<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:28514.wais]
THE CRITICAL ROLE OF
COMMUNITY HEALTH CENTERS IN
ENSURING ACCESS TO CARE
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND
COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
MAY 4, 2006
Serial No. 109-86
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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COMMITTEE ON ENERGY AND COMMERCE
JOE BARTON, Texas, Chairman
RALPH M. HALL, Texas JOHN D. DINGELL, Michigan
MICHAEL BILIRAKIS, Florida Ranking Member
Vice Chairman HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RICK BOUCHER, Virginia
PAUL E. GILLMOR, Ohio EDOLPHUS TOWNS, New York
NATHAN DEAL, Georgia FRANK PALLONE, JR., New Jersey
ED WHITFIELD, Kentucky SHERROD BROWN, Ohio
CHARLIE NORWOOD, Georgia BART GORDON, Tennessee
BARBARA CUBIN, Wyoming BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
HEATHER WILSON, New Mexico BART STUPAK, Michigan
JOHN B. SHADEGG, Arizona ELIOT L. ENGEL, New York
CHARLES W. "CHIP" PICKERING, Mississippi ALBERT R. WYNN, Maryland
Vice Chairman GENE GREEN, Texas
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DEGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MIKE DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire TOM ALLEN, Maine
JOSEPH R. PITTS, Pennsylvania JIM DAVIS, Florida
MARY BONO, California JAN SCHAKOWSKY, Illinois
GREG WALDEN, Oregon HILDA L. SOLIS, California
LEE TERRY, Nebraska CHARLES A. GONZALEZ, Texas
MIKE FERGUSON, New Jersey JAY INSLEE, Washington
MIKE ROGERS, Michigan TAMMY BALDWIN, Wisconsin
C.L. "BUTCH" OTTER, Idaho MIKE ROSS, Arkansas
SUE MYRICK, North Carolina
JOHN SULLIVAN, Oklahoma
TIM MURPHY, Pennsylvania
MICHAEL C. BURGESS, Texas
MARSHA BLACKBURN, Tennessee
BUD ALBRIGHT, Staff Director
DAVID CAVICKE, General Counsel
REID P. F. STUNTZ, Minority Staff Director and Chief Counsel
SUBCOMMITTEE ON HEALTH
NATHAN DEAL, Georgia, Chairman
RALPH M. HALL, Texas SHERROD BROWN, Ohio
MICHAEL BILIRAKIS, Florida Ranking Member
FRED UPTON, Michigan HENRY A. WAXMAN, California
PAUL E. GILLMOR, Ohio EDOLPHUS TOWNS, New York
CHARLIE NORWOOD, Georgia FRANK PALLONE, JR., New Jersey
BARBARA CUBIN, Wyoming BART GORDON, Tennessee
JOHN SHIMKUS, Illinois BOBBY L. RUSH, Illinois
JOHN B. SHADEGG, Arizona ANNA G. ESHOO, California
CHARLES W. "CHIP" PICKERING, Mississippi GENE GREEN, Texas
STEVE BUYER, Indiana TED STRICKLAND, Ohio
JOSEPH R. PITTS, Pennsylvania DIANA DEGETTE, Colorado
MARY BONO, California LOIS CAPPS, California
MIKE FERGUSON, New Jersey TOM ALLEN, Maine
MIKE ROGERS, Michigan JIM DAVIS, Florida
SUE MYRICK, North Carolina TAMMY BALDWIN, Wisconsin
MICHAEL C. BURGESS, Texas JOHN D. DINGELL, Michigan
JOE BARTON, Texas (EX OFFICIO)
(EX OFFICIO)
CONTENTS
Page
Testimony of:
Handley, Elisabeth, Division Director for Policy and Development,
Bureau of Primary
Health Care, Health Resources and Services Administration, U.S.
Department of Health and Human Services 14
Brooks, Roy C., Commissioner, Tarrant County, Texas 37
Grant-Davis, Kathy, Executive Director, New Jersey Primary Care
Association 40
Hawkins, Dan, Vice President for Federal, State, and Public Affairs,
National Association of Community Health Centers, Inc. 43
THE CRITICAL ROLE OF COMMUNITY
HEALTH CENTERS IN ENSURING
ACCESS TO CARE
THURSDAY, MAY 4, 2006
HOUSE OF REPRESENTATIVES,
COMMITTEE ON ENERGY AND COMMERCE,
SUBCOMMITTEE ON HEALTH,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:42 p.m., in Room
2123 of the Rayburn House Office Building, Hon. Nathan Deal
(chairman) presiding.
Members present: Representatives Deal, Bilirakis, Gillmor, Shimkus,
Ferguson, Burgess, Pallone, Rush and Green.
Staff present: Ryan Long, Counsel; Katherine Martin, Professional
Staff Member; Brandon Clark, Policy Coordinator; Chad Grant,
Legislative Clerk; John Ford, Minority Counsel; and Jessica McNiece,
Minority Research Assistant.
MR. DEAL. The committee will come to order and the Chair
recognizes himself for an opening statement. I am proud to say that we
have four expert witnesses appearing before us this afternoon that will
help us examine the issues relating to the reauthorization of enabling
legislation for community health centers.
Without question, community health centers are an integral part of
our country's healthcare delivery system, providing healthcare services
to people in communities that would not otherwise have access to such
care.
As many of you know, this subcommittee has exclusive jurisdiction
over legislation regarding community health centers and we are
committed to being good stewards of this program. We join the
President in strong support of community health centers and we applaud
the thousands of community health centers, employees and volunteers
that contribute so much to the success of the program.
Again, I want to welcome our witnesses and I will introduce the
panels as they appear and I thank them for their participation. As you
have probably determined, the House has now completed its work on the
floor and this gets to be a little bit of a hairy time for us at this point.
So I am going to cut my opening statement short in hopes that my fellow
committee members might follow suit. But we do welcome you here.
[The prepared statement of Hon. Nathan Deal follows:]
PREPARED STATEMENT OF THE HON. NATHAN DEAL, CHAIRMAN, SUBCOMMITTEE ON
HEALTH
The Committee will come to order, and the Chair recognizes himself for
an opening statement.
I am proud to say that we have four expert witnesses appearing before
us this afternoon that will help us examine the issues related to the
reauthorization of enabling legislation for Community Health Centers.
Without question, Community Health Centers are an integral part of our
country's health care delivery system, providing health care services to
people and communities that would not otherwise have access to such care.
As many of you know, this Subcommittee has exclusive jurisdiction over
legislation regarding Community Health Centers, and we are committed to being
good stewards of this program. We join with the President in our strong
support of Community Health Centers, and we applaud the thousands of Community
Health Center employees and volunteers that contribute so much to the success
of this program.
Again, I welcome our witnesses and thank them for their participation.
In the interest of time, I would ask my fellow Committee Members to waive
their opening statements or keep them as brief as possible so that we can
allow our witnesses to leave at decent hour. I would also like to ask for
Unanimous Consent that all Committee Members be able to submit statements and
questions for the record.
I now recognize the Ranking Member of the Subcommittee, Mr. Brown from
Ohio, for five minutes for his opening statement.
MR. DEAL. And at this time I would recognize my good friend from
Texas, Mr. Green, for an opening statement.
MR. GREEN. Thank you, Mr. Chairman, and I would like to ask
unanimous consent for the statement from our Ranking Member, John
Dingell, be placed into the record.
MR. DEAL. Well, I would ask unanimous consent that all committee
members have the right to submit their statements and their questions for
the record. Without objection, so ordered.
[Additional statements submitted for the record follow:]
PREPARED STATEMENT OF THE HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF MICHIGAN
Mr. Chairman, thank you for calling this hearing today to highlight
the critical role that Community Health Centers play in ensuring access to
care for millions of Americans nationwide.
Community Health Centers are local, non-profit, community-owned
healthcare providers that serve low-income and medically under-served
communities. They provide healthcare services to more than 15 million people
annually, 6 million of whom have no health insurance coverage. They are
located in more than 3,400 communities in every single State, including my
home State of Michigan where we have approximately 30 health centers.
Community Health Centers are vital to the health and well-being of our
country's most vulnerable citizens.
Currently, there are over 41 million uninsured Americans and untold
numbers of under-insured persons. Due to the slowing economy, this number is
increasing at a rapid pace. As a result, demand for healthcare services has
increased drastically, forcing risky delays for important primary and
preventive healthcare services.
For almost 40 years, America's Health Centers have helped communities
meet escalating health needs and address costly and devastating health
problems, from infant health development to chronic illness, to mental health,
substance addiction, homelessness, domestic violence, and HIV/AIDS. Community
Health Centers span urban and rural communities across the Nation and their
remarkable success has earned them broad bipartisan support among Federal,
State, and local policy-makers. We should continue to do everything within
our power to support these Health Centers and provide them with the resources
they need so that they can continue to do their jobs as successfully and
effectively as they have for the past four decades.
Legislation reauthorizing Community Health Centers should be
considered soon by this Committee. But I note that we should also not forget
the valuable contribution school-based health centers also make to communities
across our Nation. I hope that we can consider developing some program
enhancements for school-based health centers either during the consideration
of the Community Health Centers reauthorization or at some time in the near
future.
PREPARED STATEMENT OF THE HON. JOE BARTON, CHAIRMAN, COMMITTEE ON ENERGY
AND COMMERCE
Good morning. Mr. Chairman, I commend you for holding this hearing.
I look forward to working with you and the rest of the Subcommittee as we
consider the role played by community health centers in the health care
delivery system.
At the end of this year the authorization of community health
centers will expire and this Committee needs to examine how we can ensure that
this program continues to provide affordable and quality care to those who
need it most. Community health centers have received widespread support not
only at the federal level but more importantly, at the local level where the
care is being administered. It is important to note that these centers are
great sources of preventative health care, which helps to control ever-
increasing health care costs. It is our responsibility as federal
representatives to ensure that taxpayer's money is being spent efficiently
and community health centers have demonstrated that they are effective in
achieving this goal.
The statistics are impressive. There are over 900 community health
centers providing a broad spectrum of health services to 3600 localities, both
urban and rural, located in every state and territory in the nation. Of the
total number of community health center patients, 90% live below 200% of the
federal poverty line. The list of primary health care services administered
by community health centers is long-mammograms, dental services,
immunizations, prenatal care, mental health services, chronic disease
management, and cholesterol checks.
Community health centers are at the heart of our nation's health
care safety net. They work to provide care to the medically underserved and
are able to identify services unique to each community, constantly focusing on
building on their successes. Most importantly, these centers provide a
favorable alternative to patients who would otherwise utilize emergency rooms
for non-emergency services, which results in alarmingly high costs. By
providing preventative care, we keep people in the community healthier.
Healthy people use fewer services and this decreases the burden on our health
care delivery system, including the Medicare and Medicaid programs.
Certainly, as with any program, there is room for improvement.
However, we should continue to keep in mind that community health centers are
highly successful both in containing costs but more importantly, serving the
health care needs of local communities. I am interested to hear from our
witnesses how they believe the program can be strengthened.
I look forward to hearing from our witness from the Health Resources
Service Administration about how this program is administered and what the
goals are for the final year of the President's Expansion Initiative. I also
look forward to hearing from our three witnesses on the second panel. Mr.
Hawkins, from the National Association of Health Centers, for the perspective
he can provide in examining the program through the numerous centers across
the nation. Likewise, I want to thank Ms. Grant-Davis for testifying as to
how the various community health centers in the state of New Jersey
serve their patients. And finally, I especially want to thank Tarrant County
Commissioner Roy Brooks for coming in all the way from Texas to share how his
community was able to create and new community health center and how the
community is benefiting from this achievement. Thank you Chairman Deal for
calling this hearing today and I welcome the witnesses.
PREPARED STATEMENT OF THE HON. TOM ALLEN, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF MAINE
Mr. Chairman, thank you for holding this hearing today to examine
the important role of Federally Qualified Community Health Centers in
providing access to health care for Americans living in medically underserved
communities. President Bush and I agree about the importance of federal
investment in Community Health Centers (CHCs). I am pleased that the
President's budget includes a request for an additional $181 million
for CHS, which would bring the overall federal investment in CHCs to almost
$2 billion in FY07. This federal investment will go a long way to fulfill the
President's commitment to create 1,200 new or expanded health center sites by
the end of next year.
CHCs have a unique place in our health system, abiding by four key
principles: serving all citizens regardless of their ability to pay; targeting
resources to high need areas; providing access to comprehensive primary care
services; and governance and direction by the community being served.
CHCs are a particularity important component of Maine's health care
infrastructure. We have twenty-nine centers operating in federally designated
Health Professions Shortage Areas (HPSAs) throughout the State. Twenty
percent of Maine residents live in HPSAs for primary care, 18 percent in
mental health HPSAs; and 65 percent in dental HPSAs. One in ten Maine
residents receives care at a CHC during a given year. Approximately fifteen
percent of Maine Medicare (MaineCare) beneficiaries statewide are CHC patients.
CHCs are a model of efficient, cost-effective primary care delivery
which save health system dollars. For example, CHCs save the MaineCare
program more than thirty percent in annual spending per beneficiary due to
lower emergency department utilization, reduced specialty care referrals, and
fewer hospital admissions.
I look forward to working with my colleagues to reauthorize the
Community Health Centers program. CHCs are a shining example of how federal
investment in health care can improve access across this nation for citizens
in underserved communities, many of whom have no other means of health care
coverage.
PREPARED STATEMENT OF THE HON. TAMMY BALDWIN, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF WISCONSIN
Thank you Mr. Chairman and thank you to the witnesses who are joining
us today.
I cannot say enough good things about the amazing work that Community
Health Centers do. The Community Health Centers in my district-in Madison and
Beloit, WI-are incredibly vital parts of their communities and I am
continually amazed at the variety of critical services that they offer.
For some people, the Community Health Center is the only place where
they can access dental care. For others, it's the only place that provides
affordable care. And for yet others, it's the only place where they can
easily communicate with their health care providers without the interference
of language barriers.
The tie between Community Health Centers and the communities they
serve is invaluable and is something that must be preserved through continuing
the majority-patient requirement for governance boards. The requirement that
51% of board directors be patients provides Community Health Centers with an
incredible tool to ensure that they are, indeed, meeting the needs of the
community.
I think it's important to note that we are currently in the middle of
Cover the Uninsured Week. As we know, there are currently 45.8 million
Americans without health insurance, and millions more are underinsured.
We all know that Community Health Centers play a vital part in
providing the uninsured and underinsured with access to affordable care, but I
think it's important for us to take one moment to reflect that while this
access is fantastic and greatly appreciated, it is still not health insurance.
Community Health Centers cannot-and should not-bear the burden of providing
care for all of our nation's uninsured, and I look forward to this
Subcommittee addressing the need for systematic change of our crumbling health
care system.
Lastly, I'd like to voice my support for H.R. 5201, the
reauthorization bill that my colleagues Mr. Bilirakis and Mr. Green (of Texas)
have introduced and of which I was proud to be an original cosponsor. I look
forward to working with members of this Committee to move forward a
reauthorization that preserves the current structure of Community Health
Centers and ensures their continued ability to be vital parts of our
communities.
Thank you Mr. Chairman.
PREPARED STATEMENT OF THE HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF CALIFORNIA
Thank you, Mr. Chairman, for holding this important hearing on
Community Health Centers (CHCs). I believe the witnesses today will highlight
the crucial role that CHCs play in providing quality health care to
underserved communities across America.
For over 40 years, CHCs have provided high-quality, affordable primary
care and preventive services to the nation's most vulnerable populations.
Today, there are over 900 CHCs operating in 3,600 urban and rural sites in
every U.S. state and territory. In 2003, CHCs treated over 12 million people
in underserved areas, including 4.8 million uninsured patients. They
performed mammograms on over 200,000 women, gave check-ups and preventive
services to 1.6 million children, and administered 2.2 million immunizations.
CHCs also offer services that many other providers do not, such as
transportation, translation, and culturally sensitive health care that helps
overcome common barriers to health care.
In my home state of California, over 1.8 million Californians were
served at CHCs in 2004. In California's 14th Congressional District, which
I'm proud to represent, there are 14 CHCs. I cannot emphasize enough what an
important part of the health care safety net CHCs are, providing care to the
uninsured and underinsured who would otherwise lack access to health care.
Community Health Centers are essential, efficient, and effective and I'm proud
to support efforts to enhance their important mission.
The Health Centers Program, set forth in Section 330 of the Public
Health Service Act, was renewed in 2002 and is set to expire on September 30,
2006. I thank my colleagues, Representatives Michael Bilirakis and Gene
Green, for introducing H.R. 5201, the Health Centers Renewal Act of 2006 and
I'm proud to be an original cosponsor of this important bipartisan legislation
which reauthorizes the Community Health Centers Program through 2011.
I urge my colleagues on this Subcommittee and in Congress to support
H.R. 5201 and reauthorize the Community Health Centers Program so we can
continue to provide health care services to those who need them most.
PREPARED STATEMENT OF THE HON. PAUL E. GILLMOR, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF OHIO
Thank you, Mr. Chairman for holding this important hearing.
Earlier this week, I visited Fremont Community Health Services, a
Community Health Center located in my district. As some of you may know,
shortly after Hurricane Katrina hit last summer, Fremont Community Health
Services raised $20,000 to send two doctors, three nurses, and a mobile health
unit to assist a sister Community Health Center in Biloxi, Mississippi.
However, the medical team was soon hit in the form of government red tape,
delaying their departure -- The Health Resources and Services Administration
(HRSA) advised Fremont that they would not be covered in terms of
malpractice insurance under the Federal Tort Claims Act (FTCA) should they
choose to provide medical services in temporary locations, across state lines.
