Text of
Printed Hearing
The Committee on Energy and Commerce
W.J. "Billy" Tauzin, Chairman
Authorizing Safety Net Public Health Programs
Subcommittee on Health
August 1, 2001
10:00 AM
2322 Rayburn House Office Building
<DOC>
[107th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:74851.wais]
AUTHORIZING SAFETY NET PUBLIC HEALTH PROGRAMS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
AUGUST 1, 2001
__________
Serial No. 107-57
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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___________________________________________________________________________
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COMMITTEE ON ENERGY AND COMMERCE
W.J. ``BILLY'' TAUZIN, Louisiana, Chairman
MICHAEL BILIRAKIS, Florida JOHN D. DINGELL, Michigan
JOE BARTON, Texas HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia SHERROD BROWN, Ohio
STEVE LARGENT, Oklahoma BART GORDON, Tennessee
RICHARD BURR, North Carolina PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
GREG GANSKE, Iowa ANNA G. ESHOO, California
CHARLIE NORWOOD, Georgia BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois TOM SAWYER, Ohio
HEATHER WILSON, New Mexico ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona GENE GREEN, Texas
CHARLES ``CHIP'' PICKERING, KAREN McCARTHY, Missouri
Mississippi TED STRICKLAND, Ohio
VITO FOSSELLA, New York DIANA DeGETTE, Colorado
ROY BLUNT, Missouri THOMAS M. BARRETT, Wisconsin
TOM DAVIS, Virginia BILL LUTHER, Minnesota
ED BRYANT, Tennessee LOIS CAPPS, California
ROBERT L. EHRLICH, Jr., Maryland MICHAEL F. DOYLE, Pennsylvania
STEVE BUYER, Indiana CHRISTOPHER JOHN, Louisiana
GEORGE RADANOVICH, California JANE HARMAN, California
CHARLES F. BASS, New Hampshire
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
David V. Marventano, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health
MICHAEL BILIRAKIS, Florida, Chairman
JOE BARTON, Texas SHERROD BROWN, Ohio
FRED UPTON, Michigan HENRY A. WAXMAN, California
JAMES C. GREENWOOD, Pennsylvania TED STRICKLAND, Ohio
NATHAN DEAL, Georgia THOMAS M. BARRETT, Wisconsin
RICHARD BURR, North Carolina LOIS CAPPS, California
ED WHITFIELD, Kentucky RALPH M. HALL, Texas
GREG GANSKE, Iowa EDOLPHUS TOWNS, New York
CHARLIE NORWOOD, Georgia FRANK PALLONE, Jr., New Jersey
Vice Chairman PETER DEUTSCH, Florida
BARBARA CUBIN, Wyoming ANNA G. ESHOO, California
HEATHER WILSON, New Mexico BART STUPAK, Michigan
JOHN B. SHADEGG, Arizona ELIOT L. ENGEL, New York
CHARLES ``CHIP'' PICKERING, ALBERT R. WYNN, Maryland
Mississippi GENE GREEN, Texas
ED BRYANT, Tennessee JOHN D. DINGELL, Michigan,
ROBERT L. EHRLICH, Jr., Maryland (Ex Officio)
STEVE BUYER, Indiana
JOSEPH R. PITTS, Pennsylvania
W.J. ``BILLY'' TAUZIN, Louisiana
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Baker, Diana................................................. 126
Benjamin, Kathryn, Executive Director, Southeast Lancaster
Health Services............................................ 38
Brewton, David, Director of Development, East Liberty Family
Health Center.............................................. 52
Duke, Betty James, Acting Director, Health Resources and
Service Administration..................................... 24
Hall, Robert, President, National Council of Urban Indian
Health..................................................... 87
Heinrich, Janet, Director, Health Care-Public Health Issues,
U.S. General Accounting Office............................. 105
Monson, Hon. Angela, Oklahoma State Senate and Vice
President, National Conference of State Legislatures....... 83
O'Leary, Linda, Federation of American Health Systems, Chief
Nursing Officer, Regional Medical Center, Bayonet Point,
Hudson, Florida............................................ 115
Pietrantoni, Adele, Trustee, American Pharmaceutical
Association................................................ 135
Roberts, Cory, Director of Anatomic Pathology, St. Paul
Medical Center, Department of Pathology, Dallas, Texas..... 131
Roberts, Russell, John M. Olin Senior Fellow, Weidenbaum
Center on the Economy, Government and Public Policy,
Washington University, St. Louis, Missouri................. 140
Singer, Jeff, President & CEO, Health Care for the Homeless.. 76
Wiltz, Gary Michael, Teche Action Clinic..................... 29
Material submitted for the record by:
McGovern, Hon. James P., a Representative in Congress from
the State of Massachusetts and Hon. Michael K. Simpson, a
Representative in Congress from the State of Idaho,
prepared statement of...................................... 153
National Association of Chain Drug Stores, prepared statement
of......................................................... 155
National Rural Health Association, prepared statement of..... 159
(iii)
AUTHORIZING SAFETY NET PUBLIC HEALTH PROGRAMS
----------
THURSDAY, AUGUST 1, 2001
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Health,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:12 a.m., in
room 2322, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Burr, Bryant,
Ehrlich, Pitts, Brown, Strickland, Barrett, Capps, Pallone,
Wynn, Green.
Staff present: Marc Wheat, majority counsel; Anne Esposito,
policy coordinator; Nolty Theriot, legislative clerk; Dave
Nelson, minority counsel; John Ford, minority counsel; and
Cartay Johnson, clerk.
Mr. Bilirakis. The hearing will come to order. I would like
to start by welcoming our witnesses. I know that it can be
difficult to drop everything, as you all have, and you are
probably among the busiest people in the country, to come to
Washington to testify, especially on such short notice, and we
want to thank you, and want to apologize to you but, that is
the way things are done up here and that is unfortunate, but
that is the way it is.
As I understand it the rules only require a 1-week notice
of hearings. We talk with the minority, we do our best to give
2-weeks notice of all hearings. Notices, I suppose, can be done
in many ways. There are vocal notices, oral notices, discussion
notices, and then there is, of course, the written notice.
I think it is important that we are having this hearing
when we are having it because we have an entire month ahead of
us when Congress will not be in session and the staffs on both
sides of the aisle are so very, very busy these days with the
Managed Care legislation, prescription drug legislation, and
all the authorizing that we have to do and that sort of thing,
so it gives them, I think, uninterrupted by the rest of us to
work on a bipartisan piece of legislation regarding the
subjects over the recess. So, for that reason, we decided to
hold the hearing this week.
I do apologize, as I said earlier, for the short notice to
the witnesses and, to a lesser extent, the members for the
short notice. But it is important that we begin to look at
these serious issues. We can sit back and talk about procedure,
and this took place and that took place, and this did not take
place, and make an awful lot out of it, but hopefully when we
get that out of the way, we can reach out and shake hands and
work together. I trust that that is going to take place. I know
that my relationship with Mr. Brown is such a good one that
that will be the case.
We are discussing issues related to the programs and
professionals that deliver health care services to many of our
Nation's citizens. First, we will hear testimony on two vitally
important health care programs, the Community Health Center
Program and the National Health Service Corps.
The second panel will explore the growing workforce
shortages among nurses, pharmacists and medical technologists.
And, again, I would like to welcome all of our witnesses and
thank them.
Community Health Centers deliver care in rural and urban
communities which are designated as medically undeserved
because of the inadequate supply of health care providers. That
is an especially big cause of mine, I might add. The mission of
these centers is to provide both primary and preventive health
care. Community Health Centers provide care in 3,000
communities to over 12 billion Americans, regardless of their
ability to pay.
The National Health Service Corps also plays a critical
role in providing care for undeserved populations. Through the
service-obligated and volunteer programs, the National Health
Service Corps recruits, trains and places primary care
providers, including dentists, nurses and physician assistants,
in both urban and rural health care shortage areas. Program
participants are health professionals who receive educational
assistance in return for a period of obligated service--and I
might add at this point parenthetically, that that is something
that has bugged me for a long time, the fact that they are able
to buy-out of their obligation is something that I don't think
they should have the right to do, and Mr. Brown and I might
talk a little further about that as time goes on.
The National Health Service Corps plays a significant role
in placing providers into areas that have difficulty attracting
health professionals. Allied health professionals play a
valuable and necessary role in the delivery of high-quality
health care. Nurses, pharmacists and medical technologists make
up a significant portion of this primary care workforce, and
recent evidence suggests that we may have shortages of these
important caregivers.
Nurses are a mainstay in today's health care system.
Certainly our nurse on this committee, Ms. Capps, is a mainstay
in our health care system. These medical professionals on the
front lines of care are dedicated to helping patients pull
through their most vulnerable moments, and I would like to
extend a warm Florida welcome particularly to Linda O'Leary,
Chief Nursing Officer, at the Regional Medical Center in
Bayonet Point, Florida, in my congressional district. I thank
you, Ms. O'Leary, for coming here to share your views with us
on the nursing shortage.
As you know, the United States General Accounting Office
has reported that there is an emerging shortage of nurses in
the country. By 2020, millions of Baby Boomers will be retiring
and expecting quality health care as senior citizens. These
individuals will need the care and comfort qualified nurses
provide, and we must do what we can to ensure an adequate
supply of nurses to meet this demand.
In December 1999, in legislation sponsored by Mr. Brown and
myself, we requested that the Health Resources and Service
Administration complete a study on the pharmacist workforce.
HRSA's report to Congress stated, and I quote, ``Evidence
clearly indicates the emergence of a shortage of pharmacists.''
When I read in the newspaper the other day the starting
salaries, in Florida particularly, of a pharmacist coming right
out of pharmacy school--Sherrod, I think we picked the wrong
profession.
Pharmacists play an increasing role in the care that many
patients receive, and a shortage could negatively impact this
care. Pharmacists and their related services help patients with
medication compliance, review records to check for drug-to-drug
interactions--which are a leading cause of medical errors, as
we know--and counsel patients and doctors on medication
options. With increased demand in utilization of medication
therapies, we must make sure that we have enough qualified
pharmacists.
It has been brought to our subcommittee's attention that we
are also facing a shortage in the medical technology area.
Medical technologists play a crucial role in the detection and
diagnosis of diseases by analyzing body fluids, tissues and
cells. My wife is a medical technologist. I met her when she
was doing this at one of the hospitals back in Florida.
Medicine today and in the future will place increased
pressure on medical laboratories to diagnose disease early
through the use of advanced screening technology. Therefore, it
is imperative that we have trained medical and clinical
laboratory technologists to fill this important role.
I would say again, parenthetically--maybe even more for the
benefit of Mr. Brown and the minority--I don't know what the
solution is to these shortage problems. That is why we hold
these hearings so that we can try to get some ideas of how we
can address matters such as this.
As health care delivery becomes more complex, we must be
sure that we have the trained professionals and infrastructure
necessary to address the increasing demand for health care
services. And, again, I look forward to hearing from the
witnesses today, and would now yield to Mr. Brown for an
opening statement.
[The prepared statement of Hon. Michael Bilirakis follows:]
Prepared Statement of Hon. Michael Bilirakis, Chairman, Subcommittee on
Health
This hearing will now come to order. Today we are discussing issues
related to the programs and professionals that deliver health care
services to many of our nation's citizens. First, we will hear
testimony on two vitally important health care programs--the Community
Health Center program and the National Health Service Corps. Our second
panel will explore the growing workforce shortages among nurses,
pharmacists and medical technologists. I would like to welcome all of
our witnesses here today and thank them for taking the time and effort
to appear before the Subcommittee.
Community Health Centers deliver care in rural and urban
communities which are designated as medically underserved because of
the inadequate supply of health care providers. The mission of these
centers is to provide both primary and preventative health care.
Community Health Centers provide care in 3,000 communities to over 12
million Americans, regardless of their ability to pay.
The National Health Service Corps also plays a critical role in
providing care for underserved populations. Through the service-
obligated and volunteer programs, the National Health Service Corps
recruits, trains and places primary care providers--including dentists,
nurses, and physician assistants--in both urban and rural health care
shortage areas. Program participants are health professionals who
receive educational assistance in return for a period of obligated
service. The National Health Service Corps plays a significant role in
placing providers into areas that have difficulty attracting health
professionals.
Allied health professionals play a valuable and necessary role in
the delivery of high quality health care. Nurses, pharmacists and
medical technologists make up a significant portion of this primary
care workforce. And, recent evidence suggests that we may have
shortages of these important caregivers.
Nurses are a mainstay in today's health care system. These medical
professionals, on the front lines of care, are dedicated to helping
patients pull through their most vulnerable moments. I'd like to extend
a warm Florida welcome to Linda O'Leary, Chief Nursing Officer at the
Regional Medical Center at Bayonet Point. Thank you for coming all the
way from the 9th district of Florida, my district, to share your views
with us on the nursing shortage. As you know, the United States General
Accounting Office (GAO) has reported that there is an emerging shortage
of nurses in this country. By 2020, millions of baby boomers will be
retiring and expecting quality health care as senior citizens. These
individuals will need the care and comfort qualified nurses provide,
and we must do what we can to ensure an adequate supply of nurses to
meet this demand.
In December of 1999, in legislation sponsored by Mr. Brown and
myself, we requested that the Health Resources and Services
Administration (HRSA) complete a study on the pharmacists workforce.
HRSA's report to Congress stated that, ``evidence clearly indicates the
emergence of a shortage of pharmacists.'' Pharmacists play an
increasing role in the care that many patients receive, and a shortage
could negatively impact this care. Pharmacists, and their related
services, help patients with medication compliance, review records to
check for drug-to-drug interactions (which are a leading cause of
medical errors) and counsel patients and doctors on medication options.
With increased demand and utilization of medication therapies we must
make sure that we have enough qualified pharmacists.
It has been brought to our Subcommittee's attention that we are
also facing a shortage in the medical technology arena. Medical
technologists play a crucial role in the detection and diagnosis of
diseases by analyzing body fluids, tissues, and cells. Medicine today
and in the future will place increased pressure on medical laboratories
to diagnose diseases early through the use of advanced screening
technologies. Therefore, it is imperative that we have trained medical
and clinical laboratory technologists to fill this important role.
As health care delivery becomes more complex, we must be sure that
we have the trained professionals and infrastructure necessary to
address the increasing demand for health care services.
I look forward to hearing from the witnesses today. I will now
yield to Mr. Brown for an opening statement.
Mr. Brown. Thank you, Mr. Chairman, I appreciate that. I
appreciate the desire of the chairman to bring reauthorization
and other legislation to the floor in September when we return.
It is a goal that my Democratic colleagues and I strongly
support.
I am concerned, however, as the chairman mentioned, about
the schedule of hearings, particularly broad-scope hearings and
important hearings like this one, on such short notice. Staff
for both the majority and the minority should have been
afforded at least 2 weeks to prepare. One week is simply not
enough with a panel of the stature of this. Of the 13
witnesses, 12 had no written testimony submitted as of midday
yesterday, the day before the hearing. That is not the fault of
you as witnesses, no formal invitations were sent out until
late Monday afternoon. Democratic staff didn't receive
confirmation of a critical witness, Dr. Roberts on the second
panel, until after 3 on Monday. I specifically ask that the
record be kept open to receive rebuttal testimony on the
economic positions taken by Dr. Roberts.
Mr. Bilirakis. Without objection.
Mr. Brown. Thank you, Mr. Chairman. I would hope also that
in the future we can agree on reasonable notice for complex
hearings, suggest to the chairman--and we have talked about
this privately and he has always been very, very cooperative--
the chairman of the subcommittee suggest that 2 weeks is a
minimum timeframe for proper preparation.
Moving on to the substance, which obviously is of much more
concern to the witnesses, I want to thank all of you for
testifying today. I want to extend a special welcome to Diana
Baker, an R.N. and Assistant Nurse Manager at the Urology/
Gynecology Unit at Cleveland Clinic, from Newton Falls, Ohio.
We are covering a lot of ground on a number of important
issues, including Community Health Centers, the National Health
Service Corps, and the shortage of three valuable health care
providers--nurses, pharmacists and medical technicians.
There is a misperception in this country that Medicaid
offers a health care safety net for all low-income people.
Medicaid, though, does not go far enough. In Ohio, 51 percent
of uninsured patients are not eligible for Medicaid and
virtually none of uninsured nonparents is eligible for
Medicaid. National Health Service Corps and Community Health
Centers provide health services to an undeserved and uninsured
population ineligible for Medicaid, a population that faces
poverty, homelessness, poor living conditions, isolation, lack
of doctors, all of this obviously poses serious barriers to
quality care. These programs together enable us to serve
populations that otherwise would fall through the cracks of our
patchwork public/private health care system.
The NHS enables health professionals to go where no other
health professionals would go, providing access to health care
and working to eliminate health disparities in undeserved
areas. Reauthorization will make this program stronger.
Earlier this year, the chairman and I circulated a letter
to the Appropriations Committee expressing support for
increased funding for Community Health Centers. Two hundred
nineteen of our colleagues signed the letter, the largest
number of House Members ever to support funding for Health
Centers. The President has said he is committed to doubling the
number of Health Centers over the next 5 years. Congressional
bipartisan support for health centers is stronger than ever.
Health Centers and the National Health Service Corps continue
to improve the quality of life for so many uninsured families.
The second panel will discuss workforce shortages. Many of
us on this committee have been working closely with a number of
nursing groups, including the ANA, including the Service
Employees International Union, and hospital groups on this
issue. Right now, the average of employed Register Nurses is 45
years old and increasing. Ominously, the number of graduates
from nursing programs declined by 1995 and 1999 almost 14
percent.
My colleague, Congresswoman Capps, has worked very hard on
this issue, has kept this issue in front of this subcommittee,
in front of this Congress, and I am pleased, as many others
are, to be a co-sponsor of the bill she introduced that
addresses the long-term critical concerns facing her
profession, facing the nursing profession.
As this Congress considers its role, I would urge my
colleagues that patient safety should guide our decisions. For
every day a hospital floor is staffed with exhausted nurses
working overtime, patients' lives are at risk.
Congressman Shimkus has introduced legislation with respect
to the shortage of medical laboratory technicians, individuals
responsible for such lifesaving work as screening women for
cervical cancer and recognizing the resistance of pathogens,
more commonly known as anti-microbial resistance.
I also want to thank my colleague, Mr. McGovern, for his
diligent work on behalf of the pharmacists shortage issue.
Americans filling are more prescriptions today than ever. It is
critical that pharmacies are adequately staffed to ensure that
patients are familiar with how to use their prescriptions.
Mr. Chairman, in closing, I want to raise an issue that is
not being discussed at today's hearing, the Community Access
Program, a valuable program that the President has elected not
to fund. People praise managed care for coordinating care. The
CAP program is a demonstration program that coordinates care
for the uninsured. Failure to fund this program creates
duplication of services and compromises the potential of safety
net providers who could be working together. I hope we look at
this issue more closely in the near future, and I thank the
chairman for his cooperation at all times.
Mr. Bilirakis. And I thank the gentleman. Mr. Pitts, for an
opening statement.
Mr. Pitts. Thank you, Mr. Chairman, and thank you for
holding this important on public health this morning. It has
been my pleasure to coordinate the Public Health Working Group
as part of this subcommittee, and to develop legislation that
builds on the success of Community Health Centers and provides
real solutions to the challenges they face. Community Health
Centers provide invaluable medical care to millions of
Americans without health insurance, low-income working
families, rural residents, agricultural farm workers, and those
living with HIV or with mental health needs.
Today, we will hear from experts in public health, those
who are in the field every day meeting the health needs of
those in their community. I am especially pleased to have with
us today Kathy Benjamin, from the Southeast Lancaster Health
Services, from my congressional district. I visited the Health
Center for the first time several years ago, one of my first
site visits after coming to Congress. I then recently visited
it again last week.
It is encouraging to see the positive impact they have on
the lives of families, especially women and children. The
Southeast Lancaster Community Health Center takes seriously its
responsibility to serve the surrounding community and the city
of Lancaster, and they are successful in providing quality
health care. Yet, each day they, along with Community Health
Centers across the country, face many challenges, challenges
which through this hearing we will have the opportunity to hear
first-hand.
While these servants would rather spend their time meeting
the health needs of families who come to them, they must spend
too much time dealing with the shortage of health care
professionals, problems with Medicare and Medicaid
reimbursement, community outreach, inadequate facilities, or
limited funding. Their hands are full. We must work diligently
to address these challenges.
Further, Mr. Chairman, President Bush has provided a model
to build bridges between faith-based organizations and
government agencies. There are many such professional Community
Health Centers throughout the country that are faith-based, and
we must look at ways to empower them to better meet the needs
of their community.
I would like to recognize David Winningham, the Director of
Development at Esperanza, a faith-based Community Health Center
located in northeast Philadelphia, one of the most depressed
areas in the city. Esperanza is a poster child for the
successes and challenges that faith-based community health
services provide. They not only meet the health needs of
families in their community, but also seek to impact and change
lives. Ask those who work at Esperanza why they do what they
do. They will respond that they are compelled by love to serve
those in need, and we must work with them. Mr. Winningham has
prepared a statement and I would like to submit it for the
record, and I encourage everyone to read it.
Mr. Bilirakis. Without objection.
[The statement follows:]
Prepared Statement of David Winningham, Director of Development,
Esperanza Medical Clinic
Esperanza Medical Clinic was begun under the leadership of Dr.
Carolyn Klaus in 1987. Dr. Klaus, working with a number of concerned
health professionals from several urban churches, had discerned a need
for a holistic, high quality, and culturally sensitive health care
center in North Philadelphia.
Esperanza's (Hope in Spanish) main program is operation of a
community health care clinic to treat and prevent injury and disease.
It has a full-time board certified staff of bilingual physicians,
nurses, nurse practitioners, and physician assistants specializing in
cardiology, pediatrics, women's health, family medicine, internal
medicine, and infectious diseases. Health Partners, Inc has deemed
Esperanza a ``Center of Excellence'' for the diagnosis and treatment of
HIV/Aids.
Esperanza holistic health care approach focuses on prevention.
Patients are educated on a wide variety of issues ranging from diabetes
care to coping with depression, from dealing with the welfare system to
learning the ingredients of a successful marriage. Almost half of our
visits are with children, so we have the opportunity to affect the way
the next generation approaches their health care.
Esperanza provides individual and family counseling. In conjunction
with their primary health care program, the counseling program works to
positively impact the emotional, mental, spiritual, and social health
of the community it serves.
Why is this so important? Many of the Hispanics in our community
cannot access health care services because of cultural, language, and
financial barriers.
<bullet> We estimate that 85% of our patients are 100% below the
federal poverty line
<bullet> 26.9% of the Hispanic births in Philadelphia were to teenage
mothers, the highest of any racial group <SUP>1</SUP>
---------------------------------------------------------------------------
\1\ Philadelphia Dept. of Public Health, Vital Statistics Report
1998
---------------------------------------------------------------------------
<bullet> 73.7% of all children born to Hispanic mothers answered,
``no'' to the question, ``Is mother married to father?''
<SUP>2</SUP>
---------------------------------------------------------------------------
\2\ Ibid
---------------------------------------------------------------------------
<bullet> The poverty rate for children under 18 in Philadelphia is
37.5% compared to the U.S average of 20.8%. <SUP>3</SUP>
---------------------------------------------------------------------------
\3\ American Institute for Research 1995
---------------------------------------------------------------------------
<bullet> Those receiving welfare (AFDC and TANF) in Philadelphia is
12.5% compared to the U.S. average of 3.6%. <SUP>4</SUP>
---------------------------------------------------------------------------
\4\ American Institute for Research 1998
---------------------------------------------------------------------------
Because all of our medical staff is bilingual, many have or do live
in the Culture. Esperanza is a light of hope in North Philadelphia
because no one is turned away because they cannot pay for medical care.
In Esperanza's last fiscal year, our physicians saw 9,266 patients
while our counselors averaged forty-one visits a month. At the
beginning of 2000, we were forced to discontinue accepting any new
patients. The patient load and examination room availability had
reached the maximum level for proper care. In June of this year, we
added two physicians and additional medical personnel to our staff and
reopened to new patients who are arriving at a rate of almost 300 per
month.
Last year, 85% of our patients were either Medicaid or Medicare
recipients while 6% were self-pay. The problem lies with the delay in
reimbursements from the government. As of this writing, we were still
waiting for almost $200,000 in reimbursements from 1999
As with most organizations, payroll and rent are the biggest
expenses and Esperanza is no exception. Our staff of physicians and
other medical personnel is paid roughly 30-35% of what they could be
earning with for-profit organizations. Our rent is reasonable but we
could use more space.
It is not unusual for our medical professionals and staff to go
without salary beyond the normal pay schedule. Needless to say, it
causes financial difficulty for many of our already underpaid staff.
Having said this, Esperanza has minimal turnover of personnel because
of their overwhelming commitment to the work done here. Those employed
at Esperanza believe in its mission and that everyone is entitled to
the excellent healthcare provided in our clinic.
Please allow me to tell you just one real-life story of those we
serve in North Philadelphia. For the purpose of this testimony, lets
call our patient ``Maria.''
Maria is a young Hispanic woman in her early 20's born and raised
in North Philly, a place known by the local police as ``the badlands.''
Her community has this reputation because it has the highest homicidal
and suicidal rates in all of Pennsylvania. Crime is rampant, housing is
deplorable, and people live in this narrowly defined area where drugs
and poverty are the everyday influences with which they must contend.
Although Maria is a second generation Hispanic, she prefers Spanish
culture and speaks mostly Spanish. Despite the fact that she is a US
citizen, she does not see herself as one with the same rights as other
groups enjoy. As with most Hispanics in this area, Maria's experience
with social institutions has proven challenging, to say the least. In
essence, she has trouble communicating with and does not trust the
people who represent these community organizations and has asked for
our help with the many difficulties of her existence. Maria is an
exemplification of the typical person in North Philadelphia. Her life
has been a succession of pain and sorrow. She is the mother of two
children, one of which is a three-month old daughter born with both
brain and heart damage.
Several weeks ago, Maria called our center in an acute emotional
crisis. The only person that had a relationship with her was our head
nurse, Andrea. Because the nature of her call was psychological, one of
therapist was asked to follow-up. Maria was suicidal.
Maria's husband was working. Her mother was unavailable as she was
caring for her other daughter who was recently released from a
psychiatric institution. Maria turned to her friends at Esperanza.
We were able to ``jump through hoops'' in order to get Maria to
Esperanza to meet with a team consisting of a pediatrician, a family
practitioner, head nurse, and a therapist. Together we were able to
assess, make a plan of action, and implement it in order to serve this
patient.
Several days later, she was scheduled to meet her therapist at the
center. However, when the hour came, her therapist received a call from
a very anxious and depressed young woman stating that desperately
needed her appointment but could not come for lack of childcare. The
therapist responded by saying she would come for the session in Maria's
home. Maria was relieved that the staff would go so far as to visit her
in her home.
When the therapist arrived for the session, she was astonished by
the conditions she saw. The first floor of the house was cluttered with
large black trash bags, trashcans overflowing, walls half built and
construction materials everywhere. The dust was so awful that it was
virtually impossible to breathe. Maria was determined to make this
house a ``home.''
Maria took Liz to the second floor. They decided to have their
session while sitting on the bed of the two year old daughter. Directly
in front of them was the 3 month old in her crib. She was connected to
feeding tubes, which nourished her young body in order to keep her
alive. They sat there and talked endlessly as if she had never told
anyone about her life and all its difficulties. No support from family.
No support or confidence in social agencies. But now she feels she has
an ally. One who understands her culturally and emotionally.
When Liz returned to Esperanza, she came across a local pastor who
is supportive of our center. I told him of the need Maria had to have
her construction work finished. He joyfully agreed to use a group of
teenagers from a suburban church to volunteer their time to serve this
family.
This is the holistic nature of the work of Esperanza. It is very
difficult to describe the emotional impact that such lives have on its
staff. It is true that their trauma vicariously affects us all. But
because of the presence of our living God, Who goes ahead of us, we are
more than equipped to walk side-by-side with these broken lives.
We are grateful for the funding made available for community health
centers in our country. We would not be able to provide the services we
do to the citizens of Philadelphia without them. Having said that, we
could use your influence to see that the reimbursement process is
improved. As I said earlier, we are still waiting on annual wrap-around
reimbursements from 1999.
Thank you for the opportunity for me to present the work of the
dedicated staff of Esperanza Health Center to his committee.
Mr. Pitts. In closing, the reauthorization of Community
Health Centers is an extremely important issue and one that the
committee and the House cannot hesitate to address. There are
many families and children around the country that need quality
health care, it is our responsibility to reach out to ensure
that this need is met.
I look forward to hearing the testimony of our
distinguished witnesses. Thank you, Mr. Chairman, and I yield
back the balance of my time.
Mr. Bilirakis. I thank the gentleman. Ms. Capps, for an
opening statement.
Ms. Capps. Mr. Chairman, thank you for holding this very
important hearing today. I am very pleased that we are focusing
on America's public health safety net and, in particular, the
shortage of nurses in the workforce, and I have been discussing
these related issues with you for some time, and perhaps given
the shortness of the notice for the hearing, we can consider
this a first step in our discussion of some very important
topics.
Clearly, this hearing will deal with important programs,
and I hope it will be inclusive of ones like the Community
Access Program, which help local agencies coordinate their
efforts to provide health care.
In my district, the Lompoc Valley Community Health Care
Organization has received funds from this program, and I am
proud to support Mr. Green's legislation to authorize the
program. But I have a special interest in the nursing shortage.
As has been indicated, I have been a nurse, I have been a nurse
for 41 years, and have been working on this particular issue in
Congress for the past 2 years. I have known first-hand the
challenges that my profession faces, and the importance of
nurses in my district have also informed my motivation to be
involved in this important discussion.
Nurses are the first line of defense in our Nation's health
care system, and too often last in line for support. Today the
nursing community is facing a dire situation which actually
translates into meaning that our society is facing a dire
situation. There is an ongoing shortage of nurses in the
workplace that threatens access to quality of care for many
Americans. To make matters worse, a greater crisis is looming
just over the horizon that could strain the health care system
to the breaking point. We have an aging nursing workforce and a
dwindling supply of new nurses. Right now, as has been
mentioned already, the average age of employed Registered
Nurses is 43 years old. By 2010, 40 percent of the R.N.
workforce will be over 50. At the same time that so many are
approaching retirement, we are facing an incredible shortfall
of well-trained, experienced nurses in all fields, and this
just as the 78 million members of the Baby Boom generation
begin to retire and need a greater amount of health care.
That is why I worked with Representative Sue Kelly and my
colleagues here on the Energy and Commerce Committee,
especially Representative Ed Whitfield, as well as Ranking
Member Dingell and Ranking Member Brown and, in the Senate,
Senators Kerry and Jeffords and various nursing and hospital
groups, to craft what we are calling the Nurse Reinvestment
Act.
Our bill establishes a National Nurse Service Corps to
provide scholarships to nursing students who agree to work in
health care facilities that are critically short of nurses. We
have done this in the past. It is time to do it again.
The bill also provides for public service announcement and
nursing recruitment programs to help health care providers and
nursing groups promote nursing and caregiving careers, health
careers. The Nurse Reinvestment Act also establishes a career
ladder grant program to help nurses afford more training and
education so that they can advance to the next level of
nursing, which also must include training of faculty for
nursing education so that schools will be able to help us in
this crisis time. And the bill extends Medicare coverage for
clinical nurse training to nonhospital providers and increases
the Federal Medicaid match for nursing home clinical education
of nurses to provide 90 percent of State costs. And, finally,
the House legislation provides for grants to develop public/
private partnerships between hospitals, nursing schools, and
high schools who are maybe interested in health training
programs for young people to model after a program just
beginning now in my home town of Santa Barbara, which pairs a
high school, a local hospital and a nursing school.
This legislation has broad bipartisan support already, with
167 co-sponsors. It has been endorsed by nursing and provider
groups across the health care spectrum. These include the
American Nurses Association and American Organization of Nurse
Executives, the American Hospital Association, the American
Association of Colleges of Nurses, the Association of Women's
Health Obstetric Neonatal Nurses, the American Health Care
Association, the American Association of Homes and Services for
the Aging, the Emergency Nurse Association, the National
Hispanic Medical Association.
So, it is my hope, Mr. Chairman, that the subcommittee can
move this legislation as soon as possible. This hearing I count
as our first step along that path, and look forward to working
with you on all topics including this legislation.
Mr. Bilirakis. I thank the gentlelady. I would like to
share with you, Lois, what is happening down in my district
regarding the shortage of both nurses and educators, teachers.
There is a local community college, a junior college really,
for years and years St. Petersburg Junior College was a 2-year
school. Just recently they went to the Legislature and asked to
be considered a 4-year college for purposes of offering degrees
in nursing and in teaching, and were successful. So, that is
kind of their way to try to address these shortages. We have
got to look at all ways. Quite often, government is just not
enough, and should not be considered enough.
The Chair now yields to Mr. Bryant for an opening
statement.
Mr. Bryant. Thank you, Mr. Chairman, I will be brief. I
just want to make a couple of points, and then I know we have
had some other people come in who will want to make a
statement, but I am eager to hear the panel of witnesses that
we have today, and I thank you for being here today and being
patient with us as we all wade through these statements.
Two quick points. I represent, in Tennessee, a very diverse
district of wealth and come of the more rural counties that are
in the State, at the same time, and particularly with the
latter I am concerned in the rural communities with the quality
of care and the safety net factor that we have talked about and
will talk about today.
Second, I would concur with my colleague from California,
Ms. Capps, and others I am sure that have mentioned the
potential for shortfall that we have with nurses and other
technicians and trained medical people out there. I hope we
haven't made a serious mistake here in underestimating the need
there, and I hope there is time still to correct that.
To the point now, my mother was a nurse, and she is 94, and
we are ready to shop her around. If the bonus is right, we
might bring her out of retirement.
All she knows how to do, I think, is give penicillin shots.
We have advanced a little bit since those days, but with that I
will yield back the balance of my time.
Mr. Bilirakis. Thank you. Mr. Green, for an opening
statement.
Mr. Green. Thank you, Mr. Chairman, and I appreciate your
holding this hearing on the state of our Nation's health care
safety net programs. These programs that are instrumental in
our efforts to provide health care for all Americans, even
those who can't pay.
Community Health Centers and the National Health Service
Corps are central components in our efforts to reach out to
underserved Americans. More than 1,000 Community Health Centers
serve 11 million Americans in all 50 States. Almost half of the
patients served at CHCs are uninsured. These centers deliver
comprehensive health and social support services to people who
otherwise would face major financial, social, cultural or
language barriers to obtain quality and affordable health care.
The National Health Service Corps helps staff these Centers
and other safety net providers by giving physicians incentives
to serve in low-income and underserved rural and urban
communities. Since its founding 30 years ago, the Corps has
provided more than 23,000 health professionals to meet the
needs of the underserved in these vulnerable populations. These
dedicated clinicians also provide primary and preventative care
to individuals whose only other source of health care might be
the emergency room. Together, these two entities have
successfully improved health care in our Nation's rural and
inner-city areas. But I don't think we can talk about health
care safety net without discussing the Community Access
Program, and I was concerned with the administration's effort
to eliminate this program. Hopefully we can work together to
continue this program because it has shown such success in its
early life.
And, Dr. Wiltz, I appreciate your testimony and success
from Louisiana. Since Mr. Tauzin is not here, I am the only one
here that doesn't need an interpreter for somebody from
Louisiana, since we speak Cajun and Spanish in Texas, along
with whatever else.
The CAP program provides grants to help agencies coordinate
preventative and primary care for the 42 million Americans
without health insurance. First created as a demonstration
project in 2000, CAP grants have helped private and public
safety net providers to join forces to improve health care
services for the uninsured. And I have introduced CAP
legislation--I appreciate the support of my colleagues--that
would authorize it for 5 years so we can continue to build on
the success we have had this last year. CAP helps fill the gaps
in our health care safety net by improving infrastructure and
communication among the agencies. With better information,
agencies can provide preventative primary and emergency
clinical health services in a coordinated and integrated
manner.
Mr. Chairman, let me just mention one CAP grantee in
Broward County was able to use CAP funds to form an
informational health line and referral system to publicize
health care prevention and points of access for health care
services, and I learned that every day in Houston, if we can
have somebody treated with prevention, we can sure save money
on our emergency care.
Another program in Chicago, the CAP program has instituted
Disease Management with Best Practices, to address the county's
disproportionately high mortality rates from diabetes and
cancer. Thanks to the CAP program, the consortium was able to
reach more than 300,000 residents with these diseases in the
Chicago area.
There are many other examples, and I have a report from the
National Association of Public Hospitals, which outlines the
success of the CAP programs across the country and, Mr.
Chairman, I ask unanimous consent to submit that program for
the record.
Mr. Bilirakis. Without objection.
[The information referred to follows:]
Communities in Action: Success Stories from NAPH CAP Grantees
alabama
Jefferson County Department of Health
In Jefferson County, Alabama, the CAP grantee, Jefferson County
Department of Health (JCDH) is using its funding to improve continuity
of care and access for Birmingham residents and its surrounding areas.
The two main objectives of the Jefferson County Community Access
Program, known as JeffCoEasy! (Jefferson County's Easy Access to
Services for You!) are: (1) to improve access by establishing effective
collaboration, information sharing and clinical and financial
coordination among all levels of care in the community network and (2)
to implement best practices, engage in continuous performance
improvement, staff development, and real-time feedback of outcomes of
care.
To meet these objectives, JCDH and partner, Cooper Green Hospital,
have launched an extensive marketing campaign describing the website,
hotline, and resource center to make consumers aware of available
health care services. The county also has implemented a unified
enrollment and eligibility program for clinics to assess patients who
may qualify for publicly funded programs. Also, they purchased
electronic medical record software and modified it to integrate with
their current infrastructure. CAP funding is being used to install the
electronic medical record at five network sites. This network will
allow staff members to track patient medical history, observe important
documentation from previous providers, monitor clinic visits and
ultimately provide better service and continuity of care. The
electronic medical record also features a linking component in which
family members' medical records will be coupled together to ease
accessibility. Currently, the project is in the piloting stage where
they have one site equipped at Baptist Medical Center. At this time,
this site is training staff members on using the new software.
For more information on this program, please contact Terry Gunnell
at (205) 930-3779 or email him at gunte@jccal.org.
california
Alameda County Medical Center
In Alameda County, the CAP grantee's goal is to improve continuity
of care. Alameda County Medical Center (ACMC) and several collaborative
partners, Alameda Health Consortium and its ten member clinics, the
Alameda County Health Care Services Agency, the Alameda Alliance for
Health, and the Community Voices project, will use their CAP grant to
support work on building a county-wide seamless system of care for
patients.
They plan to enhance the function of the specialty care
coordination unit that currently employs two nurses and two medical
clerks. The medical clerks currently make appointments for patients at
specialty care clinics. To enhance this activity, ACMC and their
collaborators are developing a tracking system that will verify whether
patients went to their specialist appointment and allows staff to view
what services were received. This program will help decrease the number
of referrals by identifying when duplicate services are ordered.
Additionally, CAP funding is being used to assure that tile specialist
refer the patients back to their primary care physicians for follow up
treatment. Furthermore, ACMC is also considering placing select high-
demand specialty care services at nonhospital ambulatory care sites in
order to improve access to care.
For more information about this program, please contact Ana M.
O'Connor at (510) 891-5708 or email her at aocoonor@acmedctr.org.
Contra Costa County
In Contra Costa County of California, Contra Costa Health Services
(CCHS) and two community clinics operate the current safety net system
of care. In order to increase their capacity to care for the uninsured
and underinsured, these organizations are focusing their CAP grant on
three objectives: creating an information system to link all the
safety-net partner sites to reduce duplication and fragmentation of
care, reduce financial and cultural barriers for receiving care, and to
identify and implement cost savings through group purchasing.
While early in their program, CCHS is developing software that
provides demographic, programmatic, medical, and care reminder
information to link programs and partner organizations. Also, this
information will provide data that will be used to initiate case
management programs for asthma, diabetes, and cellulites. CCHS and
their partners are also meeting regularly to combine their resources to
better integrate preventive services.
To identify specific financial and cultural barriers, CCHS is
conducting a patient survey to identify and assess patient's
perceptions about hardships to receiving care, such as language and
transportation problems. In examining financial barriers, Contra Costa
plans to review existing fee schedules and then establish fees for
high-use procedures. Financial counselors can use this information to
encourage patients to obtain treatment at a fixed cost. Furthermore,
CCHS plans to increase cultural competency among staff and providers by
developing training programs that focus on culturally competent disease
management. For example, patients from a specific ethnic background may
need diabetes disease management programs tailored to their dietary
preferences.
To meet their third objective of reducing and containing costs, the
partners are negotiating contracts with laboratories, diagnostic
imaging services, and pharmaceutical vendors.
For more information on this program, please contact Mary Foran at
(925) 370-5055 or email her at mforan@hsd.co.contra-costa.ca.us.
Los Angeles County Department of Health Services (LAC)
The Los Angeles County Department of Health Services is
coordinating a CAP grant that includes two projects that use
information technology to improve the system's infrastructure and
access to care. One project is a joint electronic appointment system to
allow patients more immediate access to care by coordinating
appointments among participating clinics. The second project is a web-
based referral system that ties Community Health Centers with high
volumes of primary care patients to the County's acute care hospitals
that provide specialty care. This project will replace an inefficient
system for referring approximately 100,000 patients from Community
Health Centers to specialists. LAC is hopeful that they can demonstrate
that the web-based referral system improves health outcomes and better
utilizes resources.
For more information please contact Ingrid Lamirault at (213) 989-
7152 or email her at ilamirault@dhs.co.la.ca.us.
San Francisco Community Clinic Consortium (SFCCC)
The San Francisco CAP grantee is using its funding to improve care
coordination and further integrate the public and non-profit safety net
health care systems. To meet their goal, the San Francisco Department
of Public Health (SFDPH), San Francisco Community Clinic Consortium
(SFCCC) and their partners are planning for a common registration
system, installing electronic medical record software, standardizing
referral systems, and integrating behavioral health care within primary
care. These SFCCC clinics refer approximately 40,000 clients annually
to SFDPH for specialty, inpatient, and urgent care.
Currently, SFCCC and SFDPH are meeting to develop a common
registration system. A taskforce is meeting to assess common
registration data and develop recommendations to establish a uniform
registration system across the SFDPH community health network (CHN) and
the SFCCC sites. This registration system will identify an unduplicated
number of uninsured residents who obtain services at both SFCCC/CHN and
SFDPH primary care sites. Also, once a patient enters the system, the
patient's data will be available for program eligibility
determinations. Greater efficiency in the registration process will
reduce processing time and delays.
Another integration component is the community health network's
electronic medical record, called the Lifetime Clinical Record (LCR).
The LCR contains individual clinical information on every client, and
is a major step toward a computerized patient record. Currently, the
LCR has been installed in one pilot clinic. Since its implementation,
the pilot clinic documented improvement in physician morale and staff
retention, improved continuity of care, and increased access to care.
CAP funding is allowing the LCR to be linked to 10 more clinic sites.
To supplement the LCR system, SFCCC is establishing a referral
system between specialists and primary care physicians that is designed
to reduce emergency room visits, as specialists will direct patients to
their primary care physician to receive follow-up care. Providers at
SFCCC and SFDPH will undergo training to reinforce common procedures
for referrals.
