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would be eliminated in rural areas, IHS sites, inner-city areas, at Federal facilities?


Answer. For the current year there are over 200 scholarship HPOL sites of which 73 percent are rural. About 74 percent of the total are in community or migrant health centers 20 percent are in on IHS reservations and 6 percent are in Bureau of Prisons facilities. The placement of NHSC obligors in a HPSA to repay their service obligation would not contribute to the de-designation of that HPSA. In fact, an obligor can only fulfill their obligation if they serve in an area that retains its HPSA designation. Only if, after the service obligation is completed, the former NHSC obligor chooses to continue to remain and deliver health care in that HPSA, would the provider be counted in the physician to population ratio used in determining the HPSA designation.

Question. How much additional funding would be required for the scholarship and loan repayment programs to eliminate all existing HPSAs in the next two years?


Answer. The assignment of obligated providers does not eliminate the designation but would provide service on an interim basis until a provider is permanently located in the area. recruit the necessary number of obligors to reach an NHSC field strength by the end of FY 1993 equal to the 4,400 primary care practitioners required in HPSA's would cost on the order of $250 to $300 million. This estimate assumes that the additional primary care providers required by the end of FY 1992 would be recruited under the NHSC loan repayment program.

It is not reasonable to expect, however, that the only mechanism that would provide obligors for service in the given time frame, the loan repayment program, would be sufficiently attractive that it would be possible to recruit and assign the requisite number of providers within the next two years in order to resolve all 2,000 primary care HPSA.

The request before you will permit very substantial progress in addressing the problem of health provider shortages in rural and certain urban areas. This progress will accelerate once the supply of scholarship obligors is reestablished. However, the ultimate solution to the problem will require increased retention of obligors after the obligation has completed, attracting non-obligated individuals, the restoration of the scholarship pipeline, and the expansion of the State loan repayment program over the next several years.

Question. What have recent program evaluations indicated about the effectiveness of the NHSC programs?

Answer. Although there are no recent formal studies, it has been learned over the past few years that the most reliable method of attracting health professionals is the scholarship program which has now been reestablished through in the FY 1991 and FY 1992 budgets. Other approaches which have been emphasized in recent years, such as the Federal and State loan repayment programs, are demonstrating their success in attracting providers to many less hard to fill underserved areas. We expect these loan repayment programs to become more attractive, especially to physicians with

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educational loan balances totalling $85,000 or more, if loan repayments can be made in lump-sums early in the repayment period which will dramatically reduce the borrower's outstanding balances and associated interest.


Under provisions of OBRA 89, State MCH block grant programs are required to improve the health of mothers and children consistent with the Healthy People 2000 national health goals and objectives.

Question. What steps has HRSA taken to assure that States are implementing these goals and objectives in their MCH programs?

Answer. OBRA 89 amendments to Title V of the Social Security Act significantly changed the Maternal and Child Health (MCH) Block Grant program to improve State's planning and accountability and to make it consistent with the Year 2000 health goals and objectives.

Among the changes to the Block grant was the requirement that the States submit an application for their Block grant allocations. The application, among other requirements, must include a statewide needs assessment and a plan for meeting the identified needs. Upon enactment of the legislation the Maternal and Child Health Bureau (MCHB) quickly prepared and issued application guidance material to the States. MCHB provided technical assistance to the States through a series of meetings informing the States of the new requirements of Title V and providing assistance in preparing their applications. The Bureau established an effective system to ensure that the applications were received, processed, and reviewed in time to make awards at the beginning of the fiscal year, when funds became available.

Another major change to the MCH Block Grant program is the requirement that States, beginning in FY 1992, report on data and information describing the extent to which the State has met the Year 2000 goals and objectives for maternal and child health. The MCHB has actively engaged the States in assisting them to meet their reporting requirements. In the FY 1991 application guidance the MCHB identified explicit data elements and variables for which reporting would be necessary and even cited known source of data when possible. Many of the States provided information related to their plans for annual reporting in FY 1991 and identified areas in which the acquisition of data would be difficult. This information has been utilized by MCHB in identifying areas in which technical assistance in the data area will be required. MCHB staff will be conducting on-site technical assistance in the States on the reporting requirements.


Dr. Harmon, I'd like you to present the Subcommittee with a picture of access to health care services today. I understand you have a map that shows this information.

Question. In rural areas of the country like my state, is access to primary care services getting better or worse?

Answer. Several measures available to us indicate that access to primary care services in rural areas may not be improving despite significant increases in the total number of physicians practicing in the nation. In 1988, urban counties had almost twice the number of primary care physicians per 10,