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me the States. Under each State I want to know how many of these scholars, as you call them, got scholarships and were paying it back and working in the States, and what it is today. I would like to take a look at that.

See, I just know what it is for Iowa, and I think it is, you say, about six, and some of those obligations, if I am not mistaken, are up this year, of those six. I think maybe as many as three or four of them, maybe?

Dr. GASTON. I do not have the exact number, but we will lose around 600 of our field strength this year, nationwide.

Senator HARKIN. And how many have you got coming in the pipeline?

Dr. GASTON. We only have 130 in the pipeline.

Senator HARKIN. That is what I mean. See, we are still going downhill on this, and I am trying to get this thing turned around.

Dr. GASTON. Well, we have a major increase in funding this year that will help. As I mentioned, we will be able to give over 400 new scholarships. We will be able to give over 280 Federal loan repayments. We also will be able to increase the number of States that are involved in the State loan repayment program. And next year we will have further increases. Scholars will increase to 500, so that we will be definitely increasing the pipeline.

As you know, recruitment funding was limited in recent years. It went way down.

Senator HARKIN. It went way down, and we are trying to get it back up again, and I know there is going to be a lag period. I understand that. But are there any suggestions you might have to plug up that gap?

I mean I know we are going to have a gap, but I am telling you that at least for the next few years, we are going to keep increasing the funds and get more scholarships out there. But we are going to have a gap there.

Dr. GASTON. We are going to have a gap. You are absolutely right, Senator. Even though we will award 400 or 500 scholarships next year, there will be a period of at least 7 years before they are available to serve. We are trying to fill the gap through the Federal loan repayment program, and through the State loan repayment program. And we have funded State cooperative agreements and State primary care associations that have to be very active in this process.

Dr. HARMON. And Senator, we are getting hundreds more of the loan repayment people out into the field, starting with 1991 with the new funds. We do not have to wait for them to finish their scholarship training and their residency.

Senator HARKIN. Say that again? I am sorry, I missed that.


Dr. HARMON. Well, we do not have to wait for the loan repayment recipients to finish their training. They are coming out of training and going right to work in the field, so we will have hundreds of those going out. So we do not have to wait for the Federal and State loan repayment recipients.

Dr. GASTON. Senator, if I might add, these are physicians that are finished with their training this year.

Senator HARKIN. I am sorry, say that again.

Dr. GASTON. With regard to Federal loan repayments, we will have hundreds of providers that will be available this year for immediate service, because as they finish their training this year, they will sign a contract with us and immediately go to a medically underserved area while we pay back their loan. We do not have to wait for them to finish their training.

Dr. HARMON. Another important point, Senator, is that the physician assistants, nurse practitioners, and midwives have a shorter training period, and can be out in the field in 142 or 2 years in some cases. At least 10 percent of the resources are going to those kinds of practitioners, and they especially go to rural areas, depending on State law.


Senator HARKIN. I raised with Dr. Sullivan the other day the issue that, again to repeat the premise you state, high instances of infant mortality occur in those areas where we lack health professionals. Have you seen the inspector general's report of November of last year, your inspector general of the Department of Health and Human Services, on infant mortality and community health centers?

Dr. HARMON. Yes; I am aware of that report.

Senator HARKIN. Well, he said there was a direct correlationsat right there where you are the other day and said I asked him, and he said, yes. In those cities where they investigated, where they have a community health center that is funded, and active, incidence of infant mortality is low.

In those same kinds of cities, where they have no community health center, they do not have the health professionals, it is not active, the incidence of infant mortality is very high.

I raised the question then, why do we need this special study in these 10 target areas? It seems to me we know what works. Community health centers work, and if that reduces infant mortality, that is where we ought to be putting our funds.

So I raised this question with Dr. Sullivan. I have raised it with almost everyone else that has been here to testify. It seems to me that if we want a healthy start, you cannot do it unless we have the primary care doctors, the nurse practitioners, the midwives, the physicians assistants, all these things are going to go out there and help with prenatal care.


So I kept flipping back on this book and looking at all the things that are zeroed out under health promotion and disease prevention. Graduate program in health education, public health traineeships, allied health projects, primary care, family medicine, residency training, general internal medicine, pediatrics, family medicine departments, physicians assistants. All zeroed out.

I can even keep going here. All of these are zeroed out. No funds are proposed for these, and I am just wondering how we square that with the inspector general's report that these are the kind of people that we need out there to really reduce infant mortality.

I ask you the question, how does it square?

Dr. HARMON. Well, the 1992 budget proposal seeks to target resources in the highest incidence areas of infant mortality, and use some of those, many of those interventions you are mentioning, but to target them.

Regarding the health professions budget, it is targeted toward minority health professions, $88 million for professionals who are more likely to serve in the highest need areas. Also, the National Health Service Corps increase will help to locate health professionals in some of these areas of greatest need, as will the health professions student loan approach, which is proposed.

On the health professions, there are considerable funds that go into that kind of support from HCFA, through the Medicare direct and indirect funding of graduate medical education, nursing, and allied health education. And also, there is a role for State and local government and the private sector in the health professions, and also in targeting infant mortality, which are all parts of our healthy start proposal.

Senator HARKIN. Does the budget proposal before us reflect original budget request?

Dr. HARMON. I am sorry. I did not catch that.

Senator HARKIN. Does the budget proposal before us reflect your original budget request?

Dr. HARMON. No; I would be happy to submit for the record what our request was, Senator.

Senator HARKIN. I would appreciate that. Thank you.

(CLERK'S NOTE.-Answer to the question can be found in questions submitted by the subcommittee.)



Senator HARKIN. Dr. Harmon, would you please give the committee an update on the Ryan White AIDS Care Act. Which additional cities are eligible for title I emergency assistance today? Which cities are predicted to be eligible by October 1? Are additional cities likely to become eligible during 1992? And last, what is the status of the title II funds? Have States gotten those funds yet? How much money was put in there, $87 million?

