Mr. Chairman and Members of the Subcommittee:
It is a pleasure to be with you this morning to discuss pending
Public Health Service bills and our priorities for
reauthorization during this Congress. I am accompanied by Dr.
Ciro Sumaya, Administrator of the Health Resources and Services
Administration (HRSA), and Dr. Frank Sullivan, Associate
Administrator of the Substance Abuse and Mental Health Services
Administration (SAMHSA).
HEALTH CENTERS CONSOLIDATION
On March 3, 1995, we forwarded to the Congress a proposal to
reauthorize and consolidate four programs of the Health Resources
and Services Administration: Community Health Centers; Migrant
Health; Health Care for the Homeless; and Health Care for
Residents of Public Housing.
Established by Congress to address defined sets of needs in a
specific way, the health centers programs have for almost thirty
years effectively responded to the challenges of medical
underservice and assured access for millions of underserved and
uninsured individuals. In response to today's changing health
care environment, the health centers have become increasingly
involved in managed care arrangements and have developed networks
of care with other community partners. Whether today, or in the
future, health centers will continue to play a critical role in
the delivery of services to underserved and vulnerable
populations.
Reauthorization of these health center programs is critical. The
centers provide a medical home for millions of underserved and
uninsured people, assuring access to cost-effective, high quality
preventive and primary care services and improving the health
status of the Nation's underserved and vulnerable populations.
Continued Lack of Access to Preventive and Primary Health Care
Services
Although we have recently witnessed many changes in the financing
and delivery of health care services -- for example, the rapid
growth of managed care and the accelerated development of health
care networks -- there are still many people who lack access to
basic primary and preventive care services. These individuals are
disproportionately poor and minority, lack adequate or do not
have any health insurance, all of which combine to result in
sicker patients and more expensive treatment and care. Further,
these individuals face geographic and cultural barriers, as well
as health provider shortages.
HRSA's health centers programs are an important part of
addressing this problem. Currently, a Federal health center
investment of approximately $750 million leverages a $2 billion
network (including Medicare and Medicaid billings) of over 700
organizations and 2,100 service delivery sites, providing
services to over 7.7 million people. This health center
investment has acted as the safety net for millions of people
otherwise at risk for poor health outcomes.
Health Centers and the Changing Health Care Environment
Health Centers across the country are responding to the rapid
changes in today's health care marketplace. In particular,
health centers are recognizing the critical importance of forming
or being a part of an integrated system of health delivery in
order to continue serving their patients under managed care
arrangements. The trend within the health care industry, in
general, and the States, in particular, has been a movement
towards managed care.
Health centers have responded to this trend by participating in
the development of networks. The basic premise of health center
involvement in integrated service networks is that as the
delivery of services moves toward managed care arrangements for
the Medicaid population, health centers must participate in these
arrangements in order to assure access for underserved
individuals. As of July 1996, approximately 450 health centers
are involved in integrated networks.
To assist the health centers in the development of such networks,
the HRSA's Bureau of Primary Health Care launched the Integrated
Service Network (ISN) Development Initiative in FY 1994. ISN
grants were awarded in FY 1994 and FY 1995. At present at total
of 54 grantees are funded. In addition, as more and more health
centers have become involved in managed care, health maintenance
organizations have increasingly recognized the advantages of
contracting with the health centers programs.
Administration's Proposal
In general, the Administration's proposal reauthorizes and
consolidates the health centers and service programs under one
new health center authority. All of these programs provide
community- based, organized systems of preventive care and
primary care for medically underserved populations. Although
some of the programs are targeted to specific populations most
are jointly funded thus assuring access to whole communities as
well as the targeted populations.
The "cluster" approach proposed by the Administration is
consistent with our commitment to simplify the way in which
communities seek Federal assistance. By consolidating the
funding previously requested under the separate programs the
total number of grants will be reduced producing a reduction in
Federal administrative costs. Also, it will make grants more
flexible, and less burdensome for communities applying for and
receiving the grants.