While the Fremont mobile unit was eventually granted temporary FTCA coverage
from HHS by allowing permanent federal employees onsite to swear-in the group
as "temporary federal employees," the same temporary federal liability
coverage was not extended to Fremont Community Health Services last January
when they attempted to assist the Biloxi Health Center yet again - because
there would not be a permanent federal employee on-site this time around to
temporarily "federalize" the medical team.
The Community Health Center in my district is not alone. In fact,
as a result of Hurricane Katrina, many Community Health Center sites were
either totally destroyed or closed due to damage, or damaged but still
operating. Although these Health Centers were calling for the help of sister
facilities throughout the country, Health Centers ready and willing to provide
that help simply could not, due to a lack of FTCA coverage. It took so long
for a team of Iowa Health Center volunteers to get the "federal green light"
that after a week in New Orleans waiting, and not working, they went back
home. A group of Texas Health Centers looked to by-pass the federal review
process by purchasing private liability coverage for health care providers
coming in from out of state, but were unsuccessful -- it turned out that the
insurance market would not support new coverage for such a high-risk hurricane
relief effort.
After raising this issue several times with HHS, and encouraging them
to exhaust all avenues of administrative authority to provide FTCA coverage
for such instances of natural disaster and public health emergency, HRSA has
indicated that a legislative change will be needed to address this issue. And
H.R. 3962, introduced last fall by Mr. Schwarz of Michigan would do just that
-- extend FTCA liability coverage for Health Center employees who travel
offsite, or across state lines to provide care at health centers affected by
President-declared natural disasters and public health emergencies.
I encourage my colleagues on this panel to join me in need to bring
further awareness to this issue and debate the merits of H.R. 3962, with the
hopes of enacting it soon. By doing so, we can do our part to ensure access
to care, and not deny it when people need it the most. We cannot wait for
another natural disaster or potential public health emergency.
Without objection, I would like to insert an Associated Press article
into the public hearing record reporting on this matter in further detail.
With that, I welcome the panel of witnesses today, look forward to their
testimony, and yield back by time.
PREPARED STATEMENT OF THE HON. CHARLIE NORWOOD, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF GEORGIA
Thank you Mr. Chairman.
We are approaching 1,000 community health centers with 3,600 sites
serving over 13 million Americans.
There are over 80 in Northeast Georgia alone. They operate in rural
communities where health services are either scarce or non-existent. They
provide care for the poor, so they don't use the emergency room.
I don't think I can say it any simpler -- health centers are working
and should be reauthorized. While I'd be open to modest changes, I think the
current program is a success.
While 25% of our population lives in rural areas, only 10% of
physicians practice there.
Rural Americans, like many folks in my district are more likely to
live below the poverty level and be uninsured.
Health centers address their needs, including treatment, preventive,
and emergency care. They treat anyone from the area regardless of their
ability to pay. They are also Medicare and Medicaid providers -- guaranteeing
access for our poor and elderly.
While healthcare costs have risen, health centers have kept theirs
well under those of other providers. Patients of health centers are
healthier, use emergency rooms less and save money. In Georgia they save the
state $13.4 million each year in Medicaid costs alone! They are a good deal
for poor Americans and taxpayers.
I have been an enthusiastic supporter of this program and am glad the
President has supported the expansion of centers in 200 new communities.
However, they cannot meet the demand for their services without the right
funding and staffing.
I have worked with Mr. Bilirakis to increase funding and more people
will be served and centers will open as a result. As for staffing I'd like
to point out that Title 7 funding, which I have defended with Congresswoman
DeGette for years, exists to recruit health professionals to serve in rural
areas.
I hope the appropriators are listening --We preserve Title 7 and we
alleviate the health professions shortages described by the Journal of the
American Medical Association that exist in rural health centers.
Recognizing and reauthorizing this program is critical to ensuring our
nation's uninsured and rural populations have access to affordable, quality
preventative and primary care services.
Thank you and I yield back
PREPARED STATEMENT OF THE HON. EDOLPHUS TOWNS, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF GEORGIA
Mr. Chairman, thank you for having this hearing on the nation's
community health centers. The panels today will testify to the great
importance of the work of these centers in providing care for those most at
risk in our communities. Our goals here today should not be to change the
structure of what has already been successful. Rather we should be
talking about enhancing and expanding what has already worked.
The cost effective services provided by health centers contribute to
the social and physical well-being of millions of Americans from school
children and the elderly to adults who have NOWHERE else to go for health
care. That is why I am in favor of a substantial increase in funding for
community health centers.
Mr. Chairman, in Brooklyn, New York, Twelve Community Health Centers
serve almost 200,000 people a year, an increase of nine percent over three
years. They provide cost effective health services for our low-income
residents, including immunizations, mammograms, prenatal and perinatal
services, cancer screenings, child health services and a host of other
critical services. We should expand these services so that thousands
of other low income residents can have access to critical care.
Thank you.
PREPARED STATEMENT OF THE HON. FRED UPTON, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF MICHIGAN
Mr. Chairman, I am a strong supporter of the Community Health Center
program and look forward to working with you on reauthorizing this vital
health care safety net program. We are very fortunate that the poor,
uninsured or underinsured, homeless and migrant populations in urban and
rural communities in my Southwest Michigan Congressional district are
well-served by three networks of community and federally qualified health
centers, with a total of ten clinic sites providing accessible, high-quality
primary and dental care services. I have great respect for the commitment
and dedication to our most vulnerable citizens that I have witnessed in the
administrators and health professionals at these health centers. They are
a special breed fulfilling a challenging mission.
MR. GREEN. Mr. Chairman, I wish I could tell you I am going to
keep mine short but I think this is such an important issue. I want to
thank you for holding the hearing as Democratic co-sponsor on this with
Congressman Bilirakis from Florida. I think it is fitting our
subcommittee is holding this hearing on Cover the Uninsured Week,
since health centers are a critical part of our country's safety net.
In 2005, health centers provided care to six million uninsured
individuals who represented 40 percent of the patient population at health
centers. Ninety-one percent of the health center patients are low-income
and 36 percent are Medicaid beneficiaries. Without a doubt, health
centers are meeting their vision of providing much needed healthcare to
medically underserved in our country. Much of this success can be
attributed to core elements of the section 330 statute Congress put in
place to authorize the health center program.
To be eligible for Federal funding, health centers must be located in
medically underserved communities, the majority governed by
community members utilizing the centers for healthcare. And they must
provide comprehensive primary and preventative healthcare with
services available to all community residents regardless of the patient's
ability to pay. This focus on primary and preventative healthcare has
yielded a tremendous savings for our healthcare systems as health centers
provide the uninsured and underinsured with access to care that they
would otherwise seek from a hospital emergency room.
Access to affordable primary care health centers has reduced the
need for inpatient and specialty care because medical problems in health
center patients are treated earlier before they reach emergency
proportions that require a trip to the emergency room or inpatient
hospital care. In fact, studies suggest that health centers save Medicaid
approximately 30 percent in annual spending on beneficiaries receiving
care at our Nation's health centers.
The successful result is these health centers have become the medical
home for more than 15 million Americans. Health centers also represent
the Nation's largest primary care system with one in nine Medicaid
beneficiaries and one in five low-income individuals receiving care at
these centers.
I have a personal interest in this issue, as we have been working for
years in the Houston area to establish additional community health
centers to serve our growing uninsured and underinsured population. My
State of Texas unfortunately ranks number one in the level of uninsured
with 25 percent of Texans living without health insurance. The statistics
for the Houston area are just as troubling, more than 30 percent of Harris
County residents living without health insurance.
Despite the obvious need for additional community centers in the
Houston area, we have been playing catch up for quite a while. Last
year, our area was awarded five additional FQHCs, bringing our total to
nine, including look-alike centers. When you consider nine sites, more
than one million uninsured however in the Houston area will still have
fewer than ten FQHCs while other cities, such as Chicago, have more
than 70 sites.
In the Houston area we know that our work is not done. As a Nation,
we have a long way to go before we meet the President's goal of locating
a health center in every low-income county in this country. In fact,
studies suggest that there are still more than 904 counties in the U.S. in
need of a health center. To ensure these goals are met, it is crucial we
reauthorize the health center program, whose reauthorization expires this
year.
Mr. Bilirakis and I have introduced H.R. 5201 to do just that. In our
legislation, we authorize a program until 2011, keeping intact the core
elements of the program that has been critical to its success. I would like
to thank the majority of the subcommittee for co-sponsoring the
legislation and hope our committee leadership will put the
reauthorization at the top--at the important part of the top of our agenda.
And again, I want to thank our Chairman, the Ranking Member, and
our witnesses who are appearing today and I look forward to the
testimony. And I will give thoughts toward the next step we need to take
to ensure continued success of health center programs. Thank you, Mr.
Chairman.
MR. DEAL. I thank the gentleman. I now recognize my friend, Dr.
Burgess, for an opening statement.
MR. BURGESS. Thank you, Mr. Chairman. And I, too, will not use
all of the time. But I do want to thank you for calling the committee
today, a subject that is important to me and the community that I
represent.
Community health centers comprise an important component of our
healthcare system. By providing comprehensive primary health, mental
health, oral screenings and substance abuse to low-income and
underinsured patients, health centers fill an important gap in the
healthcare safety net. As Mr. Green just pointed out, more than 60
percent of federally qualified health centers patients have no other health
insurance and many others are underinsured. It is essential that the
health clinic exist in every community where need exists. Unfortunately,
this is not the case in every community, especially the area of Texas that
I represent.
President Bush has made a serious commitment to expand
community health centers to more underserved communities. I have
been working over the last several months with my county
commissioner, Roy Brooks, who is here today, to establish another
federally qualified health center in Tarrant County, Texas. Over that
time, there have been difficulties, but the stakeholders involved
understand the importance of establishing a clinic in the southeast part of
the city of Fort Worth. Diseases, chronic diseases, such as congestive
heart failure, hypertension, diabetes and some of the highest rates of
infant mortality anywhere in the country persist in this corner of Texas
and the need for a health center is indeed critical.
After the devastation of Hurricane Katrina with so many Louisiana
residents taking flight to Texas and especially North Texas, the need has
only been compounded. So I look forward to working with
Commissioner Brooks and our friends at HRSA and the National
Association of Community Health Centers to make this goal a reality.
And Mr. Chairman, just a point of personal privilege, I do want to
thank Commissioner Brooks. He readjusted his schedule, came all the
way up here today to be with us. As often pointed out back home
during--we just had our primary a few months ago in Texas and Mr.
Brooks and I are not on the same ballot but we are frequently on the
same page, especially when it comes to issues like a community health
center. And I believe, if I am not mistaken, Mr. Brooks is here with his
daughter and we are very happy to welcome you to the committee today.
Thank you, Mr. Chairman. I will yield back.
MR. DEAL. I thank the gentleman and I recognize Mr. Ferguson, the
Vice Chairman of this subcommittee, for his opening statement.
MR. FERGUSON. Thank you, Mr. Chairman. Thank you for holding
this important hearing on community health centers. I want to begin by
welcoming Ms. Kathy Grant Davis, who is Executive Director of the
New Jersey Primary Care Association, which is in Princeton, New
Jersey. Our community health centers in New Jersey provide critical
care and services to many underserved populations in my home State,
including migrant and homeless health centers. Ms. Davis' organization
and community health centers throughout our Nation are a valuable
resource for taking care of people in our communities.
For more than 40 years, health centers have provided high quality,
affordable primary care and prevention services. The people served by
these organizations are from underserved populations, as I say, and are
often isolated from other forms of care used by the community. They
may be isolated by language and economic factors, and community
health centers are there to serve them.
I look forward to Kathy's testimony today and testimony from our
other panelists, and I look forward to working with the committee and
you, Mr. Chairman, to reauthorize these valuable community healthcare
partners and I yield back.
MR. DEAL. I thank the gentleman. Well, we made good progress
there. I am pleased to introduce our first panel, which consists of Ms.
Elisabeth Handley, who is the Division Director for Policy and
Development of the Bureau of Primary Healthcare at U.S. Health and
Human Services, commonly referred to as HRSA. And the subject of
today's hearing is The Critical Role of Community Health Centers in
Ensuring Access to Care. Ms. Handley, you are certainly in a unique
position to comment on that and we would welcome your opening
statement. I would say to all of those who will testify that your written
statements have been made a part of the record and you may feel free to
elaborate on anything that you would like to. But we are pleased to have
you and will recognize you at this time.
STATEMENT OF ELISABETH HANDLEY, DIVISION
DIRECTOR FOR POLICY AND DEVELOPMENT, BUREAU
OF PRIMARY HEALTH CARE, HEALTH RESOURCES
AND SERVICES ADMINISTRATION, U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES
MS. HANDLEY. Thank you, Mr. Chairman, and members of the
subcommittee for the opportunity to meet with you today on behalf of the
Health Resources and Services Administration to discuss the critical role
of health centers and access to care. I have this oral statement and I
believe you have just given me permission to submit my entire written
statement for the record. Thank you.
For more than 40 years, the health centers program has helped build
high quality and cost-effective primary care delivery systems that serve
low-income residents in inner cities and in rural and isolated areas. I am
proud today to update you on the success and growth of the health
centers program.
The President's Health Center Initiative, which began in fiscal year
2002, complements the President's proposals to increase health insurance
coverage in private and public insurance programs and to help all
Americans gain access to affordable, high-quality healthcare. By any
measure, we have been enormously successful implementing the
President's Health Center Expansion Initiative.
In 2005, the health center system served an estimated 14 million
people. That is over 3.5 million more than in 2005 at more than 3,740
delivery sites. This represents an increase of more than 770 new and
expanded sites since 2001. The fiscal year 2007 budget will continue the
President's commitment to create 1,200 new or expanded sites to serve
over 15.8 million people in fiscal year 2007.
The President proposes an additional $181 million for the sixth year
of the President's expansion plan to significantly expand the health
center safety net by increasing the number of access points and the
people served. The requested increase would fund the development of
182 new access points. That is new starts administered by a new grantee
organization and satellites of existing grantees, 120 expanded existing
sites and serve 1.2 million new patients.
New access points will be competitively established through health
centers targeting the neediest populations and communities by replicating
existing models of success. Expanded access points will be targeted in
communities where an existing health center's ability to provide care
falls short of meeting documented service delivery needs of the
uninsured and underserved populations. By significantly expanding the
number of existing access points, increased penetration into these
populations will be achieved.
In addition, the President has established a new goal to help every
poor county in America that lacks a health center by establishing a new
health center or a rural health center. Within the total request, $52
million will be directed for a new initiative to fund health centers in poor
counties around the Nation. With the fiscal year 2007 requested
increase, the President's Health Center Initiative is on track to establish
or expand 1,200 sites and to serve an additional 3.5 million patients over
the 2001 level.
However, there is a likelihood that without special attention some
high-poverty counties throughout the country may not successfully
secure a health center site. So this new initiative will target 80 high
poverty counties without a health center site. The goal of the new
initiative is to carry the success of the current initiative further to ensure
that every poor county that can support one healthcare center site has
one.
Access to primary and preventative health services is critical,
especially in poor counties that are medically underserved. Health
centers are unique among primary care providers for the array of
enabling services they offer, including care management, translation,
transportation, outreach, health education. They commit significant
resources to managing chronic conditions, too, diabetes, asthma and
cardiovascular disease, for example. In 2004, health centers provided
over 52 million encounters, over 250,000 mammograms, 1.5 million
PAP tests and nearly 2.4 million encounters for immunizations, as well
as over 425,000 HIV tests and counseling and prenatal and delivery care
for 364,000 women. Over 95.7 percent of the grantees also provided
translation services.
The overall effectiveness of the health center program has been
proven in numerous studies and evaluations. Under the Administration's
ratings of Federal programs, the health center program receives the
highest possible ranking, effective. Programs rated effective, according
to OMB, set ambitious goals, achieve results, are well managed and
improve efficiency. The program achieved this rating based on the fact
that it's designed to have a unique and significant impact and that
evaluations indicate that the program is effective at extending high-
quality healthcare to underserved populations.
Mr. Chairman, in conclusion, I would like to note that health centers
offer high-quality, prevention-oriented, case-managed, family-focused
primary care services that result in appropriate and cost-effective use of
ambulatory, specialty, and inpatient services. Primary care is delivered
for all life cycles and includes a full range of health services. In
administering grants for the health centers program, we take great pride
in the high evaluation given the program and in the bipartisan support of
the Congress for the program. And we fully recognize that the program
works only as a partnership with those extraordinary local primary care
providers who provide indispensable quality clinical services to
underserved Americans with few healthcare alternatives. Thank you.
[The prepared statement of Elisabeth Handley follows:]
PREPARED STATEMENT OF ELISABETH HANDLEY, DIVISION DIRECTOR FOR POLICY AND
DEVELOPMENT, BUREAU OF PRIMARY HEALTH CARE, 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 meet with you today on behalf of the Health Resources and
Services Administration (HRSA) to discuss the Health Centers Program.
We testified before the Subcommittee on August 1, 2001, to discuss
the most recent reauthorization of the Health Centers Program. At that time,
the funding for the program was approximately $1.2 billion. We thank you for
both your efforts in reauthorizing the program and ensuring funding to expand
this worthwhile program to accomplish the President's Initiative, with a
requested FY2007 funding level of approximately $2 billion.
Today, I am proud to update you on the success and growth of the
program to date. By any measure, we have been enormously successful
implementing the President's Health Center Expansion initiative-an effort
designed to establish or expand 1,200 health center sites and serve over
15.8 million patients in FY 2007. This continues to be a priority because
we know that these funds go to provide direct health care services for
our neighbors who are most in need.
