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
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
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
- 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
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.
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
- 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
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
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
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
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.
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.
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
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.
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.