Subcommittee on Health
August 1, 2001
10:00 AM
2322 Rayburn House Office Building

The National Health Service Corps (NHSC) plays a critical role in providing care for underserved individuals by placing clinicians in urban and rural communities with serious shortages of health care providers. Without the National Health Service Corps I would not have had the opportunity to touch the lives that I have. Also, I would not have been sensitized to the larger issues that affect this country relative to the uninsured and the underserved populations. I have learned so much about health policy and how taking a systems approach is essential to finding a solution to the problems that plague our communities across this nation.

Currently 2,500 NHSC clinicians, including physicians, dentists, nurse practitioners, physician assistants, nurse midwives, and mental and behavioral professionals, provide health care services to 4.6 million Americans, including 2.2 million health center patients. Caught up in a backlog of legislative issues, the authorization for the NHSC unfortunately expired last year. This important program is in peril without Congressional action this year.

While the NHSC program has proven successful in addressing health professional shortages in many areas, severe lack of funding has undermined the program's ability to meet its primary goal. Only $129.4 million was provided for the NHSC for FY 2001. According to HHS, more than 12,000 physicians would be needed to place sufficient providers in all health professions shortage areas (4 times the current number of NHSC providers), and more than 20,000 (8 times the current number of NHSC providers) would be needed to bring all areas of the country to the same staffing ratios for providers that are used by both managed care organizations and health centers. If health centers are to meet the challenge of doubling their capacity to serve the underserved, the National Health Service Corps needs to be doubled to provide the health professionals needed to staff health centers and other health professional shortage areas.

The NHSC also needs to be streamlined to work more effectively with safety net providers, including health centers, which share the goal of improving health care access in underserved areas. The placement of NHSC providers at health centers should be simplified in order to better meet the health care needs of the uninsured and low-income individuals who reside in medically underserved areas. Currently, health centers must apply for designation as a Health Professional Shortage Area (HPSA) in order to be eligible for NHSC placements, although the law already mandates that health centers be located in Medically Underserved Areas (MUA). This duplicative and bureaucratic mandate hinders the ability of health centers to recruit medical professionals in a timely manner.

Health Centers Need the Support of Congress to Fulfill Their Mission

Health centers request that this Subcommittee and the Congress act to support our work in several specific ways. We have been, and will continue to fulfill our mission of providing high quality health services to the medically underserved at low cost. We will continue to bring needed health care professionals to underserved communities, and to work in partnership locally to meet community needs and to improve health outcomes for the people we serve. Specifically, we need your help in four key ways:

First and foremost, we need the stability that comes from knowing that you will reauthorize and strengthen our health centers program, which provides the core support for our operations.
Second, we need you to reauthorize and strengthen the National Health Service Corps program, a vital partner in the plan to double the number of people we serve.
Third, we ask for your help in securing the funding increases needed by health centers and the NHSC to double the number of people served by health centers over the next 5 years.
Finally, we ask you to support the efforts of local safety net providers and others to better organize care for the uninsured and underserved, such as those funded under the new Community Access Program (CAP).

Reauthorize and Strengthen the Health Centers Program

In 1996, the Congress consolidated four separate targeted primary care programs (Migrant Health, Health Care for the Homeless, Public Housing Health Centers, and Community Health Centers) under a single authority, extending the consolidated program for five years. The new authority also included a limited new provision to fund health center-led networks and a new federal loan guarantee program for managed care. The consolidated health centers authority, at Section 330 of the Public Health Service Act, expires on September 30, 2001, and therefore requires reauthorization this year. Moreover, several key improvements are needed in the current health centers law, including:

Restoration of facility construction, modernization, and expansion as allowable uses of funds. Many health centers operate in facilities that desperately need renovation or modernization. In some cases, rapidly growing patient populations have strained the capacity of existing facilities; other facilities are old, or inadequate for the efficient delivery of primary health care. Almost 65 percent of all health center facilities are more than 10 years old, and 30 percent are more than 30 years old. A recent survey of health centers found that almost two-thirds of them currently need to upgrade, expand or replace their current facilities. Moreover, many needy communities are not yet served by health centers-new facilities will have to be built (or existing facilities modernized, expanded or replaced) in order to extend health center services there. Restoring the government's ability to make grants for capital projects is critical to enabling health centers to maintain, modernize and expand their current facilities - or to replace old facilities or build new ones - to meet the growing demand for their safety net services.
Enhancement of current Section 330 loan guarantee authority to cover facility loans. Health centers' capital needs could also be more successfully met by enhancing the current federal loan guarantee authority in Section 330 -- which only permits the issuance of loan guarantees to support the development of managed care networks and plans -- to include loan guarantees for facility construction, modernization, and expansion, and for acquisition of facilities and equipment.
Clarification of authority to support health center-controlled networks. As noted in my earlier discussion of our Bayou Teche Community Health Network, many health centers currently collaborate with each other, and with other community providers, in a variety of different networks and partnerships designed to improve their cost-effectiveness and to improve access to and the quality of care for their patients, especially uninsured patients. However, support for the ongoing operation of such networks is not authorized under current law, a shortcoming that needs to be addressed, especially in light of the increasing opportunities for health centers to collaborate for the benefit of their patients and communities.

