Prepared Testimony of Claude Earl Fox, M.D., M.P.H.
Administrator, Health Resources and Services Administration
Senate Health, Education, Labor, and Pensions Subcommittee
on Public Health
March 22, 2001
Mr. Chairman, and Members of the Subcommittee: I am Dr. Claude Earl
Fox, Administrator of the Health Resources and Services Administration
(HRSA), and I am very pleased to appear before you today to give an
update and to discuss an important issue for this country today: access
to critical primary care services for uninsured and medically underserved
individuals.
I would like to lead off with two maps, to show you two ways of looking
at health care in the United States. The first map shows the need
by those counties designated in whole (bright red) or in part (light
red) as Primary Care Health Professional Shortage Areas (HPSAs) and/or
Medically Underserved Areas (MUAs). The second map shows need by counties
with a high (bright green), moderate (lighter), or low (lightest)
percentage of the population that is uninsured. Comparison of the
maps illustrates two reasons for lack of access to health services
that HRSA, through Health Centers and the National Health Service
Corps, tries to address: Across Appalachia, the Sun Belt, and the
Southern Border, lack of access corresponds with high rates of uninsurance,
while in the Midwest, stretching into the Northwest and Alaska, lack
of access is not so much a matter of insurance, but the fact that
there are too few primary care clinicians. Now let me show you how
Health Centers and the National Health Service Corps are trying to
meet the need. In the overlays, the stars (black) are Health Centers,
the dots (magenta) are National Health Service Corps clinicians, the
dots in white are either dental or mental health clinicians. As you
can see, there are some places where we are succeeding, but as you
can also see, Health Centers and the National Health Service Corps
are not addressing every underserved area. The maps, I believe, demonstrate
clearly the importance of both the Consolidated Health Centers and
the National Health Service Corps reauthorizations. The President=s
FY 2002 Budget also reflects the important role of these programs.
The President has proposed a multi-year initiative to expand and increase
the number of health center sites by 1,200 over the next five years.
The Budget will also outline our legislative proposal for strengthening
the National Health Service Corps.
HRSA is charged with improving the health of Americans who are too
poor, too sick, or too isolated to access essential health care services
through building primary care delivery systems in places where they
are sorely lacking -- rural communities, public housing complexes,
and urban areas where private health care systems are scarce or nonexistent.
Let me illustrate this need by painting you a picture of one particular
underserved rural area B
Raymond, New Hampshire. I can assure you this area and its six surrounding
communities do not take primary health care services for granted.
In 1984, this rural area needed access to care -- a portion of this
population was at great risk of, or suffered from, preventable disease,
but was experiencing great difficulty in recruiting a physician to
practice there. To respond to this need, the National Health Service
Corps made an investment in a needed physician, Dr. Karen O. Brainard.
Dr. Brainard helped her health center employer, Lamprey Health Care,
to establish a practice in Raymond. After her initial service was
over, Dr. Brainard decided to stay in Raymond, and continues
to serve as a provider to thousands of the area=s
residents. She has demonstrated great leadership among her colleagues
and great compassion and dedication to her needy patients. She and
her colleagues have also delivered over 3,500 babies during the past
17 years. Dr. Brainard and Lamprey Health Care have a deserved reputation
for practice management and integrated service delivery. Dr. Brainard=s
service is genuinely appreciated by the community of Raymond. The
display of affection from this community for their physician -- and
the dedication of this physician in return -- are an example of the
spirit that keeps us going and makes our work so rewarding. Without
this necessary investment in a National Health Service Corps physician,
this community would still have difficulty accessing care.
At HRSA, we are helping to assure that babies are born healthy, children
are immunized, and adults receive the kind of ongoing, preventive
care that keeps them productive at work when they are well -- and
out of expensive emergency rooms when they are sick. Through expanding
primary care capacity, we are also decreasing disparities in health
status experienced by the poor and uninsured and underinsured individuals.
We are honored to be entrusted with such an important mission and
justifiably proud of what our health care professionals have achieved
in the field. However, we are also concerned that despite our best
efforts to create a climate that helps families B
there continues to be a great need for the kinds of programs that
HRSA supports.
Today, there are approximately 42 million Americans with no health
insurance and 48 million Americans lack access to a primary care provider.