In 2005, the health center system served an estimated 14 million
people-almost 3.5 million more than in 2001-at more than 3,740 service
delivery sites that represents an increase of more than 770 new and expanded
sites since 2001. Health Centers are located in all 50 States, the District
of Columbia, and the territories.
The President's 2007 budget proposes an additional $181 million for
the sixth year of the President's expansion plan to significantly expand the
Health Center safety net by increasing the number of access points and people
served. Approximately $181 million would fund the development of 182 new
access points (new starts administered by new grantee organizations and
satellites of existing grantees), 120 expanded existing sites, and serve 1.2
million new patients. New access points will be competitively established
through Health Centers targeting the neediest populations and communities by
replicating existing models of success. Expanded access points will be
targeted in communities where an existing Health Center's ability to provide
care falls short of meeting the documented services delivery needs of the
uninsured and underserved populations. By significantly expanding the number
of existing access points, increased penetration into these populations will
be achieved.
With the FY 2007 requested increase, the President's Health Center
Initiative is on track to establish or expand 1,200 sites over the 2001 level.
However, there is the likelihood that without special attention, some high
poverty counties throughout the country may not successfully secure a Health
Center site. Included in the President's commitment is the goal to create a
Health Center site in every poor county that lacks a Health Center site and
can support one. Within the total request, $52 million will be directed to
fund 80 new Health Centers sites in poor counties around the Nation. Access
to primary and preventive health care services is critical, especially in poor
communities that are medically underserved.
Health Centers Program
The distinguishing mission of the Health Centers Program is to
empower communities to solve their own local access problems and to improve
the health status of their under served and vulnerable populations by building
community-based primary care capacity and by offering case management, home
visiting, outreach, and other enabling services. The program also addresses
significant challenges facing communities by targeting public housing,
homeless, and migrant health center development as well.
Health Centers provide access to high quality, family oriented,
comprehensive primary and preventive health care, regardless of ability to
pay. Health Center grantees, as a result of their receiving from HRSA a
grant under section 330 of the Public Health Service (PHS) Act, are eligible
for enhanced benefits including Medicaid/Medicare reimbursement, access to the
Federal Tort Claims Act (FTCA) program for health center malpractice coverage,
and access to the program for discount drugs for patients under section 340B
of the PHS Act.
Under section 330, Health Centers are required to provide primary
health services, including those related to family medicine, internal
medicine, pediatrics, obstetrics, or gynecology that are furnished by
physicians and where appropriate, physician assistants, nurse practitioners,
and nurse midwives. Additional required basic health services include
diagnostic laboratory and radiological services and a series of preventive
health services, including prenatal and perinatal services; appropriate
cancer screening; well-child services; immunizations against vaccine-preventable diseases; screenings for elevated blood lead levels;
communicable diseases and cholesterol; pediatric eye, ear, and dental
screenings; and preventive dental services.
Health Centers Requirements
To receive section 330 grant funds, a clinic must meet a number of
statutory requirements. The Health Center must: be located in a federally
designated medically underserved area (MUA) or serve a federally designated
medically underserved population (MUP); be a public or private nonprofit
health center; provide comprehensive primary health services, referrals, and
other services needed to facilitate access to care, such as case management,
translation, and transportation; have a governing board, the majority of whose
members are patients of the Health Center; provide services to all in
the service area regardless of ability to pay; and offer a sliding fee
schedule that adjusts according to individual family income.
The requirement that a majority of board members be Health Center
patients makes these clinics unique among safety net providers and is
designed to ensure that the centers remain responsive to community needs.
Under section 330, a Health Center applicant needs to demonstrate the
establishment of a governing board that has a 51 percent consumer majority,
meets monthly, selects the Health Center's services and hours, approves the
Health Center's annual budget, selects the Health Center's director, and
establishes the Health Center's general policies.
Health Centers Awards Process
HRSA accepts, on a competitive basis, applications from eligible
organizations seeking a grant for operational support for new and existing
Health Centers. Eligible organizations are public or nonprofit entities
including tribal, faith-based and community-based organizations.
The largest category of grant awards includes new access points
encompassing both new clinic starts and satellites of existing clinics.
Other categories include grants to expand medical capacity at existing
locations.
All eligible and responsive grant applications are referred to an
Objective Review Committee (ORC), comprised of experts in the delivery of
community health care services, for their independent review and
recommendations. When funding decisions are made, each applicant receives a
notification letter listing strengths and weaknesses of each section of their
application as noted by the ORC. This review approach provides valuable
technical assistance for improving future applications for both awardees and
those we were not able to approve during a particular cycle.
Technical Assistance
HRSA works directly with communities to develop needed resources
through the primary care associations in each State. These primary care
associations, funded by HRSA, provide ongoing technical assistance involving
guidance and options for organizations interested in applying for Health
Center grants and to existing Health Center grantees interested in expanding
their comprehensive primary care services.
In addition, HRSA assists applicants through grant-writing workshops
and other technical assistance activities that are provided through a
cooperative agreement with the National Association of Community Health
Centers. Such activities assist applicants to: demonstrate a high level of
need in the community; present a sound proposal to meet this need; show that
the organization is ready to rapidly implement the proposal; display
responsiveness to the health care environment in the service area; and
demonstrate collaborative and coordinated delivery systems for the provision
of health care to the underserved in their communities.
Federally-funded health centers are similar to other health care
businesses. Like most businesses, at any point in time, approximately 4
percent of health centers are experiencing significant challenges to their
viability. HRSA, with assistance from interdisciplinary teams that may
include contractors, grantees and staff, provides intensive technical
assistance to grantees to address problems. At all times, continuity of
service for the affected population is the first priority under consideration
in addressing such challenges.
Health Centers Services
Health Centers offer ambulatory services that reflect the diverse
needs of the populations they serve. Because of the combination of low
incomes, linguistic barriers, and frequently poor health status, Health Center
patients require access to enabling services as well as comprehensive primary
care services.
Health Centers are unique among primary care providers for the array
of enabling services they offer, including case management, translation,
transportation, outreach, eligibility assistance, and health education.
Health Centers commit significant resources to managing chronic conditions
including diabetes, asthma, and cardiovascular disease.
In 2004, Health Centers provided more than 52 million encounters,
over 250,000 mammograms, over 1.5 million pap tests, and nearly 2.4 million
encounters for immunizations, as well as over 425,000 HIV tests and
counseling, perinatal and delivery care for 364,000 women. Over 95.7 percent
of grantees provided translation services either directly or by referral.
Health Centers are staffed by a combination of clinical, enabling,
and administrative personnel. They are typically managed by a chief
executive officer and a clinical director. Depending on the size of the
patient population, the clinical staff consists of a mixture of primary care
physicians, nurse practitioners, physician assistants, substance abuse and
mental health specialists, dentists, hygienists, and other health
professionals.
Health Centers Financing
Health Centers receive funding from a variety of sources. A
majority of Health Centers revenue comes from Federal resources including
Medicaid, Medicare, the section 330 grant, SCHIP and other Federal programs.
On average nationwide, HRSA grants comprise 23 percent of Health Center
revenue, but as little as 15 percent depending on the individual community and
grant application. At 35 percent, Medicaid is the largest source of revenue
for Health Centers, followed by Federal grants. Health Centers serve about
10 percent of all Medicaid enrollees nationally.
For Health Centers' revenues, in addition to Medicaid and the section
330 Federal grant funding, Medicare accounts for 6 percent, self-pay for 6
percent, other third-party payers 7 percent, other State/local government or
foundations account for 18 percent and the remaining 5 percent from other
sources.
Health Centers Background
The development of the Consolidated Health Centers Program began
over 40 years ago with the creation of the migrant health center program
and followed by the neighborhood health center demonstration projects
initiated in 1965 and first funded by Congress as part of the War on Poverty.
By the early 1970s, about 100 neighborhood health centers had been established
under the Economic Opportunity Act. These centers were designed to provide
accessible, dignified personal health services to low-income families.
Community and consumer participation in the organization and a
patient-majority governing board were features of the Health Center model.
With the phase-out of the Office of Economic Opportunity in the early 1970s,
the centers supported under this authority were transferred to the Public
Health Service. The mandate of the centers was broadened so that
comprehensive primary and preventive services were provided to all who came
through the doors. The Community Health Center program, as authorized
under section 330 of the Public Health Service Act, was established in 1975.
A reauthorization that consolidated the separate authorities of the Community,
Migrant, Homeless and Public Housing Health Centers under section 330 took
place in 1996. Most recently, the Health Care Safety Net Amendments of 2002
reauthorized the Consolidated Health Centers Program through 2006. The 2002
Health Center reauthorization requires that grants be awarded for FY 2002 and
beyond in such a way that maintains the proportion of the total appropriation
awarded to migrant, homeless and public housing applicants in FY 2001. In
general, about 81 percent of funding is awarded to community health centers,
with the remaining 19 percent divided across migrant, public housing, and
homeless health centers.
Health Centers' Effectiveness
The overall effectiveness of the Health Center program has been
proven in numerous studies and evaluations. Under the Administration's rating
of Federal programs, the Health Center program receives the highest possible
ranking -- "Effective." Programs rated "Effective," according to the Office
of Management and Budget, "set ambitious goals, achieve results, are
well-managed and improve efficiency." The program achieved this rating based
the fact that it "is designed to have a unique and significant impact," and
that "evaluations indicate the program is effective at extending high-quality
health care to underserved populations."
Conclusion
Health Centers offer high quality, prevention-oriented, case-managed,
family-focused primary care services that result in appropriate and
cost-effective use of ambulatory, specialty and in-patient services. Primary
care is delivered for all life cycles, and includes a full range of health
services. In administering grants for the Health Centers Program, we take
great pride in the high evaluation given the program, and the bipartisan
support of Congress, and fully realize that the program works only as a
partnership with those extraordinary local primary care providers providing
indispensable quality clinical services to underserved Americans with few
health care alternatives. We look forward to working with the Committee and
the Congress in reauthorizing the Health Center program. I would be happy to
answer any questions at this time.
MR. DEAL. Thank you. I will begin the questioning. First of all, we
understand that the President's Initiative is designed to try to help the, as
we would call them, poor counties. Would you explain the criteria that
are used to determine who gets priority in the grant process? I have a
rural district by and large, but it is on the fringe of the Atlanta
metropolitan area. And some of my counties that do not have a hospital
and in some cases do not have a doctor, do not qualify based on income,
because we have some of those commuters who are commuting into
Atlanta that have rather high incomes that skew the average income for
the county. But it is still a medically underserved area in terms of
personnel available in the community. Does the issue of medically
underserved, is that a criteria that you consider, as well?
MS. HANDLEY. Let me describe a little bit about the way the
program might look or the concepts behind the program. First of all, let
me give you a sense of the way the money part of it would work.
We anticipate HRSA awarding $48 million to 80 new access points
with the fiscal year 2007 budget and $4 million for 50 planning grants.
And the conceptual framework for the program is to have a health center
in high poverty counties where there is no existing health center and
there is high poverty but where there is also an ability to support a health
center. We haven't determined all of the program parameters at this
point in time.
MR. DEAL. One of the issues that Dr. Burgess has raised with us
privately, and he may get back to ask the question in greater detail, is the
requirement as I understand it, that 51 percent or a majority of the
makeup of the board must be patients themselves. And in new startup
centers I would think that would be a difficult situation. There has been
some suggestion that perhaps we should look at some alteration on
startup centers in order to be able to satisfy that. Have you found that to
be a deterrent and a problem in new startup centers?
MS. HANDLEY. Mr. Chairman, what you are referring to, the
governance requirement is that a majority, which is generally speaking
about 51 percent of the board, be comprised of consumers. And we
believe that it is sort of a cornerstone of the program in that it provides a
consumer input to the leadership and decision making that takes place in
the organization. We do understand that new starts will need to have
time to come into compliance with the requirements. How they will
come into compliance is a part of their application but we give them
additional time after they have actually become a new start and been
funded, to come into compliance with our requirements. We have not
found this to be an issue with a great number of health centers, even
with--it hasn't been an issue in the program.
MR. DEAL. One of the things that we have struggled with in this
committee dealing with the cost of healthcare, is an effort to try to
decrease the number of emergency room presentations, especially for
non-emergency reasons. Do you have any evidence that community
health centers help to deal with that number of emergency room
presentations?
MS. HANDLEY. I have not come prepared with any data today but
we would be happy to provide data later. What I can say is that the
primary healthcare provision that the health centers do is really essential
to providing a medical home for millions of Americans. And the fact
that they have a medical home where they can get primary and very
comprehensive primary care services means that they are going to have
less of a need for using an emergency room or going to other kinds of
providers.
MR. DEAL. Well, I think you have hit on the term that I have heard
repeatedly and that is medical home. When I ask in my local community
some of the people who are conducting the questioning of various
individuals who had repeat performances or repeat appearances at the
ER, they were asked who their medical home doctor was and they gave
the name of the ER doctor. We would like to change that pattern and
obviously, I do think that community health centers do a good job of
providing that alternative medical home, which has the effect I think of
reducing those ER visits, especially the non-emergency presentations.
Thank you very much. I am going to recognize Mr. Green for his
questions.
MR. GREEN. Thank you, Mr. Chairman. And we have some stats, at
least for Harris County because we have a small number but because we
are partnering with creating these current hospital systems in the area,
that will show in their participation based on their belief, and these are
both for-profit and non-profit, their belief that they will lower the number
of visits if there is a community health center close that will take them.
But we will get that information at least. And again, ours is small in
Harris County compared to the number of centers, but I am sure we can
get that information nationwide. Ms. Handley, the President stated as a
goal having a community health center in every poor county in the
country. And the National Association of Community Health Centers
teamed with George Washington University estimated that 929 poor
counties in our country are without a health center. The Administration's
budget proposed a $181 million increase in health center funding for
fiscal year 2007, which would bring the total funding to nearly $2 billion
next year. As we consider the authorization through 2011, what
authorization levels does HRSA believe we need in the out years, the
2010 or 2011, to keep us on the path to achieve the President's goal?
MS. HANDLEY. I am not in a position, sir, to respond to what we
need in additional out years to meet the goal.
MR. GREEN. Okay. Coming from--
MS. HANDLEY. We can get that for the--
MR. GREEN. Coming from our side, of course, we would like to
have no cap on it and get whatever we can get through the appropriations
process, but sometimes that is not always possible. I appreciate that
information you shared with the committee. Last summer the GAO
issued findings from a study of the Health Center Program. Under the
Health Center Program, centers are required to provide referrals for
specialty care that are not deliverable at the center. And about only one
of the beauties of it is that you do have full gamut of access--dental,
psychiatric. The GAO found that many health centers are having
difficulties finding specialty care for patients, especially for the
uninsured. Many of the difficulties are due to a shortage of available
specialists. The result, according to the GAO, was long waiting lists for
health center patients to see specialty care. Can you comment on the
actions HRSA has taken to remove the barrier to care and what was
posed as a threat to the patient's health and in my view works against the
success of our centers to achieve reducing health disparities? Has that
been an issue with some of our health centers in other parts of the
country?
MS. HANDLEY. I am not aware of whether it has been an issue in
other parts of the country, sir. I think I would have to get back to you
with an answer for that.
MR. GREEN. Okay. If you could just get back to me whenever you
can.
MS. HANDLEY. Sure.
MR. GREEN. Mr. Chairman, that is all the questions I have. Thank
you.
MR. DEAL. I thank the gentleman. Dr. Burgess, I haven't stolen all
of your questions but I did steal the one about the makeup of the board.
But you are recognized for questions.
MR. BURGESS. Thank you, Mr. Chairman. You can steal my
questions all you like. Did you get a satisfactory answer?
MR. DEAL. I expected you to explore it further.
MR. BURGESS. Well I guess, Ms. Handley, that remains a concern of
mine. I heard part of your answer to the Chairman and I will admit I
haven't been here very long. I've only been in Congress three years, but
my observation of the startup time for the only clinic in Tarrant County
was years. One of the stumbling blocks of setting that up was having to
constitute the board. And the education of board members to be able to
run what is realistically--I mean, I have run a clinic before. I have run a
medical practice and it is a difficult financial venture that if you make the
wrong decisions can all come apart at the seams. What would be wrong
with relaxing some of those requirements for a short period of time,
particularly in an area like Tarrant County or maybe down in Houston
where we have had people displaced by Hurricane Katrina and so the
ranks of the uninsured have swelled in those areas? What would be
wrong with relaxing those board requirements for a short period of time
to allow the clinic to become up and functional and then identify people
who are served by the clinic to become additional board members and
ultimately make up the 51 percent?
MS. HANDLEY. Well sir, currently the way the process works is if
they want to become a new access point they don't actually have to have
the 51 percent. They have to have a plan to getting to the majority on the
governance board. So in essence, there is a time period during which
they can get the board and accumulate the board.
MR. BURGESS. How long a time period is that, if I may?
MS. HANDLEY. I think the period is a reasonably long period that
might extend to as long as a--
MR. BURGESS. Could you get that information to the committee?
MS. HANDLEY. Yes.
MR. BURGESS. And perhaps the precise language that a group would
need to follow if they were to do that? You know, one of the problems I
have is I look at that map of where the Federally qualified health centers
are in this country and I see a bunch in the east, I see a bunch paralleling
the Mississippi River. I see a bunch in California. I don't see many in
north Texas. What are they doing right that we are doing wrong that
allows them to have the clinics and us not?