We also support action to: restore a requirement to continue allocating overall health centers program funding across the community, migrant, homeless, and public housing sub-authorities in the same manner as BPHC has done over the past 5 years; ensure a continued focus and targeting of funds on these vulnerable populations; and clarify that certain individuals are eligible for care under the Homeless and Migrant Health programs.

Reauthorize and Strengthen the National Health Service Corps

Health centers strongly support action to reauthorize and increase funding for the NHSC this year. The NHSC also needs to be streamlined to work more effectively with safety net providers, including health centers, which share the goal of improving health care access in underserved areas. Today, some 15 percent of the 6500 clinical providers working at health centers are NHSC Scholarship and Loan Repayment recipients - and the ability of health centers to serve additional people will depend directly on the continued growth of the NHSC. Several key improvements are needed in the program, including:

· Automatically designate all Federally Qualified Health Centers and Federally Certified Rural Health Clinics that meet the accessibility and affordability requirements (above) as Health Professional Shortage Area (HPSA) facilities. The NHSC and the health centers programs are intended to address the same goal (to meet the health care needs of underserved populations). As noted earlier, providing automatic HPSA facility status to health centers and rural health clinics, thus making them eligible for placement of NHSC personnel, will reduce bureaucratic barriers and allow coordinated use of federal resource in meeting the health care needs of areas that lack sufficient health care services.

Ensure fairness in priority consideration for NHSC placements. While intended to ensure that all Corps placements were made in areas of highest need, the current criteria used to determine whether a site is included on the high priority placement list has actually had the effect of discriminating against health centers and other similar entities, because it severely restricts the Secretary's flexibility to consider certain factors as indicators of need, including documented access barriers such as linguistic or cultural isolation, transportation barriers, and other factors highly correlated with underservice - such as large uninsured, elderly, disabled, or minority populations. Thus, an area or population distinguished by the above-noted characteristics, but with a relatively low infant mortality rate or what appears to be an adequate supply of health professionals, for example, would be penalized by being deemed a low priority for the placement of a new NHSC assignee.

Establish due process rights in cases of HPSA de-designations and priority list development. Under current law, the Secretary is required to notify interested organizations and individuals in an area of that area's de-designation as a HPSA, but is not required to follow the same procedure in the case of a population group's or facility's de-designation. Furthermore, while current law requires the Secretary to publish annually list of priority placement sites for new NHSC assignments, it does not require notice to entities that are not included on the list, nor does it provide any due process rights to such entities to provide supplemental information or to file an appeal of their exclusion. Such due process rights are a central part of many other statutes, and should be included in the NHSC law, particularly in view of the consequences of the loss of HPSA designation or priority status to areas that had previously been considered high-priority shortage areas.

· Require all NHSC Scholarship and Loan Repayment recipients, as well as all NHSC placement sites, to (1) serve all residents regardless of ability to pay (2) bill and collect from third party payers for care furnished to covered individuals and (3) discount normal charges for out-of pocket costs based on ability to pay. Section 334 currently requires that Corps personnel ".to the maximum extent feasible, provide.services.to all individuals in, or served by, such HPSA regardless of their ability to pay for services.." These provisions need to be applied to all NHSC placements and to be clarified to reinforce the principle that a vital purpose of the NHSC is to reduce access barriers for everyone living in communities lacking health professionals, regardless of their income or ability to pay for services. In addition, language is needed to require the Department of Health and Human Services to monitor this requirement to determine whether Corps personnel and their sites are actually meeting these requirements and to enforce compliance.

Eliminate duplication of effort in the placement of NHSC personnel. After completing their taxpayer-funded medical education, many NHSC Scholars request -- and HHS often approves -- a waiver of their NHSC service obligation if they agree to establish a "private practice option (PPO)" in a designated HPSA. In most such cases, the Scholar is free to practice in virtually any HPSA (whereas those who fulfill their service obligation through assignment are targeted to high-need HPSAs). Currently, these "private practice option" clinicians are not subject to the requirement that they open their practice to all in the community regardless of ability to pay; and, in some cases, these NHSC-subsidized for-profit practices have been found to resist caring for uninsured - and even Medicaid-covered - patients, instead referring them to nearby health centers and other local safety net providers. Congress should remedy this by restricting PPO placements to HPSAs that are not currently being served by a health center or rural health clinic, except where the PPO clinician is placed at the center or clinic.