At HRSA, we support programs that have proven effective at providing
direct services to those who might otherwise be without health care:
the National Health Service Corps (NHSC) and the Consolidated Health
Centers.
As outlined in the President=s
FY 2002 Blue Print Budget, the Administration proposes the elimination
of the Community Access Program (CAP). After a careful review, the
Administration concluded that further fragmenting the resources available
to public health providers by establishing yet another funding stream
was not the most effective or efficient way to improve health care
access for the uninsured. Rather, the Administration believes we should
invest in proven programs B
like the Community Health Centers B
and provide communities with increased flexibility through the President=s
Healthy Communities Innovation Fund, which allows communities to address
health care access challenges in innovative ways using existing resources.
Consolidated Health Centers
I would like to start with a key policy priority -- the Administration=s
plan for an investment in health care for the underserved, in particular,
the strengthening of the Health Center safety net, by launching an
effort that will increase access at 1,200 new and significantly expanded
sites over five years and eventually double the number of persons
served by Health Centers. There are approximately 42 million people
in the United States who are uninsured and at least 48 million lack
access to a regular source of health care. Many of our Nation=s
uninsured and medically underserved people live in inner-city neighborhoods
and rural and frontier communities where there are few or no physicians
or health care services. These Americans have lower life expectancy
and higher death rates from cancer and heart disease compared to the
general population -- because of inaccessibility to primary care services.
The Consolidated Health Centers, which are a critical component of
the American health care safety net, delivered health care services
in 1999 to approximately 9 million patients, 3.7 million of whom are
uninsured, through a network of over 3,000 community-based health
center sites. By expanding access through 1,200 new and significantly
expanded health center sites, the initiative=s
long-term goal is to strengthen the health care safety net for those
most in need and double the number of people served. These sites will
offer quality primary health care services to all regardless of their
ability to pay. The Consolidated Health Centers will continue to build
partnerships with local hospitals and providers, managed care organizations,
and other Health Centers, to ensure a more stable health care delivery
system. The community-based Health Centers comprise a consolidation
of the Community Health Centers, Migrant Health Centers, Health Care
for the Homeless programs, and Health Care for Residents of Public
Housing. Collectively, these programs provided case-managed, family-oriented
preventive and primary health care services in 1999 to approximately
9 million people, including 3.7 million children living in medically
underserved rural and urban communities. The Health Center program
has an extraordinarily successful track record of delivering cost-effective,
high quality primary health care to underserved, low income, and minority
populations for over 30 years. The Health Centers comprise over 750
community-based organizations with over 3,100 sites employing 50,000
full-time employees, representing over 75,000 employed individuals
(including 6,500 primary care clinicians), and involving 10,000 community
members participating on Health Center boards. The Health Center patient
population consists of approximately:
- 86 percent below 200 percent of poverty;
- 40 percent uninsured (Health Center uninsured patients have increased
at twice the national rate since 1990);
- 31 percent Medicaid recipients;
- 64 percent minorities;
- 40 percent children; and
- 30 percent women of child-bearing age.
Health Centers are invaluable safety net providers: essential, effective,
and efficient. They are located in low income and minority neighborhoods,
underserved rural communities, and in communities with a disproportionate
number of people at risk for poor health outcomes. Over 85 percent
of Health Center patients are below 200 percent of poverty. Approximately
67 percent of Health Center patients are below 100 percent of the
Federal Poverty Level. Sixty-five percent of Health Center patients
are people of color (35 percent Hispanic, 25 percent African American,
4 percent Asian and Pacific Islander, and less than 1 percent Native
American).
Health Centers serve one in every 6 low income child, one in every
10 low income uninsured individual, one in every 8 Medicaid recipient,
one in every 4 homeless person, one in every 5 migrant farmworker,
and one in every 12 rural resident. The homeless community is particularly
in need of health services -- nearly 550,000 homeless patients (75
percent of whom are uninsured) are served through culturally competent
clinicians -- homeless individuals and families who might otherwise
have not received care from a safety net provider. Also, nearly 600,000
patients of Health Centers are migrant farm workers. As major safety
net providers, in Calendar Year 1999, Health Centers accounted for:
- over 36.6 million encounters;
- more than 270,000 HIV tests and counselings;
- over 900,000 pap smears;
- almost 2 million immunizations, and
- perinatal and delivery care for 137,000 women.
