Department of Health and Human Services


OFFICE OF


INSPECTOR GENERAL


HEALTH EDUCATION ASSISTANCE LOAN


(HEAL) 

ERVJCES' -1 

Richard P. Kusserow 

INSPECTOR GENERAL 

'0 

OEI-02-90-00980 olq"'d 
EXECUTIVE SUMMARY


PURPOSE 

The purpose of this inspection is to ascertain the degree of implementation, effectiveness and 

support for the recent regulatory reforms of the Health Education Assistace Loan (HAL) program. It also assesses whether further reforms, such as performance standards and 

risk-sharng; are considered necessar and what their possible effectiveness might be. 

BACKGROUND 

This study was initiated because of high-level concerns about financial problems the HEAL 

program has been experiencing due to an increasing default rate. The Public Health Service 

(PHS) projects the Student Loan Insurance Fund (SLIP) wil not have suffcient funds to pay the 

increasing number of claims. 

The Deparent has, over the last few years, announced regulatory reforms to reduce the HEAL 

default rate and keep the SLIP solvent. These include requirng schools to conduct entrance and 

exit conferences and needs analyses, and having lenders conduct credit checks, exercise due 

diligence, including preclaim assistance, and initiate litigation where collection attempts have 

failed. 

Performance standards and risk-sharng have both been proposed as furter ways to strengthen 

HEAL. Lastly, and very significantly, the President s budget for Fiscal Year 1991 calls for the 

phasing out of the HEAL program. However, the phasing out wil requir Congressional action 

and may take many years due to the long-term nature of the loans. 

METHODOLOGY 

This inspection was based on: a literature review; an examination of HEAL Annual Reports; a 

stratified random sample of 120 school programs paricipating in HEAL; and information 

gathered from 120 financial aid offcers from the sample schools and from offcials of the top ten 

HEAL lending institutions. Contacts were also made with several Federal managers experienced 

in risk-sharng in other Federal programs to determine to what extent it has been effective in 

helping to reduce default rates. 
FINDINGS 

Reforms Are Widely Implemented And Generally Supported; Opinions Vary About Their 

Effectiveness. 

The inspection found that both schools and lenders are fully implementing the recent feforms. 

All reforms are supported by both schools and lenders with the exception of litigation. However 

preliminar evidence suggests that litigation is successful in 25 percent of the cases. Overall 

both schools and lenders feel it is too soon to judge the long-term effectiveness of the reforms. 

Some impact has, nevertheless, already been noticed. 

Most Schools And Half The Lenders Believe Performance Standards Wil Be Effective; Almost 

All Oppose Their Use. 

Although most schools object to the implementation of performance standards, more than 

two-thirds feel that performance standards wil be either somewhat or very effective in reducing 

the default rate. Half the lenders agree that performance standards will be effective. This 

approach was successful in reducing the default rate in the Health Professions Student Loan 

(HPSL) program, also sponsored by the Deparent. 

Mixed Views Exist On The Use And Value Of Risk-Sharing. 

Both the schools and lenders believe schools should not be required to paricipate in risk-sharng 

and doubt that the schools ' paricipation would be effective. However, schools see lenders in 

that role and feel lender paricipation wil be effective. Nolenders support risk-sharng for 

themselves. One-half say that they wil drop out of HEAL with risk-sharng, and some mention 

that it would cause them to be more restrctive and limit who gets the loans. In any event 

neither group feels risk-sharng is actually needed to save HEAL. 

RESPONDENT RECOMMENDATIONS 

When asked for suggestions on how to improve the HEAL program, schools and lenders most 

frequently volunteered the following innovative ideas: 

Change the terms of the loan, such as eliminating compounding interest and reducing 

the interest rate (which are now being done by a few lenders), and reducing the 

maximum loan amount and basing a tiered insurance premium on the default rate of 

each discipline. 

Impose stricter penalties for defaulters, such as garnisheeing wages, offsetting 

Medicare and Medicaid reimbursement, withholding professional licenses and 

providing no bankruptcy forgiveness. 
Improve communication and coordination among schools, lenders, borrowers and the 

Federal government. 

RECOMMENDATIONS 

We recommend that performance standards be implemente without delay. Our 

recommendation is based on predictions of schools and lenders that they wil be effective, by the 

successful recent experience of the HPSL program with performance standards, and by our 

analysis of HEAL default experience to date which suggests substantial future savings with the 

use of performance standards. It shows that if all schools had maintained a default rate of no 

more than five percent it would have resulted in $20.5 million not being claimed, which 

represents almost 18 percent of all default dollars since the program began. These stadards 

would be a useful tool should the program be retained and would, of course, be beneficial durig a phase-out period. 