We also support action to: allow NHSC scholarship and loan repayment recipients to fulfill their service obligation on a part-time basis, so long as both the recipient and the placement site agree and the total obligation is fulfilled; assist NHSC communities and sites in developing incentives - such as locum tenens, mini-sabbaticals, and continuing professional education - to support the retention of NHSC providers after their service obligation ends; and eliminate the community cost-sharing provision, which is routinely waived for 95 percent of all sites and poses an undue burden both on economically hard-pressed communities and on the NHSC program.

Support increased resources to meet an ever-growing need for care.

Health centers are doing their part to address this problem, but more must be done to serve the growing number of families who do not have access to health care services. More than 16.5 million uninsured individuals currently do not have access to a regular source of health care. We urge the Committee to actively support the increased funding that is needed to at least double access to care for uninsured and underserved patients in the next five years. This can be achieved by increasing federal appropriations for health centers - and for the NHSC program as well -- by at least 15 percent per year over the next 5 years. This plan would ensure access to quality health care for 20 million individuals by FY 2006, including 9 million uninsured persons.

In Louisiana, our community health center system consists of twenty-six delivery sites across the state. This is far too few for a state that has most of the worse health indicators in the nation and a place where every county or parish is deemed medically underserved and a health professional shortage area. Louisiana is one of the more blatant examples of the need to double the number of people served by health centers. As our state Secretary of Health has indicated its time to invert the pyramid in our state so that primary care becomes the foundation and we build up and out from there. The Teche Action Clinic has already demonstrated the efficacy of this concept by conducting the first public health clinic conversion to that of a community health center. We have also engaged in a planning process with a neighboring parish, St. John the Baptist, to continue this effort in our region of the state. This type of collaboration and partnership goes to the essence of the community health center model.

Assist and support efforts by the core safety net and other providers to better organize care for the uninsured locally.

Last year, Congress provided $125 million in second-year funding for the Community Access Program (CAP), a relatively new effort designed to encourage collaboration among health care providers and other community organizations to improve access to care for the growing number of Americans without health insurance. This new effort is patterned after two similar initiatives undertaken in recent years by major philanthropic foundations (the Kellogg Foundation and the Robert Wood Johnson Foundation). As members of the principal federal program directed at providing access to health care for uninsured and underserved Americans over the past 35 years, we offer the following points for your consideration:

Health centers welcome any effort that holds the promise of improving access to needed care for the uninsured and for other underserved populations, especially for efforts to help get other local providers to commit to providing needed services for our uninsured patients and others in an organized fashion. Accordingly, we strongly recommend that this Subcommittee support the continuation of efforts such as those funded under the CAP demonstration;
·At the same time, we strongly believe that that any such efforts should complement and do not duplicate the work of other federal programs that are already targeted at providing desperately-needed services and care to low income, largely uninsured populations -- like health centers, the NHSC, Ryan White CARE Act programs, and others as well; and
Because true safety net providers -- those, I repeat, with a legal obligation to provide care to persons who cannot afford to pay -- are at the very core of health care delivery for the uninsured in local communities today, and have years of experience and the resulting expertise in organizing the provision of care for this population, then we believe that these local efforts must clearly include local safety net providers, not just as participants but as core decision-makers and grant recipients.

Conclusion

In summary, health centers are doing their level best to fulfill the expectations of this Subcommittee - and indeed of this Congress and our President. With your continued help and support, we will continue to meet these expectations even as we grow to meet more of the most pressing health care needs in communities all across the country.

As I look over the last 19 years of my career I can honestly say that I can see the fruit of our labor, a priceless gift in one's lifetime. As I work and plan with the staff at home our aim is to have greater than a one-generational impact, not only on our own patient population, but also on the larger community. I think that my experiences can best be reflected in a remark made by one of my patients who I had just seen through a life threatening episode whose visiting daughter asked me how did I come to be in Franklin, Louisiana. I responded that I came via the National Health Service Corps. Her response was while I don't know much about the program you are referring to; all I can say is thank God for the National Health Service Corps. I also thank God for the NHSC and for the health centers program, and the wonderful, often miraculous effects they are having on people and communities all across America.

Thank you for this opportunity to present my views. I and my health center colleagues across the country look forward to working with all the members of the Subcommittee to improve and expand access to vital health care services for many more of America's uninsured and underserved.

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Authorizing Safety Net Public Health Programs

Health Centers Need the Support of Congress to Fulfill Their Mission

Reauthorize and Strengthen the Health Centers Program

Conclusion