The Senate Labor and Human Resources Committee has approved
legislation (S. 1044) which in large part accepts our
recommendations. We urge you to move forward with the
reauthorization and consolidation of HRSA's health centers and
services programs.
HEALTH PROFESSIONS TRAINING
The Administration is committed to establishing a sound
legislative foundation for furthering leadership and strategic
support in the field of health workforce development, including
the health professions programs.
These programs have achieved remarkable success as a national
resource --
-
They have significantly enhanced the quality of primary
care curriculum and fostered a growth in the interest of medical
students in generalist practice.
- Funding of residency training opportunities in family
medicine, general internal medicine, and general pediatrics have
increased our national supply of much needed primary care
physicians.
- They have opened opportunities for greater numbers of
minorities to pursue and succeed in health professions careers
and thereby expanded the access of millions of Americans to basic
medical care.
- They have spurred unprecedented growth in student
enrollment among the mid-level professions of nurse practioners,
nurse midwives, nurse anesthetists, and physician assistants.
- Through establishment of interdisciplinary training centers
in geriatrics we have improved the quality of health care
received by older Americans and the training given to their
health care professionals.
As you are aware, Titles VII and VIII of the Public Health
Service Act authorize a large number of individual programs of
support to health professions and nursing schools and students.
Last year, as part of our effort to reinvent Government, we sent
to the Congress a proposal to replace these multiple existing
categorical grant authorities with new "cluster" authorities
addressing five broad areas of program need:
- Health Professions Workforce Development;
- Enhanced Area Health Education Centers;
- Minority/Disadvantaged Health Professions;
- Primary Care Medicine and Public Health Training; and
- Nursing Education and Practice.
This proposal, if enacted, would reduce the total number of
awards and provide administrative savings through a reduction in
required applications and reports by consolidating dozens of
specific authorities into the functional categories listed above.
In addition to simplifying program administration, the
consolidations would sharpen the focus of these programs on
outcome and encourage collaboration among the health and
educational institutions.
The Senate Labor and Human Resources Committee has approved
legislation (S. 555) very similar to our health professions
proposal. In addition, S. 555 includes a provision regarding
fellowships and training authority for the Centers for Disease
Control and Prevention and reauthorization of the office of
Minority Health. We support S.555 and urge you to give it your
careful consideration.
MENTAL HEALTH AND SUBSTANCE ABUSE PERFORMANCE PARTNERSHIP GRANTS
In this Congress, the Administration has proposed Performance
Partnership Grants (PPGs). This is a new approach in which the
Federal Government and the States work together as partners to
achieve significant improvements in health outcomes. Performance
Partnerships create an opportunity and a structure within which
the Federal government and States can channel their efforts and
resources to achieve specific improvements in the health status
of the American people.
The potential power of these partnerships flows from a focus on
measurable results, and the energy and commitment that come from
a shared vision. Washington cannot legislate a vision or strategy
that is right for every State, Tribe and community in the
country. We can, however, create a process through which
national, State and local interests can be negotiated and
agreements reached that are tailored to needs and priorities of
our communities.
In some respects, PPGs are somewhere between traditional block
grants, which do not provide either accountability for the
expenditure of Federal funds or achieving measurable outcomes,
and categorical grants for earmarked block grants which limit the
role of the States, communities and consumers because health
priorities are set at the Federal level. But in other respects,
they constitute an entirely new, stronger approach that builds on
other outcomes-oriented activities such as State benchmarking,
and Healthy People 2000.
The PPG approach fundamentally changes the roles and expectations
of the Federal government and the States. The Federal role will
be to facilitate a continuous national dialogue about the health
objectives that are key to achieving better health status among
all Americans, to work with States to support their efforts, to
identify areas of risk and opportunity, to provide technical
assistance, and to report regularly on how the Nation and
individual States are performing. States will have the
flexibility to select objectives that meet their determined needs
and priorities and will be accountable for making progress toward
meeting them. Monitoring and reporting on performance -- results
achieved under the grants -- will keep the Congress and the
American people informed about what they are getting in return
for funds spent.
