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Testimony on Health Professions & Nursing Education Programs by Claude Earl Fox, M.D., M.P.H.
Acting Administrator
Health Resources and Services Administration
U.S. Department of Health and Human Services

Before the Senate Committee on Labor and Human Resources, Subcommittee on Public Health and Safety
April 25, 1997

Mr. Chairman and Members of the Committee:

I am pleased to appear before you this morning to discuss the reauthorization of the health professions and nursing education programs carried out under Titles VII and VIII of the Public Health Service Act. I am accompanied today by Neil Sampson, Acting Director of the Bureau of Health Professions.

In my remarks, I will speak about the current status of health professions and nursing education and related workforce issues. I will also describe in general terms our proposals for reauthorizing the Titles VII and VIII programs. We are committed to working with you to establish a sound legislative foundation for Federal leadership and strategic support for health workforce development.

Health Professions and Nursing Programs - Current Status

The Federal government has a 30 year history of involvement in health professions and nursing education through discretionary programs. The primary purpose of early Federal programs was to address national shortages in the health professions. Today there are few health occupations with national shortages, with notable exceptions among the public health specialities and some allied health occupations. Indeed, the 1996 Institute of Medicine report concluded there is an oversupply of physicians, particularly specialists and the recent report of the National Advisory Council on Nursing Education and Practice concluded that the nursing supply will keep pace with the growth in population at least into the next millennium.

The Titles VII and VIII health professions and nursing education programs were most recently reauthorized in 1992. This law directed the focus of health professions and nursing education programs away from eliminating health worker shortages towards meeting the needs for health workers in primary care and in medically underserved areas. Scholarships and low-cost loan programs were made conditional upon service in primary care. For many of these grant programs, the 1992 law established a general preference for applicants who demonstrated success in placing graduates in medically underserved communities.

Again, these programs have responded successfully to their legislative mandates. In the past five years, progress has been made in the areas of enhancing primary care, diversity, and geographic distribution. Titles VII and VIII programs designed to expand the nation's capacity to prepare primary care providers, particularly those who serve underserved populations, have had marked success. For example:

  • Thirty-three percent of the 1995 Family Practice residency graduates of Title VII programs entered practices in medically underserved communities.

  • Over 69% of the graduates of currently funded General Internal Medicine/General Pediatrics residency training programs practice in primary care, compared to 45% of a similar national sample of residents whose training was not supported through a Title VII supported program.

  • Thirty-nine percent of the most recent physician assistant graduates of this Title VII program practice in medically underserved communities. Thirty-two percent of these graduates are themselves from under represented minority backgrounds.

The 1992 reauthorization also focused on enhancing the diversity of the nation's health workforce. The literature clearly demonstrates that individuals from minority and disadvantaged backgrounds are more likely to serve in underserved communities. Our Centers of Excellence Program (COEs) and our Health Careers Opportunity Programs (HCOP) have had marked success in bringing under represented individuals into the health workforce. For example, an average of 68% of all HCOP program participants who applied to medical school in the years 1989 to 1995 were accepted. This compares to an average or 48% of all under represented minority applicants, and 50 % of all medical school applicants.

Other programs, such as the General Practice Dentistry Residency Program address both the need for primary care providers and enhanced workforce diversity. Of the 1995 graduates of this program, 33% were either African Americans, Hispanics, or Native Americans. This figure is more than 50% above the percentage found in the nation's population.

Titles VII and VIII programs have also been effective in increasing the distribution of health care providers and collaboration among institutions and providers. Fifty-four percent of all graduates of the rural interdisciplinary program are employed in rural and frontier areas, and all of these programs target health professions shortages areas. The Area Health Education Center Programs, AHECS, have made contributions to the nation's workforce distribution in both rural and urban underserved communities. Nearly ninety percent of all Geriatric Education Centers are consortia of three or more colleges, universities, hospitals and community agencies.

Some believe that these programs meet their legislative mandates, although a 1994 GAO report found the impact of Titles VII and VIII programs difficult to measure. Determining these programs' impact on national workforce patterns is also limited by the type and scope of reporting data available. There is also widespread consensus that the Federal role in health workforce development should be to address those critical issues that the current health care market cannot meet, when the failure to meet these challenges jeopardizes our ability to provide quality care for all, but especially the most vulnerable populations.

Encouraging providers to serve in underserved communities and increasing the diversity of the health professions, remain important components of the Federal role in health workforce development. To accomplish important national workforce goals, we must replace multiple existing categorical grant authorities with consolidated authorities that address broad areas of program need. To maximize the impact of Federal support for these programs, we must leverage cooperation from the private sector and State and local governments. Partnerships between academic institutions and the communities they serve will be critical to relevant workforce development.

Our goal in this reauthorization must be to revise these many categorical programs to reflect new Federal workforce strategies. We must increase the Government's flexibility to establish program and funding priorities and to respond in a time of rapidly emerging health workforce challenges. Our authorities must target our limited resources to high priority needs which cannot be met by the market factors, the private sector, or State and local governments acting alone. Our programs should encourage collaboration among stakeholders, including health professions educators and employers, and between academic institutions and communities. Moreover, in the reauthorization of these programs, we would seek the ability to refocus programs on targeted and emerging workforce issues.

The Administration's Proposal

The Administration would propose to reauthorize Titles VII and VIII using a consolidated approach. Program consolidation was first proposed two years ago, in response to the National Performance Review report prepared in 1993. This report specifically recommended consolidation of the PHS health professions grant authorities. In response, the Administration proposed a legislative package that would create program clusters and forwarded this proposal to the Committee on March 3,1995. S. 555, the Kassebaum, Kennedy, Frist bill, to reauthorize the health professions and nursing programs passed the Senate in the final hours of the 104th Congress. This bill would have consolidated the health professions programs into five clusters, similar to those proposed by the Administration. The Secretary had written Chairman Kassebaum to indicate her support for this consolidated approach presented in S. 55ts, or other appropriate public or private nonprofit entities. Under specific conditions, for-profit entities should be eligible to participate in health professions and nursing training activities. We believe that by expanding applicant eligibility, we can increase flexibility in responding to health workforce needs.

We believe that the programs and provisions we are seeking are consistent with the President's FY 98 budget request, which targets funding for health professions workforce development into the areas of diversity and distribution programs because they focus best on solving the problem of geographic maldistribution, while providing limited funding for primary care medicine, nursing, public health, and dentistry programs. In light of the rapidly evolving health care system and corresponding need for providers, we would seek to maintain as much flexibility as possible in all program areas.

Mr. Chairman, we look forward to working with the Committee on the development of this important legislation.

This concludes my prepared remarks. Mr. Sampson and I will be pleased to answer any questions you may have.

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