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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
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.
NHSC LOAN RECIPIENTS
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 11⁄2 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.
INFANT MORTALITY-COMMUNITY HEALTH CENTERS
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.
HEALTH PROFESSIONS PROGRAM
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.