Along with referral training, primary care providers are attending
continuing education sessions conducted by the UCSF Division of
Psychosocial Medicine and UCSF School of Pharmacy to learn care
techniques for behavioral health problems, limited English speaking
patients, and homeless individuals. Primary care physicians at SFCCC
have experienced an increase in patients needing treatment for mental
health and substance abuse problems. In the past, these patients were
often referred to specialists because some primary care physicians
lacked training in prescribing, psychotropic drugs. The CAP funding
will provide training to primary care physicians in basic behavioral
health treatment.
For more information on this program, please contact Dick Hodgson
at (415) 345-4230 or email him at rhodgson@sfccc.org.
San Mateo Health Services
In northern California, San Mateo Health Services has formed a
consortium with, El Concillio of San Mateo County, AFL-CIO Central
Labor Council and the Health Plan of San Mateo in order to strengthen
current efforts to maximize the use of California's existing state and
federal programs such as Medi-Cal, and to increase enrollment in the
Health Services' medically indigent adult program, called the Wellness
Education Linkage Low Cost Program (WELL). The partners are enhancing
these enrollment efforts by providing low-income residents with access
to health education and disease management services. Due to their
similar goals, these organizations formed the WELL coalition. CAP
funding is supplementing and strengthening the efforts of the WELL
Coalition by reaching and enrolling more uninsured families through
cultural, community and employer networks.
Since its funding in March 2001, the WELL Coalition has hired six
health advocates who are working with the County's Human Service Agency
to target uninsured residents and enroll them in available federal and
state health insurance programs. The target populations are uninsured
working families, uninsured or underinsured low-income union members,
immigrant families, and the medically indigent. In addition, El
Concillio and the Labor Council have hired community health workers
whose aim is to provide low-wage union members and immigrant families
with increased access to health care services through multi-cultural
health education, health screening, and prevention. San Mateo is unique
in that over 21,000 start-up companies exist with fewer than 20
employees; therefore, these businesses are not required to provide
health insurance for their employees. This phenomenon has created an
abundance of working families without health insurance. CAP activities
along with a California Medi-Cal/Healthy Families outreach grant are
financing efforts to assess and reach these individuals and others like
them. Through these initiatives, the WELL Coalition is making progress
toward their goals of reducing San Mateo County's uninsured population
by 35%.
For more information about this program, please contact Toby
Douglas at (510) 541-3251 or email him at tjdouglas@co.samateo.ca.us.
colorado
Denver Health and Hospital Authority (DHHA)
The CAP grantee from Colorado, Denver Health and Hospital Authority
used their CAP grant to facilitate enrollment in publicly funded health
insurance and to enhance case management for chronically ill adults
with physical, behavioral, and substance abuse problems.
To meet the first goal, the DHHA's CAP program has hired six
enrollment specialists to facilitate enrollment of eligible individuals
into publicly sponsored programs such as Medicaid, the Child Health
Plan Plus (SCHIP), and the Colorado Indigent Care Program. These
enrollment specialists take applications from individuals and families
in community settings. Once individuals have applied for a program, the
enrollment specialists track the status of the applications and perform
follow-up procedures.
DHHA's CAP program is making steps toward its second objective
through its adult case management program, which aims to alleviate
fragmentation of care. For example, this program is designed to improve
health outcomes and lower costs for uninsured adult patients who are
frequent users of the healthcare system and have physical, behavioral,
and/or substance abuse problems. To address this issue, the CAP grantee
has hired two case managers, a nurse and a social worker, to identify
issues, to access resources, to attend clinic visits, and to develop
case management plans for the patients. After the assessment,
consenting patients are referred to a Continuity of Care Clinic that is
designed to care for this high-risk population.
For more information about this program, please contact Liz Whitley
at (303) 436-4071 or email her at lwhitely@dhha.org.
florida
Broward Regional Health Planning Council
In Florida, the goals of the CAP grantee, Broward Regional Health
Planning Council, are threefold: to promote a centralized eligibility
and referral system to improve access to healthcare services while
providing increased awareness of existing resources, to improve data
management and case tracking for the uninsured population through an
enhanced information management system, and to improve care for the
uninsured through better case management. Through these initiatives,
Broward Regional Health Planning Council aims to increase enrollment in
existing health programs, improve referrals for healthcare needs, and
improve health outcomes for targeted health populations such as
diabetes, asthma, and HIV/AIDS.
To meet their first objective, the CAP grantee and First Call for
Help, Inc. are workin together to form an information health line and
referral system that will link community providers to patients in order
to publicize healthcare prevention and provide points of access for
health care services. Residents of Broward County can access these
services by dialing 211 on their telephone.
Along with this goal, Broward County Human Services Department,
Memorial Healthcare System, North Broward Hospital District and First
Call for Help are collaborating on using new information technology
software to improve eligibility determinations for Medicaid, WIC, and
KidCare. This project allows health care organizations and caseworkers
access to the Broward Information Network (BIN). Caseworkers can use
BIN and the new software to identify programs for which patients are
eligible. This software can be used to create basic client files also.
In three months of operation, Memorial Healthcare System and North
Broward Hospital District have improved care, to vulnerable populations
by providing disease management, information about available resources,
and linking patients to the healthcare delivery system. One case
manager reports that she has worked with over 150 new clients to
facilitate prompt access to care. Another case manager reported that
she was able to inform a diabetic patient about the benefits of using
new needles for insulin.
For more information about this program, please contact Mike
Delucca at (954) 561-9681 x 252 or email him at mdelucca@brhpc.org.
illinois
Cook County Bureau of Health Services
The Cook County Bureau of Health Services West Corridor Partnership
solidifies the public private partnership among the County, the Chicago
Department of Public Health, federally funded community health centers,
and community hospitals in the Western corridor of Cook County. Through
this partnership the over 400,000 uninsured and underinsured residents
of these communities will have access to all levels of health care,
including much needed sub specialty care. State of the art technology
will be employed to insure timely access for appointments, for
monitoring and case management to avoid duplication of services, to
decrease no-show rates, and provide appropriate sharing of information
to provide higher quality and ultimately less costly care.
Disease management ``best practices'' is also being piloted across
the partnership for diabetes care and cancer care and screening.
Community residents have higher than the national and County average
mortality rates from both diabetes and cancer. Over 300,000 residents
will benefit from focused attention on these disease entities.
For more information on this program, please contact Mary Driscoll
at (312) 633-8236 or email her at driscoll@hektoen.org.
indiana
Health and Hospital Corporation of Marion County
In Indianapolis, the Community Access Program has allowed for
expansion of the Wishard Advantage program, which currently provides a
full range of health services to 25,000 uninsured individuals, to an
additional 8,000 people. Through the collaboration of CAP, the Health
and Hospital Corporation of Marion County was able to extend the
Wishard Advantage program to include all other safety net providers in
the community as partners. This coordinated care to the uninsured will
improve the full range of vertical health care services currently being
provided and reduce inappropriate hospital admissions.
For more information on this program, please contact Seema Verma at
(317) 221-2309 or email her at sverma@hhcorp.org.
louisiana
Louisiana Public Health Institute
New Orleans' CAP grantee, Louisiana Public Health Institute (LPHI)
is improving continuity of care and access to care by implementing an
electronic interface linking the Medical Center of Louisiana with two
community health centers, and Daughters of Charity Health Center. Using
CAP funds, an affiliation agreement between the hospital and the two
health centers was reached in which LPHI purchased software and hired
an analyst to develop software that has enabled the clinics to share
diagnostic information, patient histories, and emergency discharge
reports with the hospital.
LPHI plans to create care coordination programs, grant medical
staff privileges for clinic physicians to provide care at the hospital,
and establish risk management protocols for high-risk patients. The
care coordination programs will encourage maintenance of the
relationship between patient and the primary care provider
relationship. Moreover, LPHI is considering granting medical staff
privileges so that physicians from the clinic can provide patient care
at the hospital. In addition, LPHI is hiring a care coordinator to
examine high-risk patients to determine how to improve care in order to
reduce the number of subsequent visits for these patients. These
initiatives are increasing the continuity of care for New Orleans
residents.
For more information about this program, please contact Anne Witmer
at (504) 539-9481 x 102 or email her at awitmer@lphi.org.
massachusetts
Boston Medical Center (BMC)
Boston Medical Center's, CAP funding is being used to improve
continuity of care by purchasing web-based data services that will
allow them to access secure data from ten community health centers and
a major teaching hospital via the internet, in order to follow patients
across episodes of care. This Web-based reporting and analysis tool
will enable the grantee to turn data into meaningful information that
can be used to improve and increase the continuity of care for
uninsured patients. This data reporting system would not be available
without the CAP funding. Prior to the CAP grant, the parties did not
have access to sufficient data to manage care across different sites.
Furthermore, using this data tool will be a model for other state
agencies and hospitals.
The software will enable hospitals and community health centers to
share patient information and produce reports that can be used to track
and better manage patient care for the 75,000 uninsured individuals who
are registered in the BMC CareNet Plan (a program for the uninsured in
Massachusetts). Clinical work groups will use this data to track
episodes of care and develop intensive disease management and case
management programs that will improve the access, quality and
continuity of care. For example, this data will be used to help manage
asthma care and monitor medication compliance. This should result in
reduced use of the emergency department by asthma patients.
For more information on this program, please contact John Cragin at
(617) 414-5117 or email him at john.cragin@bmc.org.
Cambridge Health Alliance
The CAP grantee in Cambridge, Massachusetts, launched in March of
2001, set a target of enrolling at least 50,000 of the community's
57,000 uninsured in a comprehensive, coordinated system of care by year
four of the project, building upon a relationship between the Cambridge
Health Alliance and more than 50 community partners. Other goals
include enhancing preventive and early intervention services, enhancing
care coordination, and implementing a shared database and care system
to facilitate enrollment and case management. The collaborators agree
that the level of cooperation and coordination among them would not
have occurred without the seed funding provided through CAP.
For more information on this program, please contact Linda Cundiff
at (617) 591-6930 or email her at lcundiff@challiance.org.
minnesota
Hennepin County Medical Center
The Community Lifeline Project of Hennepin County, Minnesota, is
using some of its CAP funding to provide community-based person-to-
person support in navigating the health delivery system for the
uninsured. For example, they have:
<bullet> enhanced a multi-lingual health information and referral phone
line that fielded 1,491 calls in the first quarter of 2001
alone;
<bullet> hired 1 community health educator and 8 community health
workers to assist 2,208 individuals apply for available public
insurance programs;
<bullet> arranged for transportation to clinic appointments for 114
patients who might otherwise have been ``no-shows'' (the number
of monthly rides increased more than threefold in the first
three months of the year)
<bullet> placed community health workers at the county hospital
emergency room and in community clinics to provide health
education and information on appropriate use of emergency
services; and
<bullet> held 15 community based health education fairs to further
enhance outreach to the community.
For more information about this program, please contact Luann
Nyberg at (763) 593-7709 or email her at
luanne.nyberg@co.hennepin.mn.us.
missouri
Kansas City Care Network
Truman Medical Center and the Kansas City Care Network are using
their CAP grant to implement technological advancements in their health
system. Partnering with Community Resource Network (CRN), Kansas City
CareNet aims to provide shared software and computer connectivity
between health care providers servicing the uninsured and underinsured
in the Kansas City area.
By providing electronic connectivity, the CAP grantee's goal is to
link local health-related and social service agencies through web
hosting and inter/intranet technology in order to create a
comprehensive database of health and social service information.
Providers will then be able to access data to better serve their
clients and offer the community a more seamless safety net system. This
technology is providing the KC CareLink patients with an improved
referral process and better overall coordinated care.
In a short time, KC CareNet has already organized information
technology (IT) work groups, and completed the initial assessment of
participating organizations' technology capabilities. KC CareNet has
also recruited a Community Advisory Board, which oversees this project.
Furthermore, staff members are researching local and national sources
on HIPAA in order to be compliant when implementing this new
technology.
For more information on this program, please contact Linda Davis at
(816) 513-6348 or email her at Linda L Davis@kcmo.org.
new york
New York City Health and Hospitals Corporation (NYCHHC)
Within New York City and its five boroughs, New York City Health
and Hospitals Corporation uses its CAP grant to achieve three goals:
(1) improve birth outcomes in target communities, (2) facilitate and
increase access to comprehensive clinical services, and (3) enhance
community health education and outreach.
In a short time, NYCHHC is witnessing the results of their first
objective through the ``Sister Friend'' program where high-risk
expectant mothers are matched with mentors during their pregnancy. As
of June, the program had enrolled over 20 participants per site in the
program. Of those enrolled, five high risk mothers have delivered full
term healthy babies. Furthermore, the program focuses on the mental
health needs of their program members. For example, one woman in the
program miscarried and remained in the program to undergo treatment for
depression. A future goal of the program is to establish mental health
screening for expectant mothers.
To meet their second objective, CAP funds will support a telephonic
dial-up network to transmit specialty care referrals between 8
healthcare sites and HHC hospitals. Over the course of the year, they
anticipate that this automated system will manage 4,800 referrals. This
service will increase continuity of care, decrease missed appointments
and reduce ER visits.
To meet their third objective, NYCHHC is conducting educational
activities and forums for diverse patient groups to inform them how to
enroll and obtain health care services. Sessions about the US health
care system, Child Health and Family Health Plus programs, advance
directives and end of life issues have been conducted for Asian
Americans, Eastern Europeans, and Russian immigrants. By hiring
educators from the same cultural background as these communities,
NYCHHC believes that these individuals have been able to better
maneuver the health care system. This has resulted in more people
enrolling in health programs and using more appropriate levels of care.
For more information on this program, please contact Nina Sporn at
(212) 788-3604 or email her at spornn@nychcc.org.
tennessee
Erlanger Health System
Servicing residents living in Hamilton County, Tennessee, and its
surrounding service area of eight southeast Tennessee counties, three
northwest Georgia counties, and one northeast Alabama county, Erlanger
Health System is using its CAP funding to achieve two main goals:
improving access to primary care physicians to decrease emergency room
usage, and increasing prevention initiatives within the community to
lower avoidable health problems. To achieve the first objective,
Erlanger hired three community health representatives who are focusing
on different ethnic groups. By building relationships with local
community organizations, churches and community centers, these
community health representatives are facilitating several programs to
educate individuals about healthcare issues such as utilizing health
screenings, how to access services when needed, and how to complete
healthcare forms. Other duties of the health representatives include
managing client information, reminding patients of their medical
appointments, documenting medical histories, making follow-up calls,
and arranging transportation. Through the representative's guidance,
patients learn to use their primary care physicians on a regular basis
instead of the emergency room.
To address their second goal, Erlanger Health Systems is
collaborating with other organizations such as the Homeless Coalition,
First Call for Help, and Hamilton County Health Department to help
educate citizens about healthcare issues. For example, Erlanger and
Hamilton County Health Department are working together to increase
preventive care for adults by offering immunizations for parents and
children at the beginning of the school year. Another notable example
is Erlanger, City of Chattanooga and Hamilton County Parks and
Recreation Departments are sponsoring exercise programs with the
community to promote healthy lifestyles, which may prevent health
problems later in life such as heart disease. Moreover, by increasing
the number of preventive health opportunities, collaborations between
organizations will prove to be beneficial to the local healthcare
providers as well as the entire community.
For more information about this program, please contact George
Ricks at (423) 778-2718 ricksge@erlanger.com.
Regional Medical Center at Memphis/Shelby County Health
As part of its CAP grant, The Memphis Community Access Program will
implement a new system for referring uninsured patients seeking non-
emergent care in the emergency room to primary care providers
participating in the coalition. Prior to implementing the referral and
appointment system, however, the grantee has conducted a rigorous
evaluation of the cultural competency of the participating providers,
to design a training program that can be specifically tailored to the
cultural needs of the nonwhite uninsured populations in different areas
of the city.
For more information about this program, please contact Brenda
Theus at (901) 545-8565 or email her at Btheus@the-med.org.
texas
The El Paso Hospital District/R.E. Thomason General
Using CAP funding, The El Paso Hospital District plans to decrease
emergency room visits and increase enrollment in existing publicly
funded programs. They are meeting these objectives by implementing a
24-hour Community Call Center, expanding the role of community health
workers, and establishing a web-based information system.
Open to all El Paso County residents, the community call center
answers medically related questions, refers social services calls to
community health workers, and facilitates enrollment into existing
programs. Using CAP funding, this grantee hired three nurses, five
community healthcare workers, and one call center coordinator, all of
whom are fluent in Spanish, to staff the call center. During the first
month of operations, the center received almost 500 calls, of which
approximately half were clinically related and half were for social
services. For the medical calls, triage nurses recommend a course of
care by following nationally certified adult and pediatric protocols.
Using these care procedures, the triage nurses have reduced
inappropriate emergency room use.
When social service calls are received, they are referred to
community health workers, known as ``promotoras.'' Promotoras perform a
variety of tasks including promotion of preventive services and
conducting community outreach. Furthermore, these community health
workers make referrals to other state agencies for individuals and
families to gain more information on programs such as WIC, SSI, and
subsidized housing. Similarly, the community health workers help enroll
individuals into programs like Medicaid.
Currently, El Paso County Hospital District, and other community
partners, including community health centers, are collaborating on the
development of a web-based information system to connect providers from
with health community workers by allowing them access to health
documents and demographical information. By expanding the role of the
promotoras, these health workers can serve to facilitate issues related
to health care and management, such as case management. The community
health workers will also be able to identify which patients meet
eligibility requirements of existing programs.
For more information on this program, please contact Mary Helen
Mays at (915) 545-4810 or email her at mhmays@elp.rr.com.
Harris County Public Health And Environmental Services
In Harris County Texas, after one month of operation, the CAP
coalition is already improving care for uninsured pregnant women. For
example, prior to receiving CAP funding they organized and trained 22
volunteer Community Health Workers to act as liaisons with people in
one of their communities to provide health education, information about
available resources and a link into the health care delivery system
which was previously unavailable. During the first month after
receiving funding, just one of these workers reported that she had
worked with 50 clients to facilitate access to care, including
arranging for quicker prenatal care, identifying patients with serious
complications that needed immediate attention, facilitating enrollment
in various programs for health and social services, and generally
navigating an otherwise perplexing and complex system of care.
For more information on this program, please contact Ron Cookston
at (281) 447-2800 or email him at rcookston@hd.co.harris.tx.us.
The University of Texas Medical Branch at Galveston
In Galveston, Texas, a safety net coalition project known as ``The
Jesse Tree'' has been able to leverage its federal CAP funding to
greatly enhance its access to private charitable donations. The project
now enjoys the support of well over 100 private organizations and
individuals, whose contributions enable the project to substantially
extend the reach of the federal grant dollars. This fundraising effort
would not have been possible without the credibility and feasibility
seeded through the CAP grant.
For more information on this program, please contact Ben Raimer, MD
at (409) 772-5033 or email him at bgraimer@utmb.edu.
Mr. Green. I would also like to point out that the
Institute of Medicine, the IOM, one of the most prestigious
health research organizations in the country, has recommended
the creation of a new Federal initiative similar to the CAP
program to help improve coordination and communication among
safety net providers. And the IOM recommends a minimum funding
of $2.5 billion over 5 years.
Mr. Chairman, as the title of this IOM report indicates,
our health care safety net is intact, but it is in trouble, and
it is imperative we reauthorize or authorize the CAP program so
we can strengthen our safety net and ensure that various health
care providers work together to improve the health care of
uninsured and underinsured Americans.
In closing, Mr. Chairman, I would like to compliment the
hard work of my colleague and deskmate, Ms. Capps, on her
effort in addressing the nursing shortage. I know in every
urban area and I know in rural areas we have that problem. The
nursing workforce is experiencing increasing staffing shortages
and a decline in the recruitment of registered nurses. With the
average Registered Nurse being 45 years old, and the aging of
the Baby Boom generation, this nursing shortage could seriously
diminish patient care, and I am a strong supporter of Ms.
Capps' Nurse Reinvestment Act.
Mr. Chairman, with that, I yield back my time.
Mr. Bilirakis. I thank the gentleman. Mr. Pallone, for an
opening statement.
Mr. Pallone. Thank you, Mr. Chairman, for holding this
important hearing on safety net health programs. There is no
doubt that we must do everything we can to protect Community
Health Centers and other safety net public health programs in
order to help continue their long tradition and mission of
providing care to all, especially the underserved.
Although the President has included in his budget an
increase for Community Health Centers, we must keep in mind
that the number of uninsured patients treated by Health Centers
is on the rise, and we must do everything possible to ensure
the dependability of Health Centers to those who rely on them
for health care services.
In this discussion of Health Centers, Mr. Chairman, I would
like to bring up the issue of urban Indian programs. I have met
with the National Council of Urban Indian Health, whose
programs serve health care and referral services to
approximately 332,000 urban Indians across 34 cities. The
number of American Indians living in urban areas is rising
dramatically and, accordingly, the services provided by the
Urban Health Centers become increasingly important to the urban
Indian community.
The urban Indian population has a history and continues to
suffer from health problems such as diabetes, obesity, poor
nutrition, substance abuse, and many other problems that have
devastating consequences. This stems from the fact that health
care services are substandard and health education is not at
its best.
The health status of American Indians requires special
resources and, accordingly, I would like to see a portion of
Section 330 funding go directly to Urban Indian Health Centers
for the purpose of addressing these community-specific needs.
Now, I know that we will be hearing from Bob Hall, who is
President of the National Council of Urban Indian Health, and I
know he will be expanding on the health issues of particular
importance to urban American Indians. I hope my colleagues will
learn about and appreciate the need for extra resources for the
urban American Indian community, and that we can continue with
debate and action on this very important issue. Thank you, Mr.
Chairman.
Mr. Bilirakis. I thank the gentleman and, without
objection, the opening statement of all members of the
subcommittee will be made a part of the record.
[Additional statements submitted for the record follow:]
Prepared Statement of Hon. W.J. ``Billy'' Tauzin, Chairman, Energy and
Commerce Committee
First, let me thank Subcommittee Chairman Bilirakis for holding
this legislative hearing today. I commend him for putting together what
promise to be two very informative panels of witnesses, who will
discuss several crucial issues related to public health safety-net
programs. These programs are vital to our efforts to provide care for
those most in need in this country.
As we consider these issues, we should bear in mind that there are
many uninsured Americans who need good health care, but have a
difficult time finding it. Part of the problem is that America doesn't
have enough people like Dr. Gary Wiltz of the Teche Action Clinic, in
Franklin, Louisiana.
Dr. Wiltz, who will testify on the first panel, is a very fine
Louisianan who has chosen to devote his life and practice to serving
others less fortunate than himself in underserved areas in the state. I
note that he first came to the Teche Action Clinic, a Federally-
recognized Community Health Center, through the National Health Service
Corps.
I'm interested in learning more about what we can do to encourage
more health care providers, who share a sense of duty and mission to
the poor, to do what Dr. Wiltz is doing and practice medicine in
underserved areas.
Now, by definition, underserved areas lack health care providers
because few providers are attracted to these areas in the first place.
One solution that we will examine today involves expanding care in
these areas by encouraging more faith-based charities to provide health
care services to the poor. Already, faith-based charities have been
credentialed by the Federal government and receive funding through the
Community Health Center program.
We also need to examine the broader workforce challenges
surrounding the recruitment of sufficient candidates for service in the
National Health Service Corps. This program has done a great deal to
address the shortage of health care professionals in undreserved rural
and urban areas. Yet more must be done. Currently, there are more than
14,000 areas in this country that Federal officials designate as having
a shortage of health professionals.
We need to discover whether or not difficulty in attracting
candidates to serve in the National Health Service Corps is compounded
by the problems of shortages in certain health professions in general.
What can we do to encourage more people to become nurses, medical
technologists, or pharmacists?
Mr. Chairman, I look forward to learning more about these
challenging issues from our witnesses, and thank you again for bringing
these matters into focus.
______
Prepared Statement of Hon. Ed Towns, a Representative in Congress from
the State of New York
I believe that this hearing is critical to enhancing access for the
uninsured and to address the workforce shortage problems experienced by
many of our health professionals.
Both the community health centers and the National Health Service
Corps have played a critical role in providing care to the medically
underserved. I am hopeful that this committee will maintain its
traditional support for the centers and mid-level practitioners. I am
particularly concerned about future legislative proposals, which would
impact nurse clinicians and physician assistants. These health
providers continue to be the backbone of our national primary health
care system. While many competing interests have suggested that we
eliminate the 10% set-aside for these providers in the Service Corps'
reauthorization bill, I want to stress that it is important that we
continue to support resources for the development of primary care
providers. Without the current set-aside, historically mid-level
practitioners simply did not receive corps loans and scholarships.
On the question of workforce shortages, I am hopeful that the
committee's action will reflect the needs of all aspects of the health
care systems. For example, hospitals, nursing homes, home health
agencies and many other entities are all reporting a nursing shortage
but they also all have differing needs as to what kind of personnel
shortage they are experiencing. Additionally, we need to ensure that
workforce proposals also will ensure the diversity that our country
will need in the 21st century to service the multi-lingual and multi-
cultural country that the U.S. has become.
I look forward to working with you Mr. Chairman and the members of
this subcommittee on addressing the challenges presented by the
concerns of our safety net providers.
______
Prepared Statement of Hon. Eliot Engel, a Representative in Congress
from the State of New York
Mr. Chairman, Ranking Member Brown, I want to thank you for having
this hearing today. I am pleased that the Committee is discussing
issues such as the health care workforce shortage, the status of our
nation's health centers, hospitals, and other safety net providers.
These are matters of tremendous importance that tend to get
overshadowed in the face of higher profile issues, such as Medicare
reform and a prescription drug benefit. So again, I am pleased that we
are giving the proper attention to these issues.
Our health care workforce is currently under tremendous strain due
to worker shortages in a number of areas. Areas that have been hit the
hardest are the nursing workforce, health aides, and pharmacists. While
all of these are a matter of great concern, I am particularly sensitive
to the nursing shortage. Nurses are the backbone of our health care
delivery system in every aspect of care. Nurses are on the front lines
in our hospitals, nursing homes, physician offices, and home care
agencies, and we are experiencing shortages in all of these areas. For
Congress to sit idly by while this problem worsens is an injustice to
the nursing profession, health care facilities, and especially our
patients who rely on nurses every day.
GAO Director William Scanlon has testified before Congress that the
nursing shortage is real, it is likely to get worse, and it is due to a
number of factors, including an aging workforce, fewer nurses entering
the field, and job dissatisfaction. I believe that he is correct and
that we in Congress must act to address this problem. To that end, I
have been in contact with nursing associations, hospital associations,
nursing homes, and home care agencies in New York and nation-wide to
determine what could be done to alleviate the situation. In those
discussions several dynamics of the problem have been identified, such
as fewer teachers to teach new nurses, fewer students entering into
nursing schools, an increasing number of nurses leaving the field for
more lucrative careers or because they are dissatisfied with their
jobs.
In response, I developed HR 1897, the Nurse of Tomorrow Act, which
has bipartisan support, including Ms. Bono who has worked with me on
this issue. The Nurse of Tomorrow Act is a multi-faceted approach to
this complex problem. HR 1897 is designed to create educational and
economic incentives in an effort to recruit and retain more nurses. The
legislation provides for grants to health care facilities for nurses to
continue their education and grants to nursing schools to reinvest in
their programs so that they can recruit more youth into the nursing
field. It also creates economic incentives for nurses by allowing a
$2000 tax credit, along with increased loan forgiveness funding. I have
received letters of support from the American Nurses Association, the
American Hospital Association, and other groups in New York and nation-
wide, which illustrate the importance of this issue.
I have also cosponsored HR 1436, the Nurse Reinvestment Act,
introduced by Ms. Capps. I believe that this issue requires us to take
action. I hope this Congress will take heed and pass legislation to
alleviate the nursing shortage and other areas of need. Mr. Chairman, I
thank the witnesses for their time and look forward to their testimony
on the issues before the Committee today.
______
Prepared Statement of Hon. John D. Dingell, a Representative in
Congress from the State of Michigan
Mr. Chairman, I thank you for holding this hearing today. The
programs that we will discuss make up a large part of what is commonly
referred to as the health care safety net. We aspire to make quality
health care available to all through affordable insurance, but we know
that there will always be a need for public health programs that
directly provide health care to millions of needy citizens. And when
times are the toughest, they're needed the most. As the economy
continues to cool after eight years of unprecedented growth and
prosperity, many Americans find themselves out of work or in low paying
jobs, putting health insurance for themselves and their families out of
reach.
The community health centers, National Health Service Corps, and
allied health professions programs for nurses all have proven track
records of outstanding service and effectiveness. But they face many
challenges. First among these is resources. The Bush Administration's
budget calls for an increase in Community Health Centers (CHC) funding,
but that increase is inadequate to close the gap between the number of
persons who need the services of CHCs and those who receive them. Other
safety net programs have been slated for cuts, elimination, or
inadequate increases. One of these, the Community Access Program, is
quite popular among safety net providers and should be restored, if not
increased.
The National Health Service Corps and the Title VI II health
professions programs for nurses serve an absolutely essential role of
providing personnel to medically under served areas. I intend to focus
on the present and future needs of these programs and will carefully
scrutinize any proposals aimed at fundamentally altering their
structure. While I understand the Administration's desire for
``flexibility,'' what will that mean for the needs these programs meet?
I look forward to working with all of my colleagues to build a
public health safety net that is stronger than ever.
Thank you.
______
Prepared Statement of Hon. John Shimkus, a Representative in Congress
from the State of Illinois
Thank you, Mr. Chairman, for holding this hearing on public health
issues.
Dr. Cory Roberts is testifying today regarding the shortage of non-
physician medical laboratory personnel. Due to growing concern from my
constituents, I have introduced legislation that addresses this
alarming shortage and would like to take this opportunity to discuss
the issue further.
The vital role medical laboratory professionals play in health care
must not be taken lightly. It is estimated that approximately 70-75
percent of all medical diagnoses are performed by the laboratory. Yet,
since these professionals often work ``behind the scenes,'' few people
know much about the critically important testing that laboratorians
perform every day. Laboratory personnel are often used in preventative
medicine: to detect diseases early, rule out incorrect diagnoses, and
to insure that a chosen treatment is working.
It is imperative that we work now to address this shortage, and
bring needed professionals into the laboratory field.
Vacancy rates for cytotechnologists (the professionals who
interpret cellular material such as Pap smears) and histotechnologists
(the individuals who prepare tissue specimens for cancer biopsies) are
at a startling high of over 20%, according to the American Society of
Clinical Pathologists. Shortages are also increasing for other
laboratory positions, such as medical technologists and medical
laboratory technicians.
To make matters worse, the number of accredited educational
programs for laboratory medicine positions has decreased significantly
over the past two decades with schools closing in several states. We
need to act now to reverse this trend.
The legislation I have introduced along with Mr. Jackson, Chairman
Bilirakis, and the distinguished Ranking Member, Mr. Brown, addresses
this critical shortage. HR 1948, the ``Medical Laboratory Personnel
Shortage Act'' expands existing federal programs with a focus on
laboratory personnel needs.
The bill includes provisions to expand the eligibility for the
National Health Service Corps to include medical laboratory personnel,
and expand programs for increasing medical laboratory personnel in the
areas of cervical cancer screening, antimicrobial resistance efforts,
bioterrorism, and transfusion medicine. It also increases funding for
the Allied Health Project Grants program, which helps attract
laboratory professionals to the field--especially minorities and
individuals in rural and underserved communities.
I urge my colleagues to recognize the nationwide shortage of
medicallaboratory personnel, and join with me in supporting this
importantlegislation.
Thank you, Mr. Chairman, for the opportunity to speak on this
issue.
Mr. Bilirakis. We will now go into the first panel. Dr.
Elizabeth James Duke is the Acting Director of the Health
Resources and Service Administration; Dr. Gary Wiltz is with
Teche Action Clinic, Franklin, Louisiana--I know the chairman
wanted to be here, sir, to personally introduce you, but the
energy bill is on the floor and, as you know, we have principal
responsibility over that, and that is the only reason he isn't
here. He will probably come walking in sometime. Ms. Kathryn S.
Benjamin, Executive Director of the Southeast Lancaster Health
Services, out of Lancaster, Pennsylvania; Dave Brewton,
Director of Development, East Liberty Family Health Center,
Pittsburgh, Pennsylvania--I am a former Pittsburgher, Mr.
Brewton, and went to Pitt, so I know that area somewhat--Jeff
Singer, President and CEO of the Health Care for the Homeless,
Baltimore, Maryland; The Honorable Angela Monson, Oklahoma
State Senate, Vice President of the National Conference of
State Legislatures--welcome, Ms. Monson; and Bob Hall,
President of the National Council of Urban Indian Health.
Ladies and gentlemen, I am not sure I know, with the
limited period of time, how many of you submitted a written
statement to us, but in any case it is a part of the record,
and we would hope that you would complement it and supplement
it. I will set the clock at 5 minutes. I won't cut you off, but
hopefully you can keep your statement to as close to 5 minutes
as possible.
Dr. Duke, we will start off with you. Please proceed,
ma'am.
STATEMENTS OF BETTY JAMES DUKE, ACTING DIRECTOR, HEALTH
RESOURCES AND SERVICE ADMINISTRATION; GARY MICHAEL WILTZ, TECHE
ACTION CLINIC; KATHRYN BENJAMIN, EXECUTIVE DIRECTOR, SOUTHEAST
LANCASTER HEALTH SERVICES; DAVID BREWTON, DIRECTOR OF
DEVELOPMENT, EAST LIBERTY FAMILY HEALTH CENTER; JEFF SINGER,
PRESIDENT & CEO, HEALTH CARE FOR THE HOMELESS; HON. ANGELA
MONSON, OKLAHOMA STATE SENATE AND VICE PRESIDENT, NATIONAL
CONFERENCE OF STATE LEGISLATURES; AND ROBERT HALL, PRESIDENT,
NATIONAL COUNCIL OF URBAN INDIAN HEALTH
Ms. Duke. Thank you very much, sir. I have submitted a
statement for the record. I will summarize and will stay within
your time line.
Mr. Chairman and members of the committee, thank you very
much for the opportunity to speak to you today about health
care in America.
The Health Resources and Services Administration, otherwise
known as HRSA, is committed to working toward 100 percent
access to health care and zero health disparities for all
Americans. To achieve this goal, HRSA works closely with State
and local governments and organizations to build a foundation
for a national safety net of health care services that promote
the health and well-being of our Nation's most vulnerable
individuals and families.
Under the leadership of President Bush and Secretary
Thompson, HRSA is prepared to reinforce and expand the health
care safety net to reach more vulnerable Americans who are in
need of primary health care services. The administration's
commitment is evident in its fiscal year 2002 financial support
for the cornerstone of HRSA's safety net programs, the
Community Health Centers.
As the foundation for health care safety nets in more than
3200 communities nationwide, community health centers deliver
family oriented preventive and primary health care services to
approximately 10.5 million people who live in medically
underserved areas in rural and urban communities.
The President's 2002 Budget request includes nearly $1.3
billion for Community Health Centers, an increase of $124
million above the fiscal year 2001 appropriation. Funding at
this level will allow health centers to increase the number of
existing and expanded health care access points by 200 in 2002,
providing services for up to 1 million additional people,
including 460,000 uninsured people. This increase is the first
installment of a multi-year initiative to increase or expand
health center access points by 1200 by the year 2006 and
eventually double the number of people served.
Through the President's Community Health Centers
Initiative, new grantees will address health care problems they
encounter in their communities. We will see small health
centers grow to meet the increasing needs and demands for their
services, and we will see mid-size centers grow into large-
scale operations as these additional resources provide them
with the chance to serve even more of the medical needs for a
growing and aging population.
Community Health Centers serve our most vulnerable
populations. In collaboration with State and local community
partners, HRSA's Community Health Centers are an indispensable
component of the national health care safety net.
The National Health Service Corps has been a critical
element in the safety net for over 25 years. Since 1972, the
National Health Service Corps, through its scholarship and loan
repayment programs, has placed over 22,000 health care
clinicians in a health care shortage area. Today, 2500
clinicians serve in border towns, rural areas, inner cities, in
every State, the District of Columbia, Puerto Rico, and the
Pacific Basin.
The 2002 budget launched a Presidential Management Reform
Initiative for the National Health Service Corps so it will
better be able to address the neediest communities. We are
examining the ratio of scholarships to loan repayments, to
ensure maximum flexibility in placing of National Health
Service providers. We will also seek to amend the professional
shortage area definition to reflect other non-physician
providers practicing in communities, which will enable the
Corps to more closely and accurately define shortage areas and
target their placements better. To further avoid overlap in the
provision of health care, HHS has begun its coordination with
immigration programs, including the J-1 and H-1C visa programs
which review applications for health care providers practicing
in underserved communities.
These reform proposals will build on the existing success
of the Corps and in turn strengthen the national safety net
since many providers spend all or part of their careers serving
where others choose not to go.
HRSA remains sensitive to the needs of America's rural
populations, who often lack ready access to health care
providers. HRSA's Office of Rural Health Policy coordinates
rural health policy issues within the Department of Health and
Human Services and is the Department's focal point for
coordinating public and private sector efforts to strengthen
and improve the delivery of health services to populations in
rural areas nationwide.
Bringing health care to rural areas means creating and
building medical infrastructure and allowing patients to heal
in their own communities. We know that patients tend to do
better when they are treated closer to home. Friends and family
can visit and offer support and encouragement, and knowing that
the physician lives in your community, that he sees the same
things that you do, and that she is an active participant in
the school, increases confidence, and cultural competence.
Also to increase the strength of the safety net we will
look to more tightly weave telehealth into areas where
physicians do not have the experience in treating specific
diseases. Since 1988, our growing telehealth network continues
to provide increasing access to health care expertise to
emerging communities and rural areas.
Sir, I will reserve the rest of my statement.
Mr. Bilirakis. You are welcome to summarize, if you would
like.
Ms. Duke. Basically, we are here to talk about two programs
that have had very successful history and which we seek to
expand and to strengthen. Thank you.
[The prepared statement of Betty James Duke follows:]
Prepared Statement of Betty James Duke, Acting Administrator, Health
Resources and Services Administration, U.S. Department of Health and
Human Services
Mr. Chairman, Members of the Subcommittee, thank you for the
opportunity to speak to you today about health care in America. I am
Betty James Duke, Acting Administrator at the Health Resources and
Services Administration, an agency within the Department of Health and
Human Services.
The Health Resources and Services Administration, otherwise known
as HRSA, is committed to working toward 100 percent access and zero
disparities. To achieve this goal, HRSA works closely with State and
local governments and organizations to build a foundation for a
national safety net of health care services that promote the health and
well-being of our nation's most vulnerable individuals and families.
Under the leadership of President Bush and Secretary Thompson, HRSA
is prepared to reinforce and expand the health care safety net to reach
more vulnerable Americans who are in need of primary health care
services. The Administration's commitment is evident in its FY 2002
financial support for the cornerstone of HRSA's safety net programs B
the Community Health Centers.
community health centers
As the foundation for health care safety nets in more than 3,200
communities nationwide, community health centers deliver family-
oriented preventive and primary health care services to approximately
10.5 million people who live in medically underserved rural and urban
communities.
The President's FY 2002 Budget request includes nearly $1.3 billion
for Community Health Centers, an increase of $124 million above the FY
2001 appropriation. Funding at this level will allow health centers to
increase the number of existing and expanded health care access points
by 200, providing services for up to one million additional people,
including 460,000 uninsured. This increase is the first installment of
a multi-year initiative to increase or expand health center access
points by 1,200 by FY 2006 and eventually double the number of people
served.
Through the President's Community Health Center Initiative, new
grantees will address the health care problems that they encounter in
their community. We will see small health centers grow to meet the
increasing needs and demands for their services. And we will see mid-
size grantees grow into large-scale operations as these additional
resources provide them the chance to serve even more of the medical
needs for a growing and aging population.
Community Health Centers serve our most vulnerable populations. The
Health Center patient population consists of approximately:
<bullet> 86 percent below 200 percent of poverty;
<bullet> 40 percent uninsured (Health Center uninsured patients have
increased at twice the national rate since 1990);
<bullet> 31 percent Medicaid recipients;
<bullet> 64 percent minorities;
<bullet> 40 percent children; and
<bullet> 30 percent women of child-bearing age.
Health Centers serve one in every six low income children, one in
every 10 low income uninsured individuals, one in every 8 Medicaid
recipients, one in every 4 homeless persons, one in every 5 migrant
farm workers, and one in every 12 rural residents. The homeless
community is particularly in need of health services--nearly 550,000
homeless patients (75 percent of whom are uninsured) are served through
culturally competent clinicians. Also, nearly 600,000 patients of
Health Centers are migrant-farm workers.
In calendar year 1999, health centers provided a full range of
culturally competent primary and preventive health services over 36.6
million encounters. These services included:
<bullet> more than 270,000 HIV tests and counseling;
<bullet> over 900,000 pap smears;
<bullet> almost two million immunizations; and
<bullet> perinatal and delivery care for 137,000 women.
Health Centers have demonstrated their effectiveness by:
<bullet> improved health outcomes;
<bullet> increased preventive services;
<bullet> improved management of chronic diseases;
<bullet> reduced avoidable hospitalizations; and
<bullet> high patient satisfaction.
In collaboration with state and local community partners, HRSA's
community health centers are an indispensable component of the national
health care safety net.
national health service corps
Health care at many community health centers is provided by medical
professionals serving in HRSA's National Health Service Corps (NHSC).
The NHSC has been a critical element in local safety nets for over 25
years. Since 1972, the National Health Service Corps, through its
scholarship and loan repayment programs, has placed over 22,000
healthcare clinicians in areas with a health professional shortage.
Today, 2,500 NHSC clinicians serve in border towns, rural areas, and
inner cities, in every State, the District of Columbia, Puerto Rico,
and the Pacific Basin.
The FY 2002 Budget launched a Presidential Management Reform
Initiative for the National Health Service Corps so it will be better
able to address the neediest communities. We are examining the ratio of
scholarships to loan repayments, as well as other set-asides, to ensure
maximum flexibility in placing NHSC providers. We will also seek to
amend the Health Professional Shortage Area definition to reflect other
non-physician providers practicing in communities, which will enable
the NHSC to more accurately define shortage areas and target placements
better. To further avoid overlap in the provision of health care, HHS
has begun its coordination with immigration programs, including the J-1
and H-1C visa programs, which review applications for health care
providers practicing in underserved communities.
These reform proposals will build on the existing success of the
NHSC and in turn strengthen the national safety net since many NHSC
providers spend all or part of their careers serving where others
choose not to go. The NHSC has had remarkable success in placing its
providers:
<bullet> approximately 97 percent of NHSC clinicians fulfill their
service commitments;
<bullet> approximately 60 percent of NHSC alumni continue to serve the
underserved four years after the completion of their service
obligation, and 52 percent of NHSC alumni continue to serve the
underserved 15 years after the completion of their service
obligation;
<bullet> NHSC clinicians include significantly higher percentages of
underrepresented minorities than the nation's workforce, and 53
percent of the patients who receive care from NHSC clinicians
are minorities; and
<bullet> NHSC clinicians provide care to millions of Americans in
community health centers, hospital clinics, county health
departments, and Indian health clinics.
rural health and telehealth
HRSA remains sensitive to the needs of America's rural populations,
who often lack ready access to health care providers. HRSA's Office of
Rural Health Policy coordinates rural health policy issues within the
HHS and is the Department's focal point for coordinating public- and
private-sector efforts to strengthen and improve the delivery of health
services to populations in rural areas nationwide.