MS. HANDLEY. I think there has been a lot of interest and activity in
your State. As you pointed out in the beginning, really, health centers
are a small business and it takes time to get a small business up and
running. And I think there has been a lot of activity in the Primary Care
Association and the Primary Care Office in the State of Texas to grow
the health center program. And we have in fact worked closely with
them so that there have been some new look-alikes, which provide the
organizations, the health centers, with increased revenue from Medicare
and Medicaid and decreased costs for pharmaceuticals. So the State and
us through our funding of the Primary Care Association and the PCO
actually have been working together to grow these organizations.
MR. BURGESS. But let me interrupt you because Tarrant County, I
am not sure of the precise population but about a million. Just North
Denton County, population 480,000. Tarrant County has one Federally
qualified health center that opened this year and I don't remember the
trajectory for the number of years that it took to get there but I have
heard five, six, seven, even eight years length of time to get that started
up. Denton County has zero Federally qualified health centers. What do
we need to be doing in North Texas to make these facilities available to
our patients who are just as much in need as patients in states that border
the Mississippi or in the Northeast or out west? How do we develop the
program so that we can get the facilities where they are needed?
Something has been missing from North Texas and I would like you to
help me identify what that is and how to correct that problem because I
have got zip codes in my district that have infant mortality rates that
should not be in this country. They simply should not be. I have got
healthcare disparities in zip codes in my county that just should not be.
And I think part of the problem is the lack of this type of facility in those
communities has not just hurt access but it hurts utilization. People have
to go so far to a county health facility that they just simply don't bother
or they don't bother to get the blood pressure checked or the routine
checks that are going to hold the costs down. Help me with what those
other places are doing right that we are not doing.
MS. HANDLEY. Well, I think part of--two responses. One is that it
is, again, it is a small business that does take time to grow and is a
partnership within a local community. I think the second part of the
answer is that in addition to the Primary Care Association within the
State and the Primary Care Office, which is a part of the State
Department of Health, we are certainly willing to talk with you further
about how it might be possible.
MR. BURGESS. Well, I hope so because I have got the CEOs of
every hospital in Tarrant County sitting down in boardrooms with me.
They get it. They understand. They are ready to be good partners in this
but we can't move off dead center. And I guess because I am new and I
don't understand how bureaucracy works or doesn't work, I am having a
lot of difficulty understanding why I can't get these services for my
constituents. Mr. Chairman, thank you. I will yield back.
MR. GREEN. If I could ask you to yield? I know your time has run
out but since I am the only one on our side I am going to take the
phantom time, I guess. But one of the things we identified years ago was
before we get to a healthcare center is that the CAP Program that we had
for the early '90s--I know Congressman Bilirakis--
MR. BURGESS. Mr. Green, I am reclaiming my time. With all due
respect, we have been working at this. This is not just something that has
started in the last few months.
MR. GREEN. I know but--
MR. BURGESS. And I will be happy to visit with you after.
MR. GREEN. Okay.
MR. BURGESS. But I will save the committee's time. I don't think I
need that lecture today.
MR. DEAL. Well, the next person for questioning is Mr. Bilirakis
from Florida.
MR. BILIRAKIS. Thank you, Mr. Chairman. I have an opening
statement and I ask unanimous consent that it might be made part of the
record. I am sorry I wasn't here when you started out.
MR. DEAL. They have already been approved for admission in the
record.
MR. BILIRAKIS. Oh, okay. It is my understanding that over the past
four years HRSA has funded over 700 new community health center
sites with the increased funding that Congress has provided and for
which I really strongly feel the Administration should be commended. I
know that the President feels very, very strongly about this subject and I
have been pleased to lead, along with my colleagues Mr. Brown and Mr.
Green and others, the bipartisan effort to secure those increases.
Can you tell me over the past four years--well, let me back up first.
Can you tell us with certainty whether Section 330, grant funds in
general and expansion funds in particular, are being targeted to
communities with the greatest need? In other words, there is a strong
feeling for additional funding and whatnot and it has been there, it isn't
being used the way that we intend that it be used. That is the general
question.
MS. HANDLEY. Yes, sir, I do believe it is. We have need built into
the application process in a couple of ways and we are working on
strengthening the process for the future. The way it works now is that
we look at need in the application process. It is an eligibility sort of
review criteria. If you don't have a high enough need, you don't even go
through the objective review process that all competitive applications go
through if you don't meet that threshold score of need. In addition,
within the application itself there is a score that is assigned for need so
we are looking in two ways in the current process. In the future, we have
added more weight to need so for future funding cycles we anticipate that
need will become even a larger part of the process. It won't be a
screening factor. It will be built into the actual application score so that
it is 35 points out of 100. And we believe that this will make sure that
we are targeting our scarce Federal dollars to the places of greatest need
and we are providing flexibility for the applicants in that we are going to
have standardized data. But not that they have to provide every--they get
to pick from among the data items. So we think what we have for the
future will even move towards exhibiting greater need. And we
published in the Federal Register, April 26, our response to the proposed
revised need process and now have this available for the future.
MR. BILIRAKIS. Do we have many applications for a center that
basically would be approved or even have been approved but that we
don't have construction because there is inadequate funding?
MS. HANDLEY. I don't think I could really comment on that because
the statue does not make construction money available. So it is not a part
of the grant that we make with the 330 dollars.
MR. BILIRAKIS. Well, you know, I guess there is a criteria and
something about how the dollars have to be used for construction, buying
property, things of that nature. There are already a lot of storefront type
of community health centers, which are county centers and whatnot. I
mean, shouldn't we be flexible? I had just raised this question. I hadn't
really given much thought to it. But shouldn't we be flexible enough to
feel that maybe that can be done or some of our Federal dollars can be
used in that way, rather than say hey, it has got to be used this way? Or
it has to be used to purchase property. It has got to be used for a new
construction. Any opinion on that?
MS. HANDLEY. Well, our dollars are not used for construction.
They are really used for direct services for patients to get care. And
having the program requirements that we do in place assures that people
are protected. They get the full range of services that are required under
the law, as well as the organization is going to be there and be able to
continue to provide care. That it will be fiscally solvent and around for
the long-term so there is continuity of care.
MR. BILIRAKIS. Well, getting off of that a moment, I know for
instance I have visited some of these centers. Now granted, some would
be county centers, state supported, county supported. But I find that they
are 8:00 to 5:00 centers and no Saturdays and Sundays. Now, is that the
best use of that center, the best use of that money? We are talking about
people who--hopefully they work-need, but they are not going to be
able to get there during the day and not be able to get there on a Saturday
or Sunday or particularly on a Sunday. Any opinion about that? Are
there any criteria there that in terms of enabling these centers to open
other hours, even mandating that they work other hours?
MS. HANDLEY. What we require of them is that they provide care
that will meet the needs of their target population. So there is flexibility
built into our requirements. We would expect that they could provide
care at different times. That they would have some evening hours, for
example, or that they would--some of them are sometimes open on
weekends to meet the needs. And obviously if you have a migrant
community health center they are going to have a definitely different
way of delivering care and a different number of hours.
MR. BILIRAKIS. Well, it isn't just the migrant community. We are
talking about most people, particularly low-income people working 8:00
to 5:00 hours, also and not being able to--
MS. HANDLEY. Right.
MR. BILIRAKIS. It is something that I think we should explore, Mr.
Chairman. We talk about the money and we talk about this and that and
I don't know, I have got to go into this construction and purchase of
property thing with my staff on that because maybe I didn't understand it
well enough. But I am also concerned that it is there and it is not really
being utilized as well as it should be, to the fullest extent because of
these hours that they keep. Well thank you, Mr. Chairman. I am sorry I
took up lots of time.
MR. DEAL. I thank the gentleman. Mr. Rush from Illinois is
recognized for questions.
MR. RUSH. Mr. Chairman, I ask do you think that we would have
maybe time for a second round of questioning if we don't get through
our questions?
MR. DEAL. Well, let us wait until we see how many people stick
around for the second panel, okay?
MR. RUSH. Okay. All right. Real good. Thank you. Ms. Handley,
I appreciate you coming in before the committee. And let me just tell
you that I also appreciate the Administration's proposal to increase
funding for community health clinics. I know that they are on the front
line of providing basic healthcare to constituents such as mine. And I
also believe that they could also be and hopefully it won't get to this
point but I believe that it will also ultimately be a part of the overall
defense against a terrorist attack against urban areas in our nation. I
think that this country or this Congress really has not paid attention to the
role that community-based health clinics will play in regard to some kind
of outbreak or some kind of terrorist attack, especially chemical terrorist
attack, in our urban centers. I think the potential for them to be on the
front line in terms of the defense of our Nation hasn't been paid close
attention to. I am an advocate, a strong advocate for community based
health clinics. In my other life as a civil rights activist I played a role in
having free health clinics. There was a free health clinic movement back
in the Sixties and I think that was a forerunner of the Government's
participation.
I am excited about the fact that there are new access points. I think it
is 80 new access points that we are going to be providing for under the
President's budget. And let me just ask you, in my city in the Inglewood
community, which is one of the poorest communities in my city, one of
the poorest communities in the Nation, there is a scarcity of health
clinics. And I am working with a number of individuals trying to help
get that situation resolved. What is the role that your organization, your
agency, play in regards to student-based health clinics? And how do you
see student-based health clinics lining up with health clinics that are
FQHCs, okay? Do you see a role for student-based health clinics and
what is the role?
MS. HANDLEY. There are a number of student-based clinics that are
really part of other FQHCs that are already existing and operating
successfully around the country. There is no separate program
specifically for school-based programs but again, many of the existing
grantees that we have that are FQHCs have a component as a part of
them that is school-based and they are doing this successfully now.
MR. RUSH. In my experiences with this organization and with
others, it seems to me that there is not enough advance notice given to
new applicants that will give them enough time to apply for FQHCs. Is
there anything that your agency is doing to try to help remedy that
problem in terms of making sure that they know when there is going to
be applications accepted at HRSA for new clinics? You know, at one
time I understand it was, there might possibly be an application process
in December. Then maybe May. You know, these organizations are
never really given any information they can really work with that will
give them enough time to prepare for the application and to prepare an
adequate application, a competitive application. Do you have any
remedies for that type of problem?
MS. HANDLEY. You raise an important point, which is that these
small businesses need time to prepare applications. We generally
publish a preview once a year that lists what the opportunities will be and
what the timeframes will be for applications. Sometimes the challenge
with the dates that are listed in what we call the preview that has the
funding opportunities is that we don't yet have a budget. And so we
don't want to have organizations spend time and resources preparing an
application if there isn't going to be funding for that opportunity. So it is
definitely a challenging situation in terms of not wanting them to prepare
applications and the preview is our mechanism for advertising what we
believe, based on the information we have, will be the dates for the
opportunities.
MR. DEAL. The gentleman's time has expired. I recognize Mr.
Shimkus from Illinois for questioning.
MR. SHIMKUS. Great. Thank you, Mr. Chairman and I appreciate
you being here, Ms. Handley, and thanks for your time.
When I first got elected in ?96, of course my district was a little
different. I didn't have a single community health clinic in my district.
Since then and my lines have been redrawn a little bit, I have 13 and they
have really proved a great benefit to the underserved or unserved. And
so I want to echo some of the other comments about the great work that
they are doing. Illinois has had a history of medical liability issues
because of litigation and the fact that they have the Centers for Federal
Tort Claims Program, it really helps our State meet those needs. And we
continue to have other type of providers wanting the same type of
protection or help or assistance but those are all kudos.
I do have some questions on the President's Health Center Initiative,
in which his desire to place new community health centers in every poor
county and I have quite a few of those myself and some very, very rural.
I have one county that has got 5,000 citizens in it, and so have you all
discussed or debated or come up with the criteria you are going to use to
determine the eligible counties? And how will you all or OMB
determine the top poorest counties? So how are you going to define a
poor county and then how are you going to rank them?
MS. HANDLEY. What I mentioned before is that we are looking to
make $48 million worth of awards in fiscal year 2007, based on the
President's budget and that will be 80 new access points. Another $4
million would provide for 50 planning grants. And we haven't worked
out all of the program parameters but generally speaking, the eligibility
would be limited. We would have a limited competition with all the rest
of the requirements applying, except for it would be a limited
competition for the counties that were the poorest or that could support a
health center. So we haven't gotten to the point of determining--
MR. SHIMKUS. So you don't know the answer right now?
MS. HANDLEY. We haven't gotten to the point of determining which
counties and all of the details of the program.
MR. SHIMKUS. I think a lot of us would be interested in
understanding what that criteria was. And if that is going to be the role
by which the Administration wants to present it then they are going to--
and I am a great supporter of the Administration and believe they are
well intentioned. But I mean, there is going to be competition for these
and if there is going to be criteria, that criteria needs to be known and
fully vetted. So that when awards are given, that if we are going to make
that determination, this is the standard we are going to use. Then we in
essence comply with those and people know it and we feel good that the
money that is being spent is being directed in the intent that you all and
we would support.
As I mentioned, my one county is 5,000 residents. I don't know how
you are going to define in this proposal sparsely populated. Is that
another term that we are going to have to decide on how we are going to
define before we move forward?
MS. HANDLEY. Well, I understand your concern about wanting to
know the details of the program. And what I would say is that when we
do have a funding opportunity that is available, those kinds of details will
have to go into what is advertised so that people will understand the
eligibility criteria. We are just not yet at that point.
MR. SHIMKUS. Mr. Chairman, if I could just ask for the committee's
attention, to just follow this process through? And as the agency moves
forward, that we are fully apprised and given some notice on how the
Administration would prepare to move in this direction. And that is all
the questions I have on this, Mr. Chairman. I yield back.
MR. DEAL. I thank the gentleman. And we would appreciate that
kind of follow-up with the committee, if you would.
MS. HANDLEY. Sure.
MR. DEAL. I'm pleased to recognize the gentleman from Ohio, Mr.
Gillmor, for questions.
MR. GILLMOR. Thank you, Mr. Chairman. And we are happy to
have you here, Ms. Handley. I have got to say I think that the
community health centers are just a wonderful asset in this country and
they are doing a great job. I have an outstanding one in my district in
Fremont, Ohio. In fact, I visited there once again on this past Monday.
But there is one matter that concerns me and it came up as a result of
that health center. And we are talking about access to care and this is a
situation which is a great impediment to access to care that shouldn't be.
After Hurricane Katrina the Fremont Health Center sent a lot of people
down to help and we found out that once they crossed the State border
they weren't covered by the Federal Tort Claims Act. Now, that
situation got handled in a convoluted way because there were some
Federal workers down there and they were made Federal temporary
employees so then they were covered. But they wanted to go down later
and that could not be done. And there have been other members who
have had the same problem. My colleague, Joe Schwartz, had a group in
his district that wanted to do the same thing.
The bottom line is, you had qualified people that are willing to help
in a situation of great need and couldn't because of the Federal law.
Representative Schwartz and I introduced a bill which would modify that
so they could get Federal Tort Claims coverage and that bill is H.R.
3962.
Now, we did bring this to the attention of your agency. I wrote a
letter back in January referencing the situation and that bill and asking
specifically whether you thought it was a good idea and if not, did you
have another idea to deal with this situation? That was in January. In
April I did get a response from Administrator Duke. The only problem
was, it didn't answer the question, so we have absolutely nothing. So I
guess my question to you is, do you think we ought to be doing
something to remove that barrier to access the care in a way that we
could let qualified people go in situations like that and still have
protection of the Federal Tort Claims Act? And I would appreciate if
you could take a look at H.R. 3962 and see if that is a good approach or
if you have some other suggestions to make. Because I think as we go
through this process, this is something we certainly ought to correct and
correct it fairly soon.
MS. HANDLEY. Well, the Administration doesn't yet have a position
on the legislation that you are talking about. As you know only too well,
our Department's Office of General Counsel determined that the Federal
law as it is currently written does not allow the healthcare providers in
one community health center to take their health center Federal Tort
Claims Act coverage with them to the other area, the other community.
So we are not in a position that--
MR. GILLMOR. Well, I know that because that is what I told you and
I know that. My question is, because you are the agency responsible, is
that the way it ought to be? And if not, how do we correct it? And I am
not directing this at you personally but it appears from your answer and
the inner workings of your agency, which I am not blaming you for, we
might wait until next year for an answer. So let me ask you, do you have
any objection if we move forward to solve the problem, with or without
you?
MS. HANDLEY. I can't speak on behalf of the Administration. I am
sorry.
MR. GILLMOR. Okay. I understand the constraints you are under so
I appreciate that. Thank you.
MR. DEAL. I have had a request from Mr. Rush that we have
additional time for questions. I would propose that any Member who
wishes to ask additional questions would have an additional three
minutes. I would ask unanimous consent, and without objection, we will
proceed, and I will not exercise my time. Mr. Green, I would recognize
you next.
MR. GREEN. Mr. Chairman, I will defer to my colleague.
MR. DEAL. All right. Mr. Rush is recognized.
MR. RUSH. Mr. Chairman, thank you so much. I want you all to
know you all are spoiling me. You are setting a precedent here involving
all these deferments.
MR. DEAL. You just remember that.
MR. RUSH. Ms. Handley, look-alikes, can you tell me the purposes
of look-alikes and how they fit into your overall game plan as it relates to
community-based health clinics, FQHCs?
MS. HANDLEY. Yes, I would be happy to do that. The look-alike
program is one where the organizations, the community health center
don't actually get health grant funds from the Federal government. But
what they do get is the designation as an FQHC, which is important to
them for several different reasons, actually three reasons. The first
reason is it makes them eligible to get Medicare and Medicaid-enhanced
reimbursements, so they get increased revenue sources, in essence. The
second reason is with that eligibility they can also get access to the 340-
B Program, which is a program for discounted pharmaceutical prices.
And then finally, they are also eligible for HPSA designation, Health
Professional Shortage Area designation. So it is a good program for
organizations. As you know from your area there is a lot of competition
for the grant dollars that are made available each year for each
opportunity.
