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Testimony on the President's FY 1988 Budget Request for the Health Resources and Services Administration by Dr. Ciro V. Sumaya
Administrator, Health Resources and Services Administration
U.S. Department of Health and Human Services

Before the House Appropriations Committee, Subcommittee on Labor, Health and Human Services, Education and Related Agencies
February 12, 1997


Mr. Chairman and Members of the Committee:

I am pleased to appear before you today to discuss the Fiscal Year 1998 budget request for the Health Resources and Services Administration (HRSA).

HRSA has but one purpose: to preserve and protect the health of Americans who are too poor, too sick or too isolated from sources of care to access the essential health care services most of us take for granted.

We work to open doors for hardworking American families who are too rich for Medicaid, but too poor for private insurance. We serve rural communities and people in public housing, people with HIV/AIDS and pregnant women and their children.

HRSA programs put primary health care services in their neighborhoods and help to train and place the physicians, nurses and other professionals to provide them.

HRSA programs assure that babies are born healthy, children are immunized and adults receive the kind of ongoing, preventive health care that keeps them productive at work when they are well--and out of expensive emergency rooms when they are sick.

We are honored to be entrusted with such an important mission and justifiably proud of what we have achieved.

But we are also concerned that the need for the kinds of programs and services HRSA supports will only grow as more Americans find themselves outside the mainstream of our health care system.

Managed care and Medicaid go hand-in-hand as States struggle to control costs without sacrificing access. These innovations, however, leave many uninsured, underinsured, disabled and chronically ill children, women and men sitting on the sidelines, unable to find the place and health practitioner that can provide the care they need.

Welfare reform promises to increase the pressure on States to care for their underserved citizens--care that in large measure has been provided through HRSA appropriations.

Today, 40 million Americans have no health insurance. Most of them are employed, but unable to afford the estimated $6,000 annual cost of basic health insurance for a family of four.

Tragically, a growing number of American children are uninsured--9.8 million or 14 percent of our Nation's youth--have no insurance. Inadequate care early in life can predispose them to lifelong health problems, problems that can hinder their education and hamper their ability to earn a living.

For these children, for their families and for millions of other Americans who are medically underserved, HRSA programs are the ultimate safety net.

While you in the Congress and your colleagues in State legislatures work to expand the percentage of the population covered by insurance, HRSA works to keep others from falling through the gaps.

In FY 1998, HRSA intends to weave together health care systems to form a safety net that is even tighter, with more and better preventive and primary care services that reduce hospitalization and prevent chronic disease and disability.

HRSA plans to:

  • Expand access to care by tearing down cultural, geographic and economic barriers;

  • Assist States and communities to address unmet health care service needs and workforce gaps;

  • Develop partnerships with States, communities and the private sector to promote effective, integrated systems of care for the underserved; and

  • Develop and maintain a culturally and linguistically competent and diverse health care workforce.

To accomplish this important work, HRSA requests a total of $3.3 billion and 1,523 direct full-time equivalent positions. The request reflects HRSA's commitment to the President's streamlining objectives and supports the diversity of operations necessary to meet the needs of our States, our communities and our citizens.

Consolidated Health Centers

Consolidated Health Centers comprise the former Community Health Centers, Migrant Health Centers, Health Care for Residents of Public Housing, and Health Care for the Homeless programs. These programs provide access to case-managed, family-oriented preventive and primary health care services for people living in rural and urban medically underserved communities. The request for the Consolidated Health Centers cluster is $810 million, an increase of $8 million over the FY 1997 appropriation.

The increase will enable HRSA to expand the managed care infrastructure serving the medically underserved and to implement a modest increase for Healthy Schools, Healthy Communities, projects that provide family centered, community based primary care, including mental health, dental, outreach and referral services to at-risk and homeless children and families.

As expected, consolidated health centers have quickly and successfully responded to the most pressing health problems in their own communities, including high infant mortality, low immunization rates and increasing numbers of uninsured and underinsured. More surprisingly, these health centers have also proved to be a catalyst for economic development in underserved communities. Health centers generate jobs, attract health professionals and facilities, and utilize local suppliers. In FY 1996, consolidated health centers received HRSA grants of $758 million, which were supplemented with $1.6 billion in Medicaid and other health insurance reimbursement, and State and local funds for a total program level of $2.5 billion.