HRSA's Rural Health Outreach grants emphasize health care service
delivery through creative strategies that require each grantee to form
a network with at least two additional partners. By developing new
health care delivery systems, these grants have improved access to care
for more than 2.9 million citizens in rural areas.
The Rural Health Network Development grants assist in developing
organizational capacity in the rural health care sector through formal
collaborative partnerships that involve shared resources. Through these
grants, communities can acquire staff, technical experts, and other
resources needed to build successful health care networks.
Bringing health care to rural areas means creating and building
medical infrastructure and allowing patients to heal in their own
communities. We know that patients tend to do better when they are
treated closer to their homes. Friends and family can visit them, and
show them their encouragement. And knowing that the physician lives in
your home community, that he sees the same things that you do, and that
she is an active participant in the school, increases confidence, and
cultural competence.
Also to increase the strength of the safety net we will look to
more tightly weave telehealth into areas where physicians do not have
the experience in treating specific diseases. Since 1988, our growing
telehealth network continues to provide increasing access to health
care expertise to emerging communities and rural areas. As we link
these offices using state-of-the-art equipment and advanced technology
to expert centers of disease and sickness management, we are providing
critical, life-saving information to health care providers who would
otherwise lack the specific expertise.
community access program
As outlined in the President's FY 2002 Budget, the Administration
proposes the elimination of the Community Access Program (CAP). After a
careful review, the Administration concluded that further fragmenting
the resources available to public health providers by establishing yet
another funding stream was not the most effective or efficient way to
improve health care access for the uninsured. Rather, the
Administration believes we should invest in proven programs like
Community Health Centers and Medicaid.
HRSA provides communities with access to existing funding resources
that would enable them to pursue the same goals as CAP. For example,
Community Health Center funding already supports an Integrated Service
Delivery Initiative (ISDI), which provides funding to health centers to
encourage them to integrate functions with other centers and safety net
providers in their communities. In addition, in FY 2000, HRSA targeted
$41 million of its funding increase for a Health Center investment
process to fund existing health center grantees that demonstrate
effectiveness at serving a disproportionate share of uninsured and
under-insured patients.
As I mentioned in the beginning of my testimony, HRSA and the
Administration are committed to ensuring access to basic, quality
health care now and in the future. We have spent a great deal of time
and effort to strengthen and streamline HRSA programs and services that
will lead to a tighter, stronger health care safety net.
Mr. Bilirakis. Thank you, Dr. Duke.
Dr. Wiltz.
STATEMENT OF GARY MICHAEL WILTZ
Mr. Wiltz. Chairman Bilirakis, Ranking Member Brown, Ms.
Capps and Mr. Pitts, I am Gary Wiltz. I am a Board-certified
internal medicine physician and Clinical Director of the Teche
Action Clinic, a federally supported health center in the rural
bayou country of Louisiana. I appreciate the opportunity to
speak to you on behalf of the National Service Corps and the
National Association of Community Health Centers in caring for
the uninsured and underserved people of this country.
To meet the challenge of the President and the Congress
have set out in doubling the capacity of health centers to care
for the uninsured, we ask that this subcommittee and Congress
act without delay to reauthorize these programs and make needed
changes to strengthen them.
I want to thank this subcommittee for the incredible
support it has given health centers. Chairman Bilirakis and
Ranking Member Brown, thank you for actively and
enthusiastically leading the efforts of the House to increase
funding over the last 4 years. I particularly want to thank my
Representative, Chairman Tauzin, for the unwavering support he
has given to our health center and all health centers.
I am here today to tell you about both of these programs
and how they have had a profound impact on the health in our
community, and that health centers around the country are ready
to meet the challenge that we face. We have a 35-year-old
commitment to quality health care that vulnerable populations
can take to the bank.
In 1976, I was a first-year medical student at Tulane, and
my only collateral in life were my dreams. I was fortunate
enough to be selected to become a member of the National
Service Corps, and after completing my training in 1982 I was
assigned to Teche in Franklin. Looking over the last 19 years,
I can see the fruits of our labor, a priceless gift in one's
lifetime.
My experiences can best be reflected in a remark made by
the daughter of one of my patients, who I had just seen through
a life-threatening episode. She asked me how did I come to be
in Franklin, and I responded that I came via the Corps. She
responded, ``I never heard of it, but thank God for the
Corps.'' I also thank God for the Corps and for the health
centers program, and the wonderful, often miraculous, effects
they are having on the people across America. We stand ready,
willing and able to meet the challenges of caring for the
underserved, but to do so Health Centers request that this
Subcommittee and the Congress help us in the following ways:
First, reauthorize and make key improvements to the health
center program, including restoration of facility construction
and expansion as allowable uses of funds. A recent survey found
that almost two-thirds of health centers currently need to be
upgraded, expanded, or replace their facilities.
Second, reauthorize and strengthen the National Health
Service Corps program and streamline it to work more
effectively with all safety net providers to improve health
care access. The Corps has brought thousands of health care
professionals to underserved areas over the past 30 years.
Third, continue your support to fulfill the long-range plan
endorsed by the President and Congress to double the number of
people served and a doubling of the Corps over the next 5
years, which will bring quality health care to more than 20
million individuals by the year 2006.
Finally, support the efforts of local safety net providers
to better organize care for uninsured and underserved such as
those funded under the new Community Access Program, taking
care that these efforts complement existing Federal programs
and include local safety net providers as Corps decisionmakers
and grant recipients.
The success of health centers can be traced to the Corps
elements of Section 330, which require that we be located in
and serve medically underserved communities; ensure the proper
targeting of Federal resources on areas of greatest need; make
services available to all residents of the community with
regard to ability to pay, with charges based on family income;
provide comprehensive primary and preventive care services
which improve both the accessibility and effectiveness of care;
and be governed by a Board of Directors, the majority of whose
members are active patients. Nowhere are these elements more
deeply routed than at Teche where 51 percent of our Board is
composed of everyday people who are interested in making the
center a success.
Our president and several board members are also leaders in
the local faith community. Our board also includes local
business owners, educators, and government officials. The
community board has viewed our compassion to provide care that
is closely attuned to the values that reflect the spirit of our
community.
In 1999, nearly 1,000 health centers served more than 11
million people in 3,200 communities across the country,
including 1 of every 9 uninsured Americans, 1 of every 6 low-
income children, 1 of every 10 rural Americans, and more than
7.5 million people of color, in addition to 600,000 farm
workers, 600,000 homeless people. Last year, we provided 22,438
visits to 6,403 at our center, 46 percent of those patients
were uninsured.
Health Centers are a God-send for communities in providing
a patient-centered, culturally competent program with an
interdisciplinary team of providers in one location. Our center
boasts four Board-certified primary care physicians, a
Physician Assistant, two dentists, two pharmacists, and a full
complement of support staff that provide services 5-days-a-week
and after-hours coverage.
Our newest physician, Dr. Tammy Mitchell, has dreams of
establishing a preventive health program in area churches that
will be linked to our center. They would monitor hypertension
and diabetes, as well as conduct health education sessions to
reduce morbidity stemming from poor diet and other lifestyle
risk factors.
Health centers are subject to stringent Federal monitoring
of their cost-effectiveness, quality of care and management. We
provide quality comprehensive primary care to some of the
hardest to reach patients in the health system at a price
second to none. The average cost of health center services
amounts to less than $350 annually, which is less than a dollar
a day for each person served.
We also recognize the power of collaboration, and we have
developed a coordinated health care delivery system network
that is trying to connect through the use of the Internet and
telemedicine several centers of community providers across
Bayou country.
I would like to take this opportunity to thank you for the
opportunity to present our views and look forward to working
with you to improve and expand health care access to the
uninsured and underserved across the country.
[The prepared statement of Gary Michael Wiltz follows:]
Prepared Statement of Gary Michael Wiltz, Clinical Director, Teche
Action Clinic on Behalf of the National Association of Community Health
Centers
Chairman Bilirakis, Ranking Member Brown, and Members of this
Subcommittee: My name is Gary Michael Wiltz. In 1976 I was a first year
medical student at Tulane Medical School, at that time my only
collateral in life was my dreams. In seeking to make those dreams a
reality I was fortunate enough to be selected to become a member of the
National Health Service Corps. It was through that relationship that I
was assigned to Teche Action Clinic in Franklin, Louisiana in 1982.
Nineteen years later I sit before you as a Board Certified Internal
Medicine Physician and Clinical Director for the Teche Action Board,
Inc. TAB as we refer to it, is the not for profit governing body of
Teche Action Clinic, a federally-supported health center in rural south
Louisiana, in St. Mary parish. St. Mary parish like most areas of
Louisiana is rich both culturally and historically. For example the
name of our health center reflects the Native American heritage in our
community as in the term ``Bayou Teche'' which means a snake-like or
winding river and the ``Action'' reflects the period in which our
health center was born. We were incorporated in 1974 on the heels of
the civil rights movement, which motivated us to take ``action'' on the
needs of our community.
I appreciate the opportunity to speak with you today, on behalf of
the National Association of Community Health Centers, about the work of
health centers and the National Health Service Corps in caring for
uninsured and underserved people in our country. I am here today to
tell you that both of these programs have had a profound impact in
helping our community in Louisiana take care of our health care needs,
and to let you and the Congress know that we, and health centers around
the country, are ready to meet the challenge the President and Congress
have set for us: to double the capacity of health centers to care for
the underserved over the next five years.
I want to thank this Subcommittee for the incredible support it has
given health centers in carrying out their mission. Chairman Bilirakis
and Ranking Member Brown, thank you for actively and enthusiastically
leading the efforts of the House to increase funding for health centers
over the last four years, as well as to establish a prospective payment
system for health centers that will provide them a stable base when
they care for Medicaid patients. Chairman Bilirakis, thank you also for
leading the Health Center Caucus, with Representatives Danny Davis,
Mike Capuano, and Henry Bonilla. I particularly want to thank my
representative, Committee Chairman Billy Tauzin, for inviting me here
today and for the unwavering support he has given to our health center
and all of the health centers around the country.
My testimony today will focus on the following:
1. As my personal experience at our center demonstrates, health centers
are doing the job expected of them by this Subcommittee and the
Congress--providing quality health services at low cost for
millions of low-income Americans.
2. The National Health Service Corps is a critical tool that has
successfully brought thousands of health care professionals to
underserved areas over the past 30 years.
3. Health centers need the continued support of this Subcommittee, and
indeed of the entire Congress, in order to continue fulfilling
the long-range plan endorsed by the President and the Congress
to double the number of people served by health centers over
the next 5 years, and a doubling of the NHSC is an integral
part of this plan.
4. To meet this goal, health centers request that the Subcommittee and
Congress act without delay to reauthorize the health centers
program and the National Health Service Corps, and to make
needed changes to strengthen the ability of these programs to
care for the uninsured and underserved.
health centers are high quality, cost-effective providers
Health centers today represent more than 35 years of federal,
state, and local community investment in primary care infrastructure
for medically underserved people and communities. Most community,
migrant, homeless and public housing health centers receive grants
under section 330 of the Public Health Service (PHS) Act, which is
authorized by this Subcommittee. Other community-based health centers
are designated as Federally qualified health centers (FQHCs) under the
Medicare and Medicaid laws because they meet all the requirements
applicable to health centers that receive Federal grant assistance, but
sufficient grant funds are not available to provide them with Federal
support. These health centers have improved access to care and have
reduced health care costs, while sustaining and enhancing the quality
of care provided.
Health centers were established to provide access to quality
preventive and primary health care for the medically underserved--
including the millions of Americans without health insurance, low
income working families, members of minority groups, rural residents,
homeless persons, and agricultural farm workers. Since their inception,
health centers have served as a prototype for effective public-private
partnerships, demonstrating their ability to involve a wide range of
community members to meet local health needs while being held
accountable for meeting national performance standards.
The success of the health centers program is due in great part to
the core elements found in Section 330 of the Public Health Service
Act, its authorizing statute. These elements stipulate that each
federally-supported health center must:
<bullet> Be located in, and serve, a community that is designated as
``medically underserved,'' thus ensuring the proper targeting
of federal resources on areas of greatest need.
<bullet> Make its services available to all residents of the community,
without regard to ability to pay, and make those services
affordable by discounting charges for otherwise uncovered care
to low-income families in accordance with family income.
<bullet> Provide comprehensive primary health care services, including
preventive care (such as regular check-ups and pap smears) and
care for illness or injury, as well as services that improve
both the accessibility of care (such as transportation and
translation services) and the effectiveness of care (such as
health/nutrition education).
<bullet> Be governed by a board of directors, a majority of whose
members are active, registered patients of the health center,
thus ensuring that the center is responsive to the health care
needs of the community it serves.
51% of our Board of Directors is composed of everyday people in the
community who are interested in making the center a success. Our Board
President, as well as prior Board Leaders and Executive Committee
members are also leaders in the local faith community. Our Board also
includes local business owners, educators, and government officials.
The community board has fueled our compassion and desire to provide
care that is closely attuned to the values that reflect the spirit of
our community.
Health centers have an impressive record of using the federal grant
investment to care for underserved Americans. In 1999, nearly 1000
health centers served more than 11 million children and adults in 3200
communities across the country. More than 9 million people obtained
care from health centers that receive funding from the federal health
centers grant program, while another 2 million people received care
from designated FQHCs that do not receive grant funds. Health center
patients include:
<bullet> 4.6 million uninsured persons, 1 of every 9 uninsured
Americans;
<bullet> 4.6 million children, 1 of every 6 low-income American
children, including 1 of every 4 low-income uninsured children
(1.6 million);
<bullet> 4 million children and adults with Medicaid or CHIP coverage,
1 of every 9 Medicaid/CHIP recipients;
<bullet> More than 7.5 million people of color, two-thirds of all
health center patients;
<bullet> 5.4 million people living in rural communities, 1 of every 10
rural Americans;
<bullet> More than 600,000 agricultural farm workers; and
<bullet> More than 600,000 homeless persons.
Health centers are community owned and operated businesses--
professional health care organizations providing a comprehensive range
of high quality preventive and primary health care services under one
roof, in a ``one stop caring'' system. We offer care, both for
prevention and for treatment of illness or injury, and in addition
provide diagnostic laboratory and x-ray services, as well as prescribed
medications in many cases. In our center we have a substantial pharmacy
program. Health center clinicians make referrals to specialists and
admit and follow their patients in the hospital, when necessary. Health
centers provide continuous care to their patients, regardless of
changes in their insurance coverage or their health status. Many of the
medically underserved come from different cultures and have primary
fluency in languages other than English. According to the Bureau of
Primary Health Care, some 23 percent of all health center patients fit
this description--and for them, health centers employ multilingual and
multicultural providers or provide translators to ensure that the care
provided is both clearly understood and culturally appropriate. I think
that community health centers are a Godsend for communities because we
provide a humanistic, culturally competent program with an inter-
disciplinary team of providers. Our team consists of 4 board certified
primary care physicians, 1 physician assistant, 2 dentists, and 2
pharmacists, with a full complement of support staff that provide
services five days per week with after hours coverage.
Each local health center is unique in terms of the range of
services it offers and its hours of operation, reflecting local
decisions on how best to meet the health care needs of that health
center's patients. At the same time, all of the health centers are
subject to ongoing federal monitoring of their cost-effectiveness,
quality of care, and management at a level which is more stringent than
that applied to any other provider. And I'm pleased to report that, to
date, more than 250 health centers--including ours--have received full
accreditation from the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO)--an excellent, independent measure of
the quality of their care.
The care that health centers provide is financed by a variety of
sources. The federal health center grants provide, on average, about 28
percent of a health center's budget. Medicaid and CHIP payments account
for about 38 percent percent, on average, of a health center's budget.
State and local government support, and private donations, provide 14
percent of health center revenues nationally, while 7 percent comes
from private insurance, and 6 percent from Medicare. Every health
center patient contributes to the cost of his or her care, and on
average, 7 percent of income comes from patient fees. These averages
will vary for each health center, depending on the financing sources
available to people in the local community. At Teche, our program
budget has grown over the years from $250,000 when I started in 1982
with 8 staff to a $2.5 million dollar budget in 2000 with 41 staff. We
provided 22,438 visits in 2000 to 6,403 patients. Forty-six percent of
our patients are uninsured, and these patients pay on a sliding fee
scale discount according to their household income and family size.
Seventeen percent of our patients have Medicaid coverage; 21 percent,
Medicare; and 16 percent, private insurance.
Health centers are one of the best health care and taxpayer
bargains anywhere. The combination of locally responsive health care
delivery and consistent federal oversight has proved to be a winning
formula. Health centers provide comprehensive services to their
patients at an astonishingly low cost. The average total cost of health
center services amounts to less than $350 annually--less than $1 a
day--for each person served.
As a community health center physician for the past nineteen years,
I have experienced firsthand the immense value of this model of care
for our patients. Everyday in our center we see hundreds of patients
who are uninsured and are plagued with diseases that demand continuity
of care. For example, one couple that I treat are on a combined fixed
income of less than $10,000 per year, and both of them have the same
medical problems--diabetes, hypertension, hyper-lipidemia, coronary
artery disease, and osteo-arthritis. Together, they are on about 15
medications, the total cost of which would normally exceed their entire
income. However, because of our special pharmacy program, this couple
is able to avert the life threatening effects of uncontrolled disease.
Dozens of studies and reports show that health centers
substantially improve the health of individuals in their communities
and provide care in a highly cost-effective manner. The impacts health
centers have had on the health of individuals in their communities
include lower hospital admission rates, shorter lengths of stay and
less inappropriate use of emergency room services, significantly lower
infant mortality rates and reduced incidence of low birth weight,
higher childhood immunization rates, and better use of preventive
health services (like Pap smears, mammography, and glaucoma screening),
resulting in lower rates of preventable illnesses.
Several studies over the last decade have found that Medicaid
patients who regularly use health centers receive care of equal or
greater quality and cost significantly less than those who use private
primary care providers, such as HMOs, hospital outpatient units or
private physicians. These findings are consistent with those from
dozens of previous studies on the cost-effectiveness and quality of
care provided through the health center model, and in particular
documenting their substantial savings to state Medicaid programs. The
record is clear that health centers provide quality, comprehensive
primary care to some of the hardest-to-reach patients in the health
system at a price second to none.
Health centers have joined with each other and with other local
providers to form integrated service networks to coordinate and improve
their purchasing power and/or to better organize the continuum of care,
especially for those who are uninsured. These include practice
management networks, designed to improve quality through shared
expertise (such as centralized pharmaceutical or laboratory services,
clinical outcomes management, or joint management/administrative
services), to lower costs through shared services (such as unified
financial or management information systems, or joint purchasing of
services or supplies), or to improve access and availability of health
care services provided by the health centers participating in the
network. Today, nearly 400 health centers are involved in some 50-plus
local networks across more than 35 states, each designed to lower costs
and/or to improve care. Separately, some 250 or more health centers are
participating in state-wide or regional collaboratives designed to
significantly improve health care management for patients with chronic
conditions like asthma, hypertension, diabetes, cardiovascular
diseases, HIV infections, depression and environmental health
conditions. In addition, health centers all across the country have
taken steps to form networks with other local providers and to develop
the financial, legal and business acumen necessary to function
effectively in managed care. Almost three-fourths of all health centers
are participating in managed care as subcontracting providers to
managed care plans, serving more than 2 million managed care enrollees.
Our organization recognizes the importance and the power in
collaboration. We work cooperatively with several organizations in our
community, some of which receive federal grant support. We have formed
the Bayou Teche Community Health Network and our collective vision is
to build a coordinated delivery system that will reduce duplication of
services and ultimately reduce the cost of care for the population in
our respective service area. We want to do this by devising an
information technology infrastructure that uses the power of the
Internet and telemedicine technology to connect several essential
community providers across Bayou country. These providers include local
social service agencies that will be able to provide transportation and
case management so as to complete or close the gaps in the present
delivery system. We also want to use this framework to develop more
community health centers that tie into a larger system of care. This is
important because we recognize that as the Congress continues to
support these programs it is imperative that they are sufficiently
integrated into the larger systems to ensure their effectiveness and
the quality of their care.
We also believe in collaborating with other community
organizations. One of our newest physician staff members is Dr. Tammy
Mitchell. I encountered this young lady's family early in my practice,
as both of her parents are my patients. As soon as I learned of her
interest in becoming a physician I can say proudly that I was able to
do for her what my mentor Dr. Cherie Epps did for me as a medical
school student at Tulane University. Today she is practicing as a
Family Medicine Physician in our clinic. Her family also includes
several strong ministerial leaders in our community. Her dream and
desire is to establish preventive health programs in area churches that
will be linked into our community health center. Her program would be
modeled after the American Heart Association's ``Search Your Heart''
program which is a church-based heart and stroke prevention clinic. It
would consist of monitoring hypertension and diabetes, as well as
health education sessions to raise awareness and reduce morbidity
stemming from poor diet and other lifestyle risk factors.
the essential role of the national health service corps
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:
<bullet> 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.
<bullet> 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.
<bullet> 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.
<bullet> 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:
<bullet> 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.
<bullet> 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.
<bullet> 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:
<bullet> 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.
<bullet> 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.
<bullet> 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.
<bullet> 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.
<bullet> 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:
<bullet> 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;
<bullet> 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
<bullet> 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.
Mr. Bilirakis. Thank you very much, Doctor.
Ms. Benjamin.
STATEMENT OF KATHRYN BENJAMIN
Ms. Benjamin. Chairman Bilirakis, Ranking Member Brown, and
members of the subcommittee, my name is Kathryn Benjamin, and I
am the Executive Director of SouthEast Lancaster Health
Services, an independent community health center, located in
the poorest and most diverse section of the city of Lancaster,
in Lancaster County, Pennsylvania. Almost 60 employees serve
over 11,000 patients each year with high quality, culturally
competent medical and dental services, and are dedicated to
eliminating all barriers to care as we continually strive to
improve the lives of the underserved in our community.
I want to thank you for the opportunity to come here today
and testify in support of the reauthorization of the Section
330 health centers program and the National Health Service
Corps, and on the importance of these programs in providing
care to the uninsured and underserved in our community. On
behalf of the center and our patients, I ask you and the
subcommittee to reauthorize these programs this year without
delay.
I particularly want to thank my Congressman, the Honorable
Joseph Pitts, for your support of our health center and your
kindness in asking Chairman Bilirakis if I could come and
testify before the subcommittee today. Mr. Pitts, all of us at
SouthEast appreciate that you took time from your busy schedule
last week and came and visited our center to see our work, and
we look forward to working with you on these important
programs.
Our center began humbly 30 years ago, with an all-volunteer
staff. Despite these modest beginnings, we have worked hard to
achieve successes that would not have been possible without the
support and guidance of the Section 330 health center program
and the National Health Service Corps. These programs helped
thousands of health centers like ours to deliver high quality
health care to the most vulnerable populations.
We support the changes suggested by the National
Association of Community Health Centers to improve the health
centers program. The recommendations include an increase in the
level of funding of health centers, expansion of construction
authority to build facilities in new communities, enhancement
of current loan guarantee authority in Section 330 to cover
facility loans, and a clarification of funding authority for
networks. Without the Section 330 program, SouthEast would not
be able to adapt to the rapid changes in the health care
industry.
We also support National Association of Community Health
Centers suggested changes for improving the National Health
Service Corps, including an increase in the level of funding,
automatic designation of all federally qualified health centers
and federally certified rural health centers that meet the
accessibility and affordability requirements as health
professional shortage area facilities, and the option of
participants in the loan repayment program to fulfill their
service obligations on a part-time basis.
What is it about the health center program that I think
makes it so successful? The health center law and program
expectations, which we at the center refer to as ``The Rules.''
The Rules provide a well thought through recipe to ensure that
patients are given expert care when they are in the clinical
areas, that all members of the community are able to access
this care when they need it, that patients understand their
providers and their providers understand them, that chronic
illnesses are prevented rather than simply treated, and that
racial and ethnic health disparities will soon become a
condition of the past.
The health center program expectations are the embodiment
of our mission to care for our most vulnerable patients and
ensure that Federal investment in our center is used wisely and
cost-effectively.
Eliminating racial disparities and providing culturally and
linguistically appropriate care to our patients is of
particular importance to us. In the past 20 years, our
Southeast neighborhood, like many neighborhoods in your
districts, has changed significantly in its cultural make-up.
Once predominantly African-American, our community is now
mostly Hispanic, with a large African-American and a smaller
Asian population. Most Hispanic residents are recent immigrants
from Puerto Rico and the Dominican Republic and speak little
English.
With Section 330 funding, we have the ability to employ bi-
lingual nurses who work intensely with expectant mothers weekly
throughout their pregnancies. They provide nutrition
counseling, smoking cessation classes, preventive health
training, home visits, birthing and parenting classes, all
services that ensure that the mother is her healthiest and is
prepared to bring a healthy life into this world.
One of our biggest success stories is that last year, for
the first time, we eliminated racial and ethnic disparities in
our newborns. There were no statistical differences between the
newborn weights of African-American, Hispanic, and White
babies. This goal, which took us 10 years to achieve, simply
would not have been possible without support and funding from
the Section 330 program. Our Medical Director, who implemented
the program, came to us at the National Health Service Corps
and is still with us today.
Also, increased levels of funding have allowed us to employ
more diverse and highly trained providers and nurses. Through
an increase in our base grant and with the help of the National
Health Service Corps, we were able to hire an African-American
dentist this year, who has implemented a new outreach program
to encourage people of color to access dental services. In one
instance, the dentist convinced a 70-year-old African-American
woman to come in for a dental visit for the first time in her
life, and she happens to be the wife of a very influential,
well-educated and prominent person in the community.
I would like to talk specifically about the role of the
community in our health center. Like every health center,
SouthEast is governed by a board from the community. The
composition of our board of directors reflects the diversity of
our community and the patients we serve. Over half of our board
members are patients of the center, and more than two-thirds
represent minorities. Our board members offer substantial
expertise in the areas of business, finance, health care,
faith-based community organizations, human resources, law,
local and regional government. Three pastors sit on the board
of SouthEast, representing large minority congregations. They
provide valuable insight into the health care needs of the
community. As a result of this relationship, the planning has
begun to open and operate a clinic in the new community
building to be built next year adjacent to the largest African-
American church in Lancaster.
Construction funding is greatly needed, as well as ongoing
operating funds to provide not only acute health services, but
also onsite screening for chronic diseases such as diabetes,
heart disease and HIV, as well as preventive health programs
such as smoking cessation, nutrition counseling, health
lifestyle and community education programs.
Our role as a safety net provider in our community has been
strengthened by recent increases in base funding, and will
continue to be fortified if we are allowed to use Section 330
funds to expand our existing facilities and to build new sites.
Our community is facing the closure of two large medical
clinics in the next 1\1/2\ years. This will leave approximately
15,000 residents without a medical home. Two years ago, two
dental clinics closed in the community, and left about 6,000
current patients without dental homes. Our center and one other
small center in the county are the only providers right now to
low-income patients in the community, and there are 29,000
Medicaid recipients in the county, and we only have enough
resources to provide about 8,000 patients with care, so it is a
very difficult situation we are facing right now. With
expansion funds, last year we were able to hire a new dentist
to help serve, and now we need to build new sites.
In order to respond to ever-increasing numbers of uninsured
and underinsured in our community, we must have the resources
to cast an even larger safety net through the reauthorization
of the Health Center and National Health Service Corps
programs.
In summary, SouthEast and its community are grateful for
the support of this subcommittee and this work. We cannot
continue to eliminate disparities in our health care system
without the reauthorization and improvement of the Health
Centers Program and the National Health Service Corps. We urge
the subcommittee to act as soon as possible to reauthorize
these important programs. Thank you for the opportunity to
appear today. I will be glad to answer any questions.
[The prepared statement of Kathryn Benjamin follows:]
Prepared Statement of Kathryn Benjamin, Executive Director, Southeast
Lancaster Health Services
Chairman Bilirakis, Ranking Member Brown, and Members of the
Subcommittee: My name is Kathryn Benjamin. I am Executive Director of
SouthEast Lancaster Health Services (SELHS). SELHS is an independent
community health center, located in the poorest and most diverse
section of the City of Lancaster, Pennsylvania. Almost 60 employees
serve over 11,000 patients each year with high quality, culturally
competent medical and dental services, and are dedicated to eliminating
all barriers to such care as we strive to continually improve the
quality of life for the underserved.
I want to thank you for the opportunity to come here today and
testify in support of the reauthorization of the section 330 health
centers program and the National Health Service Corps, and on the
importance of these programs in providing care to the uninsured and
underserved in our community. I particularly want to thank my
congressman, the Honorable Joseph Pitts, for your support of our health
center and your kindness in asking Chairman Bilirakis if I could come
before this Subcommittee today. Mr. Pitts, all of us at SELHS
appreciated that you took time from your busy schedule last week to
come and visit our center and see our work. We look forward to working
with you on these important programs.
the community that selhs serves
SELHS is situated in the middle of a diverse, urban, and medically
underserved community. The South East area neighborhood is comprised of
over 22,000 people from whom the health center draws most of its
patients. In the past twenty years this neighborhood has changed
significantly in its cultural make-up. Whereas twenty years ago most of
the residents were African American, today it is comprised of 54%
Hispanic residents, 32% African American, 5% Asian/Pacific Islanders or
American Indian, and 9% white. A majority of the Hispanic residents in
Lancaster are recent immigrants from Puerto Rico and the Dominican
Republic and, because of this, many of them have little or no English
language proficiency. At our health center, 64% of our patients are
Hispanic, and 17% are African American.
It was estimated in 1999 that 63% of the residents of the South
East Lancaster MUA and HPSA had incomes below 200% of the poverty
level, and 35% had incomes below 100% of the poverty level. 95% of our
patients live below 200% of the poverty level, and 62% live below 100%
of the poverty level. In this community there is only one full-time
physician providing services to Medicaid patients for every 6,642
residents, and one full-time dentist providing services to Medicaid
patients for every 4,580 residents, indicating the area is a low-income
Health Professional Shortage Area or HPSA. The remaining sections of
the City of Lancaster that lie outside the HPSA are comprised of less
than 7% minority and low-income residents.
history of the center
SELHS had humble beginnings. Thirty years ago two physicians and a
nurse volunteered to provide desperately needed care to patients who
were not welcome in private practices because they had no money. Small
donations from local organizations and philanthropists covered their
supply costs. As the noble gesture of these efforts spread, more
donations came. Grant funding was applied for and received and in 1980
SELHS became a community health center when it received a grant under
section 330 of the Public Health Service Act. Slowly, more services
were offered, staff began to receive compensation and more were hired.
The organization has not stopped growing during its 30-year lifespan.
the importance of the health center program to selhs and the community
Our participation in the Community Health Center (CHC) program has
been invaluable for SELHS, both from a financial and a programmatic
standpoint. The Bureau of Primary Health Care provides not only
monetary support for the center to achieve its mission, but it also
provides key technical assistance necessary to develop a voluntary
organization into one with a continually, financially viable business
plan and appropriate managerial organizational structure. Without the
section 330 program, SELHS would not be able to adapt to the rapid
changes in the health care industry.
The section 330 health center requirements and program expectations
(``the program rules'') are stringent. They cover areas such as board
composition and responsibilities, management and financial practices,
medical and dental standards of care, best practices and treatment
protocols, culturally and linguistically competent staff, and the
provision of services that eliminate barriers to accessing care. The
rules provide a well thought through recipe to ensure that: patients of
SELHS are given expert care when they are in the clinical areas; all
members of the community are able to access this care when they need
it; that patients understand their providers and that their providers
understand them; that chronic illnesses are prevented rather than
simply treated; and that racial and ethnic health disparities will soon
become a condition of the past. The rules ensure that the federal
investment in the program and our health center is used wisely and
cost-effectively.
selhs provides comprehensive primary and preventive care
SELHS' primary medical services include two family practice
physicians, two internists, and four mid-level practitioners. Services
are provided in ``pods'', each staffed by a provider, an LPN, a medical
assistant, and a patient care coordinator during each session. Patients
are immediately taken into a private room and all services are provided
to the patient in that room. Weights, labs, provider visits, social
services, treatments, billing and collections are all provided in the
privacy of the patient room. This has dramatically increased patient
satisfaction, privacy, and efficiency. The patient no longer needs to
move from station-to-station during the visit and wait for staff to be
``freed up'' to take care of their needs. Our staff go to where the
patient is.
Additionally, we have part time contractual agreements with a part-
time pediatrician, obstetrician/gynecologist, cardiology group,
nephrologist, and chiropractor, all of whom treat referral patients at
our main site. The availability of these services has dramatically
improved our ability to diagnose and treat a fuller range of diseases,
as well as remove several access barriers for our patients who would
otherwise not be able to see a specialist in his/her office.
Our prenatal care program is just one example of how SELHS has
thrived under the CHC program rules, as have our patients. The prenatal
program alone has all but eliminated racial and ethnic disparities in
the area of low birth-weight babies. Last year the average Black,
Hispanic and White baby of SELHS weighed the same healthy weight. Why
does a program like this work? In addition to the bi-weekly and weekly
visits with medical providers, SELHS offers an intense, nurse driven
perinatal program.
Unlike in private practice medicine, SELHS' perinatal nurses work
intensively with each expecting mother on a bi-weekly and weekly basis
throughout her pregnancy. These nurses evaluate every aspect of the
expecting mother's life and lifestyle. A few of the areas covered are
nutrition counseling and the provision of vitamins, stop smoking
programs, home visits, preventive health training, birthing classes,
parenting classes, and dental care. The goal of our program is to
ensure the mother is at her healthiest throughout the pregnancy, is
prepared to bring a healthy life into this world, and is prepared to
raise a child in a mentally and physically healthy environment. School
aged moms are taught how to raise a child while completing their
educations. Rarely are babies not wanted by our patients, but if this
situation should arise, nondirective counseling on all alternatives,
including adoption, is provided.
Programs such as these are expensive and only partially funded by
the CHC program. Other local organizations contribute to the costs.
Each of these organizations realizes how valuable preventive care is,
and that the return on the investment is almost astronomical if we can
prevent the use of the neonatal intensive care unit, prevent
developmental delay, and ensure that when a child is born it is as
healthy as possible. Local donors realize that SELHS cares for the most
at-risk population in the community, and that our programs, tailored to
the patients' cultural, linguistic, and financial needs, far surpass
any other services available in the community. Eliminating barriers is
the key to our success.
In addition to our medical services, primary dental services are
offered on-site by three, full-time general dentists and a part-time
pediadontist. Preventive and screening services for children are
offered by our hygienist, who works with the local Head Start Program.
The dental and prenatal departments work closely together. The prenatal
staff refer patients to the dental department as soon as they enter the
program. Our dentists not only treat them, but also teach them about
taking care of their baby's teeth. Additional dental education is
provided in specific courses that are a part of the prenatal/birthing
classes.
SELHS has a pharmacy program funded partially by the health centers
program, but primarily by local organizations and private donors. The
most common acute medicines are purchased in bulk, kept in the clinical
areas, and dispensed as needed by the providers, at the center's cost.
The auxiliary of the local medical society coordinates the pick-up of
unused pharmaceutical samples from area physicians, organizes them, and
delivers them to the center at least twice a year. And SELHS has a
staff member who coordinates our large pharmaceutical company ``chronic
disease'' medicine program. Low income, uninsured and under-insured
patients with chronic diseases are eligible to receive free medicines
from many of the large pharmaceutical companies. The requirements are
not as difficult as they are cumbersome. On a frequent basis the
patient's physician must complete forms verifying that the patient is
in need of the medicines, and SELHS must verify the patient's income
level and insurance status. The medicines are then mailed to SELHS
where staff coordinate patient pick-up and dispensing.
The other major part of our pharmacy program is the acute medicine
voucher program. About $10,000 per year is donated from local
businesses, organizations and private donors, to pay for 100% of
individual acute prescriptions for patients who do not have the
immediate funds to pay for them.
SELHS offers free prostate screening annually with the help of a
local hospital that provides nurses and covers promotional expenses,
and a group of volunteer urologists. This year 174 men were screened
who might otherwise have not received this valuable check-up. Excellent
communication to the community through our board's close relationship
with the faith-based organizations has increased the success of this
program significantly.
Free HIV screening and counseling is provided on a daily basis in a
dedicated office at our main site. The local AIDS Community Alliance
provides trained counselors, who work closely with the medical
providers, greatly enhancing compliance with treatment protocols and
the continuity of care.
comprehensiveness of care
SELHS provides more than episodic medical and dental care, and
continues to care for patients during periods when they lose their
health insurance. There are many services that SELHS provides uniquely
in the community. Social services, nutritional counseling, incentives
for up-to-date immunizations, and the Reach Out And Read program are
highlights of some of the other services that contribute to our
success.
Recognizing that many of our patients face challenges in their
daily lives that limit their ability to comply with treatment regimens,
SELHS employs clinical support staff who follow the patients after
their visits, and provide assistance when barriers come up. Case
managers, social workers, eligibility specialists, physician assistants
and nurse practitioners intervene when needed. All patients with
chronic diseases are ``tracked'' or followed by staff who find out if
they keep specialist appointments, fill their prescriptions, get their
laboratory work done at appropriate intervals, and keep appointments at
SELHS. When a patient faces trouble in any of these areas our staff
offer assistance. Sometimes a simple reminder phone call helps, and
sometimes our social worker gets involved, and other times a visit to
the patient's home is necessary.
Our experience has shown that once an individual has begun to fully
comply with healthy lifestyle changes and/or is following treatment
protocols for a period of time, they not only establish life-time
patterns of behavior, but they affect their entire family and social
network. This is why we are so strongly dedicated to changing the lives
of our patients and our commuity, one life at a time.
Environmental issues, such as lead paint, the existence of fire-
arms in households, and home safety hazards are all discussed in office
visits. School aged children from underserved homes often do not have
many of their own books, so we give each child a book of their own at
each visit. And we have started the Reach Out and Read program, which
provides additional, age appropriate books and readers in our pediatric
waiting rooms as well.
culturally and linguistically competent care
From our board of directors to our translators, SELHS is committed
to providing healthcare and education to our patients and the community
in a culturally and linguistically friendly manor. Studies continue to
support the theory that people learn best and are most likely to comply
with suggested lifestyle changes and treatment programs when they are
delivered in their primary language and in a manner that respects and
acknowledges their traditional cultural beliefs.
SELHS is the only provider in the community that ensures the
availability of translators in the clinical area for those providers
who are not bilingual. Employees at SELHS can provide medical
translation in almost a dozen languages. Quarterly staff meetings
target various cultures and their health beliefs, as part of a program
to continually educate, update, and brainstorm on ways to improve our
services to all members of the diverse population we serve.
Recruiting bicultural and bilingual providers has been difficult
for SELHS. Whereas in the past, the National Health Service Corps
(NHSC) has successfully provided loan repayment opportunities to
several of our providers, this year we lost a bilingual and bicultural
physician because of the shortage of funds in the NHSC program. A year
prior we had the good fortune to hire a multi-lingual, bi-cultural,
board certified, family practitioner. He would only agree to an
extended contract if he would be able to receive loan repayment through
the NHSC. Five months after he began employment he received bad news:
NHSC was under-funded and, although he qualified for the loan repayment
program, there were insufficient funds for that year, and he was
welcome to apply the following year. He graciously completed a full
year of employment, and then, having no faith in the NHSC, he left our
employ.
Hiring bilingual and bicultural, or minority providers has always
been a challenge for SELHS. The NHSC offered us a great recruiting tool
in the past. The fact that its funding has not been dependable has all
but crippled the center's recruitment efforts. Bilingual and bicultural
providers are recruited with significant compensation packages all over
the country. The fact that the cost of living is significantly lower in
Lancaster, PA than the large urban areas is not a sufficient draw.
Knowing, without a doubt, that the NHSC loan repayment program is
sufficiently funded is paramount to our efforts in recruiting
culturally and linguistically competent providers at SELHS. If there is
anything you can do to help assist with this problem, we would greatly
appreciate it. Please reauthorize the NHSC program and strengthen it as
suggested by the National Association of Community Health Centers. I
have attached their recommendations to my testimony.
the community determines the care it will receive
Like every health center, SELHS is governed by a board from the
community. The composition of our board of directors reflects the
diversity of our community and the patients we serve. Over half of our
board members are patients of the center and more than two thirds
represent minorities. Board members offer substantial expertise in the
areas of business, healthcare finance, faith-based community
organizations, human resources, law, and local and regional government.
Three pastors sit on the board of SELHS, representing large minority
congregations. They provide valuable insight into the healthcare needs
of the underserved community. As a result of this relationship, the
planning has begun to operate a clinic in the new ``community
building'' to be built next year, adjacent to the largest African
American church in Lancaster. Construction funding is greatly needed,
as will be ongoing operating funds to provide not only acute health
services, but also on-site screening for chronic diseases such as
diabetes, heart disease and HIV, as well as preventive health programs
such as smoking cessation, nutrition counseling, healthy lifestyle and
community education programs.
the health centers program investment in selhs helps eliminate barriers
to care
The patients SELHS serves are very poor and have few financial
resources: 40% percent are uninsured; 42% have Medicaid coverage; 5%
Medicare; and 13% private insurance (including the SCHIP program). We
cared for 11,344 patients last year, with 28,360 patient visits. No
other organization in our community offers patients a sliding fee based
on family size and income. 95% of our patients qualify for some level
of reduced fees, most fees being reduced to the minimum fee of $6 for a
visit.
The health center grant is the financial underpinning of our
ability to care for our patients. Last year, our $864 million grant
helped us to write off uncompensated care for the uninsured and
underinsured and to provide translation services. Private donations and
Medicaid and Medicare payments also support the services we provide.
Other grants and private donations contribute to our other enabling
programs, such as the outreach programs, perinatal program, Reach Out
and Read, our mammogram fund, and our pharmacy fund.
the role of the center in the future of the community
SELHS is seen as an organization that touches the lives of almost
all, if not all, of the underserved in this community. It therefore
serves as a vital link to these individuals from the perspective of
many other organizations. The barriers we eliminate come in many shapes
and sizes. Financial barriers were the first ones SELHS sought to
eliminate. The underserved community knows that they can come to SELHS
at any time and never be refused acute treatment for financial reasons.
Additional barriers, such as transportation, language, culture,
obtaining medications, and scheduling conflicts are all minimized if
not eliminated at SELHS.
What is the future of care for the residents of our community?
Current market trends have left thousands of underserved members of the
community without essential medical and dental services. As more and
more people go off of the Welfare rolls, the number of uninsured and
underinsured people increases. Few of these people gain employment in
organizations that offer medical and dental coverage, and when coverage
is available, annual out-of-pocket expenses are high.
SELHS remains the safety net provider for many people who are newly
enrolled in managed care plans and assigned to a specific primary care
provider. Many are assigned to a provider without their
``understanding'' because of linguistic issues. These individuals still
come here, and we help them navigate the managed care world. We help
them make and carry out choices and take care of their needs while they
move through the system.
SELHS will remain the safety net provider to patients whose
providers stop accepting Medicaid. For decades local providers referred
their Medicaid and uninsured patients to SELHS. As private managed care
grew, physicians soon realized that Medicaid paid as well as the
private HMOs, and began opening their doors to the Medicaid recipients
once again. With Medicaid HMOs being mandatory this year, two of the
three local hospitals have begun to close down their outpatient
clinics. Many private physicians in the community are pulling out of
the Medicaid program. Two hospital sponsored dental clinics closed last
year, leaving over 5,000 Medicaid patients without a dental home.