How PPGs will Work
At the core of performance partnerships -- as proposed by the
Administration and the Senate's SAMHSA reauthorization bill -- is
a menu of performance objectives. States are to select
objectives from the menu, or to propose comparable "off menu"
objectives. A negotiation will then occur between the Secretary
and each State to reach agreement on the objectives to be pursued
-- this will be a negotiation between partners who share the same
goals of reducing risks to health and improving health outcomes.
Once agreement is reached, the Department and the State work
together to achieve the agreed upon outcomes.
The Secretary will monitor the State's performance under the
grant and provide technical assistance, training and support to
help the State accomplish its objectives. Both the Federal and
State governments will be accountable to taxpayers, State
legislatures and the Congress for achieving the objectives of the
grants. Central to the success of PPGs is the ability to measure
results that can be achieved through the grant programs -- the
focus will be on accountability for results, that is our goal.
Status of PPG Activities
When the Administration first made this proposal, States and
various stakeholder groups expressed reservations about the
approach, and particularly noted the difficulty of identifying
meaningful objectives that could be measured with existing data
systems.
To establish the feasibility of the concept, and to begin the
critical step of collaboration, the Secretary initiated a process
to develop a menu of objectives. We began with a series of four
regional meetings involving key stakeholders -- State, Tribal and
local governments, consumers, providers, advocacy groups, public
health experts, and interested citizens as well as Federal
officials. In a structured setting the participants identified
the results or prototype objectives they believed would be the
best measures of success. Over 1400 individuals participated,
coming from every State, the Pacific Islands, Puerto Rico and
numerous Indian tribes.
The information generated in the regional meetings has been
provided to an independent technical panel at the National
Research Council. The panel members have a comprehensive
knowledge of national and State data systems and practical
knowledge of the specific program areas. Their charge is to
refine the results produced in the regional meetings into
performance objectives for each grant area, and to identify which
of the objectives can be measured with existing data systems.
The panel will issue a draft report in mid-September, inviting
public comments and then provide a final set of recommendations
to the Secretary by early 1997.
While the regional meetings and the technical panel were
established to support the implementation of PPGs, their
importance extends beyond this particular legislative initiative.
They have become an important first step in establishing the
foundation for a new type of Federal-state partnership in data
collection and bench marking. A number of the States
participating in the meeting have indicated that they will
utilize the panel's reports in their own bench marking processes.
The meetings provided the further benefit of bringing together
program officials and constituencies whose interests are strongly
linked, but who rarely have the opportunity to consider how to
best manage their separate programs to achieve shared objectives.
The opportunity for improved communication and priority setting
among programs directed at the same populations should enhance
the effectiveness of all programs in achieving defined and
measurable results.
The Senate Labor and Human Resources Committee has unanimously
approved legislation (S. 1180) that closely parallels the
Administration's approach. We are very interested in working
with this Committee, and in collaboration with our partners at
the State and local level, including consumer and advocacy
groups, to advance the performance partnership model. PPGs are
designed to provide State and public health officials the
flexibility and resources to do their jobs -- improving the
health of their populations -- while improving the health of this
country. We believe the model will be effective and hope to
continue progress in this congress towards achieving it.
Conclusion
Today, Congress is engaged in a watershed national debate about
the role of government in society and about the setting of
priorities in times of tight fiscal constraints. By any measure,
investments in public health are money well spent. Therefore I
urge you to move these important legislative initiatives forward
during this Congress.
Thank you. I would be glad to answer your questions.
**Attached is 1 chart entitled, "PPG Process"
Chart #1
There are 5 phases in a 12-20 month span:
| Phase I | Information Gathering |
| Phase II | Technical Analysis |
| Phase III | Consultation on NAS Report |
| Phase IV | Development of State Plans |
| Phase V | Negotiation |