Consolidated health centers serve more than 10 million people, including 3.5 million children, in more than 700 community-based partnerships throughout the United States. Their patients have lower hospital admission rates, shorter hospital stays, lower total annual Medicaid costs and lower infant mortality rates than similar patients who do not use consolidated health centers.

Integral to the successful operation of these health centers are the resources and providers of HRSA's National Health Service Corps. More than 3,000 communities today benefit from the comprehensive primary care offered at facilities created and maintained through partnerships among consolidated health centers, the Corps, and State and community organizations.

HIV/AIDS

The FY 1998 budget builds on the impressive record HRSA Ryan White Comprehensive AIDS Resource Emergency (CARE) programs have amassed. Continuing the President's Investment Initiative for Ryan White, HRSA requests $40 million above the FY 1997 Appropriation.

This level will maintain efforts to bring people with HIV/AIDS into care, prolong their lives and productivity, reduce their use of expensive emergency room inpatient care, and expand systems of care for people with HIV/AIDS, even as the epidemic thrives among the Nation's most medically needy populations. At the same time, the increase will extend new, more effective drug therapies to greater numbers of infected individuals.

More specifically, HRSA's HIV/AIDS increases will include:

  • For HIV Emergency Relief grants, a $5 million increase over the FY 1997 Appropriation for a total of $455 million. This request will continue support to cities with very high numbers of AIDS cases. Coordinated outpatient health and social support services, therapies to reduce the transmission of HIV from a pregnant woman to her baby, and treatment for infections associated with HIV, such as tuberculosis, are funded through this program;

  • For HIV CARE Grants to States, an increase of $15 million is requested for a total of $432 million. With these grants, States operate HIV service delivery consortia in communities most affected by the epidemic. They provide home- and community-based care, continue insurance coverage and supply pharmaceuticals that prolong health and prevent physical deterioration. This request includes $167 million for Drug Assistance Programs, which help States make new drug therapies that significantly extend and improve the lives of people with HIV/AIDS available to uninsured or underinsured patients;

  • For Early Intervention Services, an increase of $15 million over the FY 1997 Appropriation, for a total of $85 million. These grants to federally qualified health centers and nonprofit private clinics provide comprehensive primary medical care to underserved people with HIV infection; and

  • For Maternal and Child HIV services, an increase of $4 million for a total of $40 million. These funds will create and support community-based care networks for pregnant women, children, youth, and families; will ensure that women and children participate in clinical research; will provide therapies to decrease perinatal transmission of HIV; and will provide educational materials and guidelines to providers who care for women, children, youth, and families with HIV/AIDS.

The budget further incorporates two programs newly included under the Ryan White CARE Act authorization, $17 million for the AIDS Education and Training Centers, an increase of $1 million, and $8 million for AIDS Dental Reimbursement.

Health Professions Training

The President's budget reflects the Administration's position that the Federal role in health professions education mainly should focus on workforce needs unlikely to be met through market demand alone. Increasing the number of health providers from disadvantaged backgrounds, promoting training and service within underserved communities, fostering community-based education, encouraging interdisciplinary and team training, and providing strategic information on the health workforce all fall within that realm.

HRSA health professions programs account for less than one percent of Federal health professions education and training spending. The return on investment is considerable. Graduates of HRSA-supported training programs, encouraged by HRSA loan repayment programs, provide cost-saving primary care services to vulnerable populations at HRSA-supported facilities. The yield will continue far into the future, as we build a more diverse health professions workforce that is both prepared and motivated to serve the medically underserved in our Nation.

To achieve maximum impact from these programs, HRSA has targeted the focus and priorities of its health professions budget. The FY 1998 request for the Minority/Disadvantaged Health Professions Cluster is $89 million, the same as the FY 1997 Appropriation. The request provides strong support for historically Black colleges and universities and includes a special Hispanic Initiative to provide additional training opportunities for the fastest-growing minority group in America.