SELHS is the designated safety net provider whenever these changes
occur. We expanded our dental staff when the hospital clinics closed
and have had to prioritize on emergency dentistry first, and preventive
dentistry second. We have plans to open a new clinic with some local
financial support, but need additional health center grant funds for
construction and to ensure continued financial viability.
As more clinics close and physicians refuse to treat Medicaid
patients, we must plan to expand to fill the void. And, as we continue
to screen and provide outreach education to those with undetected
chronic diseases we must be prepared to provide comprehensive care for
them in our system. We are ready to continue to meet the challenges of
caring for our community--but we need your help to do so.
why the proposed changes to the community health center program are
important to selhs
We support the changes suggested by the National Association of
Community Health Centers to improve the health centers program. I have
included them as an attachment to my statement. I want to address
specifically how some of these will help our center.
1. Reauthorize the program and increase the level of funding
I want to thank you for everything Congress has done to increase
funding for health centers over the past few years. We used what we
received from increased funding to stabilize and expand services at
SELHS, and to begin to fill the void left when other local providers
closed their doors to the underserved. SELHS has received service
adjustment awards and several increases to our base grant over the past
5 years equaling almost half a million dollars. We received increases
in 1999 of $100K, in 2000 of $70K, and $100K for 2001. These increases
have made a substantial difference in our community.
SELHS is in a position to triple its capacity to care for the
underserved, but will need additional continued financial support to
sustain the physical expansions and programs. As more outreach and
community education is provided, SELHS must grow to bring these
previously untreated members of the community into programs of ongoing
medical and dental care. Current projects planned by SELHS that would
utilize these funds include the clinic in the African American church,
a new medical site without construction costs to serve 5,000 patients,
and a new site with construction costs to house both medical and
dental, and education services, for 10,000 patients. We cannot do this
without the reauthorization and expansion of the program.
2. Expansion of construction authority to build facilities in new
communities
SELHS has long recognized the need for a community health center in
a neighboring community, in which almost 5% of the center's current
patients reside. A new clinic would have to be built to extend services
to this community and not only would some construction costs be
necessary, but some ongoing operational assistance will be necessary as
well. Restoration of the ability for health centers to use a small
portion of grant funds for construction down payments will enable us to
meet the needs of this neighboring community. Also, if we take on some
of the clinics being closed by a local hospital, we will need funds for
renovation.
3. Enhancement of current Loan Guarantee Authority in Section 330 to
cover facility loans.
As well as a down payment, the facility construction and renovation
needs I discussed above and expansions will all require facility
financing. Of paramount importance will be the availability of low cost
loans with guarantees that would cover a substantial percentage of the
cost of this financing--so revision of the loan guarantee program is
critical to our work.
4. Clarification of funding authority for networks.
SELHS is a member of CISNP (Community Integrated Services Network
of Pennsylvania), a community health center owned network that provides
shared expertise in the areas of clinical outcomes management,
operations benchmarking, management tools, and managed care
contracting. One current CISNP program we hope to participate in is a
Management Information Systems program that will lower our costs by
jointly contracting for an MIS program and sharing technical expertise.
Permitting the grant funds to be used for these purposes would greatly
help us reach this goal.
In summary, SELHS and the community it serves is grateful for the
support of this Subcommittee for this work. We cannot continue to
eliminate disparities in our health care system without the
reauthorization and improvement of the health centers program and the
NHSC. We urge the Subcommittee to act as soon as possible to
reauthorize these important programs. Thank you for the opportunity to
appear today. I would be glad to answer any questions.
Explanation of Proposed Changes in the National Health Service Corps
Statute
background
The National Health Service Corps (NHSC) plays a critical role in
providing care for underserved populations by placing clinicians in
urban and rural communities with severe shortages of health care
providers. Currently 2500 NHSC clinicians, including physicians,
dentists, nurse practitioners, physician assistants, nurse midwives,
and behavioral health professionals, provide health care services to
4.6 million Americans, including 2.2 million Health Center patients.
While the NHSC program has proven successful in addressing health
professional shortages in many areas, funding limitations have
restricted the program's ability to meet its primary goal. 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 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 (8 times the current number of NHSC providers). 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.
proposed changes to national health service corps authority
1. Reauthorize the National Health Service Corps for five-years at not
less than $150 million for the first year and for such sums as
are necessary for each subsequent fiscal year.
Explanation
Although the NHSC's most recent reauthorization was for a ten-year
period, most parties agree that five years is preferable this time. A
five-year reauthorization demonstrates continued support for the
purpose and role of the NHSC as a federal safety net program; provides
for continuity in the administration of the program; and also allows
for a more timely opportunity for Congress to review and make
modifications in response to changes in the health care environment.
The NHSC also warrants a substantial funding increase to address the
significant need in designated underserved areas for NHSC Scholarship
and Loan Repayment program recipients, and to support other critical
activities such as site development, evaluation, faculty and student
placement, retention incentives and research.
2. 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.
Explanation
The NHSC and the Health Centers Programs are intended to address
the same goal (to meet the health care needs of underserved
populations) and are administered by the same federal agency, the
Bureau of Primary Health Care. Requiring a health center to obtain a
Health Professional Shortage Area (HPSA) designation, even though each
health center already serves a ``medically underserved area or
population'' creates a bureaucratic hurdle to placement of NHSC
personnel at health centers. 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.
3. Eliminate duplication of effort in the placement of NHSC personnel.
Explanation
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.
4. Ensure fairness in priority consideration for NHSC placements.
Explanation
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.
5. Establish due process rights in cases of HPSA de-designations and
priority list development.
Explanation
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.
6. Allow NHSC scholarship and loan repayment program recipients to
fulfill their commitment on a part-time basis. This option
would only be available if such service is agreed to by 1) the
placement site or sites as well as the scholarship and loan
repayment recipients and 2) so long as the total obligation is
fulfilled.
Explanation
Flexibility should be provided to enable Scholarship or Loan
Repayment program recipients to complete their service obligation on a
full-time or part-time basis, with the approval of the placement site.
Many small rural communities may not have sufficient volume to support
a full-time health care practitioner. In addition, some sites may not
need particular types of providers on a full-time basis. Flexibility
should be given to the Department to permit part-time service in
meeting community needs. In addition, some practitioners may find part-
time service more attractive, which in turn could improve both
recruitment and retention at these sites.
7. Include a specific allocation for site development and community
needs assessment.
Explanation
The NHSC was created to meet the needs of communities that lack
access to health care services. In many cases, those shortage
communities require physical, oral, and mental/behavioral health care
services. Over the years, the NHSC has recognized that each community
has unique health needs and has placed a wide variety of health
professionals in sites to meet those needs. However, many believe that
the NHSC needs to dedicate additional resources to inform and educate
communities about the variety of placement opportunities provided by
the NHSC, and to assess the real health care needs of communities that
are applying for placement of personnel. In order to ensure that
communities receive the maximum benefit from the program, the NHSC
should allot adequate resources to inform communities of the variety of
health care resources available through the NHSC and how those
resources can best be used to meet the unique health needs of
communities, in collaboration with those communities and other health
partners.
8. Assist communities and sites in developing incentives to support the
retention of NHSC providers beyond their obligation.
Explanation
Many current and former NHSC recipients have expressed concerns
about professional isolation and burnout during their term of obligated
service. While most initially declare their intent to remain after
completing their obligation, many change their minds by the time their
assignments are completed. In many communities, the NHSC recipient may
be the only health care professional. As such, they are ``on'' 24 hours
per day, 7 days per week. Providing scheduled breaks for professional
development or personal time will increase the likelihood that
recipients will remain in these communities beyond the period of their
assignment. Examples of incentives might include support for locum
tenens, mini-sabbaticals, continuing professional education, and
increased practice management technical assistance for current
scholarship and loan repayment recipients.
9. Eliminate the community cost-sharing provision (Section 334 of the
Public Health Service Act).
Explanation
Section 334 of the Public Health Service Act (``Cost Sharing'')
requires that an entity to which a member of the NHSC is assigned must
reimburse the Federal government for the cost of that NHSC member. In
practice, this requirement is waived in almost all cases. In 1998, the
cost-sharing requirement was waived in at least 95% of cases and the
cost of collecting the remaining 5% of payments exceeded the funds
received. This provision should be eliminated because it creates an
undue burden on communities (which are economically unstable by
definition) in seeking an NHSC clinician, and it poses an unnecessary
administrative burden on the NHSC. Clearly, these dollars could be
better used in providing access to care. This action is consistent with
the spirit of the Paperwork Reduction Act and will facilitate increased
usage of NHSC' clinicians by underserved communities.
10. 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.
Explanation
Section 334 (repealed above) included language requiring 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 retained elsewhere in the NHSC statute 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 DHHS to monitor
this requirement to determine whether Corps personnel and their sites
are actually meeting these requirements and to enforce compliance.
related recommendations:
1. Exclude from Federal income, FICA, and self-employment taxation
tuition, fees and related educational expenses to individuals
participating in the NHSC Scholarship, Loan Repayment,
Community Scholarship and State Loan Repayment program (group
with other retention provisions).
Although this falls under the jurisdiction of other Congressional
Committees, and must therefore be moved through separate legislation,
all parties agree with the NHSC and the NHSC Advisory Council that
taxing students adversely affects the financial incentive to
participate in the NHSC and provide health care services in underserved
communities, many of which are frontier communities.
Explanation of Proposed Changes in the Current Section 330 Health
Centers Authority
background
In the 35 years since their creation, America's Community Health
Centers have proven their durability as a model health care program and
their resilience in adapting to a dramatically changed American
healthcare system while maintaining their original mission and purpose.
Health centers were established to provide access to quality
preventive and primary health care for the medically underserved--
including the millions of Americans without health insurance, low
income working families, members of minority groups, rural residents,
homeless persons, agricultural farmworkers, and those living with HIV
or with mental health needs. Since their inception, health centers have
served as a prototype for effective public-private partnerships,
demonstrating their ability to meet pressing local health needs while
being held accountable for meeting national performance standards. The
success of the Health Centers program can be directly traced to the
core elements found in Section 330 of the Public Health Service Act,
its authorizing statute. These elements stipulate that each federally-
supported health center must:
<bullet> Be located in, and serve, a community that is designated as
``medically underserved,'' thus ensuring the proper targeting
of federal resources on areas of greatest need;
<bullet> Make its services available to all residents of the community,
without regard to ability to pay, and to make those services
affordable by discounting charges for otherwise uncovered care
to low income families in accordance with family income;
<bullet> Provide comprehensive primary health care services, including
preventive care (such as regular check-ups and pap smears),
care for illness or injury, services which improve the
accessibility of care (such as transportation), and the
effectiveness of care (such as health/nutrition education);
<bullet> Be governed by a board of directors a majority of whose
members are active, registered patients of the health center,
thus ensuring that the center is responsive to the health care
needs of the community it serves.
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. 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.
proposed changes to section 330 health centers authority
1. Extension/reauthorization of Section 330 Health Centers authority
for at least 5 years, at not less than $1.344 billion for FY
2002 and ``such sums'' for all future years
Explanation
President Bush has publicly unveiled a multi-year plan to double
the number of people served by health centers. More than 60 percent of
Members of Congress have endorsed a similar plan. The Congress began
that effort by providing $1.169 billion for FY 2001 for Section 330, a
$150 million (15 percent) increase from the previous year. This year, a
funding increase of at least $175 million will be needed to sustain and
continue that effort. Under this plan, more than 10 million Americans
will gain access to health center services in thousands of communities
across the country.
2. Restoration of facility construction, modernization, and expansion
as allowable uses of funds (both Planning/Development and
Operational grants)
Explanation
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--these
facilities must be expanded. Other facilities are old, or inadequate
for the efficient delivery of primary health care--these facilities
must be modernized or replaced. A recent survey of health centers in 12
states 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.
However, most health centers have limited financial capacity to
undertake needed facility improvements, expansions or new site
development. Because health centers serve a large and growing uninsured
patient base, operating margins are slim to non-existent for most
health centers. That means that most health centers have only a very
limited ability to support loans for their facility needs, and thus
must rely on grants and charitable contributions. Yet, because they
serve low-income individuals who generally cannot contribute
significantly to capital campaigns, health centers have great
difficulty raising charitable contributions.
At the same time, construction costs have soared in the strong
economy. As a result, the gap between what health centers can afford
and the cost of capital projects is growing. 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.
3. Enhancement of current Loan Guarantee authority in Section 330 to
cover facility loans
Explanation
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 for managed
care-related purposes--to include loan guarantees for facility
construction, modernization, and expansion, and for acquisition of
facilities and equipment. In 1997 and 1998, Congress earmarked, out of
appropriations made for Section 330, a total of $14 million for loan
guarantees to 330-funded health centers, both for managed care purposes
authorized under Section 330 and for capital purposes as authorized
under Title XVI of the PHS Act (although Title XVI continues to exist
in the PHS Act, Congress has not directly appropriated funding for
Title XVI programs in years). Enhancing the current Loan Guarantee
authority to cover facility loans would be consistent with
Congressional intent to provide capital loan guarantees for health
centers without having to appropriate funds against an otherwise
dormant legislative authority, and would also permit other improvements
to address shortcomings in current loan guarantee policy, including:
<bullet> Allowing the guarantee to cover more than 80% (and up to 100%)
of the outstanding principal amount would allow lenders to
price the loans at significantly lower interest rates by
reducing the risk to them. Currently, OMB has determined that
the federal loan guarantee for facilities can cover only 80% of
the outstanding loan amount provided by a lender. Financial
experts have stated clearly that partial guarantees are not
sufficient to leverage capital at below-market interest rates,
because lenders still perceive significant risk in these loans
and fear that, in the event of default, they may not be able to
collect even a small amount of the unsecured debt they
financed.
<bullet> Refinancing of existing loans is currently not an eligible use
for loan guarantee funds. If the refinancing results in
significantly lower interest rates, the savings would benefit
both the health center and the government. In addition, some
health centers that have experienced financial difficulties are
not able to obtain loan renewals from lenders without
guarantees, severely limiting their use where they are most
needed.
<bullet> Permitting federal loan guarantees to be used with tax-exempt
debt financing mechanisms would allow health centers to access
the lowest cost capital available to nonprofit institutions,
benefiting both health centers and the government. Because the
interest income from tax-exempt bonds is exempt from federal
(and sometimes state) taxation, investors require lower returns
on their investments than would otherwise be the case for
taxable investments. That tax-savings would translate into
lower interest rates, allowing health centers to invest more of
their operating resources into programs and services for
vulnerable populations.
In combination with the restored capital grant authority discussed
above, a revised loan guarantee program would be more effective in
meeting the pressing capital needs of health centers.
4. Clarification of funding authority for networks at least majority
controlled and, as applicable, at least majority owned by
health centers funded under Section 330
Explanation
Health centers currently collaborate with each other, and with
other community providers, in many different forms of networks and
partnerships designed to improve access to and quality of care for
their patients, especially uninsured patients. These include practice
management networks, designed to improve quality through shared
expertise (such as centralized pharmaceutical or laboratory services,
clinical outcomes management, or joint management/ administrative
services), to lower costs through shared services (such as unified
financial or Management Information systems, or joint purchasing of
services or supplies), or to improve access and availability of health
care services provided by the health centers participating in the
network. Most of these networks, once developed, need ongoing
operational support to continue and further enhance their benefits.
However, current law only authorizes support for the planning and
development of managed care networks and plans. Expanding the types of
health center-directed networks that can receive planning and
development support, and allowing limited operational support for
networks that are owned and/or controlled by Section 330-funded health
centers, would substantially aid in achieving the health centers'
mission and objectives.
5. Restoration of proportional funding allocation requirement for
Community, Migrant, Homeless, and Public Housing Health Centers
Explanation
When four separate health center programs (Community, Migrant,
Homeless, and Public Housing) were consolidated under a single Section
330 authority in 1996, the law included a requirement for allocating
funds appropriated under Section 330 for each of the consolidated
programs in accordance with the proportion of total funding they each
had received in FY 1996. Despite the fact that this statutory funding
allocation requirement expired in 1998, BPHC has continued to adhere to
the methodology in distributing overall Health Centers funding among
the Community, Migrant, Homeless, and Public Housing health centers.
Vulnerable populations have benefited from BPHC's actions, and would be
best served by restoring the original funding allocation methodology to
the overall statute, thus ensuring the continued distribution of
Section 330 funds to key underserved populations such as farmworkers,
homeless persons, and public housing residents.
6. Clarification of eligible populations under Migrant and Homeless
Health Center sub-authorities
Explanation
During consolidation of the health center authorities in 1996,
coverage for formerly homeless individuals during the first 12 months
following their transition to permanent housing was inadvertently
dropped. Also, current authority fails to specify homeless youth as
eligible for services, even though they remain a key homeless
population. In addition, current law fails to recognize as eligible for
services many farmworkers who, due to changes in agricultural
employment, migrate for employment purposes but remain in farm work all
year. Clarifying the eligibility of farmworkers employed on a year-
round basis, as well as homeless youth and formerly homeless persons
following their transition to permanent housing would ensure that the
program remains appropriately targeted to the most vulnerable
populations.
7. Clarification on provision of required services
Explanation
Under Section 330, all federally-supported health centers are
required to provide or arrange for certain key health and related
services, including medical, diagnostic lab and radiology,
pharmaceutical, preventive dental, and patient case management
services. Centers may also furnish additional services if needed by
their patient populations, if resources are available.
Despite the statutory requirement, many health centers (especially
newer centers and those serving rural communities) have not been
adequately funded to support the provision of all required services.
While this disparity has been reduced somewhat in recent years and may
eventually be eliminated, and while the statutory requirement to
provide comprehensive services remains a vital part of the health
center model, clarification is needed to ensure that federally-
supported health centers are expected ``to the maximum extent
practicable'' to provide all required services, subject to available
resources (both federal grant and other resources).
Mr. Bilirakis. Thank you very much, Ms. Benjamin.
Mr. Brewton.
STATEMENT OF DAVID BREWTON
Mr. Brewton. Chairman Bilirakis, Ranking Member Brown, and
members of the committee, my name is David Brewton. I am
Director of Development for the East Liberty Family Health Care
Center, a faith-based community health center that has
successfully provided quality, whole-person health care for
residents of the city of Pittsburgh for nearly 20 years,
without regard to ability to pay. While I have been employed by
the Center for 5 years, my family and I have been patients
there since literally the first day the Center opened in 1982,
so I am well-acquainted with the quality, compassionate, and
accessible care the Center provides each day to all who come.
I want to thank you for the unwavering support this
subcommittee has given our health center and our colleagues
around the country in our work to care for the uninsured and
underserved. I come in support of the National Association of
Community Health Centers' position in regard to the extension,
reauthorization and expansion of the Section 330 community
health centers program and the National Health Service Corps.
I want to emphasize today that we are a demonstration of
how a faith-based health center can produce effective health
outcomes for the underserved by combining the power of faith-
based care with the institutional strength that comes from full
participation in the Section 330 health care centers program.
Our Center was incorporated as a 501(c)(3) non-profit
corporation in 1982. Our founding physician, Dr. David Hall,
had a deep sense of calling to provide health care holistically
for the poor in his hometown of Pittsburgh, and to do so as an
expression of his conviction that true healing incorporates the
physical, mental, emotional and spiritual dimensions of the
human person. A local pastor shared his vision and so in 1982
the Center opened up a small office in the basement of
Eastminster Presbyterian Church in the heart of East Liberty.
Today, the Center operates two much larger offices in the
East End, and last year provided more than 27,000 patient
encounters in home, office and hospital, without regard to
ability to pay for more than 5,000 individuals. The Center now
employs a staff of 760 with a budget of more than $3 million,
and provides more than 10 distinct forms of outreach to the
low-income community it serves to meet needs beyond the walls
of its two welcoming, culturally sensitive offices.
Faith-based and federally funded, we at the Center believe
these two forces are a powerful combination to effectively
serve everyone in our community: insured, uninsured, Medical
Assistance, Medicare, homeless, and even those who are
privately insured but want quality care with a difference.
Here is the difference that our faith-based perspective
makes: Our faith reminds us of the dignity in every human
being, created in God's image, even perhaps especially those
who do not share our particular religious values. That is why
we are in an underserved community and why we never turn anyone
away.
Our faith provides a motivation that makes our
practitioners stay with us longer than in most such demanding
settings. In our 19-plus years, we have had four National
Health Service Corps participants, all of whom are still
serving at the Center today out of a sense of God's calling. So
they develop relationships with their patients, most of whom
have never had a primary care physician before, and were used
to relying solely on strangers in emergency rooms for care.
This relationship with a family doctor is something that most
of us take for granted.
Our faith perspective means that we offer prayer with every
visit, and please, we do not force or require prayer, we simply
offer it at the conclusion of each visit, gently and
respectfully. Some patients decline, and we fully respect that
decision. There is no pressure. Sometimes a patient from a
different religious background, including Jewish and Muslim,
will also ask for prayer, and we are careful to do so in a way
that respects our similarities and differences.
Finally, our faith-based perspective means that we have not
just a compassion for people, but a passion for quality care.
It should not surprise you then that we have been innovators
and results-producers since our inception. Our Homebound
Elderly Outreach Program has been named a ``Best Practice in
Faith-based Health Care'' underwritten by the Bureau of Primary
Health Care.
A few years back, we documented 92 percent compliance with
State immunization requirements for all patients through age 2,
when the region's largest Medicaid HMO had a rate of just 62
percent.
We participate in research studies at Pittsburg's fine
universities to help improve our patients' care. And we are on
the cutting edge in some administrative areas, implementing a
computerized medical records system, the bane of our
practitioner's existence currently, which will, we trust,
enable us to measure health outcomes. And we are a founding
member of the nationally recognized integrated health care
delivery system called the ``Coordinated Care Network'', or
CCN, that is transforming the way managed care works in
Pittsburgh for those on Medical Assistance and the uninsured. I
would mention that this is a CAP-funded program.
The CCN achieves its goal by recapturing savings generated
by reduced hospital admissions because of primary care, and it
enables us to put that money back into better wraparound
preventative care for these high-cost users of the medical
system in Pittsburgh. And to demonstrate these achievements I
have included our annual and Health Care and Business Plans
from our 330 proposal.
Please be clear: our faith never, never leads us to exclude
anyone, in fact, just the opposite, it compels us to be open to
all. If we did exclude anyone, you would have a right to judge
us harshly for we would not be supporting the goals that we all
share, 100 percent access to care and zero disparities, which
brings me to my second and final point.
Here is the difference that Federal support makes. For our
first 17 years, we relied solely on private charitable support
to make up the difference between the cost of the care we
provide and what our patients can pay. Most of that comes from
church-going people--and, by the way, those folks continue
today to provide well over $1 million per year to pay for the
parts of care that no one else will. But in 1999, we were one
of the top ten applicants in the country in a competitive
cycle, and became a fullfledged CHC, and without this reliable,
renewable support we could never have grown to meet the real
needs in our community.
Private support, while significant, is just not enough.
Without CHC funding we couldn't have opened our second office
in a more underserved community than our first. We couldn't
have started our dental program, our addiction outreach
program, or our important programs in obstetrics, gynecology
and parent education. We couldn't have seen our annual visit
more than double from just 12,000 in 1996 to 27,000 last year.
And about now we would have been overrun and had to close our
doors by the more than 1,000 new patients who were added to our
rolls just this year because of Welfare Reform and
Pennsylvania's Managed Care Initiative for those on Medical
Assistance.
Beyond that, we would like to say that the guidelines and
regulations of the Community Health Center Program, while
sometimes seeming to be onerous, are actually strong
encouragements for us to be more accountable and more outcome-
oriented in all we do. It is often tempting to grumble about
``the Rules'', but our view is this: If we are going to be
faithful, we should see government standards as minimum
standards and do our best to achieve or even exceed them.
So, I urge you, therefore, to extend, reauthorize, and
expand the vital 330 program and the National Health Service
Corps to strengthen these programs in accordance with the
proposed improvements of the National Association, and I have
included these in my written statement.
Thank you so much for the opportunity and honor to present
my views here today.
[The prepared statement of David Brewton follows:]
Prepared Statement of David Brewton, Director of Development, East
Liberty Family Health Care Center
Chairman Bilirakis, Ranking Member Brown, and Members of the
Subcommittee: My name is David Brewton, and I am Director of
Development for the East Liberty Family Health Care Center, a faith-
based community health center that has successfully provided quality,
whole-person health care for residents of the City of Pittsburgh for
nearly twenty years, without regard to ability to pay. While I have
been employed by the Center for five years, I and my family have been
patients there since literally the first day the Center opened in 1982,
so I am well acquainted with the quality, compassionate, and accessible
care the Center provides every day to all who come.
I want to thank you all for the unwavering support this
Subcommittee has given our health center and our colleagues around the
country in our work to care for the uninsured and underserved. I come
in support of the National Association of Community Health Center's
position in regard to the extension, reauthorization, and expansion of
the Section 330 community health centers program and the National
Health Service Corps (NHSC). The unique perspective that I wish to
emphasize in my comments is that we are a demonstration of how a faith-
based health center can produce effective health outcomes for the
underserved by combining the power of faith-based (or what we call
``whole-person'') care with the institutional strength that comes from
full participation in the section 330 health centers program.
Our Center was incorporated as a 501(c)(3) non-profit corporation
in 1982. Our founding physician, Dr. David Hall, had a deep sense of
calling to provide health care wholistically for the poor in his
hometown of Pittsburgh, and to do so as an expression of his conviction
that true healing incorporates the physical, mental, emotional, and
spiritual dimensions of the human person. The Rev. Douglas A.
Dunderdale, Senior Pastor of Eastminster Presbyterian Church, had been
praying for a health ministry out of his church, located in the heart
of a severely medically-underserved community in Pittsburgh's East End.
When the two came together, they knew that it was a confirmation of
their visions, and in 1982, the Center opened up a small office in the
basement of Eastminster Presbyterian Church. It is important to note
that while a Presbyterian Church provided us our start, the Center is
non-denominational, and an expression of ministry supported by persons
of many different faiths who share a common sense of mission.
Today, the East Liberty Family Health Care Center operates two
offices in the East End, and last year provided more than 27,000
patient encounters without regard to ability to pay for more than 5,000
individuals. The Center employs a staff of 60 with a budget in excess
of $3 million, and provides more than ten distinct forms of outreach to
the low-income community it serves to meet needs beyond the walls of
its two welcoming, culturally-sensitive offices.
Faith-based and federally funded, we at the Center believe that
these two forces are a powerful combination to effectively serve
everyone in our community: the insured and the uninsured, those on
Medical Assistance and Medicare, the homeless, and yes, even those who
are privately insured but want quality care with a difference.1Here's
the difference our faith-based perspective makes:
<bullet> It provides a value system with deep historical roots that
helps us to care not only for the physical, but all dimensions
of human existence. It reminds us of the dignity of every human
being, who is created in God's image--even, and perhaps,
especially, those who do not share our particular religious
values. That is why we are in an underserved community, and why
we never turn anyone away.
<bullet> It provides a motivation that makes our practitioners by and
large stay with us for longer than in most such demanding
settings. In our 19+ years, we have had four NHSC participants,
all of whom are still serving at the Center today out of a
sense of God's calling. (How's that for retention!) This
enables them to develop lasting relationships with their
patients, most of whom NEVER had a primary care physician
before, and were used to relying solely on strangers at
emergency rooms for care. Because of this spiritually motivated
commitment, our ``poor'' patients develop the kind of lasting
relationships with their own family doctors at the Center that
most of us take for granted.
<bullet> It means we spend time--lots of it--with each patient to get
to know the whole person, even when insurance and federal
subsidy won't pay for that time. This is why one patient spoke
for many when she said recently: ``When I'm with Dr. Hall, I
feel like I'm his only patient.''
<bullet> It means we offer prayer with every visit--and please note--we
do not force or require prayer, we simply offer it at the
conclusion of each visit, gently, and respectfully. Some
patients decline, and we fully respect their decision. There is
no pressure. Others specifically request it and will testify
that it is the primary reason they come to us for care (never
mind that we employ 11 outstanding board certified physicians
with years of experience and from some of the best medical
schools in the country). Sometimes, our patients from different
religious backgrounds, including Jewish and Muslim, will also
ask for prayer, and we are careful to do so in a way that
respects our similarities and differences.
Finally, it means that we have not just a compassion for people,
but a passion for quality care. Our faith motivates us to provide the
best care we can and to strive to measure the results. So, it should
not surprise you that we have been innovators and results-producers
since our inception: All of our physicians are Board certified. Our
founder has received numerous awards in the community for community
outreach. Our Homebound Elderly Outreach Program has been named a
``Best Practice in Faith-based Health Care'' in a national competition,
underwritten by the Bureau of Primary Health Care (BPHC). A few years
back, we documented 92% compliance with State immunization requirements
for all our patients through age 2, when the region's largest Medicaid
HMO had a rate of 62%. We participate in research studies at
Pittsburgh's fine universities to help improve our patients' care. And,
we are on the cutting edge in some administrative areas, implementing a
computerized medical records system to measure outcomes among our
populations, and being the founding member agency of a nationally-
recognized integrated healthcare delivery system (the ``Coordinated
Care Network,'' or CCN) that is transforming the way managed care works
for those on Medical Assistance and the uninsured. Simultaneously, the
CCN is re-capturing the savings generated to provide even better wrap-
around, preventive care for these high cost users of the medical system
in Pittsburgh. (To demonstrate our achievements, I have included as
Attachments A and B of my statement our 2000 Annual Report and our
Health Care and Business Plans.)
Please be clear: our faith NEVER leads us to exclude anyone, in
fact, just the opposite: It compels us to be open to all. Period. If we
did exclude folks, you would have a right to judge us harshly, for we
would not be supporting the goals of the community health center
program which we all share: 100% access to care and zero health
disparities.
Which brings me to my second and final point. Here's the difference
federal support makes:
For our first 17 years, we relied solely on private charitable
support to make up the difference between the cost of the care we
provide and what our patients can pay. Most of it comes from church-
going people, by the way, who continue today to provide well over $1
million per year to pay for those parts of the care we provide that no
one else can or will.
But in 1999, we were one of the top ten applicants for health
center funding in a very competitive cycle, and so became a full-
fledged CHC. Without this reliable, accountable, and renewable support,
we never could have grown to meet the real needs in our community.
Private support--while significant--is simply not enough!
Without CHC funding, we couldn't have opened our second office in
the even more underserved community of Lincoln-Lemington, two miles
from our home office. We couldn't have started a dental program, our
addiction outreach program, or our important programs in ob/gynecology
and parent education. We couldn't have seen our annual visits more than
double from 12,000 in 1996 to more than 27,000 in the year 2000. And
about now, we would have been overrun and had to close our doors to the
more than 1,000 new patients who were added to our rolls just this
year, because of welfare reform and PA's managed care initiative for
those on Medical Assistance.
Beyond that, we would like to say that the guidelines and
regulations of the community health center program, while sometimes
seeming(!) to be onerous, are actually strong encouragements for us to
be more accountable and more outcome-oriented in all we do. It is often
tempting to grumble about regulations and standards, but our view is
this: if we are going to be faithful to our God, we should see
government standards as MINIMUM standards, and do our best to achieve
or even exceed them.
Through our participation in the CHC program, we have had the
opportunity to pursue JCAHO accreditation (we hope to complete this
process in the next year or two), to participate in collaboratives with
other groups around specific issues to improve our handling of high-
incidence diseases such as diabetes and hypertension, and just the
accountability that comes through knowing that we are responsible for
meeting the goals we set for ourselves in our annual federal review
process.
Are there areas of tension in this alliance of faith and government
funding? Undoubtedly. But as long as we focus on our common objective
(100% access, 0 disparities); and recognize that both church and state
have a role in the promotion of the public good, and are clear about
the distinctions of those roles, we believe that we are a forthright
demonstration of how the two can work together in integrity and
accountability.
I urge you to extend, reauthorize, and expand the vital Section 330
Health Centers and the National Health Service Corps programs, and to
strengthen these programs in accordance with the proposed improvements
of the National Association of Community Health Centers. I have
included these proposals as Attachment C of my statement.
Thank you again for the opportunity to present my views here today.
I would be pleased to answer any questions you may have.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Bilirakis. Thank you so much, Mr. Brewton, that is
quite a story.
Mr. Singer, please proceed, sir.
STATEMENT OF JEFF SINGER
Mr. Singer. Mr. Chairman, ranking member, members of the
audience, my name is Jeff Singer. I am the President and CEO of
Health Care for the Homeless of Maryland. I am also here as the
Policy Chair of the National Health Care for the Homeless
Council, and I am joined by our distinguished Executive
Director, Mr. John Lozier, as well as our Health Policy
Analyst, Bob Reed, who has done an enormous amount of work on
these reauthorization issues, and we thank Bob for that.
I am also here representing some folks who couldn't be
here. Willie, the merchant seaman, who is bound to his
wheelchair by a head injury, and spent the last winter on the
streets of Baltimore in that wheelchair because there is no
shelter that is handicapped-accessible; Harold, the coalminer
from West Virginia, who had been sleeping in an abandoned
Merdeces Benz, wrapped only in his depression and his
alcoholism; John, Mary, and their daughter, Dreesen, stranded
in Baltimore when their car broke down on their way from their
old home in Oklahoma to their new job in Connecticut, without
the money for health insurance, their savings eaten away by a
motel.
Homelessness is harmful to people's health. It causes
health problems--the infections on Willie's back from being in
the wheelchair 24-hours-a-day. It exacerbates health problems--
Harold's cold turned into pneumonia, sleeping in a car in the
winter. And it complicates treatment. Where does the homeless
person with diabetes store her insulin and syringes?
Fortunately, there is an effective Federal program to
address this program, and that is the Health Care for the
Homeless Program, one of the four Community Health Center
programs run by the Bureau of Primary Health Care. It provides
the resources to 137 Health Care for the Homeless Programs in
every State, in the District of Columbia, and in Puerto Rico,
to provide a comprehensive array of services enabling us to go
out on the streets, to get people off of the streets, and back
into the mainstream.
These 137 programs last year served 500,000 different
people. Unfortunately, that is only about a seventh of our
friends, neighbors and relatives who are experiencing
homelessness, and yet we provide very significant services.
Sixty percent of the people we see are men, and men tend to be
uninsured at higher rates than women and, in fact, 73 percent
of the people served were uninsured. Sixty percent were members
of minorities, and 15 percent were actually children.
This is an effective program, and it is a program that, in
part, is represented by the National Health Care for the
Homeless Council. The Council is a membership organization. It
provides technical assistance in education to homeless health
care providers around the Nation, but it also is interested in
public policy. We recently heard the Secretary of the
Department of Housing and Urban Development, Secretary
Martinez, say, ``After $10 billion spent on homeless services,
why does homelessness persist?'' It is a very important
question and, in fact, it has a relatively simple answer. Until
all Americans have the right to health insurance and adequate
health care, until we have a sufficient supply of affordable
housing, and until incomes permit people to live with dignity,
whether people are working and earning a living wage, or
disabled and receiving disability assistance that permits them
to purchase housing, until these things happen, homelessness
will persist. But until they happen, we are very happy to have
a Health Care for the Homeless program that reaches out to
people who need help.
In Maryland last year, we served 9,000 different people. We
had 45,000 patient encounters. In the 16 years in which we have
been in operation, we have assisted more than 70,000 different
people. We provide comprehensive care--that includes medical
care, mental health services, we are a certified outpatient
addiction treatment center, and social work services as well.
We are the first independent Health Care for the Homeless
program to be certified by JCAHO, the Joint Commission on the
Accreditation of Health Care Organizations, so we try to meet
the highest quality standards, but it is a very difficult
challenge. It is difficult in part because the costs keep
rising. We pay 30 percent more for prescriptions this year than
we did last year, and we haven't heard of any prescription
initiatives in Congress this year that will address our problem
because it is not people who are elderly, it is ordinary
Americans.
The nursing shortage has affected us. We have lost five
nurses this year to hospitals because they pay a lot more money
than we can. But these challenges can be met with your help.
We are very supportive of the reauthorization of the
program at the highest level as possible. There are particular
issues that we call to your attention. One is to maintain the
proportionality of the distribution of funds. Health Care for
the Homeless programs receive 8.6 percent of the Community
Health Center funds, and we would like to keep it that way, and
there is universal support for that.
We would also like to be able to serve people who have been
housed for 12 months after they have left the streets. We used
to be able to do that, but the reauthorization in 1996
eliminated that capacity and we would like to have it again.
And we would like to expand the definition of addiction
programs to include the outpatient treatment that most of us
can provide. And we would like to be sure that youth are
included as a target population.
I thank you very much for your assistance. The stories I
told you in the beginning all had good endings. Willie is now
in a wheelchair and we delivered a television to him the other
day. Harold, after 5 years we were able to get him Medicaid and
SSI. He had an apartment. He listened to his country music and
ate his scrapple and cleaned up the florist shop around the
corner. And John and Mary, their daughter recovered. John found
a job and, in fact, he became a Legislative Aide to Congressman
Elijah Cummings of Maryland's 7th District. We can make a
difference and, with your help, we will. Thank you.
[The prepared statement of Jeff Singer follows:]
Prepared Statement of The National Health Care for the Homeless Council
introduction
The National Health Care for the Homeless Council (the National
Council) is a membership organization comprised of health care
professionals and agencies that serve homeless people in communities
across America. The National Council works to improve the delivery of
care to people experiencing homelessness, and to reduce the necessity
for dedicated health care for the homeless programs by addressing the
root causes of homelessness. Our organizational members receive funds
through the federal Health Care for the Homeless (HCH) Program. The HCH
program is part of the Consolidated Health Centers account of the
Health Resources and Services Administration (HRSA), U.S. Department of
Health and Human Services.
Our statement covers the following points:
<bullet> explanation of the intersection of health and homelessness;
<bullet> review of the success of the federal government's primary
policy response to the immediate health services needs of
people experiencing homelessness--the HCH program;
<bullet> discussion of the challenges facing HCH projects, including
increasing demand and decreasing services;
<bullet> recommendations for reauthorizing and strengthening the HCH
program;
<bullet> recommendations for reauthorizing and strengthening the
Community Health Center (CHC) program;
<bullet> recommendations for reauthorizing and strengthening the
National Health Service Corps (NHSC) program; and
<bullet> comments on the Community Access Program (CAP).
Before we begin, the National Council expresses its profound regret
that there is still a need for discussion in this day and age about
health care access barriers facing poor people and people without
insurance. It is tragic that our nation continues to fail to guarantee
access to health insurance as a fundamental right for every American.
Ultimately, Americans' health care access challenges, including those
facing people without stable housing, must be redressed through a
universal health care system. We favor a single-payer mechanism.
Yet even universal health insurance would not preclude the need for
HCH projects. The abdication of public responsibility for affordable
housing is a two-decade long tragedy that is the fundamental factor
perpetuating homelessness. Until our nation invests in a housing stock
sufficient for and affordable to all of our neighbors, the economic,
social, and human costs of homelessness will mount.
health and homelessness
Poor health and lack of access to health care are among the causes
of homelessness. For people struggling to pay for housing and other
needs of daily living, the onset of a serious illness or disability can
easily result in homelessness following the depletion of financial
resources.
Homelessness is a health hazard. The experience of homelessness
causes poor health, exacerbates existing illness, and seriously
complicates treatment. Conditions such as frostbite, leg ulcers, and
respiratory infections are a direct result of living on the street.
Homelessness precludes good nutrition, good personal hygiene, and basic
first aid. People without a regular place to stay are also at great
risk of emotional trauma due to familial estrangement, multiple losses,
and the chaos of an itinerant lifestyle. Children and youth are
particularly affected by the chaos of homelessness with greater risk of
childhood depression, malnutrition, immunization delay, repeated
infections, developmental delay, and discontinuity of school/learning
experiences. People without a regular place to stay are also at greater
risk of physical and emotional trauma resulting from muggings,
beatings, and rape. Conditions that require regular, uninterrupted
treatment, such as tuberculosis, HIV, diabetes, hypertension,
addiction, mental illness, and pregnancy are extremely difficult to
treat or manage in the absence of a stable residence.
The consequences of restricted access to comprehensive health care
are reflected in extremely high rates of both chronic and acute health
problems among people experiencing homelessness. The Institute of
Medicine has determined that those without a regular place to stay are
far more likely to suffer from most categories of chronic health
problems in comparison to the general population.<SUP>1</SUP> Research
also demonstrates that the cost of acute care for people experiencing
homelessness is significantly higher than for the general
population.<SUP>2</SUP>
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\1\ Institute of Medicine. ``Homelessness, Health and Human
Needs.'' 1988.
\2\ National Health Care for the Homeless Council. ``Utilization
and Cost of Medical Services by Homeless Persons: A Review of the
Literature and Implications for the Future.'' April 1999.
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Access to appropriate treatment and care is hindered dramatically
by a lack of a national health care system. National data gathered by
the HCH program <SUP>3</SUP> reveals that 73 percent of HCH patients
have no source of health insurance. Inaccessible public transportation,
inflexible clinic hours, fees and payments, and residency and
documentation requirements may also present barriers to health care.
---------------------------------------------------------------------------
\3\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, Bureau of Primary Health Care, Uniform
Data System (UDS) Report for Fiscal Year 1999.
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health care for the homeless program
Origins and Current Status
The first federal response to the crisis of homelessness was the
passage of the Stewart B. McKinney Homeless Assistance Act of 1987.
Recognizing that homelessness restricts access to mainstream health
care services, Congress established through the McKinney Act a health
services program specifically designed to circumvent these barriers--
Health Care for the Homeless (HCH). The federal program extended the
success of an earlier Robert Wood Johnson/Pew Charitable Trusts
program, which demonstrated that health care services specifically
targeted to people experiencing homelessness could dramatically improve
access to care for this vulnerable population.
Congress last reauthorized the HCH program in 1996 via the Health
Centers Consolidation Act. That law consolidated community health
centers, migrant health centers, public housing primary care centers,
and HCH projects under a single, five-year authorization, but retained
each of the four programs as a distinct activity. Authorization of the
consolidated health centers account expires in September 2001.
Program Summary
The HCH program (Section 330(h) of the Public Health Service Act
[PHSA]) makes grants to community-based organizations (referred to as
``projects'' or ``grantees'') in order to assist them in planning and
delivering high-quality, accessible health care to people experiencing
homelessness. HCH projects assure access to primary care and related
services through integrated systems of care. Projects provide primary
health, mental health, addiction, and social services with intensive
outreach and case management to link clients with appropriate services.
Formal evaluations of the HCH program, including a 1995 evaluation
conducted for the Department of Health and Human Services, indicate
that the projects are meeting the health care and support service needs
of people experiencing homelessness--at levels that are unprecedented
in the mainstream indigent health care and public health insurance
systems.
Eligible Population
Projects are required to use their HCH funds to serve people
experiencing homelessness, who are defined in the PHSA as ``an
individual who lacks housing (without regard to whether the individual
is a member of a family), including an individual whose primary
residence during the night is a supervised public or private facility
that provides temporary living accommodations and an individual who is
a resident in transitional housing.''
In 1999, HCH projects served nearly 500,000 patients. 59 percent of
patients were male; 41 percent female. 60 percent were people of color.
15 percent were children and youth under age 19.
Eligible Projects
HCH projects are initiated, designed, and managed at the community
level. Any local public or private, nonprofit entity is eligible to
apply for HCH funds, including freestanding nonprofit community-based
and faith-based organizations, community health centers, hospitals,
local health departments, shelters, and homeless coalitions.
