into K through 12 programs, as we do now with K through 12 programs?

You know, there's a focus on financial literacy.

Right now, there's a focus on "entrepreneurialism".

There's a focus on career readiness.

Are we also looking at including the medical component and then also, broadening their ideas toward, "physician-ships", as well?

Sen.

Tom Davis> I do know that technical colleges, especially in Beaufort, have a focus on that at that level.

As to your question on whether or not K through 12, whether or not they're being focused on the same way that financial literacy or others might be, I don't know the answer to that question, sir, but, but certainly, I think having that introduced at an earlier age and try to inculcate that sense of community and that sense of importance, but it doesn't get at the underlying problem that, that the doctor addressed here about the sheer cost of it.

And I'm not really sure what we do in that regard.

I mean, I wish I had I wish I had all the answers, but I don't in that regard.

Dr.

Adams> I'll add that... we're talking a lot about cost.

We're talking a lot about workforce and physicians, nurse practitioners, P.A.s are, are kind of the backbone of primary care, but Mike spoke about community health workers, which are, you know, a newer type of, of, health care employee that really assists the patient trying to navigate them through the health care system.

That's a...fantastic model and it's growing.

It's providing a lot of value.

Unfortunately, there's no reimbursement for it.

You look at community paramedicine, which is paramedics that are highly trained, that are going into communities in a different way, going and checking on patients that, that their provider is specifically concerned about doing, using their expertise as a paramedic in a new and different way.

There's not reimbursement for that.

Doulas which help in the childbirth process, more and more communities, more and more mothers are finding great value in, in using a doula.

There's no reimbursement for that.

Peer support specialists or folks with, with lived experience, especially around behavioral health that, that can work in the field and, you know, understand from a deeper level what it's like to struggle with some of those challenges.

These are new types of providers that, that I think are going to, reduce costs and increase access.

And unfortunately, we don't have a consistent reimbursement methodology as a state for those at all.

None of those that I mentioned.

So I do think looking at legislative solutions to see how we can use those folks who require much in theory, much less training, but can provide the care that is appropriate and necessary and can really kind of, unclog the, the backlog in some of our health care systems.

That's something that I think is, is...We already have the workforce that is going into those new professions.

We just need to make sure that the reimbursement is there.

And then I think we would really start to see, it's very rare that you see costs come down in health care.

People talk about it a lot.

It rarely happens.

But I do think that, that, that looking at new opportunities like that using, using trained folks in different ways will actually take the burden off physicians, nurse practitioners, P.A.s.

Sen.

Tom Davis> And, and thinking about the question the gentleman asked about, I think what he's getting at and I'm as I'm sitting and thinking about it, what is giving rise to this physician shortage problem?

Is it...the cost?

Is it the amount of time you have to put in to become a physician, or is it a culture or an education thing that we can do better at K through 12?

And I frankly don't know the answer to it.

And I know empirically we're not having the pace of the number of doctors grow proportionally to the population.

You ask a great question as to why is that the case?

Is it...something we can do through K through 12?

Is it something we can do with incentives, for doctors to go into rural areas and maybe have debt forgiveness?

Is it, I mean, I honestly don't know.

I wish I knew the answer a cause and effect.

So I'd like to get at it.

But I would love to have that conversation and, and also talking with the South Carolina Medical Association.

I mean, I'm sure they have some ideas about what can we do as a legislature, either through K through 12 curriculum, through programs that encourage doctors going to rural areas, debt forgiveness, I mean, more residencies.

I mean, there are things that we can do, and I'm open to all of them.

I just don't have an answer for you, sir, as to what's a one to one correlation, there.

Dr.

Lefebvre> I do have a little bit of information.

Again, I think further study is needed for us to really understand what's happening.

But, to our state, we've actually one of the things that I think we've done really well at in the last, 8 to 10 years is increasing graduate medical education, which is that residency training program that comes after medical school.

And so, we have more than doubled family medicine residency programs, in, in the, you know, in the last 8 to 10 years.

...so it is good because we have increased training programs, increased training opportunities.

We are not seeing that we're having the number of... We have for fantastic medical schools in this state.

And we're very fortunate as a small state to have four medical schools.

And that, it really goes a long way.

We are not able to fill our primary care residency programs just out of the medical schools that we have in this state, because, you know, the medical students are not necessarily choosing primary care.

And that's really what we need to support rural communities.

So we're not able to fill these programs specifically from just our in-state medical schools.

We're pulling from other states to have their medical students come to our residency programs, and we're showing it's still a little bit early yet, because, again, these programs are 3 to 5 years in training.

So it takes a little while for us to know if this increase in G.M.E., graduate medical education is we're really seeing.

But, but so far we have not seen and this increase has been over the last ten years.

So far, we're not seeing a real increase in retention.

At the same rate that we have an increase in those graduate medical education programs.

And so we are losing physicians that train here and don't stay here.

Sen.

Tom Davis> Do you see making it easier for international physicians who are qualified, who can pass basic competency tests or qualification tests for South Carolina to make it easier for them to come to South Carolina, because it's very difficult for them right now for international doctors who are trained to come and practice here, would that be one way to address the supply problem?