COMMENTS 

Comments on the draft report were received from PHS and ASPE which concur with the 

recommendations of this report. The PHS believes that the final rule for performance standards 

wil be published by September 1991. 
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TABLE OF CONTENTS


EXECUTIVE SUMMARY 

INTRODUCTION..................................................................................................... .


PURPOSE................. ........... 


BACKGROUND ........... 


METHODOLOGY.................................................................................................... .


FINDINGS ..................................................................................................................


Reforms Are Widely Implemented And Generaly Supported; 

Opinions Var About Their Effectiveness............................................................


Most Schools And Half The Lenders Believe Performance Stadards 

Wil Be Effective; Almost All Oppose Their Use ................................................


Mixed Views Exist On The Use And Value Of Risk-Sharng ............................ 

RESPONDENT RECOMMENDATIONS ............................................................. 

RECO MMEND A TIO NS ..................................... .... 

COMMENTS........................................................................................................... . 

APPENDIX A . A - 1 

APPENDIX B B - 1 

APPENDIX C .................................................................... C - 1 
INTRODUCTION


PURPOSE 

The purpose of this inspe.ction is to ascertain the degree of implementation, effectiveness and 

support for the recent regulatory reforms of the Health Education Assistace Loan (HAL) program. It also assesses whether further reforms, such as performance standads and 

risk-sharng, are considered necessar and what their possible effectiveness might be. 

BACKGROUND 

HEAL Program 

This study was initiated because of high-level concerns about fmancial problems the HEAL 

program has been experiencing. 

The cost of financing an education in the health professions escalates every year. Rising tuition 

and living expenses make training in such fields increasingly expensive. Few students can meet 

these costs by relying solely upon their own or their parnt s income and, therefore, most depend 

on loans. In response to this need, the Federal government, States and varous private 

organizations offer loans to these students. The HEAL program, an insured-loan program 

administered by the Deparent of Health and Human Services (DHHS), is an importt source 

of such funding. 

The DHHS established the HEAL loan program in 1976. It is managed by the Public Health 

Service (PHS), in cooperation with parcipating schools and lenders. Schools determine the 

costs of attendance and the eligibilty of applicants. Lenders make determinations of the 

creditwortiness of applicants, issue loans and make collections. 

The HEAL program insures loans made by nonfederallendig institutions and was intended to 

operate without using Federal funds. It was designed to be self-sustaining by having insurce 

premiums deducted from the loan principal at the time of the award. These legislatively capped 

premiums, which have raged from 1/4 percent to a current rate of eight percent, are deposited 

into the Student Loan Insurance Fund (SLIP). The SLIP reimburses the holder of the loan 

(tyically a lending institution) for the full amount of the principal and accrued interest in event 

of the borrower s default, death, disabilty or bankptcy. 

The HEAL program allows students of medicine, dentistr, osteopathy, veteriar medicine, 

optometr, and podiatr to borrow up to $20,000 per year, not to exceed a total of $80,000 over 

the period of academic study. Students of pharacy, chiropractic medicine, health 

administration and clinical psychology may borrow up to $12 500 per year, not to exceed a tota 

of $50,000. The loans have a varable interest rate, which is capped at T-bil plus thee percent and usually accrues while the student is stil in school. Repayment begins nine months after 
graduation or after the completion of an accredited residency or other deferment not to exceed 

four years. The maximum repayment period is 25 years. 

The HEAL program has grown dramaticaly since its implementation in Fiscal Year (FY) 1978, 

in both loans disbursed and default claims paid. Disbursements totaled $85.6 milion in FY 

1979, peaked in FY 1986 to $321.4 milion, and then leveled off at $229.3 milion in FY 1988. 

In FY 1989, disbursements totalled $250.6. Claim payments increased substantially from $0. milion in FY 1979/1981 to $35.5 milion in 1988, for an 1989 aggrgate total of approximately 

$95.8 milion. 

Emerging Financing Problem 

Although the insurance premiums have increased substantially over the years, PHS projects the 

SLIP wil not have sufficient funds to pay the incrasing number of claims. To fIl this gap, the 

SLIP received a special appropriation of $25 milion in FY 1990. The PHS feels that continuing 

deficits over the next few years wil require further appropriations. 

In response to a Congressional mandate to investigate the factors causing borrowers to default, 

PHS contracted with L.J. Colker & Associates and Applied Management Sciences, Inc. to 

conduct a study in 1988 entitled, "A Review of HEAL Defaulters: Their Causes and Corrective 

Measures - Par II. " This study found the majority of sureyed HEAL defaulters to be between 

the ages of 30 and 39; male; caucasian; non-Hispanc; mared or formerly mared; and having 

an average of 1. 16 dependents. Their leading occupation was chiropractic medicine. The study 

concluded that defaults occur not because students inappropriately select HEAL as an option, but 

rather because of unanticipated problems when the tie came to repay the loan. These problems 

include delays in obtaining a license, the need to invest large sums of money when opening a 

practice, and not completing their professional education. 