The HCH program currently funds 137 grantees in all states, the
District of Columbia, and Puerto Rico. 50 percent of projects are
sponsored by community health centers. Public health departments
sponsor 19 percent. 25 percent are sponsored by private, nonprofit
organizations, and the remaining six percent are sponsored by
hospitals.
Required Services
HCH projects, like other health centers, are required to provide
the following health and enabling services:
<bullet> basic health services related to family medicine, internal
medicine, pediatrics, obstetrics, and gynecology;
<bullet> diagnostic laboratory and radiologic services;
<bullet> preventive health services, including prenatal and perinatal
screening; screening for breast and cervical cancer; well child
services; immunizations against vaccine-preventable diseases;
screenings for elevated blood lead levels, communicable
diseases, and cholesterol; pediatric eye, ear, and dental
screenings to determine the need for vision and hearing
correction and dental care; voluntary family planning services;
and preventive dental services;
<bullet> emergency medical services;
<bullet> pharmaceutical services;
<bullet> referrals to providers of medical services and other health-
related services;
<bullet> patient case management services (including counseling,
referral and follow-up) and other services designed to assist
health center patients in establishing eligibility for and
gaining access to Federal, State, and local programs that
provide or financially support the provision of medical,
social, educational, or other related services;
<bullet> services that enable individuals to use the services of the
health center (including outreach, transportation, and
translation);
<bullet> education of patients and the general population served by the
health center regarding the availability and proper use of
health services; and,
<bullet> addiction services.<SUP>4</SUP>
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\4\ This required service is unique to HCH projects. Other health
centers are not required to provide addiction services.
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In addition, most HCH projects surpass this scope of services. For
example, many HCH projects offer mental health services to their
patients. Others have secured resources from other federal programs,
state and local government, and the nonprofit and private sectors to
develop housing for their patients.
Service Delivery Locations
HCH service delivery sites vary by project, but include fixed-site
health clinics, services provided at homeless shelters and soup
kitchens, mobile medical units, and street outreach teams. Services are
provided either directly, by contract with other organizations, or by
referral to another organization.
Award Process
HCH funds, like funds for other health center programs, are
distributed via a competitive award process. Applications for HCH funds
are reviewed by an independent expert panel consisting of HRSA staff
and outside experts. The applicant must:
<bullet> describe the target population;
<bullet> demonstrate the target population's health services need;
<bullet> outline a plan to provide the health services required by the
Consolidated Health Centers law; and,
<bullet> agree to a number of requirements that are a condition for
receiving funds.
Those conditions include:
<bullet> establishing a governance body that includes significant
participation from consumers of the health services offered by
the project, including people who are experiencing or who have
experienced homelessness;
<bullet> making the statutorily-required primary health services
available and accessible promptly, as appropriate, and in a
manner which assures continuity;
<bullet> establishing and maintaining relationships with other health
care providers;
<bullet> developing an ongoing relationship with at least one hospital;
<bullet> having an arrangement with the State Medicaid agency to be
reimbursed for health services provided to Medicaid
beneficiaries;
<bullet> making every reasonable effort to collect appropriate
reimbursement for health services provided to people entitled
to public or private health insurance;
<bullet> establishing a schedule of fees or payments for the provision
of services and a schedule of discounts based on a
participant's ability to pay;
<bullet> having an ongoing quality improvement system; and
<bullet> developing a plan, budget, and data collection system.
Appropriations
In FY 2001, Congress appropriated $1.169 billion for the
consolidated health center account, which amounted to $100 million for
the HCH program.<SUP>5</SUP>
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\5\ The HCH program customarily receives 8.6 percent of the total
consolidated health center appropriation, consistent with the portion
allocated to it by Congress in the first year of authorization in the
Consolidated Health Centers Act
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challenges facing hch projects
The fundamental challenge facing HCH projects--as well as all
health centers and other health care safety net providers--is one of
insufficient resources to sustain and expand services to people with
limited or no means to pay for health care.
The failure to appropriately invest in the nation's health care
safety net prevents HCH projects from fully responding to the following
dynamics among and needs of people without stable housing.
Increasing Homelessness--As an increasing number of people have
incomes that fall below federal poverty guidelines and find themselves
living with friends, relatives, in shelters and the streets, more
people are seeking services from HCH projects. Among the new patients
of HCH services are families with children exiting the welfare system,
people with disabling addictions who have been denied access to
Medicaid and Supplemental Security Income, ``working poor'' individuals
whose earnings are insufficient to afford housing or health insurance,
emancipated and unaccompanied youth, and veterans unable to obtain
Department of Veterans Affairs health services. HCH projects do not
receive sufficient funds to adequately serve their current caseloads,
much less address the increased demand for services from these emerging
homeless subpopulations.
Financial Distress of HCH Projects--Many HCH projects report
decreasing revenues, especially from Medicaid. The enrollment of
Medicaid beneficiaries in managed care organizations has resulted in a
dramatic decrease not in the number of Medicaid beneficiaries served by
HCH providers, but in the reimbursements received from Medicaid.
Consequently, HCH projects have been forced to use federal grant and
other funds now designated for services to uninsured patients to
balance the cost of care for Medicaid patients, thereby reducing or
eliminating services for patients who lack health insurance. HCH
projects do not receive sufficient funds to adequately serve both their
Medicaid and uninsured patients.
Untreated Addiction and Mental Illness--HCH projects are required
by statute to provide access to addiction services. Many also provide
mental health services. Regrettably, inadequate funding levels have
prevented many projects from providing such services at more than an
elemental level, even though projects report that that addictions and
mental illnesses are among the most prevalent diagnoses of their
patients. Mainstream addiction and mental health services programs are
also underfunded and oversubscribed, and are also not designed
appropriately for people in homeless situations, further restraining
willing homeless patients from accessing treatment for these chronic
conditions. HCH projects do not receive sufficient funds to adequately
meet their patients' comprehensive health services needs.
Lack of Supervised Medical Care for People in Recuperation--In the
absence of a safe place in which to recuperate from illness, medical
interventions often prove ineffective for people experiencing
homelessness. The unavailability of appropriate accommodations for
those requiring supervised medical care, but not ill enough to remain
hospitalized, makes it difficult for individuals to recover from
illness and resolve their homelessness. Several HCH projects have
pioneered responses to this service gap in the form of medically-
supervised ``recuperative care.'' HCH projects do not receive
sufficient funds to develop or expand recuperative care arrangements
for patients in desperate need of such services. In most communities,
there is no other source of funding to pay for recuperative care
services to people experiencing homelessness.
reauthorize and strengthen health care for the homeless program
The HCH program, the statutory authority of which expires September
30, 2001, is still needed to ensure access to health services for
people experiencing homelessness. We urge Congress and the
Administration to reauthorize HCH for a five-year period as a distinct
program within the Consolidated Health Centers account.
In addition, we urge Congress and the Administration to amend the
HCH statute as follows:
<bullet> Establish an authorization level of at least $172 million in
FY 2002 as part of a $2 billion FY 2002 authorization level for
the Consolidated Health Centers account.
<bullet> Maintain current distribution of Consolidated Health Centers
appropriations among component programs within the account.
<bullet> Restore ability of HCH grantees to temporarily continue to
provide services to their formerly homeless patients.
<bullet> Expand range of addiction services that HCH grantees may
provide to include harm reduction, outpatient treatment,
complementary modalities, and rehabilitation, in addition to
detoxification and residential treatment.
<bullet> Explicitly identify homeless youth as an eligible target
subpopulation for innovative homeless children outreach and
comprehensive primary health services grants.
reauthorize and strengthen community health center program
Mainstream indigent health care programs have historically
underserved the homeless population. Congress recognized this reality
and established the HCH program. Due to funding limitations, however,
the HCH program is able to serve only about \1/7\ of the population
estimated to experience homelessness each year. Consequently, a
majority of people experiencing homelessness relies on mainstream
indigent health care providers, including community health centers, for
their health care.
Just as they do in other mainstream indigent health care systems,
people experiencing homelessness face multiple challenges in accessing
and utilizing community health centers. For example, the General
Accounting Office, in a 2000 report (Homelessness: Barriers to Using
Mainstream Programs, GAO/RCED-00-184), found that community health
centers: 1) may not be organized to make some of the special
accommodations homeless people may require, such as walk-in
appointments; 2) may not thoroughly address other needs that are
inextricably linked to a patient's health care needs, such as housing,
food, clothing, and other services; 3) do not tend to outstation health
services at locations and settings where homeless people congregate.
Denials of or delays in service based on inability to pay have also
been reported.
To redress the barriers that people experiencing homelessness are
facing in accessing and using community health center services, we urge
Congress and the Administration to amend the health centers statute as
follows:
<bullet> Require community health centers to develop outreach and
services plans for the homeless population to ensure that
community health centers factor the complex medical and social
needs of people experiencing homelessness into their service
system design and implementation in anticipation of the
inevitability that people without housing will be seeking care
from them.
<bullet> Ensure access to health center services regardless of ability
to pay by codifying in statute the long-standing principle that
health center services are to be available to patients
regardless of their ability to pay and by restoring provisions
of prior law that assured that extremely poor people would not
have fees or payments imposed on them.
<bullet> Ensure that health centers provide assistance in obtaining
housing in parity with current law requirements that they
assist their patients in obtaining other public benefits (e.g.,
Medicaid, Food Stamps).
<bullet> Add addiction and mental health services as optional
additional services to encourage all health centers to expand
their scope of services to include treatment for these chronic
conditions to the extent practicable.
<bullet> Add recuperative care as an optional additional service to
encourage all health centers to expand their scope of services
to include this service to the extent practicable.
reauthorize and strengthen national health service corps program
The National Health Service Corps (NHSC) program, the statutory
authority of which has expired, is still needed to ensure that Health
Care for the Homeless projects and other safety net providers are able
to recruit and retain the health services professionals necessary to
operate their programs. We urge Congress and the Administration to
reauthorize the NHSC for a five-year period.
In addition, we urge Congress and the Administration to amend the
NHSC statute as follows:
<bullet> Establish an authorization level of at least $232 million in
FY 2002 for NHSC.
<bullet> Automatically designate all federally-qualified health
centers, including Health Care for the Homeless projects, as
Health Professional Shortage Area facilities for placement of
Corps personnel.
<bullet> Ensure access to health services provided by NHSC
professionals regardless of the patient's ability to pay by
codifying in statute that services provided by entities with
NHSC placements and NHSC private practice option placements are
to be available to patients regardless of their ability to pay
and by waiving or reducing charges for people who are unable to
pay.
recommendations on community access program
Health Care for the Homeless projects share the common belief among
health care safety net providers and public officials that patients
derive improved health and other benefits and that the health care
safety net system operates more efficiently when collaboration occurs
among disparate providers serving the same people. As the principal
health care safety net providers to people with the most complex and
interrelated medical and social conditions possible, HCH projects have
had to foster collaboration among health, housing, and support service
providers in their communities. For HCH projects, collaboration and
linkages are intuitive processes.
The National Council has neither supports nor opposes authorization
of the Community Access Program or equivalent initiatives. Our members'
views on this topic differ. Some HCH projects believe that new federal
safety net health care resources should be directed to the support of
services rather than to interactive functions. Other HCH projects have
reported positive collaborative experiences that are occurring in their
communities as a result of CAP projects.
Should Congress choose to authorize CAP or an equivalent health
care safety net collaboration program, we recommend that the following
principles guide the program's development.
<bullet> The program should facilitate improved and expanded access
to a full range of health and support services for all people without
health insurance, with a focus on those hardest to ensure or hardest to
serve.
<bullet> Funds should be directed to health and support service
access improvement and expansion rather than to the establishment of
planning and collaboration infrastructure.
<bullet> Applicants should be permitted to propose population-
focused projects (e.g., improving access to targeted,
disproportionately affected and historically underserved groups, such
as homeless, migrant, or youth) as well as geography-based projects
(e.g., improving access to all people in a given service area).
<bullet> Funds should be permitted for both individual level and
system level service interventions. Examples of individual level
interventions include outreach and engagement, public health insurance
assistance and advocacy, patient case management, and direct payment
for services. Examples of system level interventions include system
integration, care coordination, and patient record exchange.
<bullet> Grantees should be the community-based primary health
provider or network of providers that is most closely connected to the
intended beneficiaries. Primary health providers are the most
appropriate, and most common, gateways to other health and support
services. They are also key players in treating patients and addressing
their basic health needs before they present at emergency and specialty
care providers.
<bullet> As a condition for receiving funds, grantees should be
expected to demonstrate collaboration with other health care safety net
providers in the community, such as community, migrant, homeless, and
public housing health centers, public and charitable hospitals, local
public health departments with service delivery components, free
clinics, academic health centers providing uncompensated care,
addiction service providers, mental health service providers, HIV/AIDS
service providers, and family planning clinics.
<bullet> The scope of health systems, programs, and providers that
should be involved in community collaboration include primary,
addiction, mental, HIV/AIDS, maternal and child, oral, vision,
emergency, and other secondary and tertiary health services.
<bullet> Community collaborations resulting from the initiative
should include support systems, programs, and providers (such as
housing providers) that are essential to the effective delivery of
health services to intended beneficiaries.
<bullet> Representatives of intended beneficiaries should be
involved at the community level in need identification, project design,
and implementation monitoring.
Mr. Bilirakis. Thank you, Mr. Singer.
Ms. Monson.
STATEMENT OF HON. ANGELA MONSON
Ms. Monson. Good morning, Mr. Chairman, Mr. Brown and other
distinguished members of the committee. I am very happy to be
here with you again today, and I promise I won't have to leave
early. I will be here as long as you need me today, Mr. Chair.
My name is Angela Monson. I am a member of the State Senate
in Oklahoma where I chair the Senate Finance Committee. I have
the pleasure today of representing the National Conference of
State Legislatures, where I serve as Vice President, soon to be
President-elect, in 1 year President of that great
organization. I also have the privilege of serving as Chair of
the National Advisory Council to the National Health Service
Corps. And I also want to note that I got my start in health
care policy as a board member of the Mary Mahoney Community
Health Center more than 20 years ago, in the eastern part of my
Senate district, so I am very pleased to be here with you to
talk about, I think, is one of the most important subjects
facing the United States today, and that is health care, health
care access, and why should the National Conference of State
Legislatures pass a policy endorsing and encouraging and
promoting the reauthorization of the National Health Service
Corps, therefore, my remarks today will primarily be geared in
that direction, but do know we support the continuation and
expanded funding of the Community Health Centers.
I have had the pleasure of supporting and authoring
legislation in Oklahoma that has provided a substantial amount
of money to our Community Health Centers, State money to our
Community Health Centers.
We realize that President Bush's proposal and the support
received for the expansion of the number of Community Health
Centers will be good, it will do good, but it will also place a
greater burden on the need for clinicians in underserved areas.
The National Health Service Corps stands ready to meet that
need. It is important that we recognize that the value of the
National Health Service Corps does extend beyond the value to
those clinicians that receive an opportunity to serve and those
individuals who receive health care services, but truly impact
the true nature of communities. The substantial change in
communities as a result of these services provided truly last a
lifetime.
It is important also to recognize that the National Health
Service Corps provides an opportunity to meet the culturally
diverse needs in our communities. The Corps facilitates the
placement of practitioners that look like the communities in
which they serve. They provide the kind of cultural competency
that is necessary to ensure that health status is improved.
I would like to spend just a few minutes, however, making
some comments on recommendations that focus on changes in ten
National Health Service Corps that I think are important to
improve the benefits of that program. First of all, increased
funding. I think we all are aware that although the National
Health Service Corps does a wonderful job in providing
clinicians in underserved communities, there is a huge demand,
a great need, that is unmet, and that need will only be met if
we are able to increase the number of clinicians that are
provided to these communities. That means additional dollars.
The Loan Repayment Program is an excellent program. We are
aware of the articles that were written last year about
problems with clinicians in communities. That problem could
have been addressed with additional revenue, with our ability
to place more loan repayers.
The Scholarship Program, which is an excellent program in
terms of recruiting and retaining clinicians who otherwise
would not be given the opportunity to enter into health care
professions need additional revenue. There is a demand there
that we cannot meet with the current funding levels.
Two other areas I would like to mention, greater
flexibility in the National Health Service Corps Program.
Greater flexibility helps meet community needs. It helps
communities identify what they really need, where those
services must be provided, how those services should be
provided, but flexibility, increased flexibility, is important
so those particular community needs might be met.
It is important also that we create flexibility in the
program to meet the needs of participating providers to allow
clinicians to serve in situations that require less than full-
time service. It is important that we also continue to look at
necessary tax relief, particularly for the Loan Repayment
Program.
Thank you for addressing the issue in our Scholar Program
last year, but it is also an issue that must be addressed in
the program across the board.
Let me simply summarize to you by encouraging you to
continue to provide this kind of attention, this kind of
guidance and leadership in the area of health care. States have
entered into the arena of attempting to provide services and
coverage for many uninsured and underinsured citizens. However,
we cannot do it alone. It is a partnership. And as we continue
to expand coverage opportunities, the need for clinicians for
these underserved and uninsured populations will even become
more evident.
Let me encourage you that as you look at the CAP program
and the National Health Service Corps and the Community Health
Centers Programs and new initiatives to meet clinician needs
the needs of communities, that we focus on coordination of
programs. The need is great. Coordination of activities and
policies is fundamental if we are going to create the kinds of
efficiencies and revenue.
Truly, the health of our country is dependent upon the
actions taken in our State Legislatures and the actions taken
by you. So, I encourage you to, for the health and well being
of our country, to take the appropriate action. I thank you for
listening today.
[The prepared statement of Hon. Angela Monson follows:]
Prepared Statement of Hon. Angela Monson, Oklahoma State Senate, Vice-
President, NCSL on Behalf of the National Conference of State
Legislatures
Chairman Bilirakis and distinguished members of the subcommittee:
My name is Angela Monson. I am a state senator in Oklahoma where I
chair the Senate Finance Committee. I am the Vice-President of the
National Conference of State Legislatures (NCSL) and also have the
privilege of serving on the National Advisory Council of the National
Health Service Corp (NHSC). It is a pleasure to be here today on behalf
of NCSL to talk about reauthorizing the National Health Service Corps.
Last year NCSL adopted policy urging you to make the
reauthorization of the NHSC a priority. The support for this program is
broad, uniting state legislators across urban/rural and racial/ethnic
lines. I am particularly pleased to be a part of the effort to move
this important reauthorization forward.
The reauthorization of the NHSC is even more important this year.
President Bush's proposal to expand the number of Community Health
Centers will create an even greater need for clinicians to serve in
underserved areas. Just last month a provision that excludes from gross
income certain amounts received under the NHSC Scholarship Program was
enacted as part of the tax relief package. This benefit is an added
incentive to program participation.
The NHSC will be a valuable partner in the effort to expand the
number of Community Health Centers, but the value of the NHSC extends
far beyond the health profession shortage areas and the uninsured and
underinsured individuals and families who benefit from the service
requirement. The NHSC facilitates the training of health professionals
who, through their service and training, will bring special skills to
all the venues they practice in over their lifetime. As our population
becomes more diverse, the importance of culturally competent health
practitioners will grow. The NHSC is certain to be an important asset.
the mission of the national health services corps
NHSC represents a model framework for providing health care
services to uninsured and underinsured individuals and families across
this nation--a unique collaboration between the federal government, the
states, and local communities. Since its development in 1970, the NHSC
has played a vital role in expanding access to needed primary health
care in communities throughout the United States. Investment in the
NHSC pays continuing dividends to the communities in which its
clinicians are placed, since two-thirds of these clinicians remain in
the community after completion of their service.
Since 1972, NHSC has recruited more than 21,000 health care
clinicians to work in areas where, because of financial, geographic,
cultural or language barriers, individuals have only limited access to
primary medical care. The Corps' focus on minority recruitment has
resulted in a significantly greater representation of African-American
and Hispanic clinicians in the Corps than exists in the national health
care force. These clinicians make an immediate and significant
contribution to the overall health of a community.
The program attracts individuals from a variety of primary health
care professions, including physicians and physician assistants, nurse
practitioners, certified nurse midwives, dentists and dental
hygienists, and mental health professionals.
State Loan Repayment Program
In addition to the NHSC Loan Repayment program, 34 states (Alabama,
Arizona, California, Colorado, Connecticut, Delaware, Georgia,
Illinois, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New
Mexico, New York, North Dakota, Ohio, Pennsylvania, Rhode Island, South
Carolina, South Dakota, Texas, Utah, Virginia, Washington, West
Virginia, and Wisconsin) currently receive grants to operate state-
based loan repayment programs. These grants match state and local
community funds to assist in the repayment of qualified educational
loans for primary health care clinicians who, in return for this
assistance, agree to practice full time in public or non-profit health
facilities in Health Professional Shortage Areas (HPSAs). The specific
benefit and eligibility requirements vary by state.
NHSC Loan Repayment Program
The NHSC Loan Repayment Program provides benefits to both the
clinician and the health facility. The clinician receives an
opportunity to retire debt associated with their health-related
training while gaining valuable experience. The health care facilities
are able to immediately fill vacancies when loan repayment program
participants are available. Everybody benefits.
NHSC Scholarships
The Scholarship Program provides a unique educational opportunity
for non-traditional students, especially minority students, low-income
students, and students living in rural areas, who might not otherwise
be able to pursue a career in primary health care. In 1998, for
example, 46.2 percent of medical students awarded scholarships were
African-American and Hispanic. Upon graduation, students have an
opportunity to make a real difference in the lives of their patients.
In 1999, one-third of all patients treated by NHSC personnel had
incomes at or below the poverty live. Many others are uninsured and
have little access to medical care through traditional providers.
State Initiatives
State efforts to provide primary health care services for their
under-served populations are long-standing and encompass a variety of
approaches. Not the least important of these approaches are state
programs to increase the number of primary health care professionals.
The State of Florida, for example, provides 26 scholarship and loan
programs for disadvantaged and/or financially needy health professions
students. In addition, Florida provides training grants designed
specifically to improve access to health care by under-served
populations, including training for primary care physicians, dentists,
and nursing professionals, as well as training grants to improve public
health.
Texas and New Mexico have developed innovative programs using
promotoras, or ``health promoters,'' neighborhood women who act as
health care advisors for others in the community. These women, in
addition to bringing more people into the health care system, help
break down language and cultural barriers contributing invaluably to
improving the ``cultural competence'' of all who work beside them.
Many states are exploring, or have already developed, opportunities
to use advances in telecommunications to enhance the provision of
medical training and health care services, including the provision of
mental health, pharmacy, and ``telemedicine.'' These efforts contribute
significantly to solutions for solving what has become a crisis in
access to primary health care in many communities.
State and local governments continue to explore the full range of
approaches to improve access to affordable, quality health care
services. These approaches include expansions of coverage through
Medicaid and SCHIP, as well as insurance reforms and innovative state-
funded programs. Despite the substantial efforts of the National Health
Service Corps and the states to develop creative approaches to
providing access to primary health care, there remains a significant
unmet need for primary health care. The National Health Service Corps,
at current funding levels, is able to meet barely twelve percent of
this unmet need.
recommendations
Increase NHSC Funding
Appropriations should be sufficient to allow the NHSC to expand to
meet the growing demand for placement by clinicians to provide primary
health care services in federally designated underserved areas. The
Corps has been successful in recruiting a large number of trained
clinicians to its Loan Repayment Program, but funding for the program
has not kept pace.
Greater Program Flexibility to Better Meet Community Needs
The goal of NHSC is to be able to educate and recruit primary
health care professionals for service in communities experiencing
critical shortages of health care providers. Many of these communities
consist largely of individuals with specific cultural experiences or
ethnic backgrounds. These communities can present special challenges in
recruiting and retaining health care providers sensitive to the
particular needs of the community. The NHSC recognizes the importance
of training culturally-competent and responsive primary health care
providers.
Reauthorization of NHSC provides an opportunity to:
<bullet> develop additional mechanisms to recruit and retain minority
participants;
<bullet> augment informal efforts to match communities with specific
cultural traditions with health care providers with shared
cultural experiences, or who are specifically trained in
culturally diverse community-based systems of care;
<bullet> increase and formalize efforts to recruit and place health
professionals who represent racial and ethnic minorities in
communities who request them;
<bullet> improve training to encompass cultural competency that
considers geographical/regional differences that may affect the
health delivery system;
<bullet> more directly involve communities in the recruitment,
selection and retention of health care professionals through
community sponsorships;
<bullet> increase the emphasis on public/private partnerships,
including faith-based institutions, to enhance community
involvement and contractual arrangements with independent
health care providers;
<bullet> develop programs to assist remote communities, those too small
for community health centers, but large enough to need
assistance in obtaining primary health care for its citizens;
and
<bullet> provide technical assistance to states and local communities
in implementing NHSC programs and maximizing resources.
Greater Program Flexibility to Better Meet the Needs of Participating
Providers
Retaining clinicians in the Corps continues to be a challenge. The
reauthorization provides a unique opportunity to explore innovative
options to encourage clinicians to stay in the program. Two ideas come
to mind.
<bullet> Part-Time Service--The establishment of demonstration projects
and pilot programs allowing participants to work less than full
time. The opportunity to serve on a part-time basis could be an
important tool in attracting non-traditional providers,
including minority health care providers, and prove to be
especially attractive in rural areas where traditional health
care centers may be not be available.
<bullet> Tax Relief--Extend to the NHSC Loan Repayment Program, the
favorable tax treatment recently afforded to the NHSC
Scholarship program in P.L. 107-16. The opportunity to exclude
from gross income for federal income tax purposes the amounts
of loan payments received from the NHSC would provide an
important incentive to clinicians and also provides increased
resources to the loan repayment program.
In Conclusion
I look forward to working with this committee and your colleagues
in both the House and the Senate to reauthorize the National Health
Services Corps this year. I thank you for this opportunity to discuss
these important issues with you today and would be happy to answer
questions.
Mr. Bilirakis. Thank you, Senator.
Mr. Hall.
STATEMENT OF ROBERT HALL
Mr. Hall. Honorable chairman and committee members, and
Vice Chairman Brown, thank you for the opportunity to present
to you this morning. My name is Bob Hall. I am President of the
National Council of Urban Indian Health, and a member of the
three affiliated tribes of Fort Berthal, North Dakota--the
Arikara, Hidatsa, and Mandan. I am also Executive Director of
the South Dakota Urban Indian Health Clinic which operates
three clinics in South Dakota. We would like to offer a few
remarks on the reauthorization of the legislation.
NCUIH is the only membership organization representing
urban Indian Health programs. Our members provide a wide range
of health care and referral services in 34 cities, to a
population of approximately 332,000 urban Indians. We are often
the main source of health care and health information for these
urban Indian communities.
According to the 1990 census, 58 percent of American
Indians live in urban areas. We expect that the 2000 census is
going to indicate that is over 60 percent now live in urban
areas. Like their reservation counterparts, urban Indians
historically suffer from poor health and substandard health
care services.
In 1976, Congress passed the Indian Health Care Improvement
Act. The original purpose of this act, as set forth in a
contemporaneous report, was to ``raise the status of health
care for American Indians and Alaska Natives over a 7-year
period to a level equal to that enjoyed by American citizens.''
It has been 25 years since Congress committed to raising the
status of Indian health care, and 18 years since the deadline
has passed for achieving the goal of equality with other
Americans, and yet Indians, whether reservation or urban,
continue to occupy the lowest rung on the American health care
ladder.
Although the road to equal health care still appears to be
a long-time coming, NCUIH believes that Section 330 programs,
the Community Access Programs and the National Health Service
Corps are all steps in the right direction. NCUIH would like to
emphasize, however, the unique characteristics of providing
health care to the American Indian population, and the
necessity for continuing to support urban Indian health
programs that focus nearly exclusively on the urban Indian
community.
Many Indians live in urban areas, some permanently, some
periodically. It is generally not practical for any one tribal
government to set up health service for only its own tribal
members in an urban area. In fact, in some urban centers, there
are as many as 40 tribal governments nearby, with members of
more than 80 different tribes participating in a single urban
program.
Urban Indian health programs have arisen specifically to
address the uniqueness of Indians in the urban setting, by
providing a culturally sensitive, highly supportive
environment. Urban Indian health programs have been
extraordinarily successful, despite limited resources, at
reaching the urban Indian population. Many Indians are not
trustful of ``mainstream'' institutions. Urban Indian programs
bridge this distrust and, in so doing, are able to more
effectively address the health care issues of the Indian
community than non-Indian health care providers. In fact, in
the State of South Dakota, the Family Planning Office of the
State has made three major attempts in the last 10 years to
increase the number of Native American women participating in
family planning programs. They have not come close to reaching
their goal. This past July 1st, we entered into a contract with
them to help achieve that. We already have 25 new enrollees in
the family planning program.
In fiscal year 2001, urban Indian health programs received
1.14 percent of the total Indian Health Service budget,
although urban Indians constituted at least 50 percent of the
total American Indian population and 18 percent of Native
Americans served by IHS dollars. NCUIH acknowledges that there
are some sound reasons why the lion's share of the IHS budget
should go to reservation Indians, however, the health of Indian
people in urban areas affects the health of Indian people on
reservations and vice-versa. Disease knows no boundaries. NCUIH
strongly believes that the health problems associated with the
Indian population can only be successfully combatted through a
significant funding directed at the urban Indian population as
well as at the reservation population.
We hope that as you consider the future of America's health
safety net programs you will give consideration to additional
support for the urban Indian health program. NCUIH plans to
work more closely with the Section 330 Community Health
Centers. We are convinced that cooperation will lead to better
results for Native peoples, however, we ask for your support in
maintaining the independence and uniqueness of urban Indian
health programs.
We know from hard-won experience the value of providing a
culturally sensitive environment for urban Indians in order to
best address the health care needs of this community. America
is nowhere near the lofty goal set by the Congress in 1976 of
achieving equal health care for American Indians, whether
reservation or Indian. NCUIH challenges this committee to think
in terms of that goal as it considers its future of health care
programs that operate in underserved communities.
NCUIH thanks this committee for this opportunity to testify
concerning urban Indian health. I would be happy to answer any
questions the committee may have. Thank you.
[The prepared statement of Robert Hall follows:]
Prepared Statement of Robert Hall, President, National Council of Urban
Indian Health
``Between the intentions of the lawmakers and the reality of
regulatory actions lies the service gap that confronts the
urban Indian. The result is untold desperation and waste of
human resources.''
Final Report of the American Indian
Policy Review Commission, Vol. 1, p. 436 (emphasis added).
i. introduction
Honorable Chairman and Committee Members, my name is Robert Hall. I
am the president of the National Council of Urban Indian Health (NCUIH)
and a member of the three affiliated tribes of North Dakota: Arikara,
Mandan and Hidatsa. I am also the Executive Director of the South
Dakota Urban Indian Health Clinic. On behalf of NCUIH, I would like to
express our appreciation for this opportunity to address the Committee
on community health centers and urban Indian programs.
NCUIH is the only membership organization representing urban Indian
health programs. Our programs provide a wide range of health care and
referral services in 34 cities to a population of approximately 332,000
urban Indians. Our programs are often the main source of health care
and health information for urban Indian communities. According to the
1990 census, 58% of American Indians live in urban areas, up from 45%
in 1970 and 52% in 1980.<SUP>1</SUP> We expect that the 2000 census
will show that over 60% of American Indians now live in urban areas.
Like their reservation counterparts, urban Indians historically suffer
from poor health and substandard health care services. NCUIH is the
successor organization to the American Indian Health Care Association
which provided advocacy and educational services on behalf of urban
Indian health organizations for nearly 15 years prior to the
establishment of NCUIH.
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\1\ According to the 1990 census, 62.3% of American Indians and
Alaska Natives reside off reservation. At that time, that figure
represented 1.39 million of the 2.24 million American Indians and
Alaska Natives. The updated 1990 census identified 58% of American
Indians and Alaska Natives as living in urban areas (the other off-
reservation Indians live in rural areas). This percentage has probably
increased significantly since 1990.
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ii. section 330, community access programs and urban indian health
programs
NCUIH strongly supports the Community Access Program, the National
Health Service Corps, and those programs authorized under Section 330
of the Public Health Service Act. NCUIH would like to emphasize,
however, the unique characteristics of providing health care to the
American Indian population, and the necessity of continuing to support
urban Indian health programs that focus nearly exclusively on the urban
Indian community.
Many Indians live in urban areas; some permanently, some
periodically.<SUP>2</SUP> It is generally not practical for any one
tribal government to set up health service for only its own tribal
members in an urban area. In fact, ``in some urban centers, there are
as many as 40 tribal governments nearby, and representation of tribes
on urban Indian programs might include over 80 different tribes.''
<SUP>3</SUP> Urban Indian health programs have arisen specifically to
address this situation. By providing a culturally-sensitive, highly
supportive environment, urban Indian health programs have been
extraordinarily successful, despite limited resources, at reaching the
urban Indian population. Many Indians are not trustful of
``mainstream'' institutions. By providing a familiar environment, urban
Indian programs bridge this cultural disconnect and, in so doing, more
effectively address health care issues of the Indian community than can
generally be achieved by non-Indian health care providers.
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\2\ One Federal court has noted that the ``patterns of cross or
circular migration on and off the reservations make it misleading to
suggest that reservations and urban Indians are two well-defined
groups.'' United States v. Raszkiewicz, 169 F.3d 459, 465 (7th Cir.
1999)
\3\ U.S. Congress, Office of Technology Assessment, Indian Health
Care, OTA-H-290 (Washington, DC: U.S. Government Printing Office, April
1986), p. 38.
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iii. federal policies and the urban indian
``Most Indians who migrate to the cities say they would have
preferred not to do so at all.''
Final Report of the American Indian
Policy Review Commission, Vol. 1., p. 436.<SUP>4</SUP>
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\4\ ***
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The urban Indian is an Indian who has become physically separated
from his or her traditional lands and people, generally due to Federal
policies. Some of these federal policies were designed to force
assimilation and to break-down tribal governments; others may have been
intended, at some misguided level, to benefit Indians, but failed
miserably. The result of this ``course of dealing,'' however, is the
same: a Federal obligation to urban Indians.<SUP>5</SUP>
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\5\ The unique legal relationship of the United States with Indian
tribes and people is defined not only in the Constitution of the United
States, treaties, statutes, Executive orders, and court decisions, but
also in the ``course of dealing'' of the United States with Indians. As
the Supreme Court noted in a major Indian law case, ``[f]rom their very
weakness and helplessness, so largely due to the course of dealing of
the federal government with them, and the treaties in which it has been
promised, there arises the duty of protection and with it the power.''
United States v. Kagama (1886) (emphasis added). Congress acknowledged
this in its findings to the Native American Housing Assistance and
Self-Determination Act: ``The Congress through treaties, statutes and
the general course of dealing with Indian tribes, has assumed a trust
responsibility . . . for working with tribes and their members to
improve their housing conditions and good economic status so that they
are able to take greater responsibility for their own economic
condition.'' 25 U.S.C. 4101(4). Notably, NAHASDA also applies to state-
recognized tribes. 25 U.S.C. 4103(12)(A).
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A. The Federal Relocation of Indians. The BIA's Relocation program
originated in the early 1950s as a response to adverse weather and
economic conditions on the Navajo reservation. A limited program was
initiated to relieve the distress by finding jobs for Navajos who
wanted to work off the reservation. Little or no job opportunities
existed on the reservation, so an employment campaign was developed for
off-reservation employment. Shortly afterward, the BIA converted its
Navajo program into a full-fledged Bureau of Indian Affairs program
applicable to many Indian tribes.
The BIA employees who developed the program made many mistakes and
miscalculations. Even before the 1950's had ended there was concern
that many relocatees were experiencing great difficulty adjusting to
life in a large city, or to their jobs. Some felt they were being
stranded far away from home. Solving reservation economic problems by
relocating Indians off of their tribal lands is roughly the equivalent
of the Federal government, during the Depression, sending Americans
oversee to find work--something the Federal government would never have
done. Many understood the relocation program as just another form of
``termination.'' A Jesuit priest on the Fort Belknap Reservation noted
that relocation programs drained the reservation of much of its
potential leadership, further weakening tribal governments.
All told, between 1953-1961, over 160,000 Indians were relocated to
cities.<SUP>6</SUP> Where they quickly joined the ranks of the urban
poor.<SUP>7</SUP> Today, the children, grandchildren and great-
grandchildren of the 160,000 Indians relocated by the BIA are still in
the cities. They maintain their Indian identity even if, in some cases,
these ``descendants have been unable to re-establish ties (including
membership) with their tribes.'' <SUP>8</SUP>
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\6\ 1992 Roundtable Conference, Urban Indian Health Programs,
Indian Health Service, ``Working in Unity Toward our Future.'' p.2.
\7\ ``Unfortunately, far too many Indians who move to the cities,
because of inadequate academic and vocational skills, merely trade
reservation poverty for urban poverty.'' H.Rep. No. 9-1026, 94th Cong.,
2d Sess. 18, reprinted in 1976 U.S. Cong. & Admin. News (USCAN) 2652,
p. 2747.
\8\ See Office of Planning, Evaluation and Legislation, Indian
Health Service, Impact of the Final Rule Final Report, Contract No.
282-91-0065, ``Health Care Services of the Indian Health Service'' 42
CFR Part 36, p. 22-23.
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B. Failure of Federal Efforts to Economically Develop the
Reservations. The second major reason Indians have moved to the city is
the near total failure of Federal programs to promote economic
development on Indian lands, coupled with the ongoing success of the
Federal efforts in the 1800's to undermine the economic way of life of
Indian peoples, locking nearly all Indians into hopeless poverty which
still plagues most reservations today. The long history of treaty-
breaking by the Federal government is an important part of this tale.
As a result, out of desperation, a number of Indians have left their
homelands to go to the cities in search of work, even without the
dubious benefit of the BIA's relocation program. Generally, these
Indians were no better equipped to handle life in the city than the BIA
relocatees and quickly joined the ranks of the urban poor. Congress has
noted the correlation between the failure of Federal economic policies
and the swelling of the ranks of urban Indians: ``It is, in part,
because of the failure of former Federal Indian policies and programs
on the reservations that thousands of Indians have sought a better way
of life in the cities. His difficulty in attaining a sound physical and
mental health in the urban environment is a grim reminder of this
failure.'' <SUP>9</SUP>
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\9\ Pub. L. 94-437, House Report No. 94-1026, June 8, 1976, 94th
Cong., 2d Sess. 18, reprinted in 1976 U.S. Cong. & Admin. News (USCAN)
2652,at p. 2754.
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C. Termination of Tribes. In 1953, Congress adopted a policy of
terminating the Federal relationship with Indian tribes. Essentially,
this was an abrogation of the Federal government's numerous
commitments, in treaties, laws, executive orders, and through the
``course of dealing'' with Tribes, to protect their interests. Many
tribes were coerced to accept termination in order to receive money
from settlements for claims against the United States for
misappropriation of tribal land, water or mineral rights in violation
of treaties.<SUP>10</SUP> The results of termination were devastating:
having lost Federal support, and without tribal sovereign authority
over an established land basis, and with tribal members no longer
eligible for Federal programs and IHS services, the Tribes collapsed.
Some members remained in the area of their old reservations; many went
to the cities, where they, too, joined the ranks of the urban poor.
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\10\ Office of Planning, Evaluation and Legislation, Indian Health
Service, Impact of the Final Rule Final Report, Contract No. 282-91-
0065, ``Health Care Services of the Indian Health Service'' 42 CFR Part
36, p. 23.
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D. Indian Patriotism--World War I and World War II. Many Indians
served the United States in time of war <SUP>11</SUP> and,
subsequently, were stationed in or near urban centers. At the end of
their service to the United States, seeing the poor economic conditions
on their reservations (resulting from the Federal war on Indians), many
chose not to go back. The fact that they chose to stay in an urban area
did not make them any less Indian, nor did it reduce the Federal
government's obligation to them.
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\11\ It is in part because of their gallant service in World War I
that the U.S. Congress granted U.S. citizenship as a group to American
Indians in 1924.
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E. The General Allotment Act. The General Allotment Act (``Dawes
Act'') had two principal goals: (1) by allocating communal tribal land
to individual Indians it would breakdown the authority of the tribal
governments while encouraging the assimilation of Indians as farmers
into mainstream American culture; and (2) it provided for unalloted
land (two-thirds of the Indian land base) to be transferred to non-
Indians. CITE. The General Allotment Act succeeded at transferring the
majority of Indian land to non-Indians and further disrupting tribal
culture. For the purposes of this testimony, we only need to note that
some Indians who received allotments became U.S. Citizens and, after
losing their lands, moved into nearby cities and towns.
F. Non-Indian Adoption of Indian Children. The common practice of
adopting Indian children into non-Indian families has created another
group of Indians in urban areas who, because of the racial bias of the
courts, have lost their core cultural connection with their tribal
people and homelands. Many of the adopted Indians have successfully
sought to restore those connections, but because of their upbringing
are likely to remain in urban areas.<SUP>12</SUP>
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\12\ In recognition of the severity of this problem, Congress
passed in 1978 the Indian Child Welfare Act to give Tribes and Indian
parents a greater say in the adoption process for Indian children. See
Indian Child Welfare Act of 1978, 25 U.S.C. Sections 1901-1963.
---------------------------------------------------------------------------
G. Boarding Schools. The Federal program of taking Indian children
and educating them away from their reservations in boarding schools
where they were prohibited from speaking their native language and
otherwise subject to harsh treatment, created a group of Indians who
struggled to fit back into the reservation environment. Eventually,
some moved to the cities. The boarding school philosophy of ``Kill the
Indian, Save the Man'' epitomizes the thinking behind this approach and
the racist Federal effort to assimilate American Indians which, as a
result, led to a number of Indians moving to urban areas.
H. The Fracturing of the Indian Nations. The result of these, and
other Federal Indian policies, has been the fracturing of Indian tribes
and the creation, in the urban setting, of highly diverse Indian
communities with members who fall into one or more of the following
categories: Federal relocatees; economic hardship refugees; members of
Federally recognized tribes, terminated tribes, state recognized
tribes, and unrecognized Tribes (that is, unrecognized by the Federal
government); <SUP>13</SUP> and adoptees.
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\13\ There are still scores of tribes working their way through the
byzantine and labyrinthine acknowledgement process, which is widely
criticized for its glacial pace and alleged bias against certain Indian
groups. Some tribes, like the Lumbee Tribe of North Carolina, have been
declared ineligible to go through the administrative process and,
therefore, are awaiting Congressional action on their long-prepared,
extensively documented petition for federal recognition.
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iv. the federal government and the provision of health care to urban
indians
The Congress has long recognized that its obligation to provide
health care for Indians, includes providing health care off the
reservation.
``The responsibility for the provision of health care, arising
from treaties and laws that recognize this responsibility as an
exchange for the cession of millions of acres of Indian land
does not end at the borders of an Indian reservation. Rather,
government relocation policies which designated certain urban
areas as relocation centers for Indians, have in many instances
forced Indian people who did not [want] to leave their
reservations to relocate in urban areas, and the responsibility
for the provision of health care services follows them there.''
Senate Report 100-508, Indian Health Care Amendments of 1987, Sept.
14, 1988, p. 25 (emphasis added).<SUP>14</SUP> Congress has ``a
responsibility to assist'' urban Indians in achieving ``a life of
decency and self-sufficiency'' and has acknowledged that ``[i]t is, in
part, because of the failure of former Federal Indian policies and
programs on the reservations that thousands of Indians have sought a
better way of life in the cities. Unfortunately, the same policies and
programs which failed to provide the Indian with an improved lifestyle
on the reservation have also failed to provide him with the vital
skills necessary to succeed in the cities.'' House Report No. 94-1026
on Pub. Law 94-437, p. 116 (April 9, 1976).