Health Centers have demonstrated their effectiveness by:
- improved health outcomes;
- increased preventive services;
- improved management of chronic disease;
- reduced avoidable hospitalizations; and
- high patient satisfaction.
Health Center low birthweights approximate the national average for
all infants and are 30 percent lower than the national average for
African American infants. Women served at Health Centers received
more up-to-date mammograms than women in the general population (62.2
percent to 44.5 percent). Health Center hypertensive patients are
three times as likely to report blood pressure under control as a
Low Income General Population comparison group.
Medicaid Health Center patients have significantly lower odds of
hospitalization for potentially avoidable conditions compared to a
Medicaid non-Health Center patient group. Health Center patients report
high satisfaction levels (94 percent overall satisfaction). Moreover,
Health Centers are efficient: Not only are Health Centers seen by
HMOs as effective partners, but studies conducted by the Center for
Health Policy Studies in November 1994 comparing Medicaid Health Center
patients and Medicaid non-Health Center patients show:
- lower cost per ambulatory visit;
- lower rate of hospital inpatient days and lower inpatient care
costs; and
- lower total costs.
In collaboration with other safety net providers, HRSA=s
indispensable Health Centers are truly the access workhorses of increased
access to the uninsured, underinsured, and underserved.
National Health Service Corps
Next, I would like to talk about another key policy priority - the
Administration=s plans for
an investment in health care, in particular, the strengthening of
community-based health care through reforming the National Health
Service Corps. First, I would like to clarify that the purpose of
the National Health Service Corps is to provide primary health care
services in response to community need. The National Health Service
Corps offers scholarships and loan repayments to health care professionals
in exchange for service commitments in communities that lack health
care providers. The National Health Service Corps has placed doctors,
dentists, physician assistants, nurse practitioners, nurse midwives,
and mental health clinicians in communities that lack access to care.
The National Health Service Corps has collaborated with communities
for 29 years and has served as an important piece of the health care
safety net by assisting frontier, rural, and inner cities to recruit
professionally competent clinicians to meet their needs. Despite the
fact that there is a reported oversupply of physicians in this country,
there is still a need for the National Health Service Corps because
maldistribution continues.
According to a report issued by the Council on Graduate Medical Education
(COGME), physicians are not being trained in the right specialties;
physicians are not working in the right places; and physicians are
not serving the populations with the greatest disparities in access
and health status. Further, the racial and ethnic diversity of the
Nation=s health care workforce
does not reflect that of our population in most need of services.
These indicators point to a need to strengthen the safety net given
unacceptably high numbers of uninsured individuals. These problems
must be tackled, and the Administration stands committed to alleviating
both the lack of access and disparities in health status. Maldistribution
is a barrier to both access to care and to the elimination of health
disparities that the National Health Service Corps is uniquely positioned
to address.
Through targeted management reforms, the National Health Service
Corps will be better able to address the neediest communities. We
propose to examine the ratio of scholarships to loan repayment contracts,
and the 10 percent set-aside of funds for physician assistant, certified
nurse midwife, and nurse practitioner scholarships, to ensure maximum
flexibility in placing National Health Service Corps providers. We
believe that flexibility is key to our ability to react to a rapidly
changing health care marketplace and environment. Through a new proposed
rule, the Administration will also seek to amend the Health Professional
Shortage Area (HPSA) definition to reflect other providers (i.e.,
nurse practitioners, physician assistants, and certified nurse midwives)
practicing in communities, which will enable the National Health Service
Corps to more accurately define shortage areas and target placements.
To avoid further overlap in the provision of health care, the Department
will enhance its coordination with immigration programs, including
the J-1 and H-1C visa programs, which sponsor applications for health
care providers practicing in underserved communities. The FY 2002
President=s Budget proposes
legislation to encourage more health care professionals to participate
in the National Health Service Corps by making scholarship funds tax
free.
Today, National Health Corps clinicians serve in every State, the
District of Columbia, Puerto Rico, and the Pacific Basin. These clinicians
include 776 scholars, 1,093 loan repayors, and, through the National
Health Service Corps= partnership
with 34 States, 446 State loan repayors. Historically, 60 percent
of the National Health Service Corps clinicians serve in rural areas,
reflecting the National Health Service Corps=
ability to respond to the access needs of these areas. In this fiscal
year, the National Health Service Corps anticipates that approximately
400 scholars will be available for service, and nearly 800 additional
scholars will be in the pipeline for future service. The composition
of the National Health Service Corps=
field strength is an expression of its interdisciplinary approach
to health care: 28 percent are physician assistants, certified nurse
midwives, and nurse practitioners; 12 percent are dentists and dental
hygienists, 6 percent are mental and behavioral health clinicians,
and 54 percent are primary care physicians.
The proposals I have just mentioned will enable us to build on the
successes of the National Health Service Corps -- a program stressing
community responsiveness, dedicated service to the underserved, and
interdisciplinary practice. Over 22,000 clinicians have provided needed
services since 1972 -- spending all or part of their careers serving
where others choose not to go:
- approximately 97 percent of clinicians fulfill their commitments;
- approximately 60 percent of National Health Service Corps alumni
continue to serve the underserved 4 years after completion of their
service obligation, and 52 percent of National Health Service Corps
alumni continue to serve the underserved 15 years after completion
of their service obligation;
- National Health Service Corps clinicians include significantly
higher percentages of underrepresented minorities (35 percent) than
the Nation=s workforce,
and 53 percent of the people who receive care from National Health
Service Corps clinicians are Minorities;
- National Health Service Corps interdisciplinary teams assist in
meeting the primary care needs of the Nation; and
- National Health Service Corps clinicians must provide services
to all, regardless of an individual's ability to pay.
-
National Health Service Corps clinicians do this by:
- staffing new health services delivery sites;
- expanding existing services;
- developing programs that impact the health of individuals and
communities; and
- providing continued care for the underserved through: patient
care services, clinical leadership, and teaching the next generation
of clinicians.
The National Health Service Corps Recruitment programs select the
best to serve the neediest. These programs are committed to selecting
health care professionals who demonstrate:
- a commitment to improve the well being of individuals;
- leadership, resourcefulness, and initiative;
- sensitivity to diversities;
- clear and appropriate communications;
- flexibility; and
- resilience.
We believe the need for a National Health Service Corps is clear,
and we can go further:
- Maldistribution of health professionals continues;
- Community demand is more than three times the number of clinicians
available;
- 800 physicians retire or leave health professional shortage areas
annually;
- Currently, the National Health Service Corps=
2,376 clinicians provide service to 3.6 million people (2 million
in free-standing sites, i.e., community clinics, hospital clinics,
private solo or group practices, county health departments, mental
health/substance abuse, Indian Health Service, and Bureau of Prison
facilities, and 1.6 million in Health Centers).
- By amending the HPSA regulation, we will be able to more accurately
pinpoint the neediest communities and target assistance to meet
their health care needs.
Over its history, the National Health Service Corps has effectively
contributed to the strengthening and expansion of the health care
safety net. We believe the National Health Service Corps stands ready
to increase access to primary care services by attracting and retaining
clinicians. We plan on transmitting a bill to the Congress this spring.
We look forward to cooperating with this Committee as we work to better
serve this program, and its clinicians, so it will have a significant
impact on the Nation=s health
-- both now and in the future.
Conclusion
In conclusion, the Administration is extremely proud of our safety
net providers, and looks forward to working with the Subcommittee
in strengthening these programs. Together, a strengthened National
Health Service Corps and expanded Consolidated Health Centers partnership
offer the Nation a strong investment in primary health care safety
net coverage -- community-based, complementary programs offering flexible,
culturally-competent, interdisciplinary services -- responsive to
community need -- an important first step in expanding access to care.
This integral partnership has resulted in the National Health Service
Corps currently placing 46 percent of its scholars and loan repayers
at Health Centers -- providing nearly 15 percent of all Health Center
clinicians. The Administration will aggressively pursue reauthorizations
to ensure that a strengthened National Health Service Corps and expanded
Consolidated Health Centers remain core, essential elements of the
health care safety net.
Chairman Frist, Senator Kennedy, and members of the Subcommittee:
I would be happy to address any questions you may have.