Dr.

Lefebvre> I think it's something we definitely have to look at and consider.

Because I and I think there's other things of, of are we making it easier for licensed physicians from other states to come here, and, and obtain, maintain their licenses here, as well.

So I think that there's certainly things in there that we should look at and consider, to are we making it, you know, I guess, are we making the pathway for those that are, licensed and already qualified to make sure that, they can if they want to, you know, choose to move and grow here in, in South Carolina, that they can do that as well.

I think it's very worth looking at it.

Sen.

Tom Davis> Can I do one more follow up?

Sierra> I want to get a chance to get to Ms.

Young here.

He's been writing things down.

We probably need to get him another piece of paper.

So let's go ahead,...give, let's get him another, another card.

Go ahead.

Mike> I think, I'm going to kind of get to all this stuff.

I think what needs to be done is kind of looking at what are the strategies that we in the other arenas are doing to make up the difference, because it's like we we try to cobble the pieces together.

And I just got back from two big conferences, national free clinics, and then the Southeast Community Health Worker one.

And so, we know that non-profits are cost saving saviors and they're seen like that.

But to know the facts too, like, for example, community health workers, it's been known to save up to $10 for every dollar invested.

Our free clinic, we know our value is about half a billion annually that we save from E.R.

visits and things like that.

But I think the point is, is that we are smaller and we're scrappy, and we can be innovative in that approach.

Right?

We can try new things.

And, you know, looking at the, the, the strategies that, that we employed, for example, our doctors donate their time for free.

That's how we got started.

And other free clinics have a different strategy.

But we're lucky enough to have these great doctors that find fulfillment.

They have the ability, the capacity to give their time and donate it.

And they, they honestly come back saying that I feel like I've been a better doctor because I've been able to do it like this, spend more time with them.

They get to connect with the patients.

And, you know, we have a we have a spiritual component to our organization.

So people feel that they're answering that Christ called to serve.

Right?

And...so that element, you know, ties into why people do what they do.

Also, like if I get into a room with doctors, I'm going to get some of them on my team, right?

When, and I love that.

But we typically only have one doctor per shift, right?

We have two.

That's great.

Sometimes we don't.

So provider shortages on our end is, is a big deal, as well.

Even though most of our doctors might only give three hours a month, one shift, right, per month, three hours.

But, I mean, it makes a huge difference.

But we are exploring other ideas, for example, nurse practitioners through the College of Nursing.

They have a contractual basis.

Right?

So we're looking at because we have limited funds, right?

I do grant writing.

I get donations.

So I'm trying to make the most out of what I get.

And, you know, they have contractual base where I think the other free medical clinic in town utilizes that certain hours per week you contract, but this is paid, right?

So this is a whole other shift for us if we were to go that route.

But yeah, those collaborations, I think that's, you know, leaning on each other.

Right?

We can't all do it ourselves.

Right.

So, we utilize specialists and have them come to us.

Wellpartners, they do vision and dental.

They've done two mobile, unit mobile clinics, which is not mobile, but remote.

They came to our house, our house, our clinics are houses.

So we're like, mi casa es su casa, you know?

They did vision for 15 patients in three hours.

Right.

We also give food share boxes so they know that the people trust our locations so they know they're going to access patients.

And, I mean, our appointments fill up because of our community health worker.

You know?

She knows how to get people excited and get them connected.

We lean on people like, Well Vista gives free pharmacy, medications, food share boxes.

We're looking into paying for people's labs.

So we're trying to reduce all those barriers.

And we do specialty care ourselves, but we'll kind of pilot it.

Like we have an OB day and a GYN day, right?

One day a month.

We have an OB doctor that sees women during their first and second trimester, and then they continue on it through Prisma.

Right?

We have a total rock star Dr.

Kari-Claudia Allen She's amazing.

And, so we, we were able to extend ourselves in proportionate ways and we're trying out new things like I'm building a mental health initiative.

Right.

And, we, we got a grant from D.H.H.S.

for a mobile clinic.

Right.

Oh.

<Congratulations>.

Thanks.

But the thing is, is, like we're able to pilot things, right?

And I really think that plays into the whole, like, we're, we're flying the plane while we, while we were building the plane while we fly it.

Right?

Like we're maybe that's where pilot comes from, right?

We're piloting it, you know, so much piloting.

But, you know, we're willing to try new strategies.

And I think that's what you see in the free clinics.

Right.

And people are invested because they're doing it for the most part because they want to be there.

Right?

I've never seen such a dedicated staff.

And most, we have 150 volunteers.

I'm like, I didn't know how to work with the volunteer staff.

How do you ask people to do more when they're just giving it for free?

So, so I had a lot of notes.

Sierra> He's been waiting for a while.

Mike> But essentially, that's it.

Yeah.

Like, you know, investing in each other and leaning on each other and collaborating.

That's, that seems to be our model that works.

And yeah, we're looking for ways to generate revenue, like innovative strategies.

I'm going to open up a thrift store that's going to help generate revenue.

Sierra> I have a final question for everyone on the panel.