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\14\ ``The American Indian has demonstrated all too clearly,
despite his recent movement to urban centers, that he is not content to
be absorbed in the mainstream of society and become another urban
poverty statistic. He has demonstrated the strength and fiber of strong
cultural and social ties by maintaining an Indian identity in many of
the Nation's largest metropolitan centers. Yet, at the same time, he
aspires to the same goal of all citizens--a life of decency and self-
sufficiency. The Committee believes that the Congress has an
opportunity and a responsibility to assist him in achieving this goal.
It is, in part, because of the failure of former Federal Indian
policies and programs on the reservations that thousands of Indians
have sought a better way of life in the cities. His difficulty in
attaining a sound physical and mental health in the urban environment
is a grim reminder of this failure.''
``The Committee is committed to rectifying these errors in Federal
policy relating to health care through the provisions of title V of
H.R. 2525. Building on the experience of previous Congressionally-
approved urban Indian health prospects and the new provisions of title
V, urban Indians should be able to begin exercising maximum self-
determination and local control in establishing their own health
programs.''
Pub. L. 94-437, House Report No. 94-1026, June 8, 1976, reprinted
in 1976 U.S. Cong. & Admin. News (USCAN) 2652 at p. 2754.
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The Supreme Court has also acknowledged the duty of the Federal
government to Indians, no matter where located: ``The overriding duty
of our Federal Government to deal fairly with Indians wherever located
has been recognized by this Court on many occasions.'' Morton v. Ruiz,
415 U.S. 199, 94 S.Ct. 1055, 39 L.Ed.2d 270 (1974) (emphasis added),
citing Seminole Nation v. United States, 316 U.S. 286, 296 (1942); and
Board of County Comm'rs v. Seber, 318 U.S. 705 (1943). In other areas,
such as housing, the Federal courts have found that the trust
responsibility operates in urban Indian programs. ``Plaintiffs urge
that the trust doctrine requires HUD to affirmatively encourage urban
Indian housing rather than dismantle it where it exists. The Court
generally agrees.'' Little Earth of United Tribes, Inc. v. U.S.
Department of Justice, 675 F. Supp. 497, 535 (D. Minn.
1987).<SUP>15</SUP>
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\15\ Federal responsibility for Indian health care is frequently
declared ``primary'' but it is not exclusive and preemptive of state
responsibility. See McNabb v. Bowen, 829 F.2d 787, 792 (9th Cir. 1987).
Congress enunciated its objective with regard to urban Indians in a
1976 House Report: ``To assist urban Indians both to gain access to
those community health resources available to them as citizens and to
provide primary health care services where those resources are
inadequate or inaccessible.'' H.Rep. No. 9-1026, 94th Cong., 2d Sess.
18, reprinted in 1976 U.S. Cond Cong. & Admin. News (USCAN) 2652, 2657.
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Congress enshrined its commitment to urban Indians in the Indian
Health Care Improvement Act where it provided:
``that it is the policy of this Nation, in fulfillment of its
special responsibility and legal obligation to the American
Indian people, to meet the national goal of providing the
highest possible health status to Indians and urban Indians and
to provide all resources necessary to effect that policy''
25 U.S.C. Section 1602(a)(emphasis added). In so doing, Congress
has articulated a policy encompassing a broad spectrum of ``American
Indian people.'' Similarly, in the Snyder Act, which for many years was
the principal legislation authorizing health care services for American
Indians, Congress broadly stated its commitment by providing that funds
shall be expended--for the benefit, care and assistance of the Indians
throughout the United States for the following purposes: . . . For
relief of distress and conservation of health.'' 25 U.S.C. Section 13
(emphasis added).
The courts have also stated that there is a trust responsibility
for individual Indians. ``The trust relationship extends not only to
Indian tribes as governmental units, but to tribal members living
collectively or individually, on or off the reservation.'' Little Earth
of United Tribes, Inc. v. U.S. Department of Justice, 675 F. Supp. 497,
535 (D. Minn. 1987)(emphasis added). ``In light of the broad scope of
the trust doctrine, it is not surprising that it can extend to Indians
individually, as well as collectively, and off the reservation, as well
as on it.'' St. Paul Intertribal Housing Board v. Reynolds, 564 F.
Supp. 1408, 1413 (D. Minn. 1983) (emphasis added).
``As the history of the trust doctrine shows, the doctrine is
not static and sharply delineated, but rather is a flexible
doctrine which has changed and adapted to meet the changing
needs of the Indian community. This is to be expected in the
development of any guardian-ward relationship. The increasing
urbanization of American Indians has created new problems for
Indian tribes and tribal members. One of the most acute is the
need for adequate urban housing. Both Congress and Minnesota
Legislature have recognized this. The Board's program, as
adopted by the Agency, is an Indian created and supported
approach to Indian housing problems. This court must conclude
that the [urban Indian housing] program falls within the scope
of the trust doctrine . . .''
Id. At 1414-1415 (emphasis added).
This Federal government's responsibility to urban Indians is rooted
in basic principles of Federal Indian law. The United States has
entered into hundreds of treaties with tribes from 1787 to 1871. In
almost all of these treaties, the Indians gave up land in exchange for
promises. These promises included a guarantee that the United States
would create a permanent reservation for Indian tribes and would
protect the safety and well-being of tribal members. The Supreme Court
has held that such promises created a trust relationship between the
United States and Indians resembling that of a ward to a guardian. See
Cherokee Nation v. Georgia, 30 U.S. 1 (1831). As a result, the Federal
government owes a duty of loyalty to Indians. In interpreting treaties
and statutes, the U.S. Supreme Court has established ``canons of
construction'' that provide that: (1) ambiguities must be resolved in
favor of the Indians; (2) Indian treaties and statutes must be
interpreted as the Indians would have understood them; and (3) Indian
treaties and statutes must be construed liberally in favor of the
Indians. See Felix S. Cohen's Handbook of Federal Indian Law, (1982
ed.) p. 221-225. Congress, in applying its plenary (full and complete)
power over Indian affairs, consistent with the trust responsibility and
as interpreted pursuant to the canons of construction, has enacted
legislation addressing the needs of off-reservation Indians.
The Federal courts have also found, that the United States can have
an obligation to state-recognized tribes under Federal law. See Joint
Tribal Council of Passamaquoddy v. Morton, 528 F.2d 370 (1st Cir.
1975). Congress has provided, not only in the IHCIA, <SUP>16</SUP> but
also in NAHASDA, that certain state-recognized tribes or tribal members
are eligible for certain Federal programs. 25 U.S.C. Section
4103(12)(A).
---------------------------------------------------------------------------
\16\ As originally conceived, the purpose of the Indian Health Care
Improvement Act was to extend IHS services to Indians who live in urban
centers. Very quickly, the proposal evolved into a general effort to
upgrade the IHS. See, A Political History of the Indian Health Service,
Bergman, Grossman, Erdrich, Todd and Forquera, The Milbank Quarterly,
Vol. 77, No. 4, 1999.
---------------------------------------------------------------------------
v. barriers to mainstream health care experienced by urban indians
<SUP>17</SUP>
---------------------------------------------------------------------------
\17\ This section is based on the September 30, 1989 report
prepared for the American Indian Health Care Association, by Ruth
Hograbe, R.D., M.P.H., Program Analyst and Donna Isham, Program
Analyst. The framework for the report is the 1988 report Minority
Health in Michigan: Closing the Gap.
---------------------------------------------------------------------------
``The lack of employment opportunities leads to a downward
spiral that reduces the urban Indian's life to a struggle for
subsistence. For example, the private practice system of health
care is certainly beyond the financial reach of most newly
arrived urban Indian families. They must depend on public
services. Yet here, the service gap reveals itself again.''
Final Report of the American Indian Policy
Review Commission, p. 437 (emphasis added).
The status of Urban Indian health is as poor as that for
reservation Indians.<SUP>18</SUP> This section describes the many
barriers that are still faced by Urban Indians in their efforts to
access adequate health care in the urban environment:
---------------------------------------------------------------------------
\18\ See Health Status of Urban American Indians and Alaska
Natives, Grossman et. al, Journal of the American Medical Association,
Vol. 271, No. 11, p. 845.
---------------------------------------------------------------------------
Physical/geographic barriers can include (1) telephone
availability; less access to transportation; and (3) high mobility.
Many Native Americans do not have phones, increasing the difficulty in
making appointments. For example, in Arizona, thirty percent of urban
Indians have no household access to phone services. Indian people have
much less access to private vehicles than the general population. Not
having a vehicle creates barriers for people who must make arrangements
with others to bring them to appointments. Public transportation (if
available) makes for a longer travel time and can be costly. The high
mobility of Indian people is another barrier to care. People who move
often are not able to follow with the same provider, and this disrupts
continuity of care and can lead to a decrease in the quality of care.
When a person moves to another area, they must go through the system
again to qualify for benefits, locate a provider, and receive care. In
addition, movement back and forth between the reservation is common,
which can significantly affect the ability of health professionals to
provide prompt, quality follow-up care.
Financial/Economic barriers also contribute to the poor quality of
urban Indian health care. People who do not have the resources, either
through insurance or out-of-pocket, to pay for prevention and early
intervention care may delay seeking treatment until a disease or
condition has advanced to the stage where treatment is more costly and
the probability of survival or correction is lower.
Medicaid is available for urban Indians, but difficult to access.
Applying for Medicaid or other medical assistance is a long and
detailed process, presenting many barriers to people who don't
understand the system or lack the necessary skills to complete the
paperwork involved. Furthermore, the required documentation is
difficult for many urban Indians to obtain. For example, if one does
not have a car, one may not have a drivers license. With high mobility
among urban Indians, there is likely to be no documentation with the
current address; or if they have just moved to the city from the
reservation, there may be no birth certificate or identification. Once
an individual is accepted, access to care is not guaranteed. Because of
Medicaid reimbursement rates and restrictions, many providers are
reluctant to accept Medicaid patients.
Health insurance coverage does not automatically remove financial
barriers to care. Many persons, particularly those employed at or near
minimum wage, have coverage through plans that do not cover preventive
or major medical care. While professional positions generally provide
health insurance, service and laborer positions generally do not. Urban
Indians hold more of those occupations that do not provide health
insurance benefits. Deductibles and co-payments are high enough that
many persons who do have health insurance cannot afford to pay them and
consequently do not seek care.
No insurance or assistance is another common barrier. Those who
have no means to pay for care are often turned away. There is a high
rate of urban Indians who are uninsured. For example, in Boston, 87% of
the Boston Indian Center's clients have no health insurance, and two
out of every three urban Indians in Arizona are uninsured.
Emergency room use is high among the poor, minorities and the
uninsured. Unfortunately, emergency room use as a primary medical
resource is costly and compromises quality care. Follow-up and
preventive services are not possible with emergency room personnel
serving as primary care providers. In Arizona, urban Indians use the
emergency room 250% more often than the general public.
Cultural/structural barriers also exist for urban Indians receiving
health care. The Indian Health Service conducted a survey which
concluded that the majority of state, county and city health
departments do not have the resources to meet the health care needs of
urban Indians. Major stumbling blocks are inadequate funds and lack of
staff trained to work with American Indians in a culturally sensitive
way. Indians may be reluctant or unable to describe their health needs
to strangers outside their own culture. Frequently, mainstream
providers misunderstand or misinterpret the reticence and stoicism of
some Indians. Other factors include a lack of trained Indian health
professionals that get placed in urban Indian health programs and
inadequate Indian outreach.
vi. conclusion
Notwithstanding all the difficulties, urban Indian health
organizations, working with limited funds, have made a great difference
in addressing the health care service gap for urban Indians. There is
much more work to be done. NCUIH thanks the Committee for this
opportunity to provide testimony on urban Indian health programs.
Mr. Bilirakis. Thank you very much, Mr. Hall. We have a
vote coming up in a few minutes. I am trying to get this worked
out somehow where maybe we can have someone run over, cast
their vote, to see if we can keep it rolling. Three votes. That
is going to be a problem then. We will have to recess when that
takes place. I will start the questioning, if I may.
Ms. Monson, very quickly, you failed to mention--you heard
my opening statement and I mentioned the fact that the National
Health Service Corps volunteers have the opportunity to buy-out
of their contract. Do you have a quick comment on that?
Ms. Monson. Yes, Mr. Chair. If you look at some of the
statistics that I have seen provided by the National Health
Service Corps, generally, our participants have met their
obligation. I know there has been some discussion about HMOs
buying out on behalf of the practitioner, their contracts, but
the default rate and the buy-out rate for the programs, I
think, if you look at the numbers, are substantially low.
Mr. Bilirakis. Should they have the right to do that? After
all, there is an obligation there that the taxpayers sent them
to school.
Ms. Monson. I guess, Mr. Chair, when the program was
initially created, that someone felt that it was important to
give some flexibility to the practitioners for varying reasons.
Maybe there should be specific reasons or circumstances within
which a clinician could buy-out or pay back their obligation.
I truly believe, however, because of our screening
techniques and when you look at those individuals that
participate in the program, they come into the program not just
because of the free education in terms of the Corps Scholarship
Program or the Loan Repayment Program, but they come because
they are committed to service in underserved areas. And I would
imagine that situation exists more than 98 or 99 percent of the
time.
Mr. Bilirakis. You may be right about those percentages,
but I have personally experienced this situation in one of the
clinics in my district, and it hurt the clinic badly.
Ms. Monson. Let me suggest one thing that we have talked
about as a Council----
Mr. Bilirakis. Well, let me just continue on. Please
consider that. You are right, maybe it is probably 98, 99
percent, I don't know what that percentage is, but I don't know
that it should be just 98, 99, I think it ought to be 100.
Ms. Monson. It should be 100 percent.
Mr. Bilirakis. Yes. So will you offer the committee
suggestions, any ideas that you may have in writing to us on
changing that, if you believe in it. If you don't, that is a
different story.
Ms. Monson. We certainly have, and we as a Council have
discussed options to address that situation. We would be happy
to provide that information.
Mr. Bilirakis. Great. Thanks, Senator.
Dr. Duke, do your statistics include the private clinic,
the non-330 clinics that exist around the country?
Ms. Duke. The statistics I used in my testimony this
morning reflect the health centers that are under the 330
progam, so that when we talk about the statistics on care for
the minorities and so forth, those are our health care clinics.
Mr. Bilirakis. So, in other words, we do not know--there is
no way to know how many clinics are out there who are doing
essentially the same type of work, that are not part of the 330
program?
Ms. Duke. We are aware of the--there are a lot of providers
that are called ``look-a-likes.'' We also have rural health
clinics and small rural hospitals that provide services as
well, so that there is a network of provision of care that goes
beyond the health centers about which my statistics spoke this
morning.
Mr. Bilirakis. So the answer then is we don't know how many
there might be. For instance, there is a Clearwater Free Clinic
in Clearwater, Florida. Are you aware of that?
Ms. Duke. Sir, I don't know the specifics of that
particular area, but I can get back to you with a fuller answer
that could lay that out, and I would be delighted to do that.
Mr. Bilirakis. Would you do that, I think that would be
very helpful.
Continuing in that vein, Ms. Benjamin and Mr. Brewton
particularly, Ms. Benjamin, your clinic, its history was in
being about 10 years before you decided to apply for 330
funding.
Ms. Benjamin. Yes.
Mr. Bilirakis. All right. And, Mr. Brewton, you indicated
that your clinic was operating a few years before apply for 330
funding. Have you seen substantial changes in terms of the
intent of the clinic? In other words, a lot of these clinics
that I have referred to, Dr. Duke, they tell me they just don't
want any government involvement. They don't want the government
telling them what to do, in spite of the fact that they need
the funding and could probably serve a lot more people, and be
able to hire some providers, whereas now they are all
volunteers, literally all volunteers, including the people at
the front desk. Can you both put in the record what changes you
have seen? Have you seen any reason why you should not have
gone into Federal funding?
Ms. Benjamin. There is absolutely no reason why we
shouldn't have gone--no, it has supplemented our services
tremendously to have----
Mr. Bilirakis. You haven't seen any change in terms of the
intent in terms of how you wanted to serve the public?
Ms. Benjamin. Not a negative intent, but a more positive
intent.
Mr. Bilirakis. Mr. Brewton, of course, did speak very
powerfully about the positive----
Mr. Brewton. Same answer. It has actually, I think, helped
us create stronger commitments, and I would also argue that
when it comes to cumbersome regulations and paperwork, compared
to managed care, you guys are amateurs.
Mr. Bilirakis. We have heard that 2 or 3 times over the
years.
Ms. Benjamin. I would also like to say that initially when
the clinic started with volunteer staff, it really started to
address the huge needs of people with children with ear
infections and things like that, that acutely needed attention.
And after Section 330 funding, the whole impetus of the center
really changed toward preventive health care, and it has
continued on in those directions, and that is how we eliminate
disparities.
Mr. Bilirakis. That is what we want, of course.
Mr. Brewton. 330 required us to form a Quality Assurance
Committee, and as a result of that committee we are taking the
individual observations of practitioners and building them into
systems that more effectively deal with all our patients, not
just hit-or-miss.
Mr. Bilirakis. I would like to spend a lot more time on
that particular subject, but my time is long over. Mr. Brown.
Mr. Brown. Thank you, Mr. Chairman. Mr. Singer, than you
especially for your testimony, it was just terrific, one of the
best I have heard here in a long time, so thank you for that,
and thank you for being with us, to all of you.
I don't normally do commercials like this, but I listened
to your comments about the homeless, about housing issues,
about health care issues, and I recently read a book by Barbara
Aronwright called ``Nickel and Dime,'' which I suggest to
everyone in this room. I have not financial interest in this,
but suggest everyone in this room that they read. And she talks
about the working poor. She actually took jobs several places
around the country, very low-paying, $6-an-hour, $7-an-hour
jobs, talked about the working poor, and especially talked
about housing and how to rent an apartment, you need the
security deposit. You often need the first and last months'
rent, so people making $6 and $7 an hour in maid service, or
Wal-Mart or in a nursing home, end up staying at terrible
hotels, paying $25 a night, end up--don't have refrigerators
and stoves, so it cost more to be poor, in many ways, because
they can't cook a batch of lentil soup and freeze and eat it
all week, they have to go to convenience stores and grocery
stores, and then their food spoils if they try to keep it, and
whatever. And she talked about one young man who got hurt at
work, he had an infection in his foot. He couldn't afford the
antibiotic. He didn't show up at work for 3 days, and he was
fired as a result. And when you talk about--you know, we talk
about health disparities in this country, we are 5 percent of
the world's population. We consume 45 percent of health care
expenditures in this world, yet we have so many people that
don't get the kind of care they should. We have the best health
care system in the world for the affluent, but for others we
often don't, unless they are lucky enough to get service from
Mr. Brewton or many of the rest of you, but we are not reaching
them. We should be ashamed of ourselves, and I don't see the
commitment in this Congress and this administration to move
forward with the way--or, for that matter, most of the last
several years, to move forward the way that we should, to not
just eliminate the health care disparities, but the income
disparities that so much go with it. And that being said, thank
you again for joining us.
Dr. Duke, I would like to ask you a question. I also want
to apologize, I have a markup in another committee, and if I am
moving in and out, it is not for a lack of interest, it is
because I have to go vote occasionally.
Dr. Duke, I was pleased to hear you affirm your agency's
commitment to the mission. I have heard, however, that you
intend to abandon the 100 percent/zero campaign. I note on your
Website the campaign name is now called ``Improving expanding
access.'' So, a copy of a memo from Laura Perki, with the
Bureau of Primary Health Care, dated July 6, ``Effective
immediately, all publications with the phrase `100 percent
access, zero health disparities,' should be changed to
`improving and expanding access to health care for all
Americans nationwide' ''.
In Ohio, the infant mortality rate for African-Americans is
2.5 times that of whites, 10 percent higher than the national
average for African-American infants, and 3.5 times higher than
the Healthy People 2010 goal. Ohio, as many other States, to be
sure, has a long way to go to reach the Healthy People 2010
goal, and I am concerned about your mission statement change.
What is HRSA's mission? Why the reason, are we just lowering
our expectations, is that what we as a government, we as a
society, this administration wants to do? Explain it to me, if
you would.
Ms. Duke. This morning, I represent President Bush and
Secretary Thompson, who are both committed to enhancing access
to quality care for all Americans and eliminating disparities
in health care, and I spoke in a cleared statement that said
that HRSA's mission is to work toward 100 percent access to
health care and zero disparities, and we are committed to
working toward that.
As a manager, one of my concerns is to set realistic goals
in the short-term that we can bite off, chew, and accomplish.
And so as we go through each year, our goal will be to
accomplish meaningful progress toward--as the statement says,
working toward 100 percent access and zero disparities. Our
goal this year is to expand our health care network across the
country, and we have committed to a budget in 2002 that would
allow us to increase and expand access points by 200 and to
increase care for 1 million people in the year 2002. That is a
down payment on a 5-year program of 5 years of expansion of our
health centers that will increase those health centers by 1200
sites and eventually double the number of patients served. We
are committed to working toward quality health care for all
Americans.
Mr. Brown. Mr. Chairman, if I could do one more question. I
hear you, but I also see sort of the direction that we may be
moving, and I look at the Title 7 program, and my understanding
is the administration is eliminating all funding for Title 7.
That includes student loans, it includes health professions,
training for diversity, it includes health professions, public
health workforce, also opposing funding for the Community
Access Programs. Were these decisions--was this downgrading of
goals--lowering of expectations might be a less judgmental way
to say it--lowering of expectations and eliminating the funding
for these programs, are these decisions made by the President,
or by Secretary Thompson, or by Dr. Duke, or who makes these
decisions--or OMB--to eliminate the funding for those to send a
message that we are not going to fund student loans, help
professions train for diversity, and these very important
Community Access Programs? Tell me that.
Mr. Bilirakis. A very brief response, please, Dr. Duke,
much briefer than the question.
Mr. Brown. Much briefer than the question. That is why the
chairman and I get along so well.
Ms. Duke. The administration's position is that they have
made decisions oriented toward the best use of available
funding. In the area of the Community Access Program, hard
choices were made to target funding for direct care of patients
and, thus, the goal of increasing by 1 million people in 2002
the number of patients who could be served from our Community
Health Center network. And that is as a commitment, a 5-year
commitment to expanding that available health care so that
eventually over 20 million people will have direct health care
as a result of the decisions reached.
The decision of the administration was that to build
another funding stream in the CAP program was not the most
efficient or effective way to bring about the improvement of
health care for the most vulnerable in our Nation.
Mr. Bilirakis. I hate to--we have this vote coming up and
it would be great if we could finish up with this panel and let
them go home, except for possibly Dr. Duke or one of your
representatives. We always like to have someone from the
administration sort of staying for the next panel so they can
sort of take notes and learn from it. If you would do that, I
would appreciate it.
Ms. Duke. I would be delighted.
Mr. Bilirakis. Mr. Pitts, to inquire.
Mr. Pitts. Thank you, Mr. Chairman. I apologize, I had to
step out. I am in a markup in another committee, and I missed
Mr. Hall's testimony, but I would like to start with you, Mr.
Hall.
Is it a requirement that someone who seeks care at an IHS
facility be an enrolled member of a federally recognized tribe
and, if so, don't the facilities, in effect, discriminate on
the basis of race?
Mr. Hall. It is true for the IHS facilities, that you have
to be an enrolled member of federally recognized tribes, but
the urban Indian clinics, because most of us are federally
qualified health clinics, that requirement is not on us. So we
see non-Indians in the urban clinic.
Mr. Pitts. How many facilities in the Indian Health
Services receive Section 330 funding?
Mr. Hall. I don't think any of them receive them direct.
Two or three of our urban clinics do have a relationship with
some of the 330 clinics in their area.
Mr. Pitts. Do you know, in your home State of South Dakota,
how many clinics receive Section 330 funding?
Mr. Hall. I believe there are 21 clinics in South Dakota,
under seven organizations that receive 330 money. Sioux Falls
has one 330 clinic, Rapid City has two, one a medical service,
one a homeless, and then the remainder of the 330 clinics are
all very rural clinics.
Mr. Pitts. Thank you. Mr. Brewton, some of the members and
staff are concerned that someone with a religious faith or
faith-based community service would somehow turn away certain
patients or refuse medical care. Can you expand a little bit on
your written testimony so that once and for all you can
disabuse any of us from any misapprehension we may have on
that?
Mr. Brewton. The best way to do that would be to invite you
to the office and to meet the practitioners who carry out the
mission, but again it is our faith perspective that says all
people are created in God's image, and so there are no barriers
to walking through the door. There is no question about what
kind of insurance you have when you first come in, nor is there
a question about are you religious or do you want to pray? Our
concern is what is your need and how can we meet that need? So
it is hard to prove a negative, but discrimination and
exclusion are just the polar opposites of what we are about.
Mr. Pitts. Thank you. Ms. Benjamin, thank you for coming
today, and I wanted to ask you to expand a little bit on
something you mentioned in the testimony, and that is your
efforts to offer service at satellite health services, and how
you work with other institutions. I think you mentioned a
Baptist Church. Can you expand on your cooperation with other
organizations in providing service?
Ms. Benjamin. Sure. In particular, we work very closely
with faith-based organizations in the community. Several of
them are represented on our board. Some of the larger
organizations are represented on our board. And some of the
discussions at the board level about accessing services have
reflected the fact that there are a lot of people in our
community who are walking around with diabetes and hypertension
that is undiagnosed, and the only way that we can probably
reach these people is to go to where they are, and they won't
be coming to the health center because they don't even know
that they need the services. So we have talked to several of
the churches about opening clinics at their churches, and one
in particular will be opening next year. So we are really
excited about being able to reach those people who are walking
around undiagnosed right now.
Mr. Pitts. In reauthorizing Community Health Centers, are
there steps that Congress can take to improve coordination
between community health centers and hospitals or between
community health centers themselves?
Ms. Benjamin. The Community Access Program will be
extremely instrumental for us. We have already, in Lancaster,
developed an infrastructure--actually all the health care
providers, including the hospitals and private physicians, the
Health Care for the Homeless group, we are all working together
and we have built an infrastructure, but we don't have funding
to staff permanently, on a daily basis, anyone to really carry
out the work, although that is very important. And, really, I
guess, National Health Service Corps will certainly help as
well.
Mr. Pitts. Thank you very much. Thank you, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman. Ms. Capps. Let us
stay within the 5 minutes, please, so we can finish up. I
wasn't talking to you, specifically.
Ms. Capps. That is my goal because I have two different
kinds of questions, so I am going to try to be brief on this.
One of the witnesses--the trouble with these panels is that
they are related, though different topics, so if I could segue
into the next panel, one of the witnesses, Dr. Russell Roberts,
argues--he is from Washington University. He argues that
government funding designed to encourage the development of
health care professionals is where I am headed, and his written
statement indicates that the market would provide the optimum
mix of doctors, nurses and other health care professionals.
First, I would like to hear what the administration thinks
of the notion of removing all government funding of health
professional education and training, and then perhaps one
panel, maybe Dr. Wiltz, just to keep it to the time, and then I
want to switch to flexibility in funding of NAHC, too.
Ms. Duke. Thank you very much. The market may produce an
aggregate number over the long-run, but then Cain said in the
long-run, you are all dead, so I will pick up that theme. Our
concern as a Nation has to be the way we produce a full-fledged
range of health care providers, including the other health
professions that don't always get mentioned, so we need to look
at all the other health care providers in addition to the
shortage areas. And shortage areas are also interesting
phenomenon as well because you may have in aggregate enough
providers, but they may not be geographically distributed,
which is one very big problem.
And a second problem is the relative diversity of the
provider population to the population at-large. And so while
the concept of the market over the long-run might be
sufficient, I think when you step back and look at the
diversity of the professions themselves, the diversity of the
population and the whole issue of geographic distribution, I
think there is a role for government. Further, there is a role
for government in actually understanding what those
availabilities are, and that is one of the roles of government,
to provide the data by which we know what professions are in
emerging shortages so that we have an opportunity as a society
to make decisions about how we will handle those.
Ms. Capps. Thank you.
Mr. Wiltz. I can tell you who I am and where I am because
of the National Health Service Corps. I was just sharing with
Dr. Duke, I found a periodical produced in 1972 which was a
period when I was a medical student. It was because of National
Health Service Corps and Scholarship Program that I was able to
attend Tulane University and serve the people that I have
served for the last 19 years.
If market forces would have solved this problem--we use the
Star Trek motto about the ``boldly go where no one else will
go''--if that were true, then profit-margin driven practices
would have gone to these areas. I do believe that government
plays a role, a vital role. We believe in population parity,
that our workforce should reflect what we are represented in
this Nation, and we have always been committed to that.
I would just like to summarize and say that we have built
them, they have come, and once they come there, we need the
people to serve them, and we need the people that can serve
them that are culturally competent and qualified to do so.
In addressing ours, I think the mantra to our State
Legislature, local problems deserve local solutions by local
people, and we need to be at the foremost front of that
argument by serving the communities that we represent, putting
the patient first, using a team approach not with a Doc at the
top, faced in the center, building the circle with all the
providers and all the wraparound services.
Ms. Capps. Thank you. And you provide a segue for my next
question which is more specific. Perhaps, Dr. Duke, to the goal
of flexibility, more flexibility in the NHSC, and this is about
nurse-practitioners. That is what you were talking about
perhaps in a way, Dr. Wiltz.
Before 1990, nurse-practitioners, midwives, physician's
assistants, got very little support from the NHSC. If there is
flexibility in the set-asides, if there is a waiver again, what
do anticipate will happen? What can we do to prevent shortfalls
in this area?
Ms. Duke. The area of shortfalls in nursing, pharmacists
and other health providers is a concern. We are trying to
document what those shortfalls are. And the Secretary has been
very concerned about, for example, the emerging nursing
shortage that we face as a Nation. He visited us for a week and
spent time with us looking at various problems that we are
grappling with every day. And he met for over an hour with a
group of representatives of the nursing profession, for
example, to look at what are the problems in the different
phases of nursing education, nursing recruitment, nursing
training, and he is very committed.
We have in our 2002 budget money for increasing the
diversity of the nursing workforce and increasing the basic
nurse training program. And also, as a result of the
Secretary's visit with us, in which we spent a good deal of
time on the subject of the emerging nursing shortage, the
Secretary went back to the Department and basically used his
transfer authority to give us an additional $5 million this
year, in 2001, for us to make available nurse education loan
repayment opportunities which we will use this year to put 400
new nurses in underserved areas, as a result of what he heard
about this shortage. So, it is an area we are very concerned
about.
Mr. Bilirakis. Thank you.
Ms. Capps. If I could get one more yes or no. The
flexibility won't eliminate the standards for nurse-
practitioners?
Ms. Duke. I am not sure I understood that question, I am
sorry.
Ms. Capps. The set-aside.
Ms. Duke. We have not put in any discussion of set-asides,
so I really am not in a position to talk about that, but I will
try to get back to you on that.
Mr. Bilirakis. We will have written questions, as we
customarily do, after the hearing, and we would expect that you
would be willing, within just a matter of a few days, respond
to those. Possibly, Ms. Capps, you can broach it that way. Mr.
Bryant. And we do have three votes, so right after Mr. Bryant
we are gone for a little while.
Mr. Bryant. Thank you, Mr. Chairman. Mr. Brewton, I don't
know what your political background is, but I want you running
my next campaign. Put that on your calendar.
Mr. Bilirakis. He is a Pittsburgher, I can probably guess
his affiliation. I am sorry, go ahead.
Mr. Bryant. One of my housemates is also from Pittsburgh
and has another persuasion, too.
Ms. Benjamin, you mentioned in either your oral testimony
or your written testimony that a majority of the Hispanic
residents that you serve have little or no English proficiency,
and I don't think there is any question that that would impact
the patient-doctor communication relationship.
My question is, what challenges, very quickly, do you face
in hiring bilingual, bicultural health professionals, and do
you have any recommendations for us?
Ms. Benjamin. Our largest challenge is the financial
challenge, and additional funding will remedy that. It is very
difficult to hire bilingual and bicultural providers,
especially physicians and physician assistants and nurse-
practitioners, actually all of them, with the amount of funding
that we can afford. And actually bilingual and bicultural
African-American providers generally cost us about 30 percent
more than non-African-American. So that is just the economy
that we have right now, and the high demand that there is for
bilingual and bicultural people.
Mr. Bryant. Thank you. Dr. Duke, several questions and, as
the chairman has indicated, you can respond in writing. I will
read through a couple of these very quickly. Is there evidence
that employers stop insuring low-wage workers once a community
health center moves into the area? And if that is the case,
what would be your suggestion on how we could address that
issue here in Congress? You could give us your answer in
writing on that one, as well as the extent to which you are
able to determine, what amount of fraud is taking place in that
area of community health center programs?
And let me move on to a couple of quick comments and,
finally, a question or two for you to answer because I am
concerned about some of the numbers. Generally, as I
understand, two programs involved here in the NHSC regarding
payment for education, one is a scholarship which obviously you
don't pay back, the other is I guess a loan type which is
repaid, and statistically I am seeing numbers that show
actually more people who are recipients of the loan repayment
stay in the area longer after their commitment expires than
people who are on scholarships, and it is something like 79.2
percent versus 61.9 percent overstay, which is what we want
them to do, their commitment. Do you have any quick answer on
that because I have another one I want to ask you, so I don't
want to take the rest of my time on that one, but do you have a
quick response to that?
Ms. Duke. The concern we have is to increase our retention
rate for both our scholars and our loan-repayers, and I will
get you more information on the difference in that ratio in
writing.
Mr. Bryant. Would you also address whether--I assume it is,
but I want to confirm it--the financial status for these
applicants for the loan program or the scholarship, if their
financial status plays a role in what they get, and I am
assuming it does, but I need to know that also.
One final question--again, on the same program, NHSC
program--our numbers show that 22 percent of the shortage
areas, when they receive doctors in this situation, actually
are enough to lift them over into another category of provider-
to-population ratio, while 65 percent of the areas, the
shortage areas, never receive any providers at all and, to me,
that shows that there is not maybe enough thought being given
to where people are assigned--when you are sending them to
areas that are already marginal almost to the point where they
don't need these types of doctors, they are not underseved
areas once they get there--to the point where you have got 65
percent of the shortage areas not receiving any doctors,
clearly underserved areas that need those. Again, if you could
address that with any comments you have now, or--since the
caution light is on and the red light is about to come on, it
would be better if you address that in your written, late-filed
testimony.
Ms. Duke. I will provide the information in writing, and
this is an area of our concern and we are looking at the
shortage designation definition.
Mr. Bryant. Thank you.
Mr. Bilirakis. I thank the gentleman, and I thank the
panel. You really have been a terrific panel, and we have
learned an awful lot from you. We have a second panel coming
up.
I am going to go ahead and recess until 12:45, give the
second panel a chance to grab a bite to eat, and the rest of
us, too. Thank you again so very much.
[Recess]
Mr. Bilirakis. The hearing will come to order. The second
panel consists of Janet Heinrich, of the General Accounting
Office; Linda O'Leary, I have already mentioned her, she is
with the Federation of American Health Systems, the Chief
Nursing Officer at the Regional Medical Center in Bayonet
Point, Florida, part of my congressional district--welcome,
Linda. Mr. Brown would like to introduce the next witness.
Mr. Brown. I am glad to say Diana Baker works as a urology/
gynecology nurse at the Cleveland Clinics, from Newton Falls,
Ohio, which, if you check the address, is the only community in
the whole country that has a single digit zip code, 44444. So,
if you learn nothing else today, you know that. Welcome, Ms.
Baker.
Mr. Bilirakis. I probably should not have done that.
Mr. Brown. A little local color, Mr. Chairman.
Mr. Bilirakis. Dr. Cory Roberts, Director of Anatomic
Pathology, St. Paul Medical Center, Department of Pathology,
Dallas, Texas; Ms. Adele Pietrantoni, a Trustee at the American
Pharmaceutical Association, and Dr. Russell Roberts, a John M.
Olin Senior Fellow at the Weidenbaum Center on the Economy,
Government and Public Policy, Washington University, St. Louis,
Missouri. Welcome, Doctor.
As per usual, your written statement is a part of the
record, and we would appreciate it if you would supplement, or
whatever the case might be. I will set the clock at 5 minutes.
I would appreciate if you would try to keep your remarks within
that 5 minutes but, obviously, if you go over slightly, I won't
cut you off, but we do want to try to finish up. We have the
energy bill on the floor, and there is generally an awful lot
of amendments to that, so we might have some interruptions, but
hopefully not. Ms. Heinrich, please proceed.
STATEMENTS OF JANET HEINRICH, DIRECTOR, HEALTH CARE-PUBLIC
HEALTH ISSUES, U.S. GENERAL ACCOUNTING OFFICE; LINDA O'LEARY,
FEDERATION OF AMERICAN HEALTH SYSTEMS, CHIEF NURSING OFFICER,
REGIONAL MEDICAL CENTER, BAYONET POINT, HUDSON, FLORIDA; DIANA
BAKER; CORY ROBERTS, DIRECTOR OF ANATOMIC PATHOLOGY, ST. PAUL
MEDICAL CENTER, DEPARTMENT OF PATHOLOGY, DALLAS, TEXAS; ADELE
PIETRANTONI, TRUSTEE, AMERICAN PHARMACEUTICAL ASSOCIATION; AND
RUSSELL ROBERTS, JOHN M. OLIN SENIOR FELLOW, WEIDENBAUM CENTER
ON THE ECONOMY, GOVERNMENT AND PUBLIC POLICY, WASHINGTON
UNIVERSITY, ST. LOUIS, MISSOURI
Mr. Chairman and members of the subcommittee, we are
pleased to be here today as you discuss issues related to the
health care workforce and the reauthorization of the Federal
safety net programs to improve access to care. My testimony
will discuss growing concern about the adequacy of the health
care workforce and emerging shortages especially among nurses
and nurse aides, and focus on some lessons learned from the
experience of the National Health Service Corps in addressing
the maldistribution of available health care professionals.
While current data on workforce supply and demand are not
adequate to determine the magnitude of any imbalance, available
evidence suggests emerging shortages for the largest categories
of health care workers, nurses and nurse aides. Both the demand
for and supply of health workers are influenced by many
factors. For example, with respect to registered nurses, demand
not only depends on the care needs of the population, but also
on how providers--hospitals, nursing homes, and others--decide
to use nurses in delivering care.
In the past, providers have changed staffing patterns,
employing fewer or more nurses relative to other workers at
various times. Recent studies suggest that hospitals and other
providers in many areas of the country are experiencing greater
difficulty in recruiting health care workers. For example, a
survey in Maryland reported a statewide average RN vacancy rate
for hospitals of 14.7 percent in 2000, up from 3.3 percent in
1997. The same survey reported a 12.4 percent vacancy rate for
pharmacists, and a 13.6 percent vacancy rate for laboratory
technicians. Many States are also reporting that nurse aide
recruitment and retention is a major workforce issue,
especially in nursing homes and home health care.
Job dissatisfaction has been identified as a major factor
contributing to the current problems in recruiting and
retaining nurses and nurse aides. Among nurses, inadequate
staff, heavy workloads, and the increased use of overtime are
frequently cited as key concerns. Low wages, few benefits, and
difficult working conditions are linked to high turnover among
nurse aides.
The demand in health care is expected to grow dramatically
in the coming years as the population continues to age. The
Bureau of Labor Statistics predicts that demand for laboratory
technologists, RNs, and nurse aides will grow by approximately
20 percent by 2008, compared to 14 percent in all other
occupations. The growth for personal and home health aides is
predicted to grow by more than 58 percent. During this time,
the number of women between 25 and 54 years of age, who have
traditionally formed the core of the nursing workforce, is
expected to remain relatively unchanged.
In addition to concerns about the overall supply of health
care professionals, the distribution of available workers
across geographic areas is an ongoing public health concern.
The National Health Service Corps is one safety net program
that directly places primary care professionals in these
medically needy areas. Some have proposed expanding the Corps
or developing similar programs to address additional health
care disciplines, such as Registered Nurses, pharmacists, and
medical laboratory personnel.
While the Corps has had some success in addressing the
geographic distribution of physicians and other providers, our
past work has identified several lessons to consider in
developing national workforce policies. These include how the
Corps identifies and measures the need for health care workers,
how the Corps placements are coordinated with other programs
and with its own placements, and what incentives, scholarships
or loan repayments, are a better approach to attract
practitioners to targeted geographic areas.
We have identified numerous problems with the way that HHS
decides whether an area is a health professional shortage area,
a HPSA, a designation required for the Corps placement. The
current approach does not count some practitioners already
working in the area, such as nurse practitioners or current
Corps members. The Corps also needs to coordinate its placement
with other efforts to attract physicians to needy areas, such
as the J-1 visa waiver program for non-U.S. citizens who have
just completed their graduate medical education in the United
States.
Another issue is how to most effectively attract health
care professionals to the Corps. We found that the loan
repayment program costs less per year of service, that loan
repayment recipients are more likely to complete their service
obligations, and that loan repayment recipients are more likely
to continue practicing in the underserved community after
completing their obligation. Therefore, it may be effective to
target a larger portion of funds to loan repayment instead of
scholarships.
In conclusion, providers' current difficulty recruiting and
retaining health care workers could worsen if demand increases
in the future. More detailed data are needed to delineate the
extent and nature of workforce shortages to assist in targeting
corrective efforts. Programs like the National Health Service
Corps can play a role in improving the distribution of health
care workers, however, it is important that we evaluate the
performance of this program adequately so that it is structured
to maximize impact.
Mr. Chairman, this concludes my prepared statement, and I
will, of course, be happy to answer questions.
[The prepared statement of Janet Heinrich follows:]
Prepared Statement of Janet Heinrich, Director, Health Care-Public
Health Issues, General Accounting Office
Mr. Chairman and Members of the Subcommittee: We are pleased to be
here today as you discuss issues related to the health care workforce
and the reauthorization of federal safety net programs to improve
access to care for medically underserved populations. As you know,
there is growing concern that many Americans will go without needed
health care services because worker shortages or geographic
maldistribution of certain types of health care professionals may
develop.
Changes in the U.S. health care system over the past two decades
have affected the environment in which a variety of health
professionals and paraprofessionals provide care. For example, while
hospitals traditionally were the primary providers of acute care,
advances in technology, along with cost controls, have shifted much
care from traditional inpatient settings to ambulatory or community-
based settings, nursing facilities, and home health care settings. In
addition, the transfer of less acute patients to nursing homes and
community-based-care settings created a broader range of health care
employment opportunities. These changes have led to concerns regarding
the adequacy of the health care workforce. And while the adequacy of
the health care workforce is an important issue nationwide, the
distribution of available health professionals is a particularly acute
issue in certain locations. These medically underserved areas, ranging
from isolated rural areas to inner cities, have problems attracting and
retaining health care professionals.
My testimony will discuss (1) growing concerns about the adequacy
of the health care workforce and emerging shortages in some fields,
particularly among nurses and nurse aides, and (2) the lessons learned
from the experience of one federal program--the Department of Health
and Human Services' (HHS) National Health Service Corps (NHSC)--in
addressing the maldistribution of health care professionals. My
comments are based on our previous work in these areas and limited
follow-up work we conducted to update the findings and recommendations
contained in earlier reports.<SUP>1</SUP>
---------------------------------------------------------------------------
\1\ See appendix I for a list of these reports.
