1/ Includes proposed reprogramming of $33,683,000 from the MCH Block Grant to Targeted Infant Mortality Initiative. UNDERSERVED COUNTIES IN THE UNITED STATES Senator HARKIN. This multicolored chart that I have put up there-perhaps you have seen it before, I am sure you have-the red areas are the designated underserved counties in the United States. The yellow ones are the ones that are fully served. Evidently the green represents ones that we just do not have the paperwork on, we do not know what the designation is, we really do not understand what those counties are, yet. Dr. HARMON. OK. To begin with, this chart shows approximately 3,200 counties or other areas including territories like Puerto Rico. The colors refer to whether or not they are designated or served as far as a health professional shortage area or a medically underserved area, served by either the National Health Service Corps or the community and migrant health center program. Now the green are those that are not designated as a shortage or underserved area. About 36 percent of the jurisdictions are green and are covered by the private sector, and not requiring Federal designation or assignment at this time. They are eligible to apply if they perceive the need. At this time they are not designated. They include 1,164 areas. The remaining two-thirds or so are designated as having all or part of the county or the jurisdiction as underserved or shortage. The yellow 382, or 12 percent, are fully served with Federal activities such as a community and migrant health center or a National Health Service Corps assignee. The orange 422, or 13 percent, are partly served through those kinds of programs. The red are the worst off; 1,232, or 39 percent, are designated but unserved by Federal program activities. Another way of looking at this is that one-half of the country is either not designated or fully served, and the other one-half is designated and either partly or completely unserved, in these designated areas. Senator HARKIN. Do you have any idea about the ones that are not designated? Do you have any kind of data on them at all? Dr. HARMON. Well, we work with the entire United States through our regional offices and State cooperative agreements to provide technical assistance to facilitate designation. It goes through the States, and our primary care cooperative agreements, Governors' offices, private sector, are all able to seek assistance to obtain designation. We think that many or most of those that are eligible are designated. There are new incentives, by the way, to pursue this, including better Medicare reimbursement. In the past there was some opposition to designation, historically, from organized medicine, for example, but that has given way now to support for designation, since there is a Medicare reimbursement incentive. We have seen an increased level of activity for that and other reasons. URBAN/RURAL HPSA'S Senator HARKIN. What can you tell me about how the area is divided between urban and rural? Can you tell me roughly what percentage of the shortage areas are rural and what percentage are urban? Dr. HARMON. I would like to have Dr. Gaston from our Bureau of Health Care Delivery and Assistance address some of those rural and urban issues of the areas. Marilyn. Dr. GASTON. Thank you, Dr. Harmon. Health professions shortage areas [HPSA's] are 70 percent rural and 30 percent urban at this time. I think it is also important to point out, though, that the number of primary care providers that are needed to remove the HPSA designation are 55 percent urban and 45 percent rural based on the populations that are unserved or underserved. But the number of HPSA's at this time are 70 percent rural, 30 percent urban. Senator HARKIN. But you say the funding proposal for this is split evenly, 50-50? Dr. GASTON. The number of primary care providers that would be needed to eliminate those HPSA's is about even because of the population distribution. Senator SPECTER. Is that split on a population line? Dr. HARMON. That is 70-30, Senator Specter, by the number of areas, but the population in those areas is about 50 percent rural, 50 percent urban. Senator SPECTER. Thank you. Senator HARKIN. Do the major pockets of high infant mortality, both urban and rural, generally have a full complement of primary care health professionals now? Or do they need more doctors, nurses, and other primary care providers? Dr. HARMON. In general, Senator, you would find high infant mortality in areas that are designated as medically underserved or health professional shortage areas. So generally they are in need of more providers. And again, we saw about one-half of the counties are either partly or completely underserved. NATIONAL HEALTH SERVICE CORPS Senator HARKIN. I want to ask you some questions about the National Health Service Corps. I spent a lot of time last year on legislation authorizing the Corps, and in my position as chairman of the subcommittee, provided the Corps' largest funding increase in the last decade. I happen to be proud of that. This program means a lot to rural States like mine. We have had a good history with the Public Health Service. We have seen it decline over the last decade, and I have every intention of bringing it back up. But I want to make sure it is fulfilling its mission. How many scholarships and how many loan repayment positions did the Corps fund in fiscal year 1990, last fiscal year? Dr. HARMON. OK, again we have some specific answers from Dr. Gaston on that. Senator HARKIN. OK. Dr. GASTON. Senator, in fiscal year 1990, we were only able to award 71 scholarships. Senator HARKIN. Seventy-one? Dr. GASTON. Seventy-one nationwide. Now, we had 74 Federal loan repayment agreements awarded, and 14 States participated in the State loan repayment program. We are very excited that this year, in fiscal year 1991, we will be able to award about 435 schol arships, of which about 275 will be doctors, and around 160 will be other types of health professionals such as nurse practitioners, certified nurse midwives, and physician assistants. Senator HARKIN. About 425? Dr. GASTON. Around 435 would be funded in fiscal year 1991. In fiscal year 1992, we should be able to increase the number of scholarships that we give up to 500. This is very important, because this year there will only be around 70 scholars available for placement. And next year we will have only around 40 to 45 available for placement. In addition, this year we can support 285 Federal loan repayment agreements. These individuals will begin service immediately. We can also support an additional 14 to 16 States in 1991 in the State loan repayment program, and possibly a few more in 1992. Senator HARKIN. OK. This is only a $5 million increase, right? How many National Health Service Corps scholarships were awarded to students from certain selected States, Iowa, North Dakota, Arkansas, last year? Dr. GASTON. Last year there were four scholarships awarded in Iowa; there were none in Arkansas; and none in North Dakota. At the present time there are six scholars serving in Iowa. There are nine scholars serving in Arkansas, and three scholars serving in North Dakota. In addition, in Iowa there is one assignee under the Federal loan repayment program and one of the COSTEPS. Senator HARKIN. Excuse me, you say there are six in Iowa right now? Dr. GASTON. Yes. Senator HARKIN. That is down? Dr. GASTON. Six scholars that are assigned Senator HARKIN. Because they got their scholarship and they are paying back their Dr. GASTON. Yes; they are paying back, they are onduty. Senator HARKIN. That is down from, say, a decade ago. How many would there have been in Iowa? Do you have any data on that at all? Dr. GASTON. Yes; we do. [The information follows:] NUMBER OF NHSC RECIPIENTS BY STATE WHO WERE SERVING THEIR OBLIGATION [As of September 30, 1986 and September 30, 1990] NUMBER OF NHSC RECIPIENTS BY STATE WHO WERE SERVING THEIR Senator HARKIN. I believe that 6 is down from, I think it was 20some, if I remember right. Dr. HARMON. That is about right for 2 years ago. Senator HARKIN. Excuse me, Dr. Harmon. What I would like you to do for me is, and maybe we have this, do we have it for each State? Voice: No; we do not. Senator HARKIN. I would like to go back about, when did they stop funding these programs, about 1982 or something like that? Go back a decade, anyway, 10 years, back to 1981 or 1982, and give |