Statement by
Elizabeth M. James Duke, Ph.D. Administrator, Health Resources and Services Administration
Fiscal Year 2004 President's Budget Request for the Hearth Resources and Services Administration
before the
The House Appropriations Subcommittee on Labor, Health and Human Srvices and Education

March 26, 2003

Mr. Chairman and Members of the Committee:

I am pleased to appear before you today to discuss the Fiscal Year 2004 Budget request for the Health Resources and Services Administration (HRSA).

HRSA's programs reach into every corner of America, providing the foundation for the safety net of health care services relied on by millions of our fellow citizens.

HRSA grantees deliver preventive and primary health care to needy, unemployed and underserved individuals and families. We administer programs like the Ryan White Care Act, that give low-income people with HIV/AIDS the medication and care they need to get better or stay well. We work with States to ensure that babies are born healthy and that pregnant women and children have access to health care. We help train physicians, nurses and other health care providers and place them in communities where their services are desperately needed. And we oversee the Nation's organ transplantation and bone marrow donation systems.

Despite these programs, and the best efforts of HRSA's 2,100 employees and our private-sector and nonprofit partners across the nation, some families and individuals continue to fare poorly. Among low-income Americans, about a third -- 10.1 million -- had no health insurance in 2001, a rate little changed from 1998. Among racial and ethnic minorities, health insurance coverage for Hispanics, African Americans and Asian/Pacific Islanders lags behind coverage rates for white non-Hispanics. The comprehensive care and services provided or financed by HRSA serve as a safety net for many of these uninsured and underinsured Americans.

Cost is not the only barrier to health care. For 65 million people in rural areas, the obstacles are distance and isolation; their communities often have too few people to support important services typically provided by health care systems in urban areas. For the Americans who are racial and ethnic minorities, obstacles to greater access to health care also may include culture and language. Some individuals avoid health care because they are unable to find health care providers who speak their language. Others decline care because they do not feel welcome at sites that are insensitive to their cultural norms and habits.

This combination of obstacles -- cost, distance, culture and language leaves U.S. minorities and residents of rural areas more vulnerable to certain diseases and less likely to receive services to prevent or treat them. These health disparities are aggravated by a serious underrepresentation of minorities in the health care workforce. Studies have shown that minority practitioners are more likely than white practitioners to serve minority and Medicaid patients.

For all Americans who are -- for whatever reason -- medically underserved, HRSA programs represent the ultimate safety net, a net whose strength depends on collaboration among partners in each community and at all levels of government.

HRSA programs draw on the full range of local assets -- schools, churches and other faith-based organizations, and community and neighborhood groups.

In FY 2004, HRSA will build on it's commitment to provide the best quality primary and preventive health care services by partnering with CDC and other HHS agencies to support the Department's prevention initiative, Steps to a HealthierUS. Steps to a HealthierUS is a bold new initiative from the Department of Health and Human Services that advances President's Bush's HealthierUS goal of helping Americans live longer, better, and healthier lives. At the heart of this program lie both personal responsibility for the lifestyle choices Americans make and social responsibility to ensure that policy makers support programs that foster healthy behaviors and prevent disease. This initiative will focus on diabetes, obesity, asthma, heart disease and stroke, cancer, and the lifestyle choices including poor nutrition, physical inactivity, tobacco use, and youth risk-taking.

In FY 2004, HRSA intends to weave together an ever-tighter health care safety net, providing more and better preventive and primary care services to reduce unnecessary hospitalizations and prevent chronic disease and disability. In pursuing these goals, HRSA requests a total funding of $5,672,376,000, a decrease of $765,043,000 below the FY 2003 appropriation. At this time, please allow me to address some of the major initiatives described in the FY 2004 President's Budget.


For more than 35 years, HRSA's primary health care programs have helped build cost-effective, high-quality primary care delivery systems serving low-income residents in inner cities and in rural and isolated areas. With the recent reauthorization of the Health Center programs through the Health Care Safety Net Amendments of 2002, HRSA can continue to work toward its goal of improving the Nation's health by improving access to basic health care needs.