---------------------------------------------------------------------------
In brief, while current data on supply and demand for many
categories of health workers are limited, available evidence suggests
emerging shortages in some fields, for example, among nurses and nurse
aides. Many providers are reporting rising vacancy and turnover rates
for these workers, contributing to growing concerns about recruiting
and retaining qualified health professionals. These concerns are likely
to increase in the future as demographic pressures associated with an
aging population are expected to both increase demand for health
services and limit the pool of available workers such as nurses and
nurse aides.
Regarding the experience of the NHSC, while the program has placed
thousands of health professionals in needy communities since its
establishment in 1970, our work has identified several areas for HHS
and the Congress to consider in discussing NHSC reauthorization. For
example, we found problems with HHS' system for identifying and
measuring the need for NHSC providers. In addition, the NHSC placement
process is not well coordinated with other efforts to place physicians
in underserved areas and does not assist as many needy areas as
possible. Finally, regarding the financing mechanism used to attract
health care professionals to the NHSC, our analysis found that
educational loan repayment is preferable over scholarships in most
situations.
health workforce issues are a growing concern
Recruitment and retention of adequate numbers of qualified workers
are major concerns for many health care providers today. While current
data on supply and demand for many categories of health workers are
limited, available evidence suggests emerging shortages in some fields,
for example, among nurses and nurse aides. Many providers are reporting
rising vacancy and turnover rates for these worker categories. In
addition, difficult working conditions and dissatisfaction with wages
have contributed to rising levels of dissatisfaction among many nurses
and nurse aides. These concerns are likely to increase in the future as
demographic pressures associated with an aging population are expected
to both increase demand for health services and limit the pool of
available workers such as nurses and nurse aides. As the baby boom
generation ages, the population of persons age 65 and older is expected
to double between 2000 and 2030, while the number of women age 25 to
54, who have traditionally formed the core of the nursing workforce,
will remain virtually unchanged. As a result, the nation may face a
caregiver shortage of different dimensions from those of the past.
Evidence Suggests Emerging Health Worker Shortages in Some Fields
Nurses and nurse aides are by far the two largest categories of
health care workers, followed by physicians and
pharmacists.<SUP>2</SUP> While current workforce data are not adequate
to determine the magnitude of any imbalance between supply and demand
with any degree of precision, evidence suggests emerging shortages of
nurses and nurse aides to fill vacant positions in hospitals, nursing
homes, and other health care settings. Hospitals and other providers
throughout the country have reported increasing difficulty in
recruiting health care workers, with national vacancy rates in
hospitals as high as 21 percent for pharmacists in 2001. Rising
turnover rates in some fields such as nursing and pharmacy are another
challenge facing providers and are suggestive of growing
dissatisfaction with wages, working environments, or both.
---------------------------------------------------------------------------
\2\ In 1999, there were approximately 2.2 million nurse aides, 2.2
million registered nurses, 688,000 licensed practical or vocational
nurses, 313,000 physicians, and 226,000 pharmacists employed in the
United States according to the Bureau of Labor Statistics.
---------------------------------------------------------------------------
Data on Health Workforce Supply and Demand Are Limited
There is no consensus on the optimal number and ratio of health
professionals necessary to meet the population's health care needs.
Both demand and supply of health workers are influenced by many
factors. For example, with respect to registered nurses (RN), demand
not only depends on the care needs of the population, but also on how
providers--hospitals, nursing homes, clinics, and others--decide to use
nurses in delivering care. Providers have changed staffing patterns in
the past, employing fewer or more nurses relative to other workers at
various times. National data are not adequate to describe the nature
and extent of nurse workforce shortages nor are data sufficiently
sensitive or current to allow a comparison of the adequacy of nurse
workforce size across states, specialties, or provider types.
With respect to pharmacists, there are also limited data available
for assessing the adequacy of supply, a situation that has led to
contradictory claims of a surplus of pharmacists a few years ago and a
shortage at the present time. While several factors point to growing
demand for pharmacy services such as the increasing number of
prescriptions being filled, a greater number of pharmacy sites, and
longer hours of operation, these pressures may be moderated by
expanding access to alternative dispensing models such as Internet and
mail-order delivery services.
Providers Report High Vacancy Rates for Many Health Care Workers
Recent studies suggest that hospitals and other health care
providers in many areas of the country are experiencing increasing
difficulty recruiting health care workers.<SUP>3</SUP> A recent 2001
national survey by the American Hospital Association reported an 11
percent vacancy rate for RNs, 18 percent for radiology technicians, and
21 percent for pharmacists.<SUP>4</SUP> Half of all hospitals reported
more difficulty in recruiting pharmacists than in the previous year,
and three-quarters reported greater difficulty in recruiting RNs. Urban
hospitals reported slightly more difficulty in recruiting RNs than
rural hospitals. However, rural hospitals reported higher vacancy rates
for several other types of employees. Rural hospitals reported a 29
percent vacancy rate for pharmacists and 21 percent for radiology
technologists compared to 15 percent and 16 percent respectively among
urban hospitals.
---------------------------------------------------------------------------
\3\ Caution must be used when comparing vacancy rates from
different studies. While nurse vacancy rates are typically the number
of budgeted full-time RN positions that are unfilled divided by the
total number of budgeted full-time RN positions, not all studies
identify the method used to calculate rates.
\4\ American Hospital Association, The Hospital Workforce Shortage:
Immediate and Future, (Washington, D.C.: AHA, 2001).
---------------------------------------------------------------------------
A recent survey in Maryland conducted by the Association of
Maryland Hospitals and Health Systems reported a statewide average RN
vacancy rate for hospitals of 14.7 percent in 2000, up from 3.3 percent
in 1997.<SUP>5</SUP> The Association reported that the last time
vacancy rates were at this level was during the late 1980s, during the
last reported nurse shortage. Also in 2000, Maryland hospitals reported
a 12.4 percent vacancy rate for pharmacists, a 13.6 percent rate for
laboratory technicians, and 21.0 percent for nuclear medicine
technologists. These same hospitals reported taking 60 days to fill a
vacant RN position in 2000 and 54 days to fill a pharmacy vacancy in
1999.
---------------------------------------------------------------------------
\5\ Association of Maryland Hospitals & Health Systems, MHA
Hospital Personnel Survey 2000, (Elkridge, MD: MHA, 2001).
---------------------------------------------------------------------------
Several recent analyses illustrate concerns over the supply of
nurse aides. In a 2000 study of the nurse aide workforce in
Pennsylvania, staff shortages were reported by three-fourths of nursing
homes and more than half of all home health care agencies.<SUP>6</SUP>
Over half (53 percent) of private nursing homes and 46 percent of
certified home health care agencies reported staff vacancy rates higher
than 10 percent. Nineteen percent of nursing homes and 25 percent of
home health care agencies reported vacancy rates exceeding 20 percent.
A recent survey of providers in Vermont found high vacancy rates for
nurse aides, particularly in hospitals and nursing homes; as of June
2000, the vacancy rate for nurse aides in nursing homes was 16 percent,
in hospitals 15 percent, and in home health care 8 percent. In a recent
survey of states, officials from 42 of the 48 states responding
reported that nurse aide recruitment and retention were currently major
workforce issues in their states.<SUP>7</SUP> More than two-thirds of
these states (30 of 42) reported that they were actively engaged in
efforts to address these issues.
---------------------------------------------------------------------------
\6\ Joel Leon, Jonas Marainen, and John Marcotte, Pennsylvania's
Frontline Workers in Long Term Care (Jenkintown, Pa.: Polisher Research
Institute at the Philadelphia Geriatric Center, 2001).
\7\ North Carolina Division of Facility Services, Comparing State
Efforts to Address the Recruitment and Retention of Nurse Aide and
Other Paraprofessional Aide Workers (Raleigh, N.C.: Sept. 1999).
---------------------------------------------------------------------------
High Rates of Turnover Experienced in Some Fields
Rising turnover rates in many fields are another challenge facing
providers and suggest growing dissatisfaction with wages, working
environments, or both. According to a recent national hospital survey,
rising rates of turnover have been experienced, particularly in nursing
and pharmacy departments.<SUP>8</SUP> Turnover among nursing staff rose
from 11.7 percent in 1998 to 26.2 percent in 2000. Among pharmacy
staff, turnover rose from 14.6 percent to 21.3 percent over the same
period. Nursing home and home health care industry surveys indicate
that nurse turnover is an issue for them as well.<SUP>9</SUP> In 1997,
an American Health Care Association (AHCA) survey of 13 nursing home
chains identified a 51-percent turnover rate for RNs and licensed
practical nurses (LPN).<SUP>10</SUP> A 2000 national survey of home
health care agencies reported a 21-percent turnover rate for
RNs.<SUP>11</SUP>
---------------------------------------------------------------------------
\8\ Hospital & Healthcare Compensation Service, Hospital Salary and
Benefits Report 2000-2001 (Oakland, N.J.: Hospital & Healthcare
Compensation Service, 2000).
\9\ As with vacancy rates, caution should be used when comparing
turnover rates from different studies. Nurse turnover rates are
typically the number of nurses that have left a facility divided by the
total number of nurse positions. However, there is no standard method
for calculating turnover, and methods used in different studies may
vary.
\10\ American Health Care Association, Facts and Trends 1999, The
Nursing Facility Sourcebook (Washington, D.C.: AHCA, 1999).
\11\ Hospital & Healthcare Compensation Service, Homecare Salary
and Benefits Report 2000-2001 (Oakland, N.J.: Hospital & Healthcare
Compensation Service, 2000).
---------------------------------------------------------------------------
Many providers also are reporting problems with retention of nurse
aide staff. Annual turnover rates among aides working in nursing homes
are reported to be from about 40 percent to more than 100 percent. In
1998, a survey sponsored by AHCA of 12 nursing home chains found 94-
percent turnover among nurse aides.<SUP>12</SUP> A more recent national
study of home health care agencies identified a 28 percent turnover
rate among aides in 2000, up from 19 percent in 1994.<SUP>13</SUP>
---------------------------------------------------------------------------
\12\ American Health Care Association, Staffing of Nursing Services
in Long Term Care: Present Issues and Prospects for the Future
(Washington, D.C.: AHCA, 2001).
\13\ Homecare Salary and Benefits Report, 2000-2001, 2000.
---------------------------------------------------------------------------
High rates of turnover may lead to higher provider costs and
quality of care problems. Direct provider costs of turnover include
recruitment, selection, and training of new staff, overtime, and use of
temporary agency staff to fill gaps. Indirect costs associated with
turnover include an initial reduction in the efficiency of new staff
and a decrease in nurse aide morale and group productivity. In nursing
homes, for example, high turnover can disrupt the continuity of patient
care--that is, aides may lack experience and knowledge of individual
residents or clients. When turnover leads to staff shortages, nursing
home residents may suffer harm because there remain fewer staff to care
for the same number of residents.
Working Conditions and Wages Contribute to Job Dissatisfaction Among
Nurses and Nurse Aides
Job dissatisfaction has been identified as a major factor
contributing to the current problems providers report in recruiting and
retaining nurses and nurse aides. Among nurses, inadequate staffing,
heavy workloads, and the increased use of overtime are frequently cited
as key areas of job dissatisfaction. A recent Federation of Nurses and
Health Professionals (FNHP) survey found that half of the currently
employed RNs surveyed had considered leaving the patient-care field for
reasons other than retirement over the past 2 years; of those who
considered leaving, 18 percent wanted higher wages, but 56 percent
wanted a less stressful and less physically demanding job.<SUP>14</SUP>
Other surveys indicate that while increased wages might encourage
nurses to stay at their jobs, money is not generally cited as the
primary reason for job dissatisfaction. The FNHP survey found that 55
percent of currently employed RNs were either just somewhat or not
satisfied with their facility's staffing levels, while 43 percent
indicated that increased staffing would do the most to improve their
jobs.
---------------------------------------------------------------------------
\14\ Federation of Nurses and Health Professionals, The Nurse
Shortage: Perspectives from Current Direct Care Nurses and Former
Direct Care Nurses (opinion research study conducted by Peter D. Hart
Research Associates)(Washington, D.C.: 2001).
---------------------------------------------------------------------------
For nurse aides, low wages, few benefits, and difficult working
conditions are linked to high turnover. Our analysis of national wage
and employment data from the Bureau of Labor Statistics (BLS) indicates
that, on average, nurse aides receive lower wages and have fewer
benefits than workers generally. In 1999, the national average hourly
wage for aides working in nursing homes was $8.29, compared to $9.22
for service workers and $15.29 for all workers. For aides working in
home health care agencies, the average hourly wage was $8.67, and for
aides working in hospitals, $8.94. Aides working in nursing homes and
home health care are more than twice as likely as other workers to be
receiving food stamps and Medicaid benefits, and they are much more
likely to lack health insurance. One-fourth of aides in nursing homes
and one-third of aides in home health care are uninsured compared to 16
percent of all workers. In addition, other studies have found that the
physical demands of nurse aide work and other aspects of the
environment contribute to retention problems. Nurse aide jobs are
physically demanding, often requiring moving patients in and out of
bed, long hours of standing and walking, and dealing with patients or
residents who may be disoriented or uncooperative.
Demand for Most Health Workers Will Continue to Grow While Demographic
Pressures May Limit Supply
Concern about emerging shortages may increase as the demand for
health care services is expected to grow dramatically with the
continued aging of the population. In most job categories, health care
employment is expected to grow much faster than overall employment,
which BLS projects will increase by 14.4 percent from 1998 to 2008. As
shown in Table 1, total employment for personal and home care aides is
expected to grow by 58 percent, with 567,000 new workers needed to meet
the increased demand and replace those who leave the field. Employment
of physical therapists is expected to grow by 34 percent, and
employment of RNs is projected to grow by almost 22 percent, with
794,000 new RNs expected to be needed by 2008.
Table 1: Projected Employment Growth for Selected Occupations, 1998-2008
----------------------------------------------------------------------------------------------------------------
Total projected
1998 Percent growth job openings,
Occupation employment (in in employment 1998-2008 (in
thousands) 1998-2008 thousands) \1\
----------------------------------------------------------------------------------------------------------------
All occupations.............................................. 140,514 14.4 54,622
Physicians................................................... 577 21.2 212
Dentists..................................................... 160 3.1 38
Registered nurses............................................ 2,079 21.7 794
Pharmacists.................................................. 185 7.3 64
Physical therapists.......................................... 120 34.0 59
Clinical laboratory technicians and technologists............ 313 17.0 93
Radiology technicians and technologists...................... 162 20.1 55
Nurse aides, orderlies and attendants........................ 1,367 23.8 515
Personal and home health aides............................... 746 58.1 567
----------------------------------------------------------------------------------------------------------------
\1\ Total projected openings are due to both growth in demand and net replacements.
Source: U.S. Department of Labor, Bureau of Labor Statistics, ``Occupational Employment Projections to 2008,''
Monthly Labor Review, November 1999.
Demographic pressures will continue to exert significant pressure
on both the supply and demand for nurses and nurse aides. A more
serious shortage of nurses and nurse aides is expected in the future,
as pressures are exerted on both supply and demand. The future demand
for these workers is expected to increase dramatically when the baby
boomers reach their 60s, 70s, and beyond. Between 2000 and 2030, the
population age 65 years and older will double from 2000 to 2030. During
that same period the number of women age 25 and 54, who have
traditionally formed the core of the nurse and nurse aide workforce, is
expected to remain relatively unchanged. Unless more young people
choose to go into the nursing profession, the workforce will continue
to age. By 2010, approximately 40 percent of nurses will likely be
older than 50 years. By 2020, the total number of full time equivalent
RNs is projected to have fallen 20 percent below HRSA's projections of
the number of RNs that will be required to meet demand at that
time.<SUP>15</SUP>
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\15\ ``Peter I. Beurhaus, Douglas O. Staiger, and David I.
Auerbach, ``Implications of an Aging Registered Nurse Workforce,''
JAMA, Vol. 283, No. 22 (June 14, 2000).
---------------------------------------------------------------------------
nhsc illustrates challenges in addressing shortages of health
professionals in certain locations
In addition to concerns about the overall supply of health care
professionals, the distribution of available providers is an ongoing
public health concern. Many Americans live in areas--including isolated
rural areas or inner city neighborhoods--that lack a sufficient number
of health care providers. The National Health Service Corps (NHSC) is
one safety-net program that directly places primary care physicians and
other health professionals in these medically needy areas. The NHSC
offers scholarships and educational loan repayments for health care
professionals who, in turn, agree to serve in communities that have a
shortage of them. Since its establishment in 1970, the NHSC has placed
thousands of physicians, nurse practitioners, dentists, and other
health care providers in communities that report chronic shortages of
health professionals. At the end of fiscal year 2000, the NHSC had
2,376 providers serving in shortage areas. Since the NHSC was last
reauthorized in 1990, funding for its scholarship and loan repayment
programs has increased nearly 8-fold, from about $11 million in 1990 to
around $84 million in 2001.<SUP>16</SUP>
---------------------------------------------------------------------------
\16\ In addition to funding for scholarship and loan repayment
awards, the NHSC receives funding for support of its providers and
operations. In fiscal year 2001, this field budget was about $41
million.
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Some have proposed expanding the NHSC or developing similar
programs to include additional health care disciplines, such as nurses,
pharmacists, and medical laboratory personnel. In considering such
possibilities, HHS and the Congress may want to consider our work that
has identified several ways in which the NHSC could be improved. These
include how the NHSC identifies the need for providers and how it
measures that need, how the NHSC placements are coordinated with other
programs and with its own placements, and which financing mechanism--
scholarships or loan repayments--is a better approach to attract
providers to those areas.
Current System for Identifying Need is Inadequate
Over the past 6 years, we have identified numerous problems with
the way HHS decides whether an area is a health professional shortage
area (HPSA), a designation required for a NHSC placement.<SUP>17</SUP>
In addition to identifying problems with the timeliness and quality of
the data used, we found that HHS' current approach does not count some
providers already working in the shortage area.<SUP>18</SUP> For
example, it does not count nonphysicians providing primary care, such
as nurse practitioners, and it does not count NHSC providers already
practicing there. As a result, the current HPSA system tends to
overstate the need for more providers, leading us to question the
system's ability to assist HHS in identifying the universe of need and
in prioritizing areas.
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\17\ Only areas designated as a HPSA may apply for NHSC providers.
Currently, HHS considers a HPSA generally to be a location or area with
less than one primary care physician for every 3,500 persons. As of
June 30, 2001, HHS identified 2,968 primary care HPSAs. To eliminate
these HPSA designations, HHS identified a need of over 6,000 full-time
physicians. HHS has different criteria for dental and mental health
HPSAs.
\18\ See Health Care Shortage Areas: Designations Not a Useful Tool
for Directing Resources to the Underserved (GAO/HEHS-95-200, Sept. 8,
1995).
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Recognizing the flaws in the current system, HHS has been working
on ways to improve the designation of HPSAs, but the problems have not
yet been resolved. After studying the changes needed to improve the
HPSA system for nearly a decade, HHS published a proposed rule in the
Federal Register in September 1998. The proposed rule generated a large
volume of comments and a high level of concern about its potential
impact. In June 1999, HHS announced that it would conduct further
analyses before proceeding. HHS continues to work on a revised shortage
area designation methodology; however, as of July 2001, it did not have
a firm date for publishing the proposed new regulations.
The controversy surrounding proposed modifications to the HPSA
designation system may be due, in large part, to its use by other
programs. Originally, it was only used to identify an area as one that
could request a provider from the NHSC. Today many federal and state
programs--including efforts unaffiliated with HHS--use the HPSA
designation in considering program eligibility. These areas want to get
and retain the HPSA designation in order to be eligible for such other
programs as the Rural Health Clinic program or a 10 percent bonus on
Medicare payments for physicians and other providers.
Better Coordination of Placements With Waivers for J-1 Visa Physicians
Is Needed
The NHSC needs to coordinate its placements with other efforts to
attract physicians to needy areas. There are not enough providers to
fill all of the vacancies approved for NHSC providers. As a result,
underserved communities are frequently turning to another method of
obtaining physicians--attracting non-U.S. citizens who have just
completed their graduate medical education in the United
States.<SUP>19</SUP> These physicians generally enter the United States
under an exchange visitor program, and their visas, called J-1 visas,
require them to leave the country when their medical training is done.
However, the requirement to leave can be waived if a federal agency or
state requests it. A waiver is usually accompanied by a requirement
that the physician practice for a specified period in an underserved
area. In fiscal year 1999, nearly 40 states requested such waivers.
They are joined by several federal agencies--particularly the
Department of Agriculture, which wants physicians to practice in rural
areas, and the Appalachian Regional Commission, which wants to fill
physician needs in Appalachia.
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\19\ See Foreign Physicians: Exchange Visitor Program Becoming
Major Route to Practicing in U.S. Underserved Areas (GAO/HEHS-97-26,
Dec. 30, 1996).
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Waiver placements have become so numerous that they have
outnumbered the placements of NHSC physicians. In September 1999, over
2,000 physicians had waivers and were practicing in or contracted to
practice in underserved areas, compared with 1,356 NHSC physicians. In
1999, the number of waiver physicians was large enough to satisfy over
one-fourth of the physicians needed to eliminate HPSA designations
nationwide. Our follow-up work in 2001 with the federal agencies
requesting the waivers and 10 states indicates that these waivers are
still frequently used to attract physicians to underserved areas.
Although coordinating NHSC placements and waiver placements has the
obvious advantage of addressing the needs of as many underserved
locations as possible, this coordination has not occurred. In fact,
this sizeable domestic placement effort--using waiver physicians to
address medical underservice--is rudderless. Even among those states
and agencies using the waiver approach, no federal agency has
responsibility for ensuring that placement efforts are
coordinated.<SUP>20</SUP> The Administration has recently stated that
HHS will enhance coordination between the NHSC and the use of waiver
physicians; however HHS does not have a system to take waiver physician
placements into account in determining where to put NHSC physicians.
While some informal coordination may occur, it remains a fragmented
effort with no overall program accountability. As a result, some areas
have ended up with more than enough physicians to remove their shortage
designations, while needs in other areas have gone unfilled.
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\20\ Historically, HHS has not supported the waiver approach as a
sound way to address underservice needs in the United States. While HHS
is considering the issue, the agency still takes the position that
physicians should return home after completing their medical training
to make their knowledge and skills available to their home countries.
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As the Congress considers reauthorizing the NHSC, it also has the
opportunity to address these issues. We believe that the prospects for
coordination would be enhanced through congressional direction in two
areas. The first is whether waivers should be included as part of an
overall federal strategy for addressing underservice. This should
include determining the size of the waiver program and establishing how
it should be coordinated with other federal programs. The second--
applicable if the Congress decides that waivers should be a part of the
federal strategy--is designating leadership responsibility for managing
the use of waivers as a distinct program.
Better Placement Process is Needed
While congressional action could foster a coordinated federal
strategy for placement of J-1 waiver physicians, our work has also
shown that congressional action could help ensure that NHSC providers
assist as many needy areas as possible. We previously reported that at
least 22 percent of shortage areas receiving NHSC providers in 1993
received more NHSC providers than needed to lift their provider-to-
population ratio to the point at which their HPSA designation could be
removed, while 65 percent of shortage areas with NHSC-approved
vacancies did not receive any providers at all.<SUP>21</SUP> Of these
latter locations, 143 had unsuccessfully requested a NHSC provider for
3 years or more.<SUP>22</SUP> In response to our recommendations, the
NHSC has subsequently made improvements in its procedures and has
substantially cut the number of HPSAs not receiving providers. However,
these procedures still allow some HPSAs to receive more than enough
providers to remove their shortage designation while others go without.
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\21\ To calculate oversupply, we counted physicians as one full-
time provider and nonphysicians (nurse practitioners, nurse midwives,
or physician assistants) as one-half a full-time provider. If only
physician placements are counted, 6 percent of these shortage areas
would still be identified as oversupplied. We consider these estimates
of oversupply to be conservative because our analysis does not include
NHSC providers placed in prior years who were still in service during
vacancy year 1993.
\22\ See National Health Service Corps: Opportunities to Stretch
Scarce Dollars and Improve Provider Placement (GAO/HEHS-96-28, Nov. 24,
1995).
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NHSC officials have said that in making placements, they need to
weigh not only assisting as many shortage areas as possible, but also
factors--such as referral networks, office space, and salary and
benefit packages--that can affect the chance that a provider might stay
beyond the period of obligated service. Since the practice sites on the
NHSC vacancy list had to meet NHSC requirements, including requirements
for referral networks and salary and benefits packages, such factors
should not be an issue for those practice locations. And while we agree
that retention is a laudable goal, the impact of the NHSC's current
practice is unknown, since the NHSC does not routinely track how long
NHSC providers are retained at their sites after completing their
service obligations. The Congress may want to consider clarifying the
extent to which the program should try to meet the minimum needs of as
many shortage areas as possible, and the extent to which additional
placements should be allowed in an effort to encourage provider
retention.
Loan Repayment Is a Better Approach than Scholarships
Another issue that is fundamental to attracting health care
professionals to the NHSC is the allocation of funds between
scholarships and educational loan repayments. Under the NHSC
scholarship program, students are recruited before or during their
health professions training--generally several years before they begin
their service obligation. By contrast, under the NHSC loan repayment
program, providers are recruited at the time or after they complete
their training. The scholarship program provides a set amount of aid
per year while in school, while the loan repayment program repays a set
amount of student debt for each year of service provided. Under the
Public Health Service Act, at least 40 percent of the available funding
must be for scholarships.
We looked at which financing mechanism works better and found that,
for several reasons, the loan repayment program is the better approach
in most situations.<SUP>23</SUP>
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\23\ See GAO/HEHS-96-28.
<bullet> The loan repayment program costs less. On average, each year
of service by a physician under the scholarship program costs
the federal government over $43,000 compared with less than
$25,000 under loan repayment.<SUP>24</SUP> A major reason for
the difference is the time value of money. Because 7 or more
years can elapse between the time that a physician receives a
scholarship and the time that the physician begins to practice
in an underserved area, the federal government is making an
investment for a commitment for service in the future. In the
loan repayment program, however, the federal government does
not pay until after the service has begun. The difference in
average cost per year of service could increase in the future
as a result of a recent change in tax law.<SUP>25</SUP>
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\24\ Amounts are in 1999 dollars. This cost analysis is based on
new scholarship and new federal loan repayment awards made in fiscal
year 1999.
\25\ In analyzing the net cost differences, we took into account
the federal income tax liability associated with scholarship and loan
repayment awards. In essence, loan repayment awards are increased to
provide for the resulting increased federal tax liability; scholarship
awards are not. However, as a result of the Economic Growth and Tax
Relief Reconciliation Act of 2001 (P.L. 107-16, Sec. 413), beginning
January 1, 2002, scholarship payments of tuition, fees, and other
reasonable educational costs will not be subject to federal income tax.
As a result, the net cost to the federal government of a year of
service under the NHSC scholarship program will increase.
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<bullet> Loan repayment recipients are more likely to complete their
service obligations. This is not surprising when one considers
that scholarship recipients enter into their contracts up to 7
or more years before beginning their service obligation, during
which time their professional interests and personal
circumstances may change. Twelve percent of scholarship
recipients between 1980 and 1999 breached their contract to
serve, <SUP>26</SUP> compared to about 3 percent of loan
repayment recipients since that program began.
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\26\ This includes scholarship recipients who defaulted and paid
the default penalty, those who defaulted and subsequently completed or
are serving their obligation, and those who defaulted and have not
begun service or payback.
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<bullet> Loan repayment recipients are more likely to continue
practicing in the underserved community after completing their
obligation. How long providers remain at their sites after
fulfilling their obligation is not fully clear, because the
NHSC does not have a long-term tracking system in place.
However, we analyzed data for calendar years 1991 through 1993
and found that 48 percent of loan repayment recipients were
still at the same site 1 year after fulfilling their
obligation, compared to 27 percent for scholarship recipients.
Again, this is not surprising. Because loan repayment
recipients do not commit to service until after they have
completed training, they are more likely to know what they want
to do and where they want to live or practice at the time they
make the commitment.
These reasons support applying a higher percentage of NHSC funding
to loan repayment. The Congress may want to consider eliminating the
current requirement that scholarships receive at least 40 percent of
the funding. Besides being generally more cost-effective, the loan
repayment program allows the NHSC to respond more quickly to changing
needs. If demand suddenly increases for a certain type of health
professional, the NHSC can recruit graduates right away through loan
repayments. By contrast, giving a scholarship means waiting for years
for the person to graduate.
This is not to say that scholarships should be eliminated. One
reason to keep them is that they can potentially do a better job of
putting people in sites with the greatest need because scholarship
recipients have less latitude in where they can fulfill their service
obligation. However, our work indicates that this advantage has not
been realized in practice. For NHSC providers beginning practice in
1993-1994, we found no significant difference between scholarship and
loan payment recipients in the priority that NHSC assigned to their
service locations. This suggests that the scholarship program should be
tightened so that it focuses on those areas with critical needs that
cannot be met through loan repayment. In this regard, the Congress may
want to consider reducing the number of sites that scholarship
recipients can choose from, so that the focus of scholarships is
clearly on the neediest sites.<SUP>27</SUP> While placing greater
restrictions on service locations could potentially reduce interest in
the scholarship program, the program currently has more than six
applicants for every scholarship--suggesting that the interest level is
high enough to allow for some tightening in the program's conditions.
If that approach should fail, additional incentives to get providers to
the neediest areas might need to be explored.
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\27\ The law provides for three vacancies for each scholar in a
given discipline and specialty, up to a maximum of 500 vacancies. For
example, if there are 10 pediatricians available for service, the NHSC
would provide a list of 30 eligible vacancies for that group if there
were 500 or fewer vacancies in total.
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concluding observations
Providers' current difficulty recruiting and retaining health care
professionals such as nurses and others could worsen as demand for
these workers increases in the future. Current high levels of job
dissatisfaction among nurses and nurse aides may also play a crucial
role in determining the extent of current and future nursing shortages.
Efforts undertaken to improve the workplace environment may both reduce
the likelihood of nurses and nurse aides leaving the field and
encourage more young people to enter the nursing profession.
Nonetheless, demographic forces will continue to widen the gap between
the number of people needing care and the nursing staff available to
provide care. As a result, the nation will face a caregiver shortage of
different dimensions from shortages of the past. More detailed data are
needed, however, to delineate the extent and nature of nurse and nurse
aide shortages to assist in planning and targeting corrective efforts.
Regarding the NHSC, addressing needed program improvements would be
beneficial. In particular, better coordination of NHSC placements with
waivers for J-1 visa physicians could help more needy areas. In
addition, addressing shortfalls in HHS systems for identifying
underservice is long overdue. We believe HHS needs to gather more
consistent and reliable information on the changing needs for services
in underserved communities. Until then, determining whether federal
resources are appropriately targeted to communities of greatest need
and measuring their impact of these reasons will remain problematic.
Mr. Chairman, this concludes my prepared statement. I would be
pleased to respond to any questions you or members of the Subcommittee
may have.
gao contacts and acknowledgements
For further information regarding this testimony, please call Janet
Heinrich, Director, Health Care--Public Health Issues, at (202) 512-
7119 or Frank Pasquier, Assistant Director, Health Care, at (206) 287-
4861. Other individuals who made key contributions to this testimony
include Eric Anderson and Kim Yamane.
Appendix I--Related GAO Reports
Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors
(GAO-01-944, July 10, 2001)
Nursing Workforce: Multiple Factors Create Nurse Recruitment and
Retention Problems (GAO-01-912T, June 27, 2001)
Nursing Workforce: Recruitment and Retention of Nurses and Nurse
Aides Is a Growing Concern (GAO-01-750T, May 17, 2001)
Health Care Access: Programs for Underserved Populations Could Be
Improved (GAO/T-HEHS-00-81, Mar. 23, 2000)
Community Health Centers: Adapting to Changing Health Care
Environment Key to Continued Success (GAO/HEHS-00-39, Mar. 10, 2000)
Physician Shortage Areas: Medicare Incentive Payments Not an
Effective Approach to Improve Access (GAO/HEHS-99-36, Feb. 26, 1999)
Health Care Access: Opportunities to Target Programs and Improve
Accountability (GAO/T-HEHS-97-204, Sept. 11, 1997)
Foreign Physicians: Exchange Visitor Program Becoming Major Route
to Practicing in U.S. Underserved Areas (GAO/HEHS-97-26, Dec. 30, 1996)
National Health Service Corps: Opportunities to Stretch Scarce
Dollars and Improve Provider Placement (GAO/HEHS-96-28, Nov. 24, 1995)
Health Care Shortage Areas: Designations Not a Useful Tool for
Directing Resources to the Underserved (GAO/HEHS-95-200, Sept. 8, 1995)
Mr. Bilirakis. Thank you very much, ma'am.
Ms. O'Leary.
STATEMENT OF LINDA O'LEARY
Ms. O'Leary. Good afternoon, Mr. Chairman and members of
the committee. My name is Linda O'Leary. I am the Vice
President and Chief Nursing Officer at Regional Medical Center
Bayonet Point in Hudson, Florida. I am pleased to testify this
afternoon on behalf of the Federation of American Hospitals on
the critical issue of the growing health care workforce
shortage.
At Bayonet Point, we have a 290-bed acute care facility
that is part of a larger hospital system, HCA, which owns 200
hospitals across the country. As the CNO, I would like to
convey my personal experiences in maintaining an adequate
workforce as well as a snapshot of the shortage as a whole.
The shortages of nurses and other health care providers
within health care facilities is a growing problem across this
country. In some areas, the crisis is imminent; in others, it
has arrived.
According to a recent survey by the American Hospital
Association, hospitals have up to 168,000 open positions,
126,000 of which are Registered Nurses. The decline in new
nurse graduates in combination with the rapid aging of the
existing pool of nurses and the aging population paints a
picture of health care delivery in significant stress.
The Florida Hospital Association recently released their
nurse staffing report which details the extent of this
shortage. The study revealed an overall vacancy rate for RNs of
15.6 percent, and because of the shortage the survey found that
the use of temporary agencies was reported by 83 percent of the
hospitals surveyed.
At HCA, our company's contract labor costs have increased
an average of 28 percent over the last year, and the labor wage
costs have gone up 7 percent in the first 6 months of this year
alone. At my hospital, our current vacancy rate for RNs is 25
percent, which translates to about 80 open RN positions.
We also have a number of recruitment efforts underway. At
our hospital, we offer tuition reimbursement for all employees
who pursue health care careers. Bayonet Point and six other
hospitals in our area have a new partnership with Pasco-
Hernando Community College. We have agreed to fund additional
teachers in the nursing program, and each hospital has the
opportunity to provide scholarship money for up to 25 students
at a time. In return, each student agrees to work for us 2 to 3
years for return of the scholarship money. We currently have 16
students joining us in August.
Another outreach effort we have underway is educating
career counselors at the junior high school and high school
levels, about the field of nursing and the opportunities within
the health care field.
Beyond recruitment, we must also focus on nurse retention.
Bayonet Point has instituted bonus programs, and we often
modify work schedules to meet personal needs. One very
important component of retaining nurses is asking their
opinion. We seek out ways to involve nurses in care and
treatment options and we look for devices to reduce the
difficult physical demands of the profession.
Our nurses are dealing with an increased acuity level and
limited resources. My job as a CNO is to listen to my staff, to
understand their concerns, and to work in partnership with them
to resolve issues as quickly as possible. I also use every
opportunity to promote nursing as a very rewarding career.
Beyond what we are doing locally, we are also focusing
efforts on recruitment of nurses abroad. Dr. Frank M. Houser,
M.D., HCA's Senior Vice President and Medical Director, just
returned from travel to India in an effort to recruit nurses,
however, the opportunities for international recruitment are
extremely limited. Regular green card applicant nurses are
still coming into the United States, but at an extremely low
rate. The H-1C and H-1B programs are extremely limited.
We would like to work with Congress and the Department of
Labor to review and expand existing visa programs so the United
States is not at a competitive disadvantage in terms of
recruiting nurses from abroad.
The problems of the shortage are so vast and so complex
that we are looking to Congress and the administration for
help. Broadly, the Federation supports legislation that seeks
to improve recruitment, nursing faculty, and community
outreach, the development of the Nurse Service Corps, eliminate
regulatory burden, and reviewing and expanding the immigration
laws. Specifically, members of this committee have introduced
legislation that would attempt to increase the number of
workers entering the nursing workforce and provide
opportunities and incentives to alleviate the shortage. The
Nurse Reinvestment Act introduced by Representatives Capps and
Kelly, has many valuable ideas, however, as written, all
Federation members would be excluded, many of which serve rural
and underserved populations. We are working to amend the
legislation to ensure that their creative solutions to the
workforce crisis are helpful to all hospitals.
The promising piece of legislation introduced by members of
this committee in the Nurse of Tomorrow Act, introduced by
Representatives Engel and Bono, the Federation applauds the
bill's sponsors for including all facilities in this
legislation.
In conclusion, I have been a nurse for over 30 years and,
frankly, I cannot imagine doing anything else. Federation
members and all health care facilities are facing a workforce
crisis. Our hospitals are on the front lines of delivering
patient care, but our most precious resource, our workers, are
in very short supply. We look forward to working with you to
attempt to solve this complex and growing problem. I would be
happy to answer any questions at this time.
[The prepared statement of Linda O'Leary follows:]
Prepared Statement of Linda O'Leary, Vice President and Chief Nursing
Officer, Regional Medical Center Bayonet Point
Good morning Mr. Chairman and members of the Committee, my name is
Linda O'Leary and I am Vice President and Chief Nursing Officer at
Regional Medical Center Bayonet Point in Hudson Florida. I am pleased
to testify this morning on behalf of the Federation of American
Hospitals (FAH) on the critical issue of the growing healthcare
workforce shortage.
The Federation is the national trade association representing some
1,700 privately-owned and managed community hospitals and health
systems providing health care across the acute and post-acute spectrum.
Our member hospitals provide care for patients in both urban and rural
America.
At Bayonet Point, we have a 290 bed acute care facility that is
part of a larger hospital system owned by HCA, Inc. We have adopted a
range of activities in my hospital, and at the corporate level to
recruit and retain an adequate supply of RNs and other caregivers. As
the Chief Nursing Officer I would like to convey my personal
experiences in maintaining an adequate workforce at Bayonet Point, as
well as a snapshot of the shortage as a whole.
the problem
The issue of shortages of nurses and other health care providers,
and retention of them within healthcare facilities, is a growing
problem across the country. In some areas, the crisis is imminent, in
others--it has arrived. Nurses in specialty areas such as operating
room nurses, emergency room nurses and intensive care nurses are in
particularly short supply.
The Federation recently convened an ad hoc task force to assist in
gathering information regarding the depth and breath of the shortage
and to solicit its members' ideas and action plans to address the
shortage. The task force has members from all Federation companies and
is composed of professionals representing a range of specialties within
their corporations.
Essentially our member hospitals have told us that:
<bullet> The shortage is hitting hospitals across the country
geographically, in rural, urban and suburban settings;
<bullet> Worker shortages are primarily in the field of nursing
(especially those in the critical care areas), but also extend
to radiological technologists, operating room technologists,
and pharmacists, to name a few;
<bullet> Hospitals have undertaken a wide range of creative recruitment
and retention activities including mentoring programs, modified
work schedules, community outreach partnerships with vocational
schools, and nursing programs, providing sites for clinical
rotations, scholarship programs, subsidizing nursing faculty
salaries and web advertising;
<bullet> The issue of state licensure complicates the ability of
workers to practice across state lines;
<bullet> Hospitals are employing a range of approaches to counteract
the shortage, including signing and retention bonuses.
A new report by Fitch, IBCA, Duff & Phelps entitled ``Health Care
Staffing Shortage'' states ``The fundamental problem is the decreasing
relative supply of nurses in this country. As of March 2001, there were
2.7 million licensed registered nurses (RNs) in the U.S., with 2.2
million employed in nursing. ``Currently, 80%-85% of hospitals have
reported a nurse shortage, and nationwide there is a 10%-12% vacancy
rate of nurses in health care facilities.''
The American Hospital Association recently completed a survey of
more than 700 hospitals across the country. Their study revealed that
``Hospitals have up to 168,000 open positions--126,000 of those are for
registered nurses.'' Also, according to the survey, 21% of hospitals
have openings for pharmacists, while 18% had unfilled positions for
radiological technologists.
The problem will grow worse as the nursing population ages.
According to the Health Resources & Services Administration (HRSA) and
the American Organization of Nurse Executives (AONE), the average age
of nurses in the year 2000 was 48. (See attached chart #1). According
to the American Nurses Association (ANA) ``Approximately 50% of nurses
are entering their 50s, and many will leave the workforce within the
next 10 years. As of 1996, only 9% of nurses were under the age of
30.'' The shortage has attracted attention across the country as
hospitals report growing vacancies and their advocates in Washington
call for action. The Federation is certainly not alone in calling for
federal assistance in this area, the American Hospital Association, the
American Nurses Association and the American Medical Association have
all issued statements recognizing the extent of the problem.
The job of an RN has changed over the last twenty years. With a
higher proportion of patients with complex care needs and greater
acuity, there has been an increased demand for nurses with specialized
training. Many nurses entered the profession because of its nurturing
nature, patient stays are now shorter and more care is delivered on an
outpatient basis, thus limiting the nurse-patient relationship. Also,
the increased use of technology demands a different and more advanced
skill set. As you in Congress are well aware hospitals and their staff
spend countless hours dealing with burdensome regulatory requirements
and filling out paperwork. This takes nurses away from the bedside
where they belong. There has also been an expansion of care delivery
settings in which nurses can work, thereby spreading the existing
workforce more thinly. Hospitals are now competing with home health
agencies, health maintenance organizations, pharmaceutical companies,
and recruitment firms to hire nurses and other providers.
Of course, while the job of a nurse has evolved, so too has the
field of opportunity for women who traditionally filled these jobs.
Fewer and fewer young women are entering the nursing profession, and to
date there has been little success in reaching out to men and
minorities to join the profession. According to a study by Peter
Buerhaus, ``Policy Responses to an Aging Registered Nurse Workforce,''
women graduating from high school in the 1990s were 35 % less likely to
become RNs than women who graduated in the 1970's.
The decline in new nurse graduates in combination with the rapid
aging of the existing pool of nurses and the aging population paint a
picture of health care delivery in significant stress. The existing
workforce shortage is projected to get much worse. Predictions for
workforce employee vacancies are difficult to nail down, however, the
Bureau of Labor Statistics states that 450,000 additional registered
nurses will be needed to fill the present demand through the year 2008.
According the General Accounting Office congressional testimony before
the Senate Government Affairs Committee on June 27, 2001, ``. . .
Enrollments in registered nursing programs have declined over the last
5 years, shrinking the pool of new workers to replace those who are
leaving or retiring. The problem is expected to be more serious in the
future as the aging of the population substantially increases the
demand for nurses.''
The State of Florida
I would like to draw your attention to some specific examples
within the state of Florida in order to illustrate the depth and
breadth of the shortage. The Florida Hospital Association recently
released their annual nurse staffing report which details the extent of
the shortage in my state. Because of the shortage--the survey found
that the use of temporary agencies was reported by 83% of the hospitals
surveyed, and that 74% of those surveyed utilized nurse travelers and
73% used on-call staff. This is a growing phenomenon. The survey found
that many hospitals used financial incentives including sign-on bonuses
and seasonal bonuses. During the survey week of February 18th-24th of
this year, the survey found that 3,087 RN positions were vacant within
the hospitals surveyed. This represents a 15.6% RN vacancy rate in the
hospitals responding. (See attached chart #2.)
