To attract health personnel to undersupplied areas, more targeted strategies have been developed. In Britain, for example, a negative incentive denies physicians a list of publicly insured patients (almost the entire population) if they locate in oversupplied areas such as London. The United States has tried positive incentives in the form of the National Health Service Corps (NHSC). The NHSC includes loan repayment features for health professionals that serve in designated shortage areas, and it encourages personnel to remain in these areas after their service period is finished. These strategies are attractive because they address both the shortage problem and the problem of student debt repayment. The General Accounting Office, however, concluded recently that the impact of these programs on underserved areas is difficult to establish (GAO, 1994). It found, however, that the increased total supply of primary care physicians and dentists in the past decade has not been accompanied by increases in ''those urban and rural areas where the greatest shortages exist" (p. 2). The Department of Health and Human Services developed an oral health initiative in FY 1994 in response to Senate concerns about limited access to "primary care oral health services" and inadequate identification of affected areas and populations (U.S. Senate Appropriations Committee, 1994, p. 41). The GAO report concluded that "these actions are not likely to have much impact, at least in the short run" (1994, p. 2].

One problem with the NHSC and related programs is restricted funding. Of the 1,069 designated dental shortage areas in 1993, only 356 had been updated since 1988 and thereby made eligible for assistance through the NHSC (J. Rosetti, personal communication to M. Allukian, April 4, 1994). Moreover, the U.S. Health Resources and Services Administration has approved only 75 dental vacancies for loan repayment participants, and at the time information was provided to this committee, only 23 positions had been filled. One report states that there are no "ready" sites available for additional dental school placements (AADS, 1994c). Such sites have the equipment, salary, and staff to support an NHSC participant. One additional problem cited earlier is that many shortage areas call for part-time positions, and such positions are particularly difficult to fill.

Representativeness of the Work Force

As noted earlier, the composition of the dental student body and the dental work force has changed rather dramatically in some



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