Some organizations make a business decision that is still worthwhile
for them if they aren't, for whatever business reasons, either ready to or
maybe not interested in applying for the grant money, to apply for the
look-alike program. And we have worked with a lot of different
organizations around the country to get them look-alike status. The
number of look-alike organizations has been growing over time and we
continue to work to make the program available and provide technical
assistance to potential applicants.
MR. RUSH. So the look-alike program is like a developmental league
for the FQHCs? What is the percentage of look-alikes that graduate into
FQHCs?
MS. HANDLEY. I don't remember the number off the top of my
head. I can supply it for the record but I know it is exactly as you
suggest, though not everybody who is a look-alike necessarily wants to
become a new access point. In fact, I remember speaking with a woman
at a large health center who for many years had a board that was just not
interested in getting any Federal funds. So it can be a really great way
for organizations to understand what the requirements are under the 330
grant program because basically a look-alike is just that. It meets all of
the requirements. But it can also be something that organizations
continue to do on their own.
MR. RUSH. Finally, for the advocates for community-based health
clinics in the Congress and on this committee, what are some of the
suggestions that you might have where we might be more helpful to your
program? And to programs that really address a need, particularly in the
poor and underserved areas? What assistance do you need? What can
we do to help you?
MS. HANDLEY. Well, the current statute has really been very helpful
in being able to make healthcare available to 14 million Americans so we
are very pleased with the program that currently exists.
MR. RUSH. Thank you, Mr. Chairman. I yield back the balance of
my time.
MR. DEAL. I thank the gentleman. Dr. Burgess, you have additional
questions?
MR. BURGESS. Yes, Mr. Chairman. I have two to ask. This is such
an important hearing that if we could be allowed to submit written
questions for the record and can we--
MR. DEAL. Yes. We have already had a UC to that effect.
MR. BURGESS. Well, Ms. Handley, going back to the issue of the
board and formation of the board and you said there are some relaxations
on time. What happens if a clinic is up and running and you all give the
go-ahead, and that board isn't ready to go when you say start the clinic?
MS. HANDLEY. I guess what I was trying to convey before was that
when you have a new organization that has not been in existence before,
we can provide grant funding for before the organization actually is
started and there is--
MR. BURGESS. But what then happens if they are not ready to go
when the clinic is started though? Is there a penalty?
MS. HANDLEY. I am not aware of a penalty, per se, in that I am not
aware of a penalty. But I do know that we have worked with
organizations to help them come into compliance, and that most
organizations are able to come into compliance, all organizations.
MR. BURGESS. Is HRSA able to waive certain requirements for
starting up a federally qualified health center?
MS. HANDLEY. We do have the capacity to waive requirements for
certain kinds of health centers.
MR. BURGESS. Can you give us examples of what you can waive?
MS. HANDLEY. I believe we can waive the governance requirements
for the migrant and homeless health centers. For example, with the
homeless population, it is going to be difficult to get 51 percent of your
members to be serving on the board.
MR. BURGESS. And what is the procedure that the clinic follows to
seek those waivers?
MS. HANDLEY. They make the request when they are applying for
their grant.
MR. BURGESS. Am I understanding when a clinic applies there are
certain windows every year that are open where the applications can be
taken and this occurs twice a year? Is that correct?
MS. HANDLEY. Generally speaking, it has been once a year. It
depends. There are different funding opportunities. The new access
points are probably the ones you are thinking about where a new
organization gets funded to operate. There is also another opportunity
that has been offered for the last 5 years and that is expanded medical
capacity. So for an existing new access point, like the one in your county
for example, in a future year might decide we would like to ask for
additional money to expand the hours of service that we have or the
number of providers we have because there is enough need that isn't
being met. So those are basically the kinds of two opportunities you are
talking about.
MR. BURGESS. It is my understanding that has been started in
Tarrant County, they would make application in June, learn in November
that they weren't accepted and the next application point would be a
month later. So the timing of that proved to be very, very awkward to try
to correct the deficiencies and have a new application in within a
month's period of time. For that reason, it took three cycles to get the
funding approved because obviously on that second cycle it was difficult
to get everything arranged to have it in order to make a successful
application. If they are only once a year, then of course that brings up
the other problem. If you miss the grant then you have got to wait all
that time. And again, we are talking about a community that is in health
despair, if I can use that term, and if I seem anxious about it, it is these
timelines become so tragic in people's lives because they are definitely
negatively impacted. So I do have some written questions I will submit,
Mr. Chairman, but my plea would be that we reauthorize this program,
we have got to look at ways of streamlining. Yes, we want to be good
stewards with the taxpayers' dollars but we want to look at ways of
streamlining this process so that we serve those people that the program
was intended to serve.
Mr. Chairman, you have been very generous. I will yield back.
MR. DEAL. I thank the gentleman. Mr. Bilirakis, do you have
additional questions?
MR. BILIRAKIS. I am going to probably pose the questions and then
let them respond in writing. One would be reviews. HRSA undertakes
periodic reviews in a way that assesses community need and the relative
weight that it gives in the award process, right?
MS. HANDLEY. Yes.
MR. BILIRAKIS. Can you share with the committee the results of
those reviews? I mean, the process that you take and the results of
those? I mean, this goes to John's questions, Mr. Shimkus' questions
and whatnot. You can do that for us, would you?
MS. HANDLEY. Yes.
MR. BILIRAKIS. All right. And you know, these are all questions
that will be asked of us by our colleagues in the process of trying to
move forward this legislation. So it is critical that we get this sort of
information.
And also as a follow-up to Dr. Burgess, I wonder if you could
provide the committee the total number of applications submitted each
year, beginning in fiscal year 2001 and the number that were scored as
fully acceptable or higher and the number that were actually funded.
That will give us the answer to I think an awful lot of questions. Will
you do that?
MS. HANDLEY. Yes, we can do that.
MR. BILIRAKIS. All right. What are we talking about here as far as a
timeline is concerned, intending to be fair? You set the timeline rather
than we. But you know, we want to move this legislation. This is a
tough year. It is going to be a tough year for legislation. I think that
there is a feeling here that we want to get it moved this year, which
means you know, two or three weeks?
MS. HANDLEY. We will move hopefully quicker than that.
MR. BILIRAKIS. Okay, great. Thank you. Thank you, Mr.
Chairman.
MR. DEAL. I thank the gentleman. Ms. Handley, we thank you for
being here today and if you would follow up on the issues that have been
raised for further response, we would appreciate it. Thank you very
much for being here.
MS. HANDLEY. Thank you very much. Thanks.
MR. DEAL. We will now ask the second panel if they would take
their seats? I am pleased to introduce the three members of the second
panel. First of all, Mr. Roy C. Brooks, Commissioner of Tarrant County
in Texas, who has already been referred to and introduced I think by Dr.
Burgess previously. Ms. Kathy Grant-Davis, Executive Director of the
New Jersey Primary Care Association, and Mr. Dan Hawkins, who is
Vice President for Federal, State, and Public Affairs of the National
Association of Community Health Centers, Incorporated. Gentleman
and lady, we are pleased to have you here. And I know Mr. Brooks is
under a time constraint about a flight so we are going to begin with you
and hopefully you will be able to stay until we get a few questions, as
well. You are recognized and we thank you for being here.
STATEMENTS OF ROY C. BROOKS, COMMISSIONER,
TARRANT COUNTY, TEXAS; KATHY GRANT-DAVIS,
EXECUTIVE DIRECTOR, NEW JERSEY PRIMARY CARE
ASSOCIATION; AND DAN HAWKINS, VICE PRESIDENT
FOR FEDERAL, STATE, AND PUBLIC AFFAIRS,
NATIONAL ASSOCIATION OF COMMUNITY HEALTH
CENTERS, INC.
MR. BROOKS. Thank you, Mr. Chairman and members of the
subcommittee. I an honored to come before you today not only to
advocate on behalf of community health centers but to urge you to take a
hard look at increasing the number of these centers in shortage areas,
such as Tarrant County, Texas.
The network of health centers in rural and urban portions of the
United States is vital to this Nation's system for providing
compassionate, culturally and linguistically sensitive comprehensive
primary care services to indigent populations. Community-based health
centers promote a continuum of high-quality, family-oriented,
comprehensive primary and preventive healthcare regardless of ability to
pay.
These patients receive a wide range of primary and preventive care
services, including adult medicine, infectious diseases,
obstetrics/gynecology, pediatrics, dentistry, pharmacy, mental health,
substance abuse treatment, school health programs, as well as disease
prevention and healthy lifestyle promotion programs. Health centers
overwhelmingly serve clients that are low-income and minority,
including targeted efforts to serve migrant and seasonal farm workers,
homeless individuals, and families and people living in public assisted
housing.
The service population includes individuals living in areas of high
crime, large numbers of unemployed and impoverished persons, many
individuals with chronic diseases such as diabetes, pregnant teens, and
substance abusers. These conditions lead to a variety of acute healthcare
problems. Many people in these areas face numerous barriers to
accessing healthcare services, including those imposed by geography,
language, culture, poverty, housing status, and immigration.
It is tragic that bureaucratic red tape, unreasonable expectations,
misguided rules, and the unbelievable administration of Federal funding
for community health centers has led to many people being deprived of
services essential to their health and well-being. I would like to discuss
with you some of my observations from a local perspective regarding
problems we have experienced during the process of establishing our
first FQHC.
Much of the red tape tangle can be attributed to program information
notices, which are known as PINS. Regarding the application process
itself, FQHC regulatory guidance is a barrier to more FQHCs being
created. Specifically the program information notices are vague and
have inherent barriers to collaborative relationships with other
community organizations, do not ensure those reviewing FQHC
applications have an understanding of community and operations issues,
and allow State CHC associations and State primary care offices to
impose their own agendas when interacting with organizations wanting
to pursue FQHC status.
In terms of affiliation agreements, the current PINS do not afford
enough flexibility to allow FQHC applicants to utilize providers
affiliated with other organizations. In the Tarrant County instance, these
would include the University of North Texas Health Science Center and
the county hospital district. These organizations have the capacity to see
patients of any other organization. As you might expect, it is hard for a
start-up clinic located in a medically underserved area and to recruit and
retain an adequate number of providers without the assistance of
organizations that are willing to collaborate with the FQHC applicant and
see their patients.
FQHC applicants should be able to utilize providers from other
community organizations if it can be demonstrated that such individuals
will be qualified and able to satisfy the agency's expectations.
Regarding management requirements and specialty services, the
PINS contain requirements on the type of executive staffing for FQHCs.
While the PINS recognize that some FQHCs may be smaller and may not
require a full-time executive director, medical director, and finance
director, it has been extremely difficult to obtain the agency's approval to
have less than full-time management. As you might expect, it is hard for
a clinic with one full-time physician to financially justify a full-time
executive director, medical director, and finance director. FQHC
applicants should be able to utilize management from other community
organizations if it can be demonstrated that such individuals will be
qualified and able to satisfy the agency's expectations.
Regarding supplantation, the PINS also prohibit the supplantation of
funds. The principle of no supplantation of funds is limiting the
willingness of some organizations to assist in the creation of new
FQHCs. Organizations that are interested in facilitating the creation of
an FQHC have been told that they will be required to commit to
maintaining their initial funding amount or risk the application being
denied because of perceived supplantation of funds. This interpretation
has discouraged some organizations that find themselves with a one-time
surplus of funds from assisting in the start-up of an FQHC.
Supplantation is a misguided rule and one of the biggest obstacles we
have to overcome in getting strong support from the Texas Bureau of
Primary Care in the 330 grant application process.
It is essential that proper safeguards be in place to assure that State or
local money is not being replaced or supplanted by Federal funds.
However, prudent consideration of community interest and support
should also be part of the equation. In our case, we spent over 2 years
trying to convince the Bureau of Primary Health Care at the Department
of Health that a clinic closed by the University of North Texas Health
Science Center had no relationship to a new site subsequently obtained
by UNT and the John Peter Smith Health Network, which is our county
hospital. This new location was offered at no charge to be the prime
location for the Fort Worth North Side Health Center in their efforts to
gain a 330 grant designation.
This is a perfect example of what all of us at the Federal, State, and
county level should be encouraging in efforts to create more access
points for healthcare, a partnership of healthcare providers and
community leaders working together for the common good. I would
encourage each of you to consider ways we can make this process easier,
not more difficult.
During the process of working with HRSA on our application,
representatives from Senator Cornyn's office and Representative
Granger's office were shocked to learn that only ten percent of a 330
grant application was based or weighted on need. The core principle for
federally qualified health centers is the requirement that they be located
in medically underserved areas or health professional shortage areas.
Logic screams at me that need is of paramount importance and should be
weighted much higher in the scoring process.
MR. DEAL. Mr. Brooks, could you summarize for us? We are way
over your allotted time.
MR. BROOKS. Sure. My last point is about proportionality. There
are areas in our country, particularly in North Texas, as Dr. Burgess has
indicated, where we have significantly less FQHCs than any other part of
the country. In particular until the last funding round, the metropolitan
area of Boston had more FQHCs than the entire state of Texas. I would
encourage taking into consideration proportionality in the next rounds.
We have already addressed the board composition, the 51 percent
requirement. Let me just state that that requirement poses two concerns.
One is that there may not be the expertise in the clinic area to mount a
start-up business. The second concern is that requiring 51 percent before
the clinic is funded puts us in a position where we have got a problem
with the relationship of our chickens and our eggs. We are required to
have consumers on a board when there is no clinic for them to be
consumers at.
In conclusion, community health centers are often the only care
option for those who need it most. And these centers have become adept
at breaking down barriers to access and providing continuity and
preventive care.
A very sad example of why we need these is in my own county in
Texas. While the infant mortality rate in Texas is just slightly lower than
the national average of 6.9 per 1,000 births, Tarrant County's rate is 7.5.
The city of Fort Worth is 8.7, and in three targeted zip codes it exceeds
12 per 1,000, which is a rate approaching that in many third world
countries. We need more FQHCs in Tarrant County to address that
concern.
Finally, I want to thank Dr. Burgess for his willingness to be a
strategic partner with me in addressing the issues of health disparities
and infant mortality for our joint constituents. And I appreciate the
opportunity to share my views with the committee.
MR. DEAL. Thank you.
MR. BROOKS. Thank you, Mr. Chairman.
[The prepared statement of Roy C. Books follows:]
PREPARED STATEMENT OF ROY C. BROOKS, COMMISSIONER, TARRANT COUNTY, TEXAS
Federally Qualified Health Centers: Benefits and Challenges
? Supplantation - One of the biggest obstacles we had to overcome in
getting strong support from the Texas Bureau of Primary Care in the 330 grant
application process was the supplantation issue. It is essential that proper
safeguards be in place to assure that state or local money is not being
replaced or supplanted by federal funds. However, prudent consideration of
community interest and support should also be part of the equation. In our
case, we spent over two years trying to convince the BPC at the Department of
Health that a clinic closed by the University of North Texas Health Science
Center had no relationship to a new site subsequently obtained by UNT and JPS
Health Network, our county hospital district. It was offered at no charge to
be the prime location for the Fort Worth Northside Community Health Center in
their efforts to gain 330 Grant designation.
This is a perfect example of what all of us at the federal, state,
and county level should be encouraging in efforts to create more access points
for health care, and that is a partnership of health care providers and
community leaders working together for the common good. I would encourage each
of you to consider ways we can make this process easier, not more difficult.
? Need -- During the process of working with HRSA (Health Resources and
Services Administration) on our application, representatives from Sen.
Cornyn's office and Rep. Granger's office were shocked to learn that only 10
per cent of a 330 grant application was based, or weighted, on need. The core
principle for Federally Qualified Health Centers is the requirement that they
be located in Medically Underserved Areas (MUA's) or Health Professional
Shortage Areas (HPSA's). Logic screams at me that Need is of paramount
importance and should be weighted much higher in the scoring process. It is
my understanding that HRSA representatives assured the congressional staffers
that this part of the scoring process would be reviewed. I strongly encourage
you to insure that HRSA address this glaring deficiency in the scoring
process.
? Board Composition -- Another core requirement of the application
process is that at least 51 per cent board of directors be composed of
patients to the clinic. This requirement is needed to assure that the board
adequately represents the community it serves. However, starting a new
business requires special skills and expertise sometimes not readily found in
the population base of the CHC. In order to maximize the efficiency and
financial soundness of a new business start-up, HRSA should relax the 51 per
cent rule for the first two years of a board's existence to allow business
expertise on the board. This two year window would allow the board to more
fully exercise its fiduciary responsibility to the community and the federal
government in the spending of federal funds.
? Proportionality -- For a whole host of reasons, some clear and
others not so clear, FQHC's are not distributed proportionate to population
throughout the country. For example, it is my understanding that, until the
last funding cycle, there are more FQHC's in the Boston Metropolitan area than
in the entire state of Texas. Further, in the third most populous county in
Texas, my own Tarrant County, we only have the one CHC referred to earlier.
With a population in excess of 1.7 million people, we should easily have three
or more community health centers. We are actively working on an additional
location at the present time. I would hope that HRSA will take proportionality
in mind in the next round of applications and perhaps give added weight to
those applications from underserved areas such as our county.
In conclusion, I urge you to reauthorize funding of Community Health
Centers, for I believe they represent the highest and best use of federal
funds in improving health care delivery to those citizens who have the
greatest need. Properly established and maintained, an FQHC can have a
critical impact in the community it serves.
MR. DEAL. Thank you. Ms. Grant-Davis, you are recognized.
MS. GRANT-DAVIS. Thank you. I want to thank you for this
opportunity to speak--
MR. DEAL. Pull that microphone a little closer, please.