Through our Minority/Disadvantaged Health Professions cluster, HRSA works closely with educational institutions and communities to improve the participation and number of America's minorities/disadvantaged providing health care services. Programs include Centers for Excellence, Exceptional Financial Need Scholarships, Financial Assistance for Disadvantaged Health Professions Students, the Health Careers Opportunity Program, the Loan Repayment/Fellowship program, Loans for Disadvantaged Students, and Scholarships for Disadvantaged Students.

The Enhanced Area Health Education Centers Cluster request of $24.7 million will be used to support community-based educational partnerships to place desperately needed health professionals in underserved urban and rural areas.

The Health Professions Workforce Development Cluster supports research on health professions needs and resources. Proposed funding is $623,000. The Primary Care Medicine and Public Health Cluster and the Nurse Education/Practice Cluster are each funded at $7.7 million to support analytical activities and demonstration projects. The long-term aim of these programs is a restructured medical, nursing, and public health workforce capable of meeting future health care needs.

Maternal and Child Health

Maternal and Child Health is HRSA's remaining programmatic priority. The FY 1998 request is equivalent to the FY 1997 Appropriation level. The important Maternal and Child Health Block Grant request is for $681 million, which will enable States to provide a broad range of necessary health services to more than 16 million mothers, infants and children. The request incorporates:

  • $570 million for block grants to States;

  • $101 million for Special Projects of Regional and National Significance; and

  • $10 million for Community-Integrated Service Systems, a set-aside that develops and expands primary care service delivery.

The FY 1998 request includes $96 million, the same as the FY 1997 appropriation, to continue the Healthy Start Initiative at its current level and intensity. This critically important effort reduces infant mortality in areas where the rates of infant death are tragically high--150 to 250 percent higher than the national average. Healthy Start reached full funding in FY 1995 and this request reflects a phasing down of the original demonstrations and a redirection and targeting of funds to new replication projects.

Organ Procurement and Transplantation

The FY 1998 request of $3.9 million for Organ Procurement and Transplantation is an increase of $1.6 million above the FY 1997 Appropriation. This increase will be directed to public and professional education to increase organ donation. While cadaveric organ donation has increased by 30 percent since 1988, the number of people waiting for organs has increased by an astronomical 300 percent. To realize the full benefit of organ transplantation, we must educate the American people about organ donation. F

amily Planning

For Family Planning in FY 1998, the request is for $203 million, an increase of $5 million over the FY 1997 Appropriation. The increase will accommodate a stronger emphasis on teenage pregnancy prevention and an expansion of clinic sites in areas of highest need.

Health Education Assistance Loans

Health Education Assistance Loans are Federally-guaranteed loans to health professions students made by non-Federal lenders. The Administration requests a FY 1998 guarantee ceiling of $85 million for guarantees to previous borrowers, $38 million to pay claims from guarantees made prior to FY 1992, $1 million to pay the net present value of claims on loans to be made in FY 1998 and $3.7 million for administration.

Program Management

Finally, to make all these worthy programs work efficiently, the Health Resources and Services Administration supports an ambitious Program Management activity. To provide national leadership and oversight, and to be an effective steward of these critically important public funds, HRSA has implemented an aggressive and successful effort to reduce operating costs and increase productivity.

Significant program appropriation increases, new program initiatives and the expanded performance measurement and reporting requirements of recent legislation has added to the HRSA program management workload. Consistent with the President's goal of reducing the size of the Federal workforce, however, HRSA has eliminated more than 200 program management FTEs, a reduction of 13 percent, in the past two years. The FY 1998 request is for $111 million, a $2 million reduction from FY 1997.

Conclusion

America has the finest, most technologically advanced medical system in the world. Our investment in AIDS research is producing therapies that were unimaginable a year ago. Infant mortality has never been lower.

These gains have been made in large measure because the Federal Government made wise and strategic investments in the Nation's health.

If we are to carry these gains forward ... if we are to create a health care system that is as equitable as it is advanced ... if we are to put effective treatments for AIDS into the hands of those that need them ... if we are to lower our infant mortality rates to levels comparable with other industrialized nations, it will be because you have continued the wise investment of Federal dollars in the health of all Americans.

HRSA FY 1998 budget is one such wise investment.

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.


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