Several programs housed in HRSA's Bureau of Primary Health Care -- the Community and Migrant Health Centers, Health Care for Residents of Public Housing and Health Care for the Homeless -- are important components of the U.S. health care safety net. Each year, these programs provide case-managed, family-oriented preventive and primary health care services to over 11 million people at more than 3,400 access points nationwide.

One in six low-income children, one in seven low-income uninsured individuals, one in 10 Medicaid recipients, and one in five homeless people benefit from BPHC's programs. Among patients served at HRSA-supported Health Centers, about 39 percent are uninsured and 35 percent are Medicaid recipients. Almost two-thirds are members of minority groups: 35 percent of all clients are Hispanics, 25 percent are African Americans, and 4 percent are Asian/Pacific Islanders and members of other minority groups.

Many Health Centers are involved in special initiatives to monitor and control diabetes, boost infant immunization rates, keep patients' blood pressure under control, and reduce the number of low birthweight babies. By tailoring services to deal with pressing local health problems, by coordinating programs and making sure services are accessible to all who need them, Health Centers help communities lower hospital admission rates, shorten hospital stays, reduce Medicaid costs and lower infant mortality rates. In addition, Health Centers have proven to be a catalyst for economic development by creating jobs, attracting health professionals and facilities, and using local suppliers.

The President's FY 2004 Budget for HRSA continues the Health Centers Presidential Initiative, which began in FY 2002. This initiative calls for $1.6 billion in spending for Health Centers, an increase of $122 million above the FY 2003 appropriation. These additional funds will allow Health Centers to create new access points that target the neediest communities, and to expand existing sites to serve up to 1.2 million new patients.

The added funds represent the third installment of the Administration's multi-year initiative, which will increase or expand health center access points by 1,200 and serve another 6.1 million patients by 2006. This expansion complements the President's proposal to increase health insurance coverage in private and public insurance programs, to help ensure that all Americans have access to health care.


Health care at many Health Center sites is provided by clinicians recruited through HRSA's National Health Service Corps (NHSC), a critical element in local safety nets for over 25 years. Since 1972, the NHSC, through its scholarship and loan repayment programs, has placed over 22,000 health care professionals in areas where there were shortages.

Today, approximately 2,300 NHSC clinicians serve in border towns, rural areas and inner cities, in every State, the District of Columbia, Puerto Rico and the Pacific Basin. Currently, 50 percent of the NHSC health care providers care for patients in HRSA-supported Health Centers; the remaining 50 percent work at similar free-standing, community-based sites. In order to expand services, Health Centers will need to significantly increase their primary care providers. The FY 2004 request is an increase of $42 million above the FY 2003 appropriation. These resources will help meet the Health Center program provider needs and enable the NHSC to address the problem of providing health care in areas where lack of access and increased health disparities exist. At this level of funding, $25 million will be targeted to increase efforts to recruit underrepresented minorities and other students and professionals from disadvantaged backgrounds into the program.


A shortage of nurses continues to threaten the quality of health care in communities across America. The nursing workforce is aging and nurses are leaving the profession. Today's new entrants are too few to replace them and to meet the growing demand. The Nurse Reinvestment Act (NRA), signed by the President on August 1, 2002, amends and expands the Title VIII nursing authorities and adds priority areas to the Nurse Education, Practice and Retention Program. The NRA also adds a Nurse Scholarship Program to the existing Loan authority. The 2004 President's Budget provides an overall investment in Nurse Workforce Development of $98 million.


Each year more than 27 million women, infants, and children are served by one of HRSA=s maternal and child health programs whether or not they have health insurance. States use HRSA's Maternal and Child Health Block Grants to provide direct health care to pregnant women and children, including children with special health needs, on a one-on-one basis in clinics, offices and emergency rooms. The FY 2004 request is an increase of $21 million above the FY 2003 appropriation and continues to support activities that underpin the public health infrastructure for mothers and children. The request will enable States to develop and coordinate a seamless, comprehensive system of care for children across HRSA programs, Medicaid and the State Children's Health Insurance Program (SCHIP).


HRSA's Ryan White CARE Act programs are a vital Federal resource in providing primary medical care and social support services for an estimated 530,000 persons living with HIV/AIDS and their families in the United States. These programs focus on reaching and treating underserved and hard-to-reach populations, slowing the progression of the disease and preventing further infections. The Centers for Disease Control and Prevention estimates that 850,000-950,000 individuals are living with HIV in the U.S., and roughly one-half of them are not diagnosed or linked to ongoing care.