The problem is further detailed by studying the vacancy rates by RN
Specialty. (See attached chart #3) Not only are we experiencing RN
shortages in Florida at a rate of 15.6%, but hospitals are experiencing
a shortage of Pediatric Critical Care nurses at a rate of 17.1%, Adult
Critical Care nurses at 16.8%, and a shortage of Medical-Surgical
nurses at a rate of 17.2%. These vacancy rates reflect a dramatic
increase from rates just a year ago. The Pediatric Critical Care
vacancy rate increased by an alarming 10%.
Experts agree that hospitals are competing with other health care
providers for their workforce. In the state of Florida, the vast
majority of nurses are still employed in the hospital setting--over 59%
in the year 2000. The other practice settings are: 18% in the
community/home health arena, 10% in ambulatory care, 7% in nursing
homes, 2% in nursing education and 4% in some other category. (See
attached chart #4)
Bayonet Point
At my hospital, our current vacancy rate for RN's is between 25 and
27%, which translates into roughly 80 open RN positions. Currently, I
have 14 RN's in specific training courses for specialties such as
operating room and critical care nurses--that number would be double if
I could find more nurses to undergo this training.
We have a number of recruitment efforts underway. HCA offers
tuition reimbursement for all employees who pursue health care careers.
Bayonet Point and seven other hospitals in our area have a new
partnership with Pasco-Hernando Community College. We have agreed to
fund additional teachers in the nursing school and have purchased the
school a full-size mannequin as a teaching tool. In return, each
hospital has the opportunity to provide scholarship money for up to 25
students at a time. Each student agrees to work for us for 2 to 3 years
in return for the scholarship money--we have 16 students joining us in
August.
Another outreach effort we have underway is educating career
counselors at the junior high and high schools about the field of
nursing and opportunities and careers within the health care field
generally. We have found that many career counselors have little
information about the career paths available.
Beyond recruitment, we must also focus on nurse retention. Bayonet
Point has instituted bonus programs for staff to increase their working
hours and we often modify work schedules to meet personal needs. We
offer a variety of pay and incentive practices to meet the specific
individual needs of our workers. One very important component of
retaining nurses is asking their opinion. We seek out ways to involve
nurses in care and treatment options and look for devices to reduce the
difficult physical demands of the profession.
The issue we all face as nurses is that it is a physically
demanding profession that requires night and weekend work. Our nurses
are dealing with an increased acuity level, demanding patients and
families and limited resources. My job as a CNO is to promote nursing
as a rewarding career, listen to my staff, understand their concerns
and work in partnership with them to resolve issues as quickly as
possible.
short term solutions
Nurse Travelers and Staffing Companies
A side effect of workforce shortages is the development and growth
of two staffing innovations: nurse travelers and nurse staffing
agencies across the country. Although both entities have been in
existence for a number of years, new companies are now recruiting
thousands of traveler nurses who work at a facility for a period of
months, weeks or days and then move on. These nurses travel the country
to locations based on pay, specialty, weather, and whim. According to
an article in The New York Times entitled ``Nurse Shortage Puts a
Premium on Staff Agencies'', July 17, 2001, ``Hospitals paid $7.2
billion last year for temporary employees, mainly nurses, according to
The Staffing Industry Report, an industry news letter. And, spending on
medical staffing is likely to increase more than 20% a year, it says,
to $8.7 billion in 2001 and $10.6 billion next year.''
A number of these traveler companies have begun initial public
offerings of their stock and are doing quite well financially despite
the downturn in the stock market. The industry report states that
traveling nurse companies charge the hospitals between $40-$50 an hour,
with higher hourly rates in high cost settings. As an added incentive
to become a traveler, these companies frequently offer other benefits
such as paid apartments, liability insurance, and health benefits for
nurses who work a minimum period of time. An executive from one of the
traveling companies based in Boca Raton, FL, Cross-Country TravCorps,
estimated the ranks of traveling nurses have doubled in the past five
years, with 15,000 nurses now crisscrossing the country. (Washington
Post ``Ranks of Traveling Nurses Grow'' June 7, 2001)
Immigration
In addition to the growing utilization of nurse travelers and
staffing agencies, a greater number of hospitals are recruiting their
workforce abroad. I wanted to provide the subcommittee with some
background information on the limited opportunities that we have to
recruit and hire foreign nurses.
The main recruitment vehicle currently is the Labor Department's
H1-C visa program. Regular green card applicant nurses are still coming
into the United States, but at an extremely slow rate. The Department
of Immigration is notorious for lengthy delays and time consuming
processes that significantly slow any sort of regular influx of foreign
nurses into the U.S. During the nursing shortage in the late 1980s,
Congress created a special visa for nurses called the H-1A visa. Under
the government program, the industry was able to recruit 6,000-7,000
nurses a year; the program expired in 1995.
Since 1995, Congress has not approved a comparable program. In
fact, in late 2000, it expanded the number of visas that could be
issued to recruit high-tech workers, but it overlooked healthcare.
Congress passed the ``Nursing Relief for Disadvantaged Areas Act'' in
1999; however, it limits the number of foreign RNs to 500 per year.
This legislation amended the Immigration and Nationality Act to
establish a four-year nonimmigrant classification (H-1C) for
nonimmigrant registered nurses in health professional shortage areas.
The program was created as a temporary, limited solution and will
expire in 2003.
The ``Nursing Relief for Disadvantaged Areas Act'' permits up to
500 foreign nurses to work in the U.S. per aggregate fiscal year. To
qualify, hospitals must have at least 190 acute care beds, be located
in federally designated areas with health care worker shortages, and
meet thresholds on Medicare (35%) and Medicaid patient mix (28%.)
Hospitals are also limited in how many nurses they can hire under this
program based on the size of the state. According to the Department of
Labor, only 14 hospitals benefited from this program. The law directs
the Secretary of Health and Human Services to recommend 1) and
alternative to the H-1C program as a permanent remedy to the registered
nurse shortage; and 2) a more effective program enforcement system.
As mentioned above, there is some confusion regarding the H-1B Visa
which was created to permit skilled foreign professionals to work in
the U.S. for a period of up to six years. The H-1B Visa is also
employer specific and is for ``professional positions.'' Such positions
are defined as specialty occupations that require critical and
practical application of a body of highly specialized knowledge. Many
medical and health occupations meet this definition, but foreign nurses
are only eligible for H-1B status if the position would typically be
filled by a nurse in a supervisory or research position. Due to the
nursing shortages HCA hospitals are facing, Dr. Frank M. Houser, M.D.,
HCA's Senior Vice President, Quality, and Corporate Medical Director,
just returned from travel to India in an effort to recruit nurses to
work in our hospitals. However, as illustrated above, the opportunities
for international recruitment are extremely limited because of existing
immigration laws. The United States is also increasingly competing for
nurses with other countries. For example, British hospitals, with the
aid of their government, have already gotten a competitive advantage.
Their recruitment offers include no visa requirements for degreed
critical care Indian nurses willing to relocate to British hospitals.
legislative possibilities for the long term
Federation members have undertaken a wide range of innovative
activities in order to recruit qualified nurses. But the problems of
the shortage are so vast and complex that we are looking to Congress
and the Administration to foster current activities, as well as provide
support for further development and funding of nursing recruitment,
education and retention.
As you know Mr. Chairman, a number of pieces of legislation have
been introduced that attempt to increase the numbers of individuals
entering the nursing field, by assisting with education and training,
and also with retention of trained health care staff. Broadly, the
Federation supports legislation that seeks to improve the following
areas:
<bullet> Recruitment--We believe that federal leadership to promote and
enhance the image of nursing would be very helpful. Many
Federation members are already reaching out within their local
communities to advance the public image of the profession, but
increased federal attention to the critical role nurses play in
our health care delivery system is key.
<bullet> Faculty--We recognize that in order to ensure a steady supply
of the most qualified nurses we need to ensure the development
and support of nursing faculty. Greater financial support of
nursing programs is also important to ensure an adequately
trained workforce.
<bullet> Community Outreach--We support federal grants that would
foster innovative community/private partnerships in shortage
areas. Examples of activities already undertaken by Federation
members include outreach to vocational programs, partnering
with nursing programs and providing sites for clinical
rotations.
<bullet> Nurse Service Corps--The Federation supports the development
of a nurse service corps that would allow loan repayment for
nurses that serve in shortage areas/facilities. Recruits for
this program should be able to provide patient care in a wide
range of settings irrespective of tax status.
<bullet> Immigration--Federal leadership to increase recruitment of
nurses is critical, but just as critical is modifying
immigration laws to allow more nurses to come to the United
States from abroad. Current immigration laws severely limit the
number of nurses who can be recruited internationally. Further
slowing down the process is the Department of Immigration and
Naturalization Services which delays legal immigration for
months at a time. We ask Congress to review the current visa
programs for nurses and consider expanding the existing H-1C
visa program and/or reauthorizing the H-1A program. Immigration
reform could help alleviate some of our staffing shortages in
short order.
Specifically, members of this Committee have introduced legislation
that would attempt to increase the numbers of workers entering the
nursing workforce and provide opportunities and incentives to alleviate
the shortage. The ``Nurse Reinvestment Act''--H.R. 1436 was introduced
by Representatives Lois Capps (D-CA) and Susan Kelly (R-NY). This
legislation would foster community partnerships and innovative programs
for recruitment. The bill would also develop a national nurse service
corps. We believe that this legislation has many valuable ideas and
could serve as a starting point, however it falls short because it does
not ensure that nurses could work in the facility of their choice.
Specifically, all Federation member facilities would be excluded from
using the Nurse Service Corps, as well as the other sections of the
bill. We would like to work with Representative Capps and Kelly to
amend the legislation to ensure that their creative solutions to the
workforce crisis are helpful to all hospitals.
The other promising piece of legislation introduced by members of
this Committee is the ``Nurse of Tomorrow Act of 2001'' H.R. 1897
introduced by Representatives Eliot Engel (D-NY) and Mary Bono (R-CA).
HR 1897 would authorize the Secretary of HHS to make grants to health
care facilities for nurse recruitment and retention activities, as well
as encourage facilities to assist in nurse education and training. The
bill also establishes refundable tax credits for nurses. The Federation
supports the ideas embodied in HR 1897, and applauds the bill's
sponsors for including all facilities in their legislation.
conclusion
CNO's are a passionate lot who firmly believe in the profession of
nursing. They work continuously to support their staff and to provide
them with the tools they need to deliver care. I have been a nurse for
over 30 years and, frankly, cannot imagine doing anything else.
Federation members and all healthcare facilities are facing a workforce
crisis. Our hospitals are on the front lines of delivering patient
care, but our most precious resource, our workers are in very short
supply. We look forward to working with Congress and the Administration
to attempt to solve this complex and growing problem.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Bilirakis. Thank you very much.
Ms. Baker.
STATEMENT OF DIANA BAKER
Ms. Baker. Good afternoon, Mr. Chairman and members of the
subcommittee. My name is Diana Baker. I am a Registered Nurse
employed as an Assistant Nurse Manager at the Cleveland Clinic
Foundation in Cleveland, Ohio. I am pleased to be here today
representing the American Nurses Association in support of your
efforts to improve the recruitment and retention of America's
registered nurses. ANA is the only full-service association
representing the Nation's RNs. I am a member of the Ohio Nurses
Association, one of the 54 constituent members of the ANA.
As this subcommittee is very aware, health care
institutions across the Nation are experiencing a crisis in
nurse staffing, and we are facing an unprecedented nursing
shortage. As RNs are the largest single group of health care
professionals in the United States, nursing shortages pose a
real threat to our Nation's health care system.
There has been some debate about the extent of the current
nursing shortage. Some say it is economic and some say it is
regional, while others say it is national. One thing is
certain, the current staffing shortage is nothing in comparison
to the systemic shortage that will become a reality in the next
8 to 10 years.
Today's nursing shortage is compounded by the lack of young
people entering the nursing profession, the rapid aging of the
RN workforce, and the impending health care needs of the Baby
Boom generation. As new opportunities have opened up for young
women and new stresses have been added to the profession of
nursing, fewer people have opted to choose nursing as a career.
New admissions into nursing schools have dropped dramatically
and consistently for the past 6 years.
The lack of young people entering nursing has resulted in a
steady increase in the average age of the working nurse. Today,
the average working RN is over 43 years old. The national
average is projected to continue to increase until 2010. At
that time, large numbers of nurses are expected to retire and
the total number of nurses in America will begin a steady
decline.
At the same time, the demand for nursing care will increase
over the next 20 years due to the aging of the population,
advances in technology and other economic and policy factors.
These combining demographic forces will soon create a true,
systemic nursing shortage. Current estimates state that the
number of nurses per capita will fall 20 percent below
requirements by the year 2020.
Now is the time to address this impending public health
crisis. The Nurse Education Act programs administered through
the Division of Nursing at the Health Resources and Services
Administration are designed to ensure an adequate supply of
nurses in underserved areas throughout the Nation. These
programs have greatly impacted the nurse workforce and have
enjoyed substantial congressional support. Building on these
programs is the best way to address concerns about the lack of
people entering nursing.
More specifically, ANA strongly supports the Nurse
Reinvestment Act which was drafted by a member of this
subcommittee, Representative Lois Capps, a fellow nurse. This
comprehensive bill addresses many issues in nurse education and
will greatly help recruitment into the profession. It enjoys
the broad support of nurses as well as institutional providers
and educators.
My written statement contains a more complete summary of
this bill. Let me just say here that the combination of
innovative recruitment techniques, curriculum support,
scholarships, and loan repayments contained in the Nurse
Reinvestment Act will enhance all aspects of nurse education.
In addition to nurse recruitment programs, I urge this
subcommittee to take a deeper look into the nurse workforce
issues. It is important to realize that demographics are not
the one and only cause of the emerging nursing shortage. The
General Accounting Office, the Congressional Research Service,
academia and private market research have all published reports
this year that cite nurse dissatisfaction as a major
contributor to the current and emerging shortage.
Dissatisfaction is prompting experienced nurses to leave the
profession and discouraging young people from entering.
I know that when I was a nursing student, working nurses
would approach me and ask me, ``Why do you want to be a nurse,
all we do is get overworked, and we are underpaid'', a clear
sign of dissatisfaction. My written statement more fully
examines the causes for nurse dissatisfaction.
Let me summarize by stating that nurses will remain
reluctant to accept positions in which we face inappropriate
staffing, are confronted by mandatory overtime, are
inappropriately rushed through patient care activities, or are
otherwise unable to provide the high quality care that we are
trained to give.
I encourage this committee to act now to support the Nurse
Reinvestment Act. The very fabric of our safety net programs
rely on an adequate supply of well-trained nurses, but we
cannot stop there. The fact is that the current nursing
shortage will remain and likely worsen if changes to the
workplace are not all addressed.
Thank you for the opportunity to provide this testimony. I
am happy to answer any questions.
[The prepared statement of Diana Baker follows:]
Prepared Statement of Diana Baker on Behalf of the American Nurses
Association
Good morning Mr. Chairman and Members of the Subcommittee. I am
Diana Baker, RN, an assistant nurse manager on the urology/gynecology
unit at the Cleveland Clinic in Cleveland, Ohio. I am pleased to be
here today representing the American Nurses Association (ANA) in
support of your efforts to improve the recruitment and retention of
America's registered nurses (RNs). ANA is the only full-service
association representing the nation's RNs. I am a member of the Ohio
Nurses Association, one of the 54 constituent member nurse associations
of the ANA.
As this Committee is aware, health care institutions across the
nation are experiencing a crisis in nurse staffing, and we are standing
on the precipice of an unprecedented nursing shortage. The current and
emerging shortage of RNs poses a real threat to the nation's health
care system. RNs are the largest single group of health care
professionals in the United States; we underpin the entire health care
delivery system.
The Nurse Education Act programs administered through the Division
of Nursing at the Health Resources and Services Administration are
designed to ensure an adequate supply of nurses in under served areas
throughout the nation. These programs have greatly impacted the nurse
workforce and have enjoyed substantial Congressional support. Building
on these programs is the best way to address the concerns that we have
all been hearing about the growing nursing shortage.
The extent of the concern about this emerging shortage underscores
the fact that having a sufficient number of qualified nurses is
critical to the health of our nation. ANA can assure you that the
emerging nursing shortage is very real and very different from any
experienced in the past. Hospitals, long term care facilities and other
health care providers across the nation are reporting problems filling
nursing positions. Employers are having difficulty finding experienced
nurses, especially in emergency departments, critical care, labor and
delivery, and long term care, who are willing to work in their
facilities. Press reports about emergency department diversions and the
cancellation of elective surgeries due to short staffing are becoming
commonplace. In addition, projections show that these current shortages
are just a minor indication of the systemic shortages that will soon
confront our health care delivery system.
It is important to realize that the causes, and therefore the
answers, for the emerging nursing shortage are complex and
interrelated. It is critical to examine issues in education, health
delivery systems and the work environment. ANA maintains that the
reasons for the current nurse vacancy rates and the impending shortage
are multifaceted. Therefore, we must approach this shortage from many
fronts.
the emerging nurse shortage
The current nursing shortage is compounded by the lack of young
people entering the nursing profession, the rapid aging of the RN
workforce, and the impending health care needs of the baby boom
generation. As new opportunities have opened up for young women and new
stresses have been added to the profession of nursing, fewer people
have opted to choose nursing as a career. New admissions into nursing
schools have dropped dramatically and consistently for the past six
years.
The lack of young people entering nursing has resulted in a steady
increase in the average age of the working nurse. Today, the average
working RN is over 43 years old. The national average is projected to
continue to increase until 2010. At that time, large numbers of nurses
are expected to retire and the total number of nurses in America will
begin a steady decline.
At the same time, the need for complex nursing services is expected
to increase. America's demand for nursing care is expected to balloon
over the next 20 years due to the aging of the population, advances in
technology and various economic and policy factors. In fact, the Bureau
of Labor Statistics ranks the occupation of nursing as having the
seventh highest projected job growth in the United States.
The increasing demand for nursing services, coupled with the
imminent retirement of today's aging nurse, will soon create a systemic
nursing shortage. A recent study published in the Journal of the
American Medical Association estimates that the overall number of
nurses per capita will begin to decline in 2007, and that by 2020 the
number of nurses will fall nearly 20 percent below requirements.
Now is the time to address this impending public health crisis. ANA
strongly supports the Nurse Reinvestment Act (S. 706, H.R. 1436), which
was drafted by a member of this Subcommittee--Representative Lois
Capps, a fellow nurse. This comprehensive bill addresses many issues in
nurse education and will greatly aide recruitment into the profession.
It enjoys the broad support of practicing nurses throughout the nation
as well as institutional providers and educators.
The Nurse Reinvestment Act contains funding for public service
announcements to educate the public about the many rewards of a nursing
career. It supports grants for health career academies to create
partnerships between health care facilities, nursing schools, and high
schools to introduce high school students to nursing curriculum. The
bill provides nursing recruitment grants to support outreach programs
in primary, junior, and secondary schools and to support nursing
students. It establishes a new nurse corps to provide educational
scholarships in exchange for commitment to serve in a health facility
determined to have a critical shortage of nurses. It supports career
ladder grant program to assist individuals, health care providers and
schools of nursing to enable the nursing workforce to obtain continuing
education--and, importantly, fosters the development of nursing faculty
needed to teach these students. It directs the Secretary of HHS to
establish rules for making payments to non-hospital-based, federally
certified hospice programs and home health agencies for the reasonable
costs of providing nurse training, and reauthorizes and modifies the
federal Medicaid match for nursing home clinical education of nurses.
The comprehensive combination of innovative recruitment techniques,
curriculum support, scholarships, and loan repayments will enhance all
aspects of nurse education. ANA wholeheartedly agrees that the solution
to the nursing shortage lies in the further development of our nation's
existing nurse population and the cultivation of our youth into this
very worthwhile profession.
recent changes in nurse employment
In addition to enhanced nurse education programs, ANA urges this
Subcommittee to take a deeper look into nurse workforce issues. It is
important to realize that demographics are not the only cause for the
emerging nursing shortage. Current staffing problems are inexorably
tied to changes in nurse employment practices over the last decade.
Just ten years ago we were emerging from the nursing shortage of
the late 1980's. Nursing workforce issues had caught the attention of
the highest reaches of the Reagan and Bush Administrations and the HHS
Secretary's Commission on Nursing had recently released recommendations
on methods to improve the work environment for nurses. Very few of
these workplace initiatives were actually implemented, but health care
facilities across the nation did institute aggressive recruitment
campaigns and wages were increased. By the early 1990's reports of
nurses shortages had significantly diminished.
Unfortunately, the picture changed abruptly in the mid-1990's. At
this time, managed care began to exert downward pressure on provider
margins. In addition, the impact of Medicare prospective payment was
taking hold. In response to financial pressures, providers eagerly
sought out and implemented programs designed to reduce expenditures.
New models of health care delivery were implemented, and highly
trained, experienced--and therefore higher paid--personnel were
eliminated or redeployed. As RNs typically represent the largest single
expenditure for hospitals (averaging 20 percent of the budget), we were
some of the first to feel the pinch. Lesser-skilled, lower-salaried
assistive staff were hired as replacements, and RN salaries decreased
in both actual and real terms.
Analysis of census data shows that between 1994 and 1997 RN wages
across all employment settings dropped by an average of 1.5 percent per
year (in constant 1997 dollars). Between 1993 and 1997, the average
wage of an RN employed in a hospital dropped by roughly a dollar an
hour (in real terms). RN employment in the hospital sector reversed to
the negative. Many providers eliminated positions for nursing middle
managers and executive level staff. Hospital employment for unlicensed
aides, however, increased by an average of 4.5 percent a year between
1994 and 1997.
The Current Employment Situation
These recent changes in nurse employment served to increase the
pressure on staff nurses who were required to oversee unlicenced aides
while caring for a larger number of sicker patients. The elimination of
management positions shortened the career ladder and decreased the
support, advocacy and resources necessary to ensure that nurses could
provide optimum care. At the same time employment security was
uncertain and wages were being cut. Numerous studies reveal that these
recent changes in RN employment have negatively impacted patient care,
the work environment for nurses, the perception of nursing as a career,
and the staffing flexibility needed to address temporary staffing
shortages.
Not surprisingly, these changes have precipitated the current
downturn in the number of people choosing the nursing profession, and
growing discontent among those who remain. A recent ANA survey revealed
that nearly 55 percent of the nurses surveyed would not recommend the
nursing profession as a career for their children or friends. In fact,
23 percent of the respondents indicated that they would actively
discourage someone close to them from entering the nursing profession.
I know that when I was a nursing student, working nurses would approach
me and advise me to find another career--a clear sign of
dissatisfaction.
A large multi-national survey recently conducted by the University
of Pennsylvania's Center for Health Outcomes and Policy Research shows
that America's nurses are particularly dissatisfied. More than 40
percent of nurses in American hospitals reported being dissatisfied
with their jobs, as compared to 15 percent of all workers. In addition,
this report shows that 43 percent of American nurses score higher than
expected on measures of job burnout. It is a sad fact that staff nurses
typically burn out and leave hospital bedside nursing after just four
years of employment.
This discontent is prompting an alarming number of our experienced
RNs to abandon nursing. The 2000 National Sample Survey of Registered
Nurses shows that a large number of nurses (500,000 nurses--more than
18 percent of the total nurse workforce) who have active licenses are
not working in nursing. Clearly, something in the practice setting is
driving these nurses away from their chosen profession.
Recent reports by the General Accounting Office, the Congressional
Research Service, academia and private market research indicated that
job dissatisfaction is a major factor contributing to the current
nursing shortage. Nurses are, understandably, reluctant to accept
positions in which we will face inappropriate staffing, be confronted
by mandatory overtime, inappropriately rushed through patient care
activities, and unable to provide the high quality care that we were
trained to give.
solutions
ANA is supporting an integrated state and federal legislative
campaign to address the many components of the current and impending
nursing shortage. Key among these is strong support for recruitment and
education initiatives such as the Nurse Reinvestment Act. In addition,
we are also supporting improvements to organization of the work of
nursing. ANA understands that in addition to attracting more young
people to the profession, we must also create a environment that
fosters the retention of our experienced nurses. Following are two
workplace initiatives we hope this Committee will consider.
Adequate Staffing
The safety and quality of care provided in the nation's health care
facilities is directly related to the number and mix of direct care
nursing staff. More than a decade of research shows that nurse staffing
levels and skill mix make a difference in the outcomes of patients.
Studies show that when there are more nurses, there are lower mortality
rates, shorter lengths of stay, better care plans, lower costs, and
fewer complications. In fact, four HHS agencies--the Health Resources
and Services Administration, Health Care Financing Administration,
Agency for Healthcare Research and Quality, and the National Institute
of Nursing Research of the National Institutes of Health--recently
sponsored a study on this very topic. The resulting report, released on
April 20, 2001, found strong and consistent evidence that increased RN
staffing is directly related to decreases in the incidence of urinary
tract infections, pneumonia, shock, upper gastrointestinal bleeding,
and decreased hospital length of stay.
In addition to the important relationship between nurse staffing
and patient care, several studies have shown that one of the primary
factors for the increasing nurse turnover rate is dissatisfaction with
workload/staffing. ANA's recent survey states that 75 percent of nurses
surveyed feel that the quality of nursing care at the facility in which
they work has declined over the past two years. Out of nearly 7,300
respondents, over 5,000 nurses cited inadequate staffing as a major
contributing factor to the decline in quality of care. More than half
of the respondents believed that the time they have available for
patient care has decreased.
The University of Pennsylvania research shows that 70-80% of more
than 43,000 registered nurses surveyed in five countries reported that
there are not enough RNs in hospitals to provide high quality care.
Only 33 percent of the American nurses surveyed believed that hospital
staffing is sufficient to ``get the work done.'' This survey reflects
similar findings from a national survey taken by the Henry J. Kaiser
Family Foundation (1999) that found that 69 percent of nurses reported
that inadequate nurse staffing levels were a great concern. The public
at large should be alarmed that more than 40 percent of the nurses who
responded to the ANA survey stated that they would not feel comfortable
having a family member cared for in the facility in which they work.
Adequate staffing levels allow nurses the time that they need to
make patient assessments, complete nursing tasks, respond to health
care emergencies, and provide the level of care that patients deserve.
It also increases nurse satisfaction and reduces turnover. For these
reasons, ANA supports efforts to require acute care facilities to
implement and use a valid and reliable staffing plan based on patient
acuity as a condition of participation in the Medicare and Medicaid
programs. In addition, we support efforts to enhance the current
minimum nurse-to-patient staff ratios in skilled nursing facilities.
Mandatory Overtime
ANA is concerned that nurses across the nation are expressing
concerns about the dramatic increase in the use of mandatory overtime
as a staffing tool. ANA understands that overtime is the most common
method facilities are using to cover staffing insufficiencies.
Employers may insist that a nurse work an extra shift (or more) or face
dismissal for insubordination, as well as being reported to the state
board of nursing for patient abandonment. Concerns about the use of
mandatory overtime are directly related to patient safety.
It is well established that sleep loss influences several aspects
of performance, leading to slowed reaction time, failure to respond
when appropriate, false responses, slowed thinking, and diminished
memory. In fact, 1997 research by Dawson and Reid at the University of
Australia showed that work performance is more likely to be impaired by
moderate fatigue than by alcohol consumption. Their research highlights
the fact that significant safety risks are posed by workers staying
awake for long periods. It only stands to reason that an exhausted
nurse is more likely to commit a medical error than a nurse who is not
being required to work a 16 to 20 hour shift.
Nurses are placed in a unique situation when confronted by demands
for overtime. Ethical nursing practice prohibits nurses from engaging
in behavior that we know could harm patients. At the same time, RNs
face the loss of their license--our careers and livelihoods--when
charged with patient abandonment. Absent legislation, nurses will
continue to confront this dilemma. For this reason, ANA supports
legislative initiatives to ban the use of mandatory overtime through
Medicare provider agreements.
I can tell you that I have made the personal decision not to use
mandatory overtime to meet staffing needs in my unit because I believe
that it fosters an environment rich for medical error and contributes
to nurse turnover. My experience as a staff nurse and an assistant
nurse manager has taught me that mandatory overtime is not a safe or
viable staffing option.
conclusion
ANA and I encourage this Committee to act now to support the Nurse
Reinvestment Act. The very fabric of our safety net programs rely on an
adequate supply of well-trained nurses. We can not stop there, however.
The fact is that the current nursing shortage will remain and likely
worsen if changes to the workplace are not immediately addressed. The
profession of nursing will be unable to compete with the myriad of
other career opportunities available in today's economy unless we
improve working conditions. Registered nurses, hospital administrators,
other health care providers, health system planners, and consumers must
come together in a meaningful way to create a system that supports
quality patient care and all health care providers.
ANA looks forward to working with you and our industry partners to
make the current health care environment conducive to high quality
nursing care. Improvements in the environment of nursing care, combined
with aggressive and innovative recruitment efforts will help avert the
impending nursing shortage. The resulting stable nursing workforce will
support better health care for all Americans.
Mr. Bilirakis. Thank you very much, Ms. Baker.
Dr. Roberts, you are up, sir.
STATEMENT OF CORY A. ROBERTS
Mr. Cory Roberts. Chairman Bilirakis, Congressman Brown,
members of the subcommittee, my name is Cory Roberts, and I am
a Board-certified pathologist and Director of Anatomic
Pathology at St. Paul Medical Center in Dallas, Texas. I am
here today representing the American Society of Clinical
Pathologists and I formerly served as a liaison member to its
Board of Directors.
You may ask why a pathologist is here to discuss non-
physician personnel shortage issues. ASCP is a unique
organization, and we have 75,000 members. Of those members
there are Board-certified pathologists, other physicians,
clinical scientists, as well as medical technologists and
technicians. Our certifying board registers over 150,000
laboratory personnel every year.
I am here to attest to the shortage, provide you with data
regarding this, as well as explain the workforce shortage
problem.
The United States is approaching a serious shortage of
laboratory personnel with vacancy rates for seven of ten key
laboratory positions at an all-time high. Vacancy rates for
cytotechnologists, the professionals who evaluate Pap smears
and other cytological material, as well histotechnologists who
prepare tissue specimens for evaluation, are at an alarming
high of over 20 percent.
The American Society of Clinical Pathologists' Board of
Registry, in conjunction with an independent polling firm,
MORPACE, out of Detroit, conducts a biennial wage and vacancy
survey, and has since 1988. We survey over 2500 medial
laboratory managers. This measures the vacancy for these ten
key laboratory personnel positions, and compares and contrasts
these data with the previous year's. The data for 2000 was
published in the March 2001 issue of the Journal of Laboratory
Medicine, and I would like to give you a glimpse of what we
found.
Vacancy rates for cytotechnologists in the northeast
average 45 percent, in the east north central region it was
almost 17 percent, and the far west region showed 33 percent.
Rural areas overall averaged a 20-percent vacancy rate, and
large cities a surprising over 28 percent. Private reference
laboratories have an average vacancy of 20 percent for
histotechnologists, while hospitals have almost 38 percent
vacancy rate for these same people.
By comparison, the vacancy rate for medical technologists
may not appear to be such a problem, however, it, too, is
worthy of concern. Vacancy rate overall for medical
technologists averages 11 percent.
While the supply of laboratory personnel is dwindling, the
demand for these professionals is continuing to increase, as
evidence, in part, by rising wages.
Median average pay rate increases from 1998 to 2000 were
larger than comparisons for any other time period in our study.
Only two laboratory professions had wage increases of less than
10 percent, and even those were over 8 percent. The
histotechnologists led the way at 15.4 percent.
In Dallas, where I practice, we currently have openings for
12 medical technologists within the University of Texas
Southwestern system, which includes my St. Paul Medical Center.
We also have five histotechnologist openings, that, in spite of
our offering signing bonuses as well as a recent across-the-
board 10 percent pay raise to our histotechnologists. I don't
want to give too many more specifics simply because of the
fierce competition among the hospitals in the region for this
limited pool of applicants.
One of the logical solutions to this would be to simply
train more professionals for these positions. That said, the
programs are in fact decreasing in number. For example, in
Michigan, the number of programs for medical technologists has
decreased from 27 to 8 in less than two decades. In California,
with its large population base, there are only two programs in
the entire State to train cytotechnologists.
According to the Health Professions Education Directory
published by the American Medical Association, from 1994 to
1999, the number of programs and the number of graduates for
medical technologists has decreased by 30 percent.
There are several reasons why the vacancy rate is
increasing. Some program directors report that their graduates
are taking positions outside of the traditional laboratory with
companies that are involved with laboratory information
systems, dot.coms, and corporations that manufacture or
distribute diagnostic reagents, supplies and materials.
With limited resources, hospitals have merged, thus
decreasing the opportunities for training sites for medical
laboratory programs. Yet, the continued demand for laboratory
services is real and, in fact, will probably grow. For example,
in Florida, the population by the year 2020 is projected to
grow by 29 percent. Those over age 65, though, will grow at a
rate of 66 percent. This disproportionate growth of those over
65 is borne out in other States as well.
Given the country's aging population, the number and
complexity of biopsy specimens and the use of molecular
techniques will likely increase during the next decade. The
average age for a medical technologist currently is 45, many
are approaching retirement. The threat of bioterrorism calls
for trained laboratory professionals to respond. The laboratory
workforce will have to be able to react accordingly with
appropriate numbers of trained professionals.
I greatly appreciate this opportunity to discuss this
problem with you all today. As a practicing pathologist, who
works with a team of medical professionals including medical
technologists and technicians, I know there is a growing
concern over this problem, and the facts bear this to be true.
Thank you again for your time and consideration.
[The prepared statement of Cory A. Roberts follows:]
Prepared Statement of Cory Roberts, Director of Anatomic Pathology, St.
Paul Medical Center on Behalf of the American Society of Clinical
Pathologists
Chairman Bilirakis, Congressman Brown, members of the Subcommittee,
my name is Cory Roberts, MD, FASCP. I am a pathologist serving as
Director of Anatomic Pathology at St. Paul Medical Center in Dallas,
Texas, and also am a partner at ProPath Associates in Dallas. I am here
today representing the American Society of Clinical Pathologists (ASCP)
where I served as a liaison member to its Board of Directors.
You may ask why a pathologist is here to discuss the shortage of
non-physician medical laboratory personnel. Well, ASCP is a unique
organization. It is a nonprofit medical specialty society organized for
educational and scientific purposes. Its 75,000 members include board
certified pathologists, other physicians, clinical scientists, and
certified technologists and technicians. These professionals recognize
the Society as the principal source of continuing education in
pathology and as the leading organization for the certification of
laboratory personnel. ASCP's certifying board registers more than
150,000 laboratory professionals annually.
I am here to attest to the shortage, provide you with national data
on the subject as well as an explanation for this workforce shortage
problem. Finally, I would like to outline some current solutions to
this growing concern.
The Problem
The United States is approaching a serious shortage of laboratory
medical personnel with vacancy rates for seven of ten key laboratory
medicine positions at an all time high. Vacancy rates for
cytotechnologists, the professionals who evaluate Pap smears and other
cellular material, and histotechnologists, the individuals who prepare
tissue specimens for cancer biopsies, are at an alarming high of over
20%.
The American Society of Clinical Pathologists' Board of Registry,
in conjunction with MORPACE International, Inc., Detroit, conducts a
biennial wage and vacancy survey of 2,500 medical laboratory managers.
The survey measures the vacancy rates for 10 medical laboratory
positions, and compares and contrasts these data with that from 1988,
1990, 1992, 1994, 1996, and 1998 studies. The data for 2000 was
published in March 2001, and I'd like to give you a glimpse of what was
found.
Vacancy rates for cytotechnologists in the northeast average 45
percent, 16.7 percent for the east north central, and 33.3 percent for
the far west. Rural areas average a 20 percent vacancy rate for
cytotechnologists, and large cities a rather surprising 28.3 percent
rate.
Private reference laboratories have an average vacancy rate of 20
percent for histotechnologists, and hospitals have a 37.7 percent
shortage of the same profession.
The west south central region of the country has a 73.7 percent
vacancy rate for histotechnologists, and the south central Atlantic
states have an average vacancy rate of 16.7 percent.
By comparison, the vacancy rate for medical technologists will not
appear to be a problem, but it too is reason for concern. Medical
technologist vacancy rate averages 11.1 percent, but rural areas show
21.1 percent vacancy and hospitals with 100-299 beds have a rate of
17.6 percent.
While the supply of laboratory personnel is dwindling, the demand
for these professionals is increasing--as evidenced, in part, by the
rise in wages.
Beginning wage increases from 1998 to 2000 were the largest
experienced since comparisons from the 1990 to 1992 studies. Pay for
nine of the 10 employee positions increased at least 6.9% from 1998 to
2000, with histotechnologist pay increasing 15.8%. Median average pay
rate increases from 1998 to 2000 were larger than comparisons for any
other time period. Only medical technologist supervisors (at 8.6%) and
medical laboratory technician staff (at 8.5%) had wage increases of
less than 10%. Histologic technicians (at 13.3%) and histotechnologists
(at 15.4%) experienced the largest increases.
In Dallas, where I practice, we currently have 12 positions
available for medical technologists within the University of Texas
Southwestern medical system (this includes Parkland Memorial Hospital
and St. Paul Medical Center). There are 5 histotechnologist positions
available. We offer signing bonuses and increased wages to attract
laboratory personnel to our facility. I am reluctant to mention exactly
what we offer because, frankly, laboratory personnel are in such demand
that neighboring health care institutions will often ``one-up'' each
other in order to draw from the same pool of applicants.
Medical Laboratory Programs
One of the logical solutions to this vacancy rate problem is to
train more students; however, the number of programs are decreasing.
For example, in Michigan, we have seen the number of programs plummet
from 27 to 8 in less than two decades. In California, there are no
programs available for histologic technicians or specialists in blood
banking. There are only two programs for cytotechnologists, one program
for medical laboratory technicians, and one for phlebotomists in that
entire state.
It is important to note that education programs for training
medical laboratory personnel are sponsored by a variety of
organizations and institutions, ranging from hospitals to degree-
granting colleges and universities.
According to the Health Professions Education Directory published
by the American Medical Association, the number of medical technology
programs decreased from 383 in 1994 to 273 in 1999. The number of
graduates in medical technology has similarly decreased from 3563 in
1994 to 2491 in 1999, a 30 percent decline in five years.
Assessment
There are several reasons why the vacancy rate is increasing and
the number of program enrollees is decreasing. A number of available
positions are outside the traditional clinical laboratory. Some program
directors have reported that graduates are gaining employment in
laboratory information systems companies, ``dot.coms,'' and
corporations that manufacture or distribute diagnostic reagents,
supplies or equipment. With limited resources, hospitals have merged,
thus decreasing the availability of training sites for medical
laboratory programs. Some programs have responded by increasing access
to other laboratory training sites, such as forensics laboratories,
blood centers, physician offices, and outpatient clinics. Yet, with
these shifts, the continued demand for laboratory services is real and
is expected to grow.
In Florida, according to the Bureau of the Census, the population
is projected to grow by 29% by 2020, and the population over age 65 is
projected to grow by 66% in the same time period. In Ohio, the
population is projected to grow by 3% by 2020, and the population over
age 65 is projected to grow by 34% in the same time period.
Given the country's aging population, the number and complexity of
biopsy specimens and the use of molecular techniques will likely
increase during the next decade. Laboratory professionals who entered
the workforce in the 1960s and 1970s will be retiring soon as the
average age for a medical technologist now is 45 years old. The threat
of bioterrorism calls for trained laboratory professionals to respond.
The laboratoryallied health workforce will need to be able to react
accordingly with appropriate numbers of trained and educated personnel.
Current Working Solutions
There are solutions to these problems. As a professional
organization, ASCP believes it holds a responsibility to address the
workforce shortage. As such, ASCP offers scholarships to medical
laboratory technology students each year to relieve some of the
financial burden of higher education, but this does not come close to
fulfilling the need. We produce career brochures and audiovisual
materials for high school students and younger children to learn about
opportunities in the laboratory. ASCP also exhibits and advertises at
the annual conference for the National Association of Biology Teachers
in an attempt to help these educators guide interested students to
careers in the laboratory.
On the public side, there are grants available to help attract
laboratory professionals to the field, especially minorities and
individuals in rural and underserved communities. The Allied Health
Project Grants program, administered by the Health Resources and
Services Administration, has been successful in effectively attracting
new allied health professionals into the laboratory field.
For example, the University of Nebraska Medical Center, my alma
mater, established medical technology education sites in four
communities in rural Nebraska, including a student laboratory in
central Nebraska, under an Allied Health Project Grant. As of 1999, of
69 graduates, 99% took their first job in a rural community, and 74%
took their first job in rural Nebraska.
The grants are also designed to create successful minority
recruiting and retention programs for medical technologists. This was
the focus of a University of Maryland, Baltimore project initiated by
allied health grant funding in 1991. Through utilizing a four phase
design, which begins with career awareness activities for elementary
and middle school students, this model provides a continuum of
activities that progressively focuses on identifying, retaining, and
advancing interested students to the completion of a baccalaureate
degree. Because of this program, the University of Maryland, Baltimore
has attained a current 70% minority medical technology student
enrollment at a majority institution, and an average 89% student
retention rate, placing it among the highest in the country. 95% of the
graduates of this program receive immediate placement.
Most allied health grant projects continue after federal funding
ends, making them a longlasting, worthwhile investment in the future of
allied health.
I greatly appreciate this opportunity to discuss this concern over
the medical laboratory personnel shortage with you. As a practicing
pathologist, who works as part of the laboratory team with medical
technologists and technicians, I know there is a growing concern over
this shortage and the data certainly bears this to be true. Thank you
again for your time and consideration.
Mr. Bilirakis. Thank you very much, Dr. Roberts.
Ms. Pietrantoni. Did I pronounce that all right?
STATEMENT OF ADELE PIETRANTONI
Ms. Pietrantoni. Very close.
Mr. Bilirakis. In other words, no.
Ms. Pietrantoni. Good afternoon, Mr. Chairman, Ranking
Member Brown, and members of the subcommittee. Thank you for
the opportunity to present the views of pharmacist caregivers
in hospitals, long-term care facilities, community pharmacies
and other practice settings across the country.
My name is Adele Pietrantoni. I am a pharmacist, immediate
part President and current Chair of the Massachusetts
Pharmacists Association, and am currently a trustee for the
American Pharmaceutical Association, the national professional
society of pharmacists.
I am here to speak about the acute shortage of pharmacists
in the United States today. In December of 2000, HRSA released
a report identifying and quantifying the degree of the current
shortage. A shortage of pharmacists is a serious problem, as
pharmacists are a valuable resource for ensuring the safety,
efficacy, and cost-effectiveness of medication therapy for the
millions of Americans who rely on medications to cure disease,
resolve symptoms and maintain health. Nurses provide the most
public face in the health care system and medical technologists
perform vital functions to support the system, pharmacists are
the patient's last line of defense to ensure the appropriate
use of medications. Pharmacists work with patients to ensure
that medications work, and to minimize the situations where
this valuable technology causes harm.
The shortage stems from a hyper-demand for medication and
medication therapy management services. This demand is evident
in the dramatic growth in the number of prescriptions prepared
daily, growth that is sure to continue, and the significant
expansion of the pharmacist's role in patient care. As the
population ages, the shortage of pharmacists and other health
care professionals will continue. Congress can play a valuable
role in helping address this serious issue.
According to the HRSA study, the number of prescriptions
dispensed in ambulatory settings increased 44 percent between
1990 and 1999. The number of ph |