We have less than ten minutes left, and I want to make sure that we all briefly are able to share.

But before I do, there's one thing I've been wanting to, I've been itching all night too.

I just didn't write it all down.

But I want to talk about the impacts in rural communities really quickly.

You know, I spoke with you, Dr.

Adams, earlier.

and one thing that you said to me that really stood out was there are people that live in some of these major cities in South Carolina that don't think that the issues surrounding health care in rural communities impacts them.

And I want you to share what you shared with me.

Dr.

Adams> Yeah.

So, you know, I've had the pleasure of doing this work for 32 years now and helping rural communities.

And, you know, throughout the years, I've run into people and they say, well, if people want all these things, why don't they move away from Bamberg or Edgefield?

And then why don't they move to Columbia or Charleston or Greenville?

I think that people don't appreciate the interdependence between our rural and urban communities.

I mean, when, when you think about our power, our water, our food, those all come from our rural communities.

And you may think, okay, you know, for instance, let's just say I grew up in Charleston.

I've lived here my whole life.

I don't plan on moving.

I have no connection to rural, you know, depending upon how you define rural, about 32% of our population and 80% of our landmass is rural.

Now, that'll change slightly as our state grows, but that's still a huge portion of our population and, and the majority of our state.

And we just, in my mind, we just can't let kind of rural communities wither on the vine.

We have, we have ten counties, in the state with no hospital.

We have, and we have 15 plus counties where they don't deliver babies unless it's a emergency at the hospital.

And, you know, the, the market works well, the free market works well when there's... somebody who's willing to pay for it, and you have a customer, when there's nobody willing to pay for it.

Then, then you have a real challenge.

So no one is falling, no health systems are falling over themselves to go provide care in Allendale or, or Saluda or places like that, because the payer mix isn't very good and because you have population decline, not growth.

So, you know, we, we've had two what I think of is pretty big communities, 80,000 plus in the state where, obstetrics have been discontinued in the last few, few years.

And, you know, that was that was done for financial reasons of the system that serve them.

But, but more and more, you're getting away from that.

Sierra> And we are, we have four minutes left in the show.

I wanted everyone to get a chance to have final thoughts.

One of the things that you mentioned, you mentioned to me was the food, and where most of those, you know, we're an agriculture state and most of those towns, those smaller rural areas are the areas where our food is cultivated and grown.

So I think I think we'll probably have about one minute each for final thoughts, maybe provide where more people can get information.

Dr.

Lefebvre> So,... we can get information about A.H.E.C., at scahec.net and all of our programs there.

And I really think, you know, we need to look, we need to work with these communities and understand what they need.

And not assume that we know what they need, and really understand from them.

You know, how can we grow this or that?

It's stable.

I think that's the biggest piece is putting something in that's going to be there for three years, and then it, and then it's no longer available to them is not going to help this.

I think we need to be really careful to make sure whatever we can build to support these communities, that it's, it's stable, sustainable, reliable for them.

Sierra> Wonderful.

Dr.

Young?

Dr.

Young> And I would say partnerships is key partnerships with other providers, like the free clinics, the F.Q.H.C.s or federal qualified health centers and community health centers, as well as, other primary care providers, specialists, hospital systems or health systems.

We all need to come together to talk about what we do and how we do and do things, and where we have an expert lane in doing those things, very similar to the, the, services you mentioned through the, the, your free clinic.

Those are provided, at community health centers for an affordable, because there's a sliding fee discount.

So partnerships are going to be key, partnering with the community to make sure that we are providing the needs based on, what they need.

Sierra> Thank you.

Senator?

Sen.

Tom Davis> I want to augment what the doctor said over here about rural communities, that the health of rural communities does affect urban areas.

They are not, they're not mutually exclusive.

And, you know, as you say, agriculture.

I mean, the rural communities provide a lot for municipalities.

And so we don't need to be thinking in those terms It's everybody's, everybody's concern.

The fact that I may live in an urban area doesn't mean that, that rural people and rural health care doesn't matter to the state, doesn't matter to me.

That's just a false premise.

Sierra> Wonderful.

And Mike?

Mike> Yeah, sure.

I think, investing in, in, in programs that could stretch the dollar really goes a long way because, for example, our doctors donate their time for free for the most part.

We have volunteers.

We don't even pay rent at our location.

So we get all this in-kind, value.

But also, you know, I just my presentation yesterday was, the heart of the clinic, building an effective C.H.W.

model in a free clinic.

And, you know, I talk about how Duke Endowment has invested in us because of our community health worker approach, other larger institutions see that.

And the way that we keep it sustainable is that we embed it into our line items.

Right?

We make it part of the budget every year.

And essentially that, yeah.

I think, community health workers, that's, that's where I'm going to really make the impact, because they listen to the community and they hear what the community needs, and that helps us drive what our programs are going to be.

Sierra> Okay.

All right.

Well, I want to thank you all for joining us today.

Everyone has provided very insightful information, and I want to thank you all for joining us tonight, as well.

For additional resources or to contact any of the guests, or their organizations, please go to, SCETV.org.

I want to thank you all.

Have a good night.

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