The President's FY 2004 Budget of $2 billion for the Ryan White HIV/AIDS program includes a decrease of $8 million below the FY 2003 appropriation. These funds will be used for formula grants to States and territories, for supplemental grants to States for Emerging Communities -- metropolitan areas with between 500 and 1,999 reported AIDS cases over the most recent five-year period, and for other HIV/AIDS activities. The request also includes a $25 million increase over the FY 2003 appropriation for the AIDS Drug Assistance Program.


HRSA's FY 2004 President's Budget includes programs, such as the Hospital Preparedness program and the Educational Incentives for Curriculum Development and Training program, that will assist the Nation in preparing for possible bioterrorist and other attacks. These programs are requested under the Public Health and Social Services Emergency Fund. HRSA will continue the Hospital Preparedness program begun in FY 2002. The FY 2004 request of $518 million is $3 million above the FY 2003 appropriation. The requested funds will be used to continue cooperative agreements with health departments in States and other eligible entities to care for victims of bioterrorism by upgrading the capacity of hospitals, outpatient facilities, emergency medical services systems, and poison control centers to improve their preparedness to work together.

HRSA will continue to operate the Educational Incentives for Curriculum Development and Training Program, which begins in FY 2003, at a level of $60 million which is a $32 million increase over the FY 2003 appropriation. This program will ensure that approximately 65,000 public health and healthcare professionals are properly equipped with the skills, knowledge and networks to address possible bioterrorist attacks.


HRSA, through its various rural health grant programs, will help strengthen small rural hospitals, improve rural emergency medical services, and encourage innovative programs through 50 state supported rural health offices. These efforts are critical because many of the more than 65 million people who live in rural America have limited access to health care. The FY 2004 request of $80 million is $77 million below the FY 2003 appropriation. The reduction includes $55 million in one-time earmarked projects .


To make these worthy programs work at maximum efficiency, HRSA has implemented an aggressive and successful effort to reduce operating costs and increase productivity. HRSA's request includes funding to support Departmental efforts to improve the HHS Information Technology Enterprise Infrastructure. The request includes funds to support an enterprise approach to investing in key information technology infrastructure such as security and network modernization. These investments will enable HHS programs to carry out their missions more securely and at a lower cost.


Our FY 2004 request also includes the assessments of six of HRSA's programs evaluated using OMB's Program Assessment Rating Tool. The HRSA programs evaluated were: Health Centers, National Health Service Corps, Health Professions, Nursing Education Loan Repayment and Scholarship, Maternal and Child Health Block Grant and Ryan White. Of the thirty-one HHS programs evaluated, HRSA's Health Centers program was the highest rated.

HRSA continues to make a strong effort to build performance management into the way it conducts its business. According to the Performance and Management Assessment section of the Budget, fifty percent of all Federal programs rated using the PART had "inadequate" performance measures. In comparison, 5 of the 6 HRSA programs rated had performance measures deemed "adequate". This is an indication of HRSA's commitment to finding ways to improve accountability and focus on results.


U.S. health care is among the finest in the world, but too many Americans have limited access to it. Because these fellow citizens lack access to high-quality, community-based health services such as those provided at HRSA-supported Health Centers, illnesses that could have been treated successfully with early interventions become medical emergencies requiring more intensive, more expensive hospitalizations

Through this budget request, HRSA will continue to be an anchor for the Nation's health care safety net, investing $5.7 billion in community-based primary health care, services for low-income individuals and people with HIV/AIDS, health services for mothers and children, and targeted health professions training. HRSA works in partnership with State and local governments and private organizations to expand access to care and thus improve the health and the lives of millions of Americans.

Pockets of need remain throughout our great country: 3,000 urban and rural communities are medically underserved; more than 300,000 people who know they have HIV, are not in care; and 40 million people live in health professional shortage areas. We can do better by these people and these places. Through HRSA's programs, we will.

Mr. Chairman and members of the Committee, I will be pleased to address any questions or comments you may have on the specifics of this budget request. I will be assisted today in answering questions by the Associate Administrators and Program Directors I previously introduced..