The PHS also has contracted with the Development Assistance Corporation (DAC) to design and 

document a forecasting model which wil estimate cash flow in futu years. This work has 

recently been completed. 

Recent Changes 

The Deparment announced regulatory reforms, effective Apri 1987, which are designed to 

reduce the HEAL default rate and keep the SLIP solvent. These reforms were based priary upon recommendations made by the Offce of Inspector Genera in a series of audits issued durig the period 1983 to 1987. They include: 

Entrance and Exit Conferences. Schools are requird to conduct entrance and exit conferences with HEAL borrowers to advise them of the terms of the loan and to educate them 

about repayment. 

Needs Analysis. 
 HEAL borrowers must undergo a financial needs test by the school to determine eligibilty and the loan amount for which they qualify. 
Creditworthiness. The lender must now apply more strngent creditwortiness standards 

in determining an applicant's eligibilty, including reviewing an applicant s credit history. 

Due diligence. 
 Lending institutions must prove increased due diligence in collecting the 

loan before fiing a default claim, including: employing collection practices that ar at 

least as extensive and as effective as those used in the collection of the lender s other 

loans; immediately notifying an appropriate consumer credit reportng agency regarding 

accounts overdue more than 60 days. 

Preclaim assistance. 
 After the lenders ' attempts at collection have failed, the lender is required to notify PHS and request preclaim assistance. The PHS then sends out a series of 

three letters with increasingly strong language to remind the borrower to repay his/her loan. 

Litigation. As of November, 1988, ifthe lenders' due diligence and PHS' s pre-clais assistance do not result in repayment, lenders and holders are required to initiate litigation. 

They must refer the case to the local court and obtain a judgement against the borrower 

prior to submitting a default claim to PHS for payment. 

Proposed Changes 

Based on Public Law 100-607, effective November 4, 1988, which authorized the Secretar to 

establish default standards for HEAL schools, regulations wil soon be proposed against which 

the default rates of schools, lenders and holders of loans in the seconda market wil be 

measured. Schools, lenders and holders with a default rate above a certn percent would not be 

allowed to parcipate in the program. 

In recent years, the Administration has advanced several other legislative proposals for 

improving HEAL, including: . eliminating the eight-percent insurance premium limit; experience 

rating the premiums by school, lender or discipline; charging the insurce premium over the 

life of the loan; trsferrng responsibilty for the loan from the Federa Government to the 

lender in cases of a borrower s death or disabilty; and extending risk-sharng for the ftrst time to 

both lenders and schools, so that both would have to pay a specified percentage of an 

outstanding loan should one of their borrowers or students default. Pror OIG reports have 

supported these proposals. Thus far, Congress has declined to implement any such reforms. 

Lastly, and very signifcantly, the Prsident s budget for Fiscal Year 1991 calls for the phasing 

out of the HEAL program. However, the phasing out wil require Congressional action and may 

take many year due to the long-term nature of the loans. 

METHODOLOGY 

This inspection was conducted in the following manner: a literature review was conducted and 

prior studies were obtained dealing with bank paricipation in the HEAL program, HEAL 

defaulters, the SLIP and possible new reforms. The HEAL Annual Reports published by PHS 

were reviewed. Next, a stratified random sample of 120 school programs parcipating in HEAL 
was developed with 32 alopathic medical, 29 dental, 17 chiropractic, 15 osteopathic medical, 7 

podiatr and 20 other specialty programs (See Appendix A). Contacts were then made by phone 

and in person with both 120 financial aid offcers from the sample school programs and with 

officials responsible for HEAL at the top ten lending institutions, which account for 94 percent 

of loans disbursed in FY 1989. Information was obtained from schools and lenders regardig how the new reforms have impacted on their use of the HEAL loan, and their perceptions 

regarding other possible reforms such as performance standards and risk-sharng. Statistics were 

gathered on default rates, disbursements, loan amounts and litigation. The experience with 

performance standards in the HPSL was analyzed. Finally, information was obtained about other 

Federal loan programs which have risk-sharng, and interviews were held with several Federal 

managers experienced in these programs to determine to what extent it has been effective in 

reducing default rates. 
FINDINGS


REFORMS ARE WIDELY IMPLEMENTED AND GENERALLY SUPPORTED; 

OPINIONS VARY ABOUT THEIR EFFECTIVENESS. 

Schools Have Implemented Reforms and Support Them Fully. 

Entrance and Exit Conferences 

Almost all schools conduct the required entrance and exit conferences. Ninety-thee percent 

counsel students individually or in groups on the HEAL application process, and ninety-seven 

percent meet with students before graduation to discuss repayment. Schools also employ other 

innovative counseling procedures to help lower the default rate. These include (1) computer 

software programs designed especially to educate students about debt management and (2) exit 

meetings between lenders and students to inform students about repayment. 