MS. GRANT-DAVIS. Okay, how is that? I want to thank you for the
opportunity to speak with you today and for the unwavering support the
subcommittee has given to America's health centers. I want you to know
that your steadfast commitment to the health center program and its
expansion has made a real difference in the lives of many underserved
Americans across the country, including my State of New Jersey.
Earlier this year I received a letter from a grandmother, which
actually really made my day, who wrote to thank our Primary Care
Association for its work in opening a new health center in Glassborough,
a very rural community where she lives. She wrote that her daughter, a
young, uninsured mother of two children who suffers from severe asthma
now has medical care and access to medications and I just want to read
part of it. She wrote, "I cannot thank your program enough for opening
the Community Health Center of Glassborough, where my daughter saw
a doctor today and received prescriptions for her asthma and for a
bronchial infection. She will be able to get well and breathe comfortably
thanks to you. Because of you she will be able to take her son for a bike
ride and run and be outside. Do you realize what a gift you have given
her."
Chairman Deal, Representative Green, and members of the
committee, I want you to realize the gift that you have given to this
mother and the 15 million people currently served by health centers: the
gift of a medical home where they can obtain high quality healthcare,
regardless of insurance status or ability to pay. Indeed, access to care at
health centers allows individuals to be productive members of their
families and their communities. I would like to ask permission to have
the letter from this New Jersey grandmother inserted into the record.
MR. DEAL. Without objection.
[The information follows:]
<GRAPHICS NOT AVAILABLE IN TIFF FORMAT>
MS. GRANT-DAVIS. Thank you. New Jersey's health centers deliver
comprehensive primary care in 90 sites to more than 322,000 patients.
Eighty-eight percent of our patients are people of color. Seventy-eight
percent have incomes at or below 100 percent of the Federal poverty
level and nearly 45 percent are uninsured. New Jersey's 21 health
centers form an essential component of the State safety net and we are
committed to providing high quality and comprehensive care.
MR. GREEN. Mr. Chairman?
MR. DEAL. Yes.
MR. GREEN. Could I ask because I know that time is late and we
don't have many members? We have read your statements. In fact, both
the Commissioner and yours. If you could summarize and then we could
get the questions and that would make it better I think for everyone, if
possible.
MS. GRANT-DAVIS. Then there are really just three points that I
would like to make.
MR. GREEN. Okay. Thank you.
MS. GRANT-DAVIS. And this actually is in response to some things
that I have heard before. But I think one of the benefits of having
community health centers is that they can develop many partnerships.
And one of the things I think is important to realize that we do work very
closely with hospitals to triage people out of the emergency rooms. That
is critically important. In New Jersey we are working with the Medical
Society of New Jersey to make sure that we have specialty care. We are
working with Susan G. Coleman Foundation. So there are many
partnerships and by having a health center it allows you to bring more
parties to the table so that you have comprehensive care.
And the last point that I would like to make is that we urge you to
provide a straightforward reauthorization of the Health Center Program
through the fiscal year 2011. And the community board, nothing
succeeds more than this because the patients have direct control of the
care that they actually are receiving. So we urge you to reaffirm these
core principles as you consider the reauthorization of the Health Center
Program and I thank you for the opportunity to talk today.
[The prepared statement of Kathy Grant-Davis follows:]
PREPARED STATEMENT OF KATHY GRANT-DAVIS, EXECUTIVE DIRECTOR, NEW JERSEY
PRIMARY CARE ASSOCIATION
Good Afternoon. My name is Katherine Grant Davis and I am here
representing New Jersey's health centers, which include community, migrant,
and homeless health centers. I am the Executive Director of the New Jersey
Primary Care Association, a membership organization of health centers
dedicated for advocating on behalf of the medically underserved.
I want to thank you for this opportunity to speak with you today and
for the unwavering support the Subcommittee has given to America's health
centers. I want you to know that your steadfast commitment to the Health
Centers program and its expansion has made a real difference in the lives of
millions of medically underserved Americans across the country including my
state. Earlier this year, I received a letter from a grandmother, who wrote
to thank our PCA for its work in opening the Community Health Center of
Glassboro, NJ where she lives. She wrote that her daughter, a young uninsured
mother of two children, who suffers from severe asthma, now has medical care
and access to medications through the new health center. She wrote:
"I cannot thank your program enough for opening the Community Health
Center of Glassboro where [my daughter] saw a doctor today and received
prescriptions for her asthma and for a bronchial infection. She will be able
to get well and breathe comfortably thanks to you. Because of you, she will
be able to take her son for a bike ride on her bike and run and be outside
when it is cold or very hot without wheezing, and no longer have pain with
each breath. Do you realize what a gift you have given her?"
Chairman Deal, Ranking Member Green and Members of the Committee, I
want you to realize the gift you have given to this Glassboro, NJ mother and
the 15 million people currently served by health centers -- the gift of a
medical home where they can obtain high-quality health care regardless of her
insurance status or her ability to pay. Indeed, access to care at health
centers allows individuals to be productive members of their families and
their communities. I would like to ask permission to have the letter
from this New Jersey grandmother inserted in the Record.
New Jersey's health centers deliver comprehensive primary care in
90 sites to more than 322,000 persons. 88% of our patients are people of
color, 78% have incomes at or below 100% of the Federal Poverty Level, and
nearly 45% are uninsured. New Jersey's 21 health centers form an essential
component of the state's safety net for health care services. We are committed
to providing high quality, comprehensive health care services in federally
designated medically underserved areas and underserved populations. New
Jersey health centers provide a comprehensive set of primary care services
and enabling services to all people, regardless of their ability to pay. Our
centers not only provide care to families, they also provide care to high risk
and special populations including people with changing insurance coverage and
those with chronic conditions and disabilities. Research has repeatedly shown
that these groups cost the system a disproportionate share of available
resources and we are committed to providing them with the best service in a
cost-effective manner. And our record of success is hard to ignore. 1 out of
every 15 poor persons in New Jersey is served by a health center. Since
2000 we have increased capacity in every county in New Jersey except for two.
Dental, medical, and mental health capacity have been increased in over 80% of
our existing centers. We have doubled the number of uninsured they we see in
just 5 years. However, in communities across our state, the need to expand
health centers is still growing steadily.
Our PCA is committed to the expansion of the health center model of
care in New Jersey. Toward that goal and with the support of HRSA's Bureau
of Primary Health Care and NACHC, the NJPCA provides training and technical
assistance to the health centers in our state in order to assist our centers
in carrying out the requirements of the statute and program requirements.
NJPCA also conducts extensive planning and implementation activities to ensure
the success of the health center expansion effort in the highest need areas of
New Jersey.
I am also happy to report that the NJPCA are our health centers are
major forces for community-wide collaborative efforts to expand access to
underserved individuals and families. We have rolled up our sleeves and have
joined together to form partnerships with other safety net providers that
truly bring people into care and improve the health of entire communities.
As an example, we are working hand in hand with the New Jersey Hospital
Association to ensure that patients are triaged to our centers since we are
a more appropriate setting for non emergent patients. In addition, we are
working with the Susan G. Komen Foundation to ensure that all women,
regardless of insurance status, are screened for breast cancer and that they
have a medical home. Lastly, we were one of the original partners of the RX
for New Jersey program, which is a company started by the drug manufacturers
in New Jersey. This program is designed to ensure that patients, who
can not afford their medication, have access to free prescriptions. We stand
ready to continue our activities in all of these areas to ensure that the
health centers in our state can build on their record of success over the
years and in this current expansion effort.
Health centers are doing the job expected of them and they 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 expand the reach of the Health Centers program in underserved
communities. That is why we urge the Subcommittee to provide a
straightforward reauthorization of the Health Centers program through FY 2011
at an initial funding level of $1.963 billion for FY 2007. Our New Jersey
health centers believe that a straightforward reauthorization of the program
is the best path forward to the continued success of the Health Centers
program in expanding access to cost-effective, high-quality health care
services to underserved communities.
Reauthorization of the program would renew the most important
requirements of the Health Centers program, including governance by a
patient-majority board, health centers' openness to all regardless of ability
to pay, location in medically-underserved areas, and the provision of
comprehensive preventive and primary care services. In particular, our
centers would not be able to help change the health status of their patients
without patient-majority boards. Nothing succeeds like community control and
health centers know that better than anyone else. Our health center boards
are stewards of the health of fellow neighbors. Health centers are truly
consumer-driven -- they put patients in the driver's seat to tailor services
to best meet the needs of their local communities. NJPCA and New Jersey
health centers urge the Subcommittee to reaffirm these core principles as you
consider the reauthorization of the Health Centers program.
Thank you for this opportunity to talk with you. If there are any
questions, I would be pleased to answer them at this time.
MR. DEAL. I thank the gentlelady. Mr. Hawkins, you are
recognized for your statement.
MR. HAWKINS. Thank you, Mr. Chairman, and members of the
subcommittee and I appreciate the opportunity to be with you this
afternoon to talk about the Health Center Program. I want to ask with
Dr. Burgess here, is there a doctor in the house? A little hoarse but we
are going to get through this and I will do it in much less than the allotted
time. You have a written statement so I don't need to repeat those
things.
I would say I actually began my career in a health center. I actually
helped start one in south Texas. Not Tarrant County but we did it with a
community group. Got it together, got funded. That center serves
40,000 people today and it has a community board, functions like a
dream. In fact, it is the regional ambulatory health center for UTSA and
San Antonio Medical School. So it can be done.
In this reauthorization, Mr. Chairman, on behalf of the Association,
the health centers and the 15 million people they serve today, we do
count the look-alikes that Mr. Rush mentioned in our patient counts.
Nothing is more important than retaining the patient majority governing
board requirements at these health centers. It is the one small place in
America's healthcare system, the only place where healthcare is of the
people, by the people, for the people, patient democracies. We believe
the Health Center Program is already a well-proven model of care and
we fully support its reauthorization without change.
I want to extend this very special note to a long-time friend and
supporter of health centers, Mr. Bilirakis and Mr. Green for introducing
H.R. 5201, with now better than 80 cosponsors to provide a
straightforward five-year reauthorization of this program. We think it is
the best starting point and hope it will serve as a marker for the
successful renewal of this program, Mr. Chairman, as you move
legislation to make that happen.
The second thing we would like to point out, it was already pointed
out earlier by Mr. Gillmor, is that there are some things we do need. One
is that the FTCA, the Federal Tort Claims Act statute does need to be
updated to take care of the problems that occurred along the Gulf Coast
following Katrina to ensure that health center clinical staff can go where
they are needed most. And so we urge you to move legislation, H.R.
3962, Mr. Schwartz and Mr. Gillmor's bill, to do that.
We also want to thank Dr. Burgess for his support in sponsoring
H.R. 1313 with Mr. Murphy. The Act that would--and to answer a
question provided earlier by a member of the subcommittee--what can
we do to help with the problem of specialty care for uninsured people?
H.R. 1313 would extend Federal Tort Claims Act coverage to physicians
who volunteer to work at health centers or to serve health center patients.
We think it is a perfect example of something that would both provide
immediate assistance and give local doctors the opportunity to make a
real, real difference.
For all of these things we thank you. We thank you, Mr. Chairman,
for your steadfast and longstanding support for the Health Center
Program over time and in particular last year. We thank you for that and
we look forward to working with you as this program is reauthorized to
reach that day when health centers are truly able to offer a healthcare
home. Medical yes but really healthcare. Medical, dental, mental health,
et cetera, to everyone who needs it in America. Thank you and we
would be happy to answer your questions.
[The prepared statement of Dan Hawkins follows:]
PREPARED STATEMENT OF DAN HAWKINS, VICE PRESIDENT FOR FEDERAL, STATE, AND
PUBLIC AFFAIRS, NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS, INC.
Mr. Chairman and Members of the Subcommittee, my name is Dan Hawkins
and I am Vice President for Federal, State, and Public Affairs for the
National Association of Community Health Centers. On behalf of America's
Health Centers and the 15 million patients they serve, I want to express my
gratitude for the opportunity to speak to you today about the federal Health
Centers program and its role in expanding and enhancing access to health care
services for medically-underserved individuals and families. NACHC and health
centers appreciate the unwavering support that this Subcommittee has offered
to health centers in carrying out their mission and we look forward to
continuing to work with you to further strengthen the program to serve
additional medically underserved communities.
Mr. Chairman, I have personally seen the power of health centers to
lift the health and the lives of individuals and families in our most
underserved communities during my time as a health center director in south
Texas from 1971 to 1977. The health center is still in operation today, and
has expanded to serve over 40,000 patients annually. The community
empowerment and patient-directed care model thrives today in every health
center in America and I am honored to be here to share with you their success
story.
Background and History of the Health Centers Program
Conceived in 1965 as a bold, new experiment in the delivery of health
care services to our nation's most vulnerable populations, the Health Centers
program has a 41-year record of success that serves as an enduring model of
primary care delivery for the country. Congress established the program as a
unique public-private partnership, and has continued to provide direct funding
to community organizations for the development and operation of health care
systems that both address pressing local health needs and meet national
performance standards. This federal commitment has had a lasting and
profound effect on health centers and the communities and patients they serve
in every corner of the country. Now, as in 1965, health centers are designed
to empower communities to create locally-tailored solutions that improve
access to care and the health of the patients they serve.
Current Statistics
Today, America's health centers serve almost 16 million people in
every state and territory. Health centers provide care to 10 million people
of color, 6 million uninsured individuals, 725,000 seasonal and migrant
farmworkers, and 700,000 homeless individuals. Over 1,000 health centers are
located in 3,600 rural, frontier, and urban communities across the country.
The communities served by health centers are in dire need of improved access
to care, and in many cases the centers serve as the sole provider of health
services in the area, including medical, dental, mental health, and substance
abuse services.
Patients can walk through the doors of their local health center and
receive one-stop health care delivery that offers a broad range of preventive
and primary care services, including prenatal and well-child care,
immunizations, disease screenings, treatment for chronic diseases such as
diabetes, asthma, and hypertension, HIV testing, counseling and treatment, and
access to mental health and substance abuse treatment. Health centers also
offer critically important enabling services designed to ensure that health
center patients can truly access care, such as family and community outreach,
case management, translation and interpretation, and transportation services.
As a result of health centers' focus on the provision of preventive
and primary care services and management of chronic diseases, low-income,
uninsured health center patients are more likely to have a usual source of
care than the uninsured nationally. 99% of surveyed patients report that they
were satisfied with the care they receive at health centers. Communities
served by health centers have infant mortality rates from 10 to
40% lower than communities not served by health centers, and the latest
studies have shown a continued decrease in infant mortality at health centers
while the nationwide rate has increased. Health centers are also linked to
improvements in accessing early prenatal care and reductions in low birth
weight.
This one-stop, patient-centered approach works. The Health Centers
program has been recognized by the Office of Management and Budget as one of
the most effective and efficiently run programs in the Department of Health
and Human Services (HHS). In fact, the Institute of Medicine and the
Government Accountability Office have recognized health centers as models for
screening, diagnosing, and managing chronic conditions such as cardiovascular
disease, diabetes, asthma, depression, cancer, and HIV/AIDS. A major report
by the George Washington University found that high levels of health center
penetration among low-income populations results in the narrowing or
elimination of health disparities in communities of color.
From Demonstration Program to Formal Authorization
The legislative history of the Health Centers program is one of
continued reaffirmation of the patients' voice in the ownership and operation
of their health care system. The Health Centers program began in rural
Mississippi, and in inner-city Boston in the mid- 1960s, to serve rural,
migrant, and urban individuals who had little access to health care and no
voice in the delivery of health services. In 1975, Congress permanently
established the Community Health Centers program at Section 330 of the
Public Health Service Act and the Migrant Health Center program at Section
329, as part of the Community Health Extension Amendments Act. The 1975
authorization was also notable because it also formally established the
patient-majority governing board, location of centers in high-need areas,
and minimum service requirements for service in statute for the first time.
In the 1980s and 1990s, the Health Care for the Homeless and Public Housing
Health Centers Programs were created. In 1996, the Community, Migrant,
Public Housing and Health Care for the Homeless programs were consolidated
into a single statutory authority within the Public Health Service Act (PHSA).
The Health Centers program was last reauthorized in 2002, as a part
of the Health Care Safety Net Amendments Act. As you know, the program is
scheduled for reauthorization this year. Health centers are grateful to the
Subcommittee for its leadership role in strengthening and improving the
Section 330 statute in 2002, further modernizing it to serve millions of new
patients. During the 2002 reauthorization, this Committee and Congress
importantly reaffirmed the program's four core elements, as it has
consistently over the entire life of the program. These core elements, which
have greatly contributed to its continued success, require that health
centers: 1) be governed by community boards a majority of whose members are
current health center patients, to assure responsiveness to local needs; 2)
be open to everyone in the communities they serve, regardless of health
status, insurance coverage, or ability to pay; 3) be located in high-need
medically-underserved areas; and 4) provide comprehensive preventive and
primary health care services.
2006 Reauthorization of the Health Centers program
As we look forward in the life of this 41-year experiment in
community health empowerment, the National Association of Community Health
Centers believes that the Health Centers program is already a well- proven
model of care, with core elements that have stood the test of time. It is
for that reason that NACHC fully supports the reauthorization of the program
without changes; in other words, a "straight reauthorization." We believe
that this is the best way to ensure that health centers can continue in their
critical role in providing access to health care services in underserved
communities.
I would like to extend a very special note of gratitude to Mr.
Bilirakis and Mr. Green for introducing H.R. 5201, the "Health Centers Renewal
Act," legislation that would provide for a straight reauthorization of the
program through FY 2011 at an initial funding level of $1.963 billion in FY
2007. The bill, supported by many Members of the Subcommittee and full
Committee, also continues intact the key program requirements that enable
health centers to provide high quality, cost --effective care that is
tailored to the specific health care needs of the communities where they
are located. We believe that H.R. 5201 provides the best starting point for
this reauthorization and we hope that the legislation can serve as a marker
for the successful renewal of the Health Centers program.
In Congress's previous reauthorizations of these bedrock
requirements, it has sent a clear message that it sees patient involvement
in health care service delivery as key to health centers' success in
providing access and knocking down barriers to health care. In this
reauthorization, nothing is more important than retaining the
patient-majority board governance of health centers in our view. Active
patient management of health centers assures responsiveness to local needs.
This begins with community empowerment, through the patient-majority
governing board that manages health center operations and makes decisions
on services provided, and leads to the fulfillment of the other core
elements of the program.
Through the direction and input of these community boards, health
centers can identify their communities' most pressing health concerns and
work with their patients, providers, and other key stakeholders to address
these issues. This has been particularly valuable as health centers address
and work to eliminate health disparities in their patient population. Board
members with unique and direct community connections determine the best
approach for removing barriers to health care, helping health centers to meet
their patients where they are, not where someone might want them to be. The
critical, distinguishing feature of the health center model of community
empowerment is that the community has been directly involved in virtually
every aspect of the centers' operations, and, in turn, each health center has
become an integral part of its community, identifying the most pressing
community needs and either developing or advocating for the most effective
local solutions.
I also want to expand on the other core features of the Health
Centers program, each of which has played a key role in the continued success
of the program. First, health centers are unique among health providers and
systems in the federal statutory requirement that they be open to all in the
community regardless of ability to pay. Like the community board requirement,
this element is what links health centers to the local neighborhoods they
serve. There is no cherry picking at health centers; everyone -- the
uninsured, underinsured, those on Medicaid and Medicare, and those who have
private coverage can receive quality health care at health centers. Health
centers are interested in addressing health needs on a community-wide basis,
and the requirement that they be open to all in the areas they serve allows
them to do just that.
Second, health centers are required under the statute to be located
in high-need, medically-underserved areas. In reauthorizing the provision
in 2002, Congress sought to ensure that much-needed, precious resources were
allocated to the communities most in need of health center services.
Location of health centers in federally-designated MUAs prevents the
duplication of services, and establishes health centers in identified
underserved communities where there are well-documented gaps in care.
Third, health centers are distinctive in the broad range of
required and optional primary and preventive health and related services
they provide under Section 330. This also includes a range of enabling
services that ensure optimal access to care. In 2002, Congress not only
reauthorized this requirement, but added to the list by including
appropriate cancer screenings and specialty referrals as required services
and behavioral health, mental health, substance abuse, and recuperative
care treatment as optional services that health centers may provide.
We believe that these core statutory requirements provide the crucial
framework for success of the Health Centers program. The program simply would
not be where it is today without these critical elements. We commend Congress
for safeguarding these requirements in every previous reauthorization of the
Section 330 program since its inception and urge you to renew these core
elements in this reauthorization.
Health Centers Meeting New Challenges
In their four-decade history, health centers have faced down and
overcome many challenges. Health centers in the 21st century are now facing
two particularly tough challenges: first, the struggle to provide health care
services in the wake of natural disasters, and second, the uphill battle
against the growing shortage of health care providers in underserved
communities.
Even as access to health care services has expanded through the
growth of the Health Center program, center administrators and community
boards are coping with a dramatic decline in both the number of graduating
medical students choosing a primary care field and in the number of dental
students. This reality led the American College of Physicians (ACP), in a
recent report, to warn that the nation's primary care workforce --
which it called "the backbone of our health care system" -- is, in its own
words, "on the verge of collapse."
The ACP report noted that too few young physicians are going into
primary care, while 35% of all currently practicing physicians are already
over the age of 55 and will soon retire. Indeed, over the past 8 years alone,
the number of Family Practice residents has fallen 22%, while the overall
number of medical residents has risen 10%. There is a very direct connection
between the findings of that report and those in a more recent article in the
Journal of the American Medical Association (JAMA), which found significant
vacancies in physician and other health professions positions at health
centers across the country. Not surprisingly, the greatest vacancy rates were
in rural and inner-city health centers, ranging from 19% to 29% of their
current workforce. By discipline, there were vacancies for more than 760
primary care physicians, 290 nurse practitioners, physician assistants, and
nurse midwives, and 310 dentists. Health center vacancy rates nationwide
varied from 13% for primary care physicians to 7% for non-physician providers
and 18% for dentists. While health centers, as they have always done,
continue to make lemonade out of lemons, they could use some additional
assistance from Congress in this endeavor.
Health Center Rely on Other Key Programs to Address Challenges
Health centers believe that one key solution to addressing workforce
challenges is the reauthorization of the National Health Service Corps (NHSC)
program, as its authority also expires this year. Health centers thank the
Committee for reauthorizing the program in 2002 and for designating health
centers as Health Professional Shortage Areas for NHSC placements. Renewal
of the NHSC is critical to ensure that there are adequate numbers of health
care providers to deliver care to health center patients. As many of
you know, the Health Centers and National Health Service Corps programs have
grown up together, and have weathered innumerable storms over the years. In
that time, the one constant in the relationship between health centers and the
Corps has been the decades-old connection to local communities and a
commitment to fill the gaps in our health care safety net. This foundation
in the community spurred the establishment of both programs, guides their
current operations, and will fuel their growth and expansion to more
underserved communities in the years to come. Nearly 4,000 NHSC clinicians,
including physicians, dentists, nurse practitioners, physician assistants,
nurse midwives, and behavioral health professionals, currently provide health
care services to millions of medically underserved Americans. Approximately
50% of NHSC clinicians serve in health center sites.
Indeed, the JAMA study mentioned above also found a high degree of
reliance among health centers on providers fulfilling a service obligation
under the NHSC program, state loan repayment programs, and the J-1 visa waiver
program. Overall, 30% of health center physicians and 26% of dentists are
fulfilling a service obligation under one of those programs. Again, the
highest such reliance was among rural and inner-city health centers, where up
to 45% of the current workforce consists of either NHSC, state loan repayment
and J-1 visa waiver obligors.
The threat of a public health emergency is a second critical challenge
for health centers in the 21st century. Health centers in Mississippi,
Alabama, and Louisiana were hard hit by Hurricane Katrina. In these Gulf
Coast states, approximately 54 health center grantees in 302 communities
serve nearly 750,000 patients. For many communities, the health center is
the first place people turn in the event of a public health emergency.
Indeed, health centers worked with other responders to provide services to
those affected by the disaster and HHS expedited funding to open new centers
in areas most directly impacted by Katrina in order expand access to health
care services. Health centers from California to Maine have treated tens of
thousands of hurricane evacuees, and many centers nationwide sent medical
teams and mobile health vans to the Gulf Coast to help their fellow health
centers besieged by people in need of medical treatment. However, their
current Federal Tort Claims Act (FTCA) medical liability coverage did not
cover them once they crossed state lines because of a ruling by HHS limiting
such coverage.
The experience of many health centers who mobilized to help their
sister health centers in the wake of Hurricane Katrina points to the need to
update the FTCA statute to ensure liability coverage for other health centers
and their employees who travel offsite to provide care at health centers
affected by a public health emergency. HHS has indicated that FTCA coverage
is only available within a state, therefore limiting health center medical
staff that could travel to help serve displaced individuals. A center in
one state may be the nearest source of primary care should an emergency occur
in another state. Texas is bearing a heavy burden of support for victims from
Louisiana. Many centers across the country stand ready to help our Texas
centers, but under HRSA's interpretation, they cannot do so. We can see no
reason for limiting this to state lines in emergencies and we strongly urge
the Committee to enact H.R. 3962, legislation sponsored by Rep. Joe Schwarz,
and cosponsored by several members of the Committee, which would address this
issue before the start of the 2006 hurricane season.
Additionally, the FTCA must also be modernized to allow health
centers to better address these looming physician shortages I outlined
earlier. Health centers would like to better utilize volunteer physicians
to help meet this need; however, the confusion surrounding medical liability
coverage often makes this prohibitive. Unfortunately, the liability
protection afforded to health center physicians under the FTCA does not
currently cover doctors who wish to volunteer their time -- causing undue
difficulty at health centers. In turn, health centers have been reluctant to
recruit volunteer physicians for fear that their current malpractice coverage
may be inadequate or insufficient. NACHC and health centers support H.R.
1313, legislation sponsored by Rep. Tim Murphy that would extend FTCA coverage
to physicians who volunteer to provide care to health center patients. We
believe that H.R. 1313 will provide immediate assistance to health centers to
address workforce shortages and, most importantly, give doctors a chance to
make a real difference in communities. NACHC and health centers look
forward to working with the Committee to address these challenges as health
centers continue their mission and work to deliver health care services to
underserved individuals and families.
Reauthorization Key to Historic Expansion of Access Through Program
Health centers recognize the relationship between timely program
reauthorization and continued funding and believe that expedited
reauthorization will make it possible for even greater expansion of access
to affordable, high-quality health services to underserved communities.
Additionally, the core elements of the Health Centers statute ensure that
health centers funded by Congress will be held to the highest possible
standards and will be accountable to the patients and communities they
propose to serve. I want to briefly expand on our vision for the expansion
of the Health Centers program in order to provide further guidance to the
Subcommittee on the funding authorization level beyond FY 2007. In 1999,
bipartisan Congressional Resolutions introduced in the House and Senate
recognized the importance of continued growth in the federal investment in
health centers. The resolution endorsed the doubling of Health Center
appropriations over five years. Combined with President Bush's expansion
initiatives, this goal has nearly been achieved, and as a result, millions
more Americans have access to the affordable, effective primary and preventive
care available at our nation's health centers.
NACHC and health centers are deeply grateful to Congress for its
support of the Health Centers program. In Fiscal Year (FY) 2006, Congress
appropriated $1.78 billion in overall funding for the Health Centers program.
The increases since 2001 have enabled hundreds of additional communities to
participate in the Health Centers program and to deliver community-based care
to more than 4 million people in the past 4 years. We are also very grateful
that Congress has provided additional funding for base grant adjustments for
existing health centers, which have seen unexpected increases in the number
of uninsured patients coming through their doors at the very same time they
continue to battle the continuously rising cost of delivering health care in
their communities. These base grant adjustments have allowed health centers
across the country to stabilize their operations and continue to provide care
to their existing patients, while also looking for ways to expand access to
necessary care.
We also appreciate the President's strong support for the program
and his request for a $181 million increase in FY 2007, which would bring
overall health center funding to $ 1.963 billion. This year we expect health
centers to serve 16 million people in every state across the country.
Despite the expansion of the program, the demand for health centers
is at record highs -- in 2004, we estimate that there were over 430
applications for new access points, only 91 of which received funding -- a
21 percent success rate. Indeed the application process is rigorous, and it
should be. Health Center program funds are awarded on a nationally
competitive basis, ensuring that the highest possible quality projects receive
approval.
Yet the need for these services is still largely unmet. 36 million
Americans remain underserved today -- individuals and families with little or
no access to medical care. With continued growth in the program and in the
federal investment, health centers can continue the successful expansion
effort in order to meet that need.
NACHC believes that a growth rate of 15% over the next five years in
the program authorization level will enable health centers to serve over 20
million Americans by 2010. Indeed, at this rate, health centers will meet the
need in America and rise to the challenge of their charter -- to serve all of
the underserved within fifteen years.
Given the increasing need for health centers, we are extremely
grateful that the President has committed to continue the growth of the
program by announcing the continuation of his Health Center Expansion
Initiative into the future. This new announcement will focus on placing new
health centers in poor counties that currently lack a health center site, a
very ambitious goal. Our own analysis indicates there are more than 920 poor
counties without a center today. Through this continued expansion, we
believe that millions of additional patients will have access to care at a
health centers in the foreseeable future. We commend the President for his
continued support of the Health Centers program and we look forward to working
with Congress to ensure that it soon reaches every community in need.
Conclusion
Health centers appreciate the unwavering support of Congress for the
program over the past four decades. Over that period, health centers have
produced a return on the federal investment in the program, by providing
access to care and a health care home to millions of patients in
medically-underserved communities across the country. Because Congress has
continued to reaffirm the core elements of the program; that health centers
are open to all, run and controlled by the community, located in high need
medically-underserved areas, and provide comprehensive primary and preventive
services, the program has successfully responded to the challenges posed by
our ever-changing health care system. On behalf of health centers across the
country, their staffs, and the patients they serve, we stand ready to work
with you to ensure that the Health Centers program is reauthorized this year
in order continue to providing a health care home for everyone who needs their
care. Thank you once again and I would be happy to entertain questions from
the Committee.
MR. DEAL. Well, thank you and let me say to Mr. Hawkins and to
your membership that we appreciate what your members do across the
country. They provide a very vital service and please relay that on behalf
of our committee today.
MR. HAWKINS. I certainly will do, Mr. Chairman. Thank you.
MR. DEAL. Let me touch on just a few and I will be brief. And we
do have people, including myself, who have got airplanes to catch and I
am going to be mindful of that.
You have mentioned several things, one being the bill that Mr.
Gillmor is the cosponsor of, on the portability and effect of Federal Tort
Claims Act coverage. Mr. Green and I were recounting some of the
incidents that came out of the Katrina situation where that was a real
concern. I suppose that you would say that your organization would
support that portability and also the issue of volunteers being covered by
it. I think that is a separate bill that has been proposed so that volunteers
who come into an environment could have that degree of liability
protection. Do you support that?
MR. HAWKINS. That is correct, Mr. Chairman. There is not a health
center in the country who hasn't reported to me that there are many,
many local doctors who would gladly, gladly volunteer to provide care,
including specialists. Orthopedists, cardiovascular surgeons who would
provide that care in the health center or even in their office, pro bono, no
charge, if only their malpractice, their liability were covered and that is
crucially important.
And yes, to answer your other question, the ability of health centers,
the outpouring of support and response for all of the health centers and
communities in the Gulf Coast following Katrina and Rita and even
Wilma was just, it was heartening. As much as the devastation was
heart-rending; heart-uplifting it was to see the response of America in
general and health centers were no different. It is only a matter of time.
It is only a question of when, not if, we are going to have the next
disaster, the next public health emergency. We need to fix this problem
so that health centers can move to where their help is needed most before
that happens.
MR. DEAL. I think we heard during testimony at a previous hearing,
even a health center that was dislodged by Katrina was told that if the
same people moved to a different location, that they might not have this
coverage.
MR. HAWKINS. That is correct and they nevertheless did it.
MR. DEAL. They just do.
MR. HAWKINS. They moved to a shelter area in a tent and provided
the care.
MR. DEAL. That just doesn't seem very logical to me so we are
hopeful that we might be able to make some progress on that front.
The other issue I would ask you to address very quickly and that is
the makeup of the board itself, majority patients served members
makeup. I recognize that you and Ms. Grant-Davis both subscribe to the
idea that that is a good principle. But we heard in the previous HRSA
testimony that in the start-up situation where Mr. Brooks says that was a
concern that HRSA perhaps would give some flexibility in that. Do you
have any knowledge as to whether or not in start-up situations HRSA has
been a little more lenient on that issue at the beginning?
MR. HAWKINS. Well, they should be because in the statute today is a
two-year waiver of the governing board requirement. So as long as--and
this is a key factor--the entity is committed to meet that 51 percent
patient majority governance expectation by the end of the 2 year period,
there is language in the law itself. This subcommittee wrote it some
years ago, that allows for a waiver of not only that. It says the Secretary
may make a grant with respect to which he or she is unable to make all of
the determinations required in Section 330. So not only the governing
board but other requirements, as well. In fact, there is great flexibility in
this statute on location and the designation of medically underserved
areas. There is a provision that allows Governors to request the
designation of an area that doesn't meet the MUA requirements. On the
delivery of services, Commissioner Brooks indicated and I am rather
surprised to hear that affiliation agreements were not allowed or that
there were bureaucratic barriers. I am here to say on behalf of the
National Association that we strongly encourage affiliation agreements.
It is the only way to maximize care to those folks. Now, there has to be a
core staff. This can't be a sham, virtual health center. But once there is
that core staff there should be affiliation agreements with good partners,
like the hospitals and the other--the medical community, et cetera, to
really have a collaborative process that can work.
MR. DEAL. All right. I am sure, Mr. Brooks, that you will have a
chance to elaborate on your point. And I agree with your point of view
that it is pretty hard when you have got only one doctor to have a
requirement that is sort of inflexible in some regards about having three
other permanent folks. That to me sort of flies in the face of common
sense. But I am going to let someone else explore that with you since my
time is up. Mr. Green?
MR. GREEN. Thank you, Mr. Chairman. And I think all three of
these witnesses brought up things that we can deal with and one is the 51
percent. I am glad to know that there is a 2 year, in the statute, that is
not something that I have seen and that gives the flexibility. I do think 51
percent after you are up and running is very important because that way
you have the community managing their own facility. And practically on
the ones we have worked with, you have to be in business for six months
anyway and by then you have a patient base and you know who may be
willing to take the time to be on the board. And also your patients who
may have leadership ability or who want to do it and keep it in their
communities. So I think if we have to, the 2 years, I am glad it is in the
statute. I want to make sure it is in the reauthorization so we will utilize
that because we have had some concern about that with the board
makeup.
But the proportionality, I agree. You know, in Texas for many years
we haven't felt like we wanted these FQHCs. My colleague, Bobby
Rush, I think Chicago has 70, but they started in 1960's doing it each
year, so we have a lot of catch-up to make, and I know that same case
with HRSA for Houston area, and I didn't even make it for Texas and
Tarrant County and that is where you need to look where the need is not
being met right now and have centers that are there and you can put them
together as local collaboratives.
Mr. Hawkins, let me ask a question because I like the idea of patient
referral efforts, and one of my goals in my areas is to have medical
schools brought in to be a referral. We will have family physicians, we
will have them do their residency, but also get substantially better care if
we have a teaching facility there. Do you know of any problem any of
our medical centers or community centers had in affiliating with medical
schools that would be providing some of that specialty care?
MR. HAWKINS. To the contrary, Mr. Green. And matter of fact, I
tell you within the first year that my health center down in Brownsville,
Texas operated, our friends and colleagues at UTMB in Galveston were
flying down all of the family practice residents to rotate through our
health center for a 3 month family practice rotation. Because they said
on Galveston Island they could not find need like there was in south
Texas. And as I mentioned, my old health center, I can take no credit for
its great success today, is today--
MR. GREEN. I am glad to know it is in Cameron County. My son
lives there.
MR. HAWKINS. Home of the brave, yeah. But it is a 40,000 patient
center and it is the regional ambulatory health center for the UT San
Antonio Medical School. Every third and fourth year medical student,
every single one of them and every family practice resident at UTSA and
ever pediatric resident, every OB/GYN resident, rotates through that
center now for six to twelve months and they are out of their residency
period. So that is a perfect example of where the collaboration--I mean,
it is synergistic. It is working all the time and that is not the only center
in America where that is happening.
MR. GREEN. Mr. Chairman, one of the things I have heard from
medical schools, is that there is not a funding base for doing that and it is
difficult for the school to be able to fund it. And I know we have a
hearing next week on graduate medical education and we might look at,
whether it is this bill or something else, to encourage medical schools to
provide that through the FQHCs. Because again, I think we raise the
level of the healthcare but we also train the next generation of family
practitioners that we need in the community. And also, you know, we
have that quality that we get from having a teaching institution.
Let me ask one other question before my time is up, in the 50
seconds. I read several studies that point to the role of health centers in
the reduction of healthcare disparities. And Ms. Grant-Davis or
Commissioner Brooks, can you speak to the role of health centers that
really show that we are eliminating the disparities? That that is the goal
originally of the community health centers and I want to make sure it is
continued even though 40 years and even though some states were a little
behind but we are trying to play catch up.
MS. GRANT-DAVIS. Yes, I would be happy to address that. In our
State we know that hypertension, asthma, and diabetes are our top three,
and so we have reengineering programs. They are called disease
collaboratives where it is a care model that is based on the particular
disease. And we have been able to demonstrate, and there are actual
national studies that demonstrate, that by using a collaborative care
model, that you can decrease the incidences of chronic diseases. Which
allows the patient to have a better quality of life and it also reduces the
disparities amongst the healthy and those that have these chronic
diseases. So there have been some wonderful care models put in place,
not only in my State but on a national basis, as well.
MR. BROOKS. In our one community health FQHC in Tarrant
County, it is located in a predominantly Hispanic community and the
community board has been able to structure a health delivery, a model,
that addresses health disparities experienced in that population,
particularly diabetes and hypertension. I don't want to leave the
impression with this committee that I am opposed to community control
of the FQHC boards. I am not. I just want to make sure that there is
enough flexibility in the application process to allow us to gear up
without penalty to 51 percent control.
From what I understand, the language says that the statute allows and
the Secretary may. This is equivocal language and we need something
perhaps a little more definite.
MR. GREEN. In what little time or few seconds I have left, I agree
and if we have to do something but I think the board makeup,
particularly after it is up and running, is important to make sure they
continue to serve that particular community.
MR. BROOKS. We agree on that.
MR. GREEN. Thank you.
MR. BROOKS. Thank you.
MR. BURGESS. [Presiding] Thank you for yielding back. I
recognize Mr. Bilirakis for five minutes.
MR. BILIRAKIS. Well, thank you. Mr. Chairman. I won't take that
time because I think we are all going in danger of missing our airplanes.
I would just ask Ms. Davis, Grant-Davis--I am sorry.
MS. GRANT-DAVIS. Yes.
MR. BILIRAKIS. You in your testimony referred to--basically we
refer to it as a clean bill, the legislation to reauthorize. We say a clean
bill and we want a clean bill means we discourage any amendments, that
sort of thing, that might sort of knock it off track. But you have heard
the concern here on the 51 percent during the startup period, whatever
that period turns out to be and we have talked here about the liability
protection. Would you be against those being offered as amendments
and possibly becoming part of the bill? I believe you--well, go ahead.
MS. GRANT-DAVIS. You are asking if I would be opposed to
amending the bill to include those?
MR. BILIRAKIS. Yes, right.
MS. GRANT-DAVIS. My experience has been that we in New Jersey
have asked for waivers before for the community board and we have had
every single one of our health centers able to meet that stipulation. As a
primary care association, my role is for technical assistance and training.
And even for a health center that has been in existence for 20 years, we
still do board training. And so once you become a board we just don't let
you out there. There is still continuation of making sure that you keep
meeting the board requirement.
MR. BILIRAKIS. Yeah, all right. But I am not sure really what your
answer is. You are very eloquent but the trouble is we are all kind of
rushed here.
MS. GRANT-DAVIS. Thank you.
MR. BILIRAKIS. And we all want to do the right thing. So would
you oppose amending the legislation because you want a clean bill, as
you had referred to earlier?
MS. GRANT-DAVIS. Okay. I am going to defer that to Mr. Hawkins.
MR. BILIRAKIS. Well, Mr. Hawkins, you don't find any problem
with the idea that the 51 percent maybe should not be applicable to a
start-up period, do you?
MR. HAWKINS. No, but Mr. Bilirakis, we absolutely support the
notion of flexibility in the start-up.
MR. BILIRAKIS. Okay.
MR. HAWKINS. I heard what Commissioner Brooks said and he may
have a very good point. That sometimes bureaucrats read the statute as
may but that doesn't mean I have to. But the language, I would strongly
recommend that you never change the shell. I don't think you want to
mandate that being the most unreasonable but--
MR. BILIRAKIS. To let the local people provide a basis.
MR. HAWKINS. But you can certainly, this committee, can make it
imminently clear in report language that may means that upon any
reasonable request by an organization asking for that time period, it
should be or if you will, must be granted. The committee can make clear
the intent. You wrote the language. You can specify that.
MR. BILIRAKIS. Yes, right. Ms. Grant-Davis, as far as the liability
protection, whether it be in the form of some sort of Good Samaritan
protection or whether it be actual liability protection from the standpoint
of subsidizing that protection, you would not have any problems with
that?
MS. GRANT-DAVIS. My understanding is that there are separate bills
that are moving.
MR. BILIRAKIS. Well, there are.
MS. GRANT-DAVIS. Right. I absolutely support them.
MR. BILIRAKIS. But I am here to tell you that this is the one that in
all probability, would have the best opportunity of getting through the
process and this is why we talk in terms of amending. You see what I
mean? Attaching thereto. So you would be a supporter of that?
MS. GRANT-DAVIS. If I can get volunteer docs under Federal Tort--
MR. BILIRAKIS. Amen to that. Right. And Commissioner Brooks,
very quickly. No questions. I just want to say to you that Dr. Burgess
has said that he is new here and doesn't understand the bureaucracy. I
am here to tell you that is probably his top issue and he has many top
issues but probably the top one is community health centers, particularly
the one in his district. He and I have already talked about that long
before this hearing. So I want you to know that his heart is really with
you as far as that is concerned. Thank you very much. Thank you, Mr.
Chairman.
MR. BROOKS. As Dr. Burgess indicated, we are on different sides of
the political aisle but we find each other to be reliable partners and have
gained a great appreciation for each other through working on these
particular issues. So I appreciate him as well.
MR. BURGESS. I thank the gentleman for yielding back. We have
been joined by the gentleman from New Jersey, Mr. Pallone. He is
recognized for 5 minutes for questions.
MR. PALLONE. Thank you, Mr. Chairman, and I apologize that I
wasn't here earlier, particularly since--and I am apologizing mainly to
Kathy Grant-Davis because she is from New Jersey and she is someone I
have known for a few years now. But we had another hearing on
Rutgers Undersea Program. Would you believe that? So I had to go to
that, too. Anyway, I just wanted to extend a special welcome to Kathy,
who serves as Executive Director of New Jersey's Primary Care
Association, a non-profit that represents New Jersey's community health
centers. And I can honestly say there are few people who have worked
harder than Kathy to ensure New Jersey's uninsured and underinsured
have continued access to quality health services. And I want to thank
you for being here today and the service you provide to our State. Thank
you. Now, I have got four questions here. I am going to have to try to fit
them in 4 minutes. I don't know if I can. But I wanted to mention,
Kathy, I am always delighted to visit the community health centers in my
district and I am impressed with the array of healthcare services they
provide to my constituents.
You mentioned the importance of the community board I guess in
your statement and I agree with you. Could you give me an example of
how a patient majority board at one of the health centers in my district,
for example, has contributed to the success of that health center in
expanding access to healthcare services?
MS. GRANT-DAVIS. I would be delighted to. We just actually
opened a new site in Red Bank in your district.
MR. PALLONE. Oh, great.
MS. GRANT-DAVIS. We opened it last week and that was as a result
of many discussions with the board about the need to expand services
into that area.
MR. PALLONE. This is separate from the--there is another private
one that exists there, right?
MS. GRANT-DAVIS. This is the VNA of Central Jersey has now
expanded a new site into Red Bank and it was that board that looked at
the demographics. They looked at the financial concerns. They looked
at where people had to travel, patient origin. I met with them on many
occasions and it was because of that board that they decided that there
was a new site that needed to be opened in the Red Bank area.
The same with the Plainfield Health Center. You remember how
their old facility looked. It was four or five exam rooms. It was that
board that did the capital campaign, the fundraising, everything to get
that new state of the art building up and running.
MR. PALLONE. Well, great. Thank you.
MS. GRANT-DAVIS. You are welcome.
MR. PALLONE. I am going to number two now. You mentioned in
your testimony, again that I missed, that the centers in New Jersey are
working with hospitals to triage more patients out of hospital emergency
rooms to the health centers. Can you just expand on that initiative a
little?
MS. GRANT-DAVIS. I would be delighted to. After years of
discussion with the hospitals about what our role should be, we have
decided to do really formal programs to make sure that we were the
primary care providers. We share facilities. We share staff. In many
cases, the health center staff is on-site in the emergency room and will
set up appointments immediately for the patients so that they have a
medical home.
And on the flip side, the hospitals are serving for what we need,
which is some specialty, diagnostic, lab. And so there is the primary care
piece and now our sister agencies are able to help us with the other piece,
as well. And so those are really formal programs and the wonderful
thing about that is that we are looking into technology. When a patient
presents at the emergency room the hospital can see right away that they
are a health center patient and there can be a sharing of records.
And so it is a really formal program and I am delighted to be
working with the Hospital Association on that.
MR. PALLONE. Well, great. Now, I am going on to number three.
You know the Robert Wood Johnson Foundation in our State recently
released a report highlighting the problems of the uninsured on a State-
by-State basis. I just wanted to ask you, what trends are you seeing in
New Jersey for the uninsured and how has that affected the health centers
and their ability to meet the need?
MS. GRANT-DAVIS. I will go back to the year 2000. We were
serving approximately 78,000 uninsured amongst all of the health
centers. In the year 2005, that number jumped to 142,000 so it almost
doubled. So in order to meet the need we have gone from approximately
40 or 50 sites now up to 90 sites in really just about every county. So as
that number continues to grow we are trying to open new sites with both
the HRSA money, as well as some State money, as well. There is still
1.1 million in New Jersey so we serve about ten percent.
MR. PALLONE. Okay. And then Mr. Chairman, I will ask one more
question here. As many of you know, the President has introduced a new
plan on how to respond to the outbreak of Avian influenza and I am
curious, what role would the health centers play in such a crisis or in a
bio-terrorism crisis? And specifically, would the health centers be able
to respond to surged capacity and do you have contingency plans in
place?
MS. GRANT-DAVIS. Yes. That is a wonderful question. I am glad
you asked that. And this is an area where as a primary care association
we have spent an inordinate amount of time to make sure that our health
centers are ready. We have written policies and procedures but I think
the most important thing we have done for them is that we make them do
drills. We just did a drill down in Camden. We had some sort of
emergency situation so everybody knows their role. We do tabletop
drills. We provide all types of training. And we have also made sure
that each health center in New Jersey is tied into its county emergency
medical system. Every single health center in New Jersey knows the
incident command system.
And so we have put together many different documents, which in
fact we have shared with many different health centers to make sure that
they are ready. We are now in the process of writing surged capacity
plans for each one of them and will be doing a major training for health
centers in New York, New Jersey, Puerto Rico, and the Virgin Islands
around a pandemic.
MR. PALLONE. Okay, thanks. Mr. Chairman, I could just ask if I
could include my opening statement in the record because I didn't--thank
you.
MR. BURGESS. Yes.
MR. PALLONE. Thank you, all the panelists.
MR. BURGESS. The gentleman's time has expired and time is
critical. I may not use all of my time for questions. I feel like the kid in
medical school who was asked a question he couldn't answer so he told
the professor, do you want the theory or the application? I feel with Mr.
Hawkins we have got the theory. With Commissioner Brooks we have
got the application.
Mr. Hawkins, I mean I absolutely agree with Commissioner Brooks.
I value and I respect the 51 percent board makeup but I don't know if the
theory is matching the application on this. We heard testimony from the
HRSA Commissioner that the points where the Secretary may waive are
for migrant, homeless, rural, and public housing populations. And I
think that Commissioner Brooks is exactly correct where he says the
language is not specific enough. And that is where we may wish to
address that in the language of the reauthorization bill because clearly,
you have got a man here of significant intellect and capability, well
respected in his community, and he had to move heaven and Earth in
order to get his first clinic started in a community of, if I am correct, now
it is 1.7 million in the county, 1.7 million. Just a little ways to the
southeast of where that clinic is, we have got a significantly underserved
area, the type of area that this clinic was designed for. It is what people
had in mind when they said let us have a federally qualified health
center. Let us tackle this 12 per 1,000 infant mortality rate. Let us tackle
these unconscionable health disparities that we are seeing.
So it is not with any intent to harm anything that is working well but
it needs to work well, as Mr. Brooks so eloquently put it, there needs to
be proportionality. It needs to work in all areas of the country.
Commissioner Brooks, no question that the hurricane of course, the
two hurricanes, didn't affect our area of Texas directly but we certainly
felt the aftershock from that. Can you relate to the committee just a little
bit of what we went through in Tarrant County after the hurricanes hit?
MR. BROOKS. Thank you for the question, Dr. Burgess. Tarrant
County was one of the areas to which evacuees were bussed. Initially,
we set up an intake center at one of our public school facilities and
staffing that intake facility was a cadre of doctors from our public
hospital. And every person who got off of a bus, before they were
assigned a pallet was assessed for their medical condition. During the
course of the peak of dealing with Katrina evacuees, we dealt with some
7,000 evacuees in Tarrant County. Of those, our public hospital serviced
about 2,500 in outpatient visits, 400 or 700 ER visits, almost 7,000
prescriptions were filled.
MR. BURGESS. Now, there is probably no way to know how many
of those 7,000 remain in Tarrant County today. Was there any type of a
guess as to the number?
MR. BROOKS. The best guess that I have been able to come up with
is somewhere between 800 and 1,000 still in Tarrant County, most of
which are in my precinct.
MR. BURGESS. In your precinct and this is of course the precinct that
has some of the greatest medical need. So in an area of great medical
need, we have added 1,000 more lives that would definitely benefit from
having this type of facility within easy access for them.
MR. BROOKS. Absolutely correct.
MR. BURGESS. You mentioned and my time is about up, too but just
something that struck me. You have got an executive director, a medical
director, a finance director, all supported by the revenue generation of
one physician? Is that--
MR. BROOKS. That is what the regulations require.
MR. BURGESS. And we haven't even talked about the nurse, the lab
technician, or the guy that empties the trash can at the end of the day.
MR. BROOKS. It appears to be a little top heavy in management.
MR. BURGESS. How many patients does that physician see then
during the day, during the average clinic cycle? Is there a limit or is it
just he can see as many as can walk in the door?
MR. BROOKS. I am afraid that that is a question that I can't answer.
MR. BURGESS. Just doing my calculations, I mean he would almost
have to see 70 or 80 folks to pay for the overhead that you are carrying
behind you. Mr. Hawkins, do you have--
MR. HAWKINS. I would just like to say that the average health center
today has 15,000 patients. That is about the equivalent of about a seven
and a half FDE physician or clinician practice. So the one doctor
practice--in fact, my understanding, I wish they were here, of HRSA's
rules is normally they really require--I mean, when they fund a $650,000
new start health center, they expect that center to get up to 3,000 or 4,000
patients within two years. That is a one and a half to two FDE doctor
practice and growing from there. So again, you may have anomalies like
this, but the average health center is running from seven to ten FDE and
that is just physicians. We are not even talking dentists.
MR. BURGESS. Well, my time--we may be able to get HRSA to
clarify that for us on the record in writing. But I want to thank our panel
for being here today. This has been an informative discussion that we
have had. My staff keeps reminding me I have got a three-star General
waiting so with that, I am going to adjourn the hearing since there are no
other members here to ask questions.
MR. HAWKINS. Ours is not to reason why, right?
MR. BURGESS. The subommittee is adjourned.
[Whereupon, at 4:36 p.m., the subcommittee was adjourned.]