Dr. HARMON. Senator, I am pleased to say that the project is on schedule. We have been working very hard with very tight deadlines. Dr. Stephen Bowen, who is the new Bureau Director, has come to us from the CDC, and is working very closely with that agency. I would like him to list some of the progress to date. Steve.

Dr. BOWEN. Senator, to date the formula grant money under title I has been awarded to all of the 16 eligible metropolitan areas; 14 of the awards were made on January 29, which was 6 days ahead of the statutory mandate, and the two remaining grants were made on March 1; their award dates were delayed at the request of the cities, because parts of their application were not completed.

During the last 2 days we have been meeting with an outside panel to review the requests for the additional resources under the competitive part of title I, and we anticipate making those awards on or before April 4. In regard to title II, $17 million has already been awarded to the States to continue their drug reimbursement programs, if they requested to continue that activity. That is an optional activity this year, but we felt it was important to make those funds available, to be sure patients were not cut off their treatment programs, if the States needed those funds.

The rest of the funds that will be awarded by State formula grant, which is a total of $60 million more to be awarded above the $17 million that has already been awarded, for a total of $77 million, will be made on or before April 1. States will be getting those resources under title II at that time.

If you repeat the other questions, I will attempt to address those. I believe they had to do with additional cities becoming eligible.

Senator HARKIN. Right. Which cities are projected to be eligible by October 1?

Dr. BOWER. Right now, two cities have passed the 2,000 case mark according to statistics compiled and summarized by the Centers for Disease Control. Oakland, CA, and Baltimore, MD, have both passed the 2,000 case mark. They will be eligible?

We can submit for the record what cities are anticipated to possibly become eligible by that subsequent date that you mentioned. Right now, the next closest area is Nassau Suffolk, NY, at about 1,730 cases, approximately.

[The information follows:)


(Ryan White Care Act, Title 1]


Formula grant

Cases as of Feb.

28, 1991

Fiscal year 1991–Statutory eligibility for formula grants under section 2601 as
of June 30, 1990:

New York, NY
San Francisco, CA
Los Angeles, CA
Newark, NJ
Miami, FL
Houston, TX
Washington, DC
Chicago, IL
San Juan, PR
Atlanta, GA
Philadelphia, PA
Fort Lauderdale, FL
Dallas, TX
Boston, MA
Jersey City, NJ
San Diego, CA

[blocks in formation]

Total Fiscal year 1992—Statutory eligibility for formula grants under section 2601 as of March 31, 1991 (currently eligible):

Oakland, CA

Bahimore, MD
Fiscal year 1993-Potential eligibility for formula grants under section 2601
based on current data (the statutory deadline is March 31, 1992):

Nassau-Suffok, NY
Seattle, WA
Tampa-St. Petersburg, FL
New Orleans, LA
West Palm Beach, FL
Detroit, MI

1,723 1,697 1,650 1,496 1,488 1,465 more.

'Eligibility for formula grants under section 2601 is interpreted to mean that, "as of June 30, 1990, in the case of grants for Iscal year 1991, and as of March 31 of the most recent hocal you fa any subsequent Ascal year" there be “a cumulative toul of maro than 2,000 cases" or "the par capla incidence of cumulative cases is not 1888 han 0.0025."

Senator HARKIN. Was Philadelphia in the first 16?

Dr. BOWEN. Yes; Philadelphia has already received its formula funds under title I and will be eligible for supplemental funds. They were among the first 16.

Senator SPECTER. I had just commented to the chairman, just hearing you mention two cities, I said to Senator Harkin, neither was in Iowa or Pennsylvania.

Dr. BOWEN. Of the two new cities.

Senator SPECTER. But I understand now that that has other aspects, so I thank you.

Senator HARKIN. I rather doubt that any cities in Iowa will ever get in that group. I just do not think so, fortunately. Oh, additional cities likely to become eligible during 1992. You mentioned one

Dr. BOWEN. Baltimore and Oakland are already past the 2,000 case mark.

Senator HARKIN. Yes; but next year. I am looking ahead.

Dr. BOWEN. There could be more in the future, as I mentioned; the next highest area, Nassau-Suffolk, NY, has more than 1,700 cases. Depending on the rate at which cases are reported, there could be four or five additional metropolitan areas which becomes eligible during the next year.

Senator HARKIN. Four or five additional.

Dr. BOWEN. Four or five additional. Whether they will have that number of cases reported by any particular date depends on a number of different factors, among which are how actively and aggressively the cities look once they get close to the 2,000 mark.

Senator SPECTER. We had such a difficult time last year on the Senate floor in trying to find adequate funding. One of the very toughest issues and most compelling, given all the background circumstances, and I am sure we are going to face even tougher problems this year.

Senator HARKIN. That is why I wanted to get some idea of how many we are looking at coming down the pike.

Dr. Harmon, that is really all I have today. I will be continuing these discussions with you on the status of the


Senator BUMPERS. You do not mind if I ask a couple of questions, do you?

Senator HARKIN. Senator Bumpers.

Senator BUMPERS. Dr. Harmon, let me ask you a couple of questions about the National Health Service Corps. First of all, I have been just elated about President Bush's attitude about that program. Ronald Reagan practically killed the Corps.

I have a number of concerns about administration of the Corps. Can

you tell me right now, how many scholarships you awarded in the fall of 1990?

Dr. HARMON. Dr. Gaston, the Director of that bureau, can respond, Senator.

Senator BUMPERS. Dr. Gaston.

Dr. GASTON. Senator, in 1990 we were only able to award 71 scholarships nationwide.

Senator BUMPERS. Only 71?

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