Virually all schools consider entrce and exit conferences and ongoing counseling as effective 

ways to lower the default rate. In fact, a few schools with low default rates specifcally attrbute 

their low rates to their counseling procedures. One respondent states, "We consider our entrance 

and exit conferences and debt counseling as substatial steps in dealing with all loan programs, not just HEAL." Many schools strss the importce of student counseling, financial planning 

and debt management in administerig HEAL. Thir-six percent of schools report increasing, 

or planning to increase, their counseling efforts despite the fact that over thre-quarers of these 

schools have default rates lower than five percent. Over one-fifth of the schools and lenders 

volunteered support for extensive student counseling as a means of assurng the continuation 

the HEAL program. 

When asked for suggestions as to how to improve the HEAL program, 23 percent of schools and 

20 percent of lenders volunteered increased student counseling and education, including 

maintaning contact with student borrowers after graduation. One respondent states that 

consistency amongst schools in their counseling is needed - students everywhere should be told 

the same thing. " Severa schools suggest implementing a financial management program to help 

students handle their borrowing; one respondent states, "I would recommend every school have a 

financial planning seminar to reach all students. " Other schools indicate that continual personal 

contact with students is essential to keeping them apprased of their debt and repayment 

obligations. Schools feel that counseling should also be extended to borrowers in residency 

programs. 

Needs Analysis


All schools report routinely employing a needs analysis to determine HEAL eligibilty and the 

amount of the loan. Almost two-thirds consider financial need as a major factor when 

recommending HEAL loans and many schools report recommending HEAL only when all other 

financial resources are exhausted. Almost an schools report that students consider only their 
need for money when applying for a HEAL loan. One respondent reflects the view of many 

when she says, "Students used to borrow a lot but since the needs analysis and counseling they 

tr to borrow as little as possible, sometimes even less than they are allowed. " One lender 

reports some decrease in HEAL usage since the needs analysis. 

Lenders Have Implemented All Reforms; Some Impact Already Seen. 

Creditworthiness 

All lenders routinely check the credt history of HEAL applicants. All but one had never run 

such checks prior to the recent reform. Sixty percent of lenders indicate that more strngent 

creditwortiness standards have decreased the number of HEAL borrowers at their institution. 

While most applicants are able to resolve their credit problems and obtain a HEAL loan, a 

majority of schools and lenders report that a small number of potential student borrowers with 

bad credit are ultimately rejected. 

Most lenders and schools support the creditwortiness requirment. Lenders believe that credit 

checks prevent some high risk borrowers from tag out HEAL loans. One lender says, " 

now have better customers. " Both schools and lenders mention that such checks make students 

aware that they have a credit history and a financial responsibilty to pay back HEAL loans. 

Seventy percent of schools feel credit checks wil be effective. A majority of lenders say that 

credit checks wil have the most impact on those students that have a credit history to assess. 

Due Dilgence


All lenders report exercising strong collection efforts to fulfll the due diligence requirement. Fifty percent of lenders responsible for collection of these loans believe increased due diigence such as contacts by phone or in persdn to secur repayment wil help reduce the HEAL default 

rate. The remaining lenders feel that they have always been exercising due diigence. Lenders 

report exercising due diigence with HEAL to the same extent as with their other loans. Some 

mention that because of intensified collection efforts some borrowers finaly file for deferment or 

initiate repayment. 

Seventy percent of school loan offcers believe due diligence wil help reduce the HEAL default 

rate. Some loan offcers who keep in contact with their borrowers feel that even stronger efforts 

than those required should be made by lenders to keep track of the borrower before he/she 

defaults. One respondent mentioned that he knew of several defaulters in his community with 

successful practices who the lender made no effort to go after. Schools feel due diligence 

increases important communication between the borrower and the lender and forces lenders to be 

more aggressive in their collection efforts. 

Twenty-three percent of schools, when asked how to ensur the continuation of the HEAL 

program, volunteered that lenders need to do the best job possible in servicing the HEAL loan. 

These respondents support greater due dilgence, stressing in parcular that collection efforts are 

key to reducing the HEAL default rate. 
Preclaim Assistance 

All lenders report referrng their delinquent borrowers to PHS for preclaim assistance after 

having exercised the required due diligence. The PHS reports that preclaim assistance was 

effective in obtaning cures - that is, successfully resolving the loan either with repayment, 

forbearance or deferment - in 93 percent of the referred cases in FY 1989. This is 18 percent 

more than the FY 1988 rate of 75 percent. One lender supports preclaim assistance and says, 

We get deferments now and they ar not turned over as defaults. 

Litigation 

All lenders initiate litigation against delinquent borrowers when preclaim assistance has failed. 

Thirty percent of lenders and forty-three percent of schools feel litigation wil be effective 

reducing the default rate. 

Lenders report a wide range in the number of cases in litigation, from six to 2200. The PHS 

estimates the dollar value of cases currently in litigation to be about $73 milion. Although the lenders are obtaining judgments against borrowers, the cases often do not result in successful 

collection efforts and PHS ends up paying the claims. Neverteless, one major lender, who 

holds 60 percent of the HEAL loans, reports that 25 percent of their cases in litigation enter 

repayment status. Another major lender agrees when he says, "Once students ar theatened with 

litigation 50 percent wil star payment, but only half of them wil probably pay. 

Despite the success of litigation, lenders still have serious reservations. Lenders consider 

litigation an expensive process which makes it diffcult to sell loans in the secondar market. 

One lender considers litigation "fritless " in those cases where borrwers simply can not pay. A few lenders note that the claims paid are ultimately larger than the initial defaults because 

interest accrues while the case is being settled. Sixty percent of-lenders report that litigation has 

made them reconsider their paricipation in the HEAL progr. While many schools feel the 

threat of litigation might motivate some borrowers to repay, they also consider it a very costly 

process, to be used only as a last resort. 

Both Lenders and Schools Feel it is Too Soon to Judge Results of Recent Reforms 

Some respondents volunteered that the recent reforms have not been implemented for a long 

enough time to judge their long-term effectiveness, and it wil be years before the tre results 

wil be known. The current default rate is more reflective of the HEAL progr prior to the implementation of the reforms. One respondent voices the concern of many when she says, There needs to be some time given to see if the changes that have come into effect recently are 

workig. " Similarly, another respondent says, "These things take time, you can t wave a magic wand and make the rate go down. 
MOST SCHOOLS AND HALF THE LENDERS BELIEVE PERFORMANCE 

STANDARDS WILL BE EFFECTIVE; ALMOST ALL OPPOSE THEm USE. 

More than two-thirds of schools feel that performance standards, that is not allowing schools and 

lenders with a default rate above a certain percent to paricipate in HEAL, wil be either 

somewhat or very effective in reducing the default rate. Half the lenders agree that performance 

standards wil be effective. Most schools and lenders feel that performance stadards wil force 

some schools out of HEAL and cause some lenders, especialy the smaller ones, to leave 

voluntarly. 

Performance standards had a positive effect on the Health Professions Student Loan program 

(HPSL), also sponsored by DHHS, which provides for long-term, low-interest loans to 

exceptionally needy students in allopathic medicine, osteopathc medicine, veterinar medicine, 

podiatrc medicine, optometr, dentistr and pharacy. Parcipating schools administer the 

program, collect repayments and are held to a performance standard of a five-percent default 

rate. The standards were ftrst proposed in 1982 and finally implemented in 1984. Upon implementation, the PHS gave schools with default rates above five-percent six months to lower 

their rates by one-half. If they succeeded in doing so, they were given another six months to 

lower their new rate by yet another fifty percent, until they finaly reached a five-percent default 

rate. Ultimately, fewer than seven schools were actually terminated from the program. Schools 

were able to successfully lower their default rates because of the following factors: they became 

more aggressive in their collection efforts; purchased some of their outstading HPSL loans; and 

transferred some of their delinquent HPSL loans into their own institutional loan programs. 

the Fall of 1985, Congress also changed the formula used to calculate the HPSL default rate, 

thereby reducing schools' rates, on average, by one-third. 

Pror to the implementation of performance standards, HPSL had been experiencing fmancial 

diffculty. The overall HPSL default rate has decreased from 12 percent in 1981/1982, to flove 

percent by the time performance standards were implemented, to a curent rate of approximately 

two percent. The HPSL program is now fmancially sound. It is important to note that a 

difference between this program and HEAL is that schools have control over the collection 

process in HPSL. 

Most schools object to performance standards being implemented. Many schools consider them 

unfai for several reasons: they have limited control over the default rate; while they approve 

HEAL applications, they are not involved in performing credit checks or in the collection 

process; and they have little contact with the borrower after graduation. Schools also consider 

unfair the possible loss of HEAL to future students who have had nothing to do with earlier 

default rates. 

Schools voice concerns about performance standards. Many volunteer that a five-percent 

standard would be too low and too diffcult to meet. In fact, most schools suggest that the only 

steps they can tae to reach a five-percent default rate are increased counseling and a 

continuation of their current efforts. One school respondent offers, "The way to reduce default is 

not to slap schools ' and lenders ' hands if they go above the rate. The answer is education of 

schools and lenders about the program." Some schools are also concerned about how the default 
rate is calculated. One respondent suggests that the government should clarfy which default rate 

is going to be used, adding, "I think it s ridiculous that if a person has six loans and defaults, it 

counts as six (defaults) instead of one. " Another issue rased by schools is that other Federal 

educational loan progrms such as the Stafford Loan progr run by the Deparent of 

Education have higher performance standar rates. In the Staford program when schools reach 

a 20-percent standard they must submit a compliance plan, and only if they get to a 30 percent 

standard are they out of the program. 

Lenders also have concerns about performance standards. Eighty percent feel at least some 

lenders would drop out of the program with the implementation of performance standards. Some 

feel performance standards would limit lending because lenders would screen borrowers more 

carefully. They also maintai that performance standards ar unfai because controllng defaults 

is difficult without the abilty to garnish wages or withhold licenses. One lender volunteers that 

a five-percent standard is too tough. Sixty percent of the lenders do not envisage takng any 

additional steps in the future to reach this mark, because they believe they are aleady doing 

what they can to keep their default rates down. 

Some schools wil need to reduce their default rates with the implementation of performance 

standards. Table 1 below shows the results of projectig the inspection sample of 120 schools to 

all 310 HEAL school parcipants (See Appendix A). One-hundred out of the 310 schools (32 

percent) have default rates which exceed five percent. Sixty-five out of 310 (21 percent) have a 

default rate above seven and one-half percent, and fifty schools (16 percent) exceed ten percent. 

Table 1 also shows the percent of 1989 dollar disbursed to these schools. An historical analysis 

of the deficits incurred by schools whose default rate exceeded five percent provides the 

following insight: If al schools had maitained a default rate of no more than five percent it 

would have resulted in $20.5 milion not being claimed, which represents almost 18 percent of 

all default dollars since the program began (See Appendi B). 

TABLE 1 

Schools With Default Rates Above performance Standards 

Performance # of schools % of schools % of 1989 HEAL 

Standard above standard above standard $ disturbed 

100 32% 31% 

21% 14% 

10% 16% 
MIXED VIEWS EXIST ON THE USE AND VALUE OF RISK-SHARING. 

Although most schools do not think they should be required to paricipate in risk-sharng, they are evenly divided on whether their parcipation would be an effective tool. Most lenders agree that schools should not be required to paricipate in risk-sharg, but ar less optimistic (30 

percent) than schools as to its effectiveness. Respondents in both groups feel that schools are 

already doing what they can in terms of counseling and have limited control over the repayment 

process. Respondents also agree that schools cannot aford to pay a share of the default claims. 

Sixty-three percent of schools and 40 percent of lenders feel risk-sharng wil cause some 

schools to drop out of the HEAL progr. 

All lenders and almost one half of schools think lenders should not be required to parcipate in risk-sharng. Two-thirds of the schools think lender parcipation in risk-sharg would help 

lower default rates, but ninety percent of lenders disagre. Several lenders mention that fmancial 

risk would not change the way they service HEAL loans. In contrast, schools believe lenders 

should incur some financial risk, because lenders have the major responsibilty for the loans and profit from HEAL. Most lenders (80 percent) and schools (58 percent) do not feel risk-sharg is needed to maintain HEAL as a solvent program. 

All lenders and over 90 percent of schools predict that the implementation of risk-sharng wil cause some lenders to drop out of HEAL, thereby possibly ending the program. Almost half of 

the lenders say they definitely would drop out of the progr if risk-sharng were to occur. 

(This is consistent with a Consumer Baners Association study of possible risk sharng in the Staford Loan Program. That study found that if risk-sharg were to be implemented, 45 percent of their 126 respondents say they would quit student lending altogether, and 30 percent say they would sharly curtail it.) 

Respondents also cite other consequences to borrowers because of risk-sharng. They feel it would cause lenders to be more restrctive and limit who gets the loans. One lender reflects this 

by saying, "We would only make loans to the cream of the crop in the cream of the crop 

schools. " This sentiment is supported by the following statement made recently by a 

Washington attorney speaking about risk-sharng with the Staford Loan Program. He said, Risk-sharng is the worst idea ever to come forward in student lending; if you re forced to car 

10% of uncovered risk, you re also going to be forced to apply traditional credit analysis to 

student loan-making decisions. If risk-sharng becomes a reality, the only way the lender can avoid the risk, no matter what the percentage, is by avoiding high-risk loans. In other words 

risk-sharng would defeat the whole purpose of the Staford Loan Program: to serve students and 

offer a federal guarantee so students, who otherwise would not be extended credit, wil have the opportnity to continue their education. " Another lender of HEAL loans says, "Schools and 

lenders wil pass on costs to students. " While stil another says, "... The actual outcome would 

be the restrction of educational access to the health professions for large numbers of Americans parcularly among the neediest and most vulnerable segments of our people. 

In attempting to gauge how effective risk-sharg was in lowering default rates we examined 

other Federal loan programs which include this feature. These programs are administered by: 

the Small Business Administration, the Economic Development Administration, the Veterans 
Administration, the Farmers Home Administration, the Martime Administration and the Federal 

Housing Administration. With the exception of one program, all have default rates of five 

percent or less. These are all non-education loans which differ significantly from HEAL in that 

their borrowers usually have a credit history, collateral and other assets. All these programs have 

always had risk-sharing. One Federal manager who considers risk-sharng necessary for his 

program states, "I can understand (HAL) lenders' hesitation (in accepting risk-sharing); 

educational loans there s no track record to go on." While a few Federal managers view 

risk-sharng favorably, most feel that it does not contrbute to low default rates. Also, no 

manager cites risk-sharng as a reason for a low default rate in his or her program. 

RESPONDENT RECOMMENDATIONS 

Both schools and lenders had suggestions for improving the HEAL program. Aside from 

suggesting increasing student counseling and education and requiring continued comprehensive 

loan servicing by lenders, respondents most frequently volunteered the following innovative 

ideas: 

Lenders (50 percent) and schools (37 percent) suggest 

changing the terms of the HEAL loan. These include some steps which are already being 

undertaken by a few lenders, such as eliminating compounding of interest or at least decreasing the frequency of compounding interest, employing graduated repayment schedules and extending forbearance and grace periods for repayment. They also include basing 

a tiered insurance premium on the default rate of each discipline and reducing the maximum amount of the HEAL loan. For example, one school reduced its default rate substantially by discouraging the use of HEAL for those students whose cumulative debt had 

reached $50 000. Schools recommend reducing the cap on the interest rate while lenders 

advocate eliminating it. 

Change Terms of HEAL Loan. 


Impose Stricter Penalties for Defaulters. 
 Lenders (50 percent) and a few schools (12 percent) suggest strcter penalties for defaulters, such as garisheeing wages, offsetting Medicare and Medicaid reimbursement, withholding professional licenses and providing no 

bankruptcy forgiveness. One school states, "Don t let bankrpt borrowers be discharged 

from repayment; we need to work with them to keep them in the system." Another declares, "Put the onus of responsibility where it should be, on the borrower... recover the 

(default) through garisheeing wages or other ways. 

Improve Communication and Coordination. 
 Schools (41 percent) and lenders (20 percent) mention that communication and coordination among schools, lenders, borrowers 

and the Federal government needs to be improved. Several schools suggest that PHS keep 

them routinely informed about any changes to the HEAL program, such as providing a policy and procedures manual. They also recommend that schools and lenders cooperate with 

each other in locating delinquent borrowers. Numerous schools suggest that coordination 

with the secondar market be improved, so that when lenders sell HEAL loans to these 

markets, borrowers know who the new holder of their loan is. They would then know 

where to file for deferment or forbearance or where to send their payments. One respon­
dent suggests a centr clearnghouse, accessible to all lenders, be established for all borrower deferment forms. One respondent recommends instituting a one-lender rule so that 

borrowers are required to go to the same lender for al of their educational loans. 

RECOMMENDATIONS 

We recommend that performance standards be implemented without delay. Our 

recommendation is based on predictions of schools and lenders that they wil be effective, by the 

successful recent experience of the HPSL progr with performance standads, and by our 

analysis of HEAL default experience to date which suggests substantial futur savings with the 

use of performance standards. It shows that if all schools had maintained a default rate of no 

more than five percent it would have resulted in $20.5 millon not being claimed, which 

represents almost 18 percent of all default dollars since the progr began. These stadards 

would be a useful tool should the progrm be retained and would, of course, be beneficial durg 

a phase-out period. 

COMMENTS 

Comments on the draft report were received from both PHS and ASPE which concur with the 

recommendations of this report. The PHS believes that the final rule for performance standards 

wil be published by September 1991. 
:::\ 

,. .........,.,,.,.,,........ .. ..........,....,............ .. ........ ............ ...... .... .... ...... .......

APPENDIX A


METHODOLOGY FOR SELECTING SAMPLE AND PROJECTING EFFECTS 

PERFORMANCE STANDARDS ON SCHOOL PARTICIPATION 

One hundred and twenty schools were contacted for this inspection. These 120 are a stratified 

random sample of all 310 schools participating in HEAL and were selected on the basis of 

specialty and number of HEAL loans per school. To make national generalizations the figures 

from the sample were weighted. The following table gives the specialty, the total number of 

participating schools within each specialty (N), the total amount of HEAL money disbursed in 

1989 within each specialty (TA), and the number of schools selected from each of the specialties. 

In addition the table shows the estimated number of schools with a default rate above 5 percent 

5 percent and 10 percent. This estimate was projected from the weighted sample of HEAL 

schools. 

Total HEAL Estimated Number of Schools 

Specialty Total # 1989 (TA) Sample with a Default Rate Above: 

& Loans of Schools Disbursements 

Schools 

10% 

Medical 

Less 

than 80 $7,989,421 

Loans 

More 

than 80 93,647,907 

Loans 

Dental 

Less 

than 40 1,462,917 

Loans 

More 

than 40 721,537 

Loans 

Osteo athic 42,409,733 

Chiro ractic 26, 833,776 

Podiatric 21 770707 

Other 871, 807 

_,n,..,.,. 

siO .:$ZSm7b7\SbS /:=\\l!lbU

Projected within each strata of the universe of 310 schools. 
APPENDIX 


METHOD FOR ESTIMATING THE DOLLAR EFFECT OF A FIVE PERCENT 

PERFORMANCE STANDARD


Examining default and claims experience data from PHS as of March 31, 1990 reveals that 124 

out of 384 schools paricipating in HEAL have a historical default rate of over 5 percent. The 

PHS defines claims losses as defaults, bankptcy, death and disability. Defaults losses are 

composed of defaults only. Based on the default rate and tota default dollars of these 124 

schools ($39,052 000), the total amount of dollars eligible for repayment was calculated for each 

school. Our calculation then showed the tota amount of default dollars would have been 

$18,529,000 had these schools always maitained a 5 percent default rate and subtracted this 

figure from the actual default dollars. This difference of $20,523,00 is the amount of HEAL 

dollars the program could have saved had a 5 percent performance standad always been in 

effect. It represents approximately 18 percent of $115,984 000 in defaults paid since the 

program began. 
APPENDIX 


COMMENTS ON THE DRAFT REPORT


C ­
\ . : .

::... . , , ;. . :. . . .. j .. . .:.,.;.) ..

DEPARTMENT OF HEATH &. HUMA SERVICES Public Health Service 

'''.0 emorandum 

Date FEB - 8 1991 

From Assistant Secretary for Health 

Subject PHS Comments on Office , of Inspector General (DIG) Draft Report


Heal1:h Education Assistance Loan (HEAL)"


Inspector General, OS


Attached are the PHS comments i" response to the subject DIG


draft report.


We concur with the report' s recommendation and have initiated 

actions for complete implementation. 

(). /k 

Mason, M. D., Dr.


Attachment 

r -,:


?DIG 

DIG-AS r;.: 

DIGDI8­

AlG-IX? 

000/10 

EX SEC
 !l I U1.­


DATE SENT 
PUBLIC HEATH SERVICE (PHS) COMMENTS ON THE OFFICE OF


INSPECTOR GENERA (OIG) DRAT REPORT " HEATH EDUCATION


ASSISTANT LOAN (HEA)" (OEI-02-90-00980)


OIG Recommendation


We recommend that performance standards be
 plemented without


delay. 

PHS Comment, 

We concur. A Notice of Proposed Rulemaking for the


plementation of performance standards for HEA was published 

Federal Reaister on October 1, 1990. The public comment 

period ended on Novemer 30, 1990, and the 122 responses

recei ved are presently under review. Because of the complexity 

of the comments, it will take several months to complete the 

review, draft the appropriate Governent response, and modify 

the draft to incorporate changes that may arise from 

Departmental clearances. Accordingly, we believe that the 

final rule should be published by Septemer 1991. In addition 

in the 


to the above actions, HRSA' s Bureau of Health Professions 

recently awarded' a contract to identify and evaluate other loan 

default prevention strategies that may be relevant for the HEA 

program . 
:: . 

::

DEPARTMENT OF HELTH II HUMAN 5ERVICE5	 Ofce of the Seet 

. Washingron. D.C. 20201 28mJ 

TO:	 Richard P. Kusserow
 CJ

Inspector General G') r'1
 ,,, c C" I'J :; -n rn FROM:	 Assistant Secretary for 

Planning and Evaluation
 en

i'- -0
 rn I" 

SUBJECT:	 OIG Draft Report: IIHealth Education Assistance Loa (HE) , II OEI-02-90-00980--CONCUENCE 

Thank you for the opportunity to review the draft report on the


OIG study of the degree of implementation

support for the recent regulatory reforms of the Health Education
 , effectiveness , and


Assistance Loan (HEAL) program. This is an important study that provides information which will be useful to the Departent


particularly now that we are examining options for legislative


changes in the Department' s health professions student assistance
 programs , including HEAL. 

I concur with your general recommendation that performance 

standards be implemented without delay. I also find of interest the respondent recommendations , particularly those of lenders and schools regarding changing t e terms of the HEAL loan decreasing the frequency of compounding of (e. g. , by

interest), basing a
 tiered insurance rate on the default rate of each discipli


reducing the maximum amount of the , and
 HEL loan. These are ideas
 that deserve serious consideration as we try to strengthen our


health professions student assistance programs.


Ma in 	 Gerry 

V ­


PDIG 

DIG-AS 

IG-EI 

. DIG-OI 


AIG-MP 


OGC/IG 

EXSEC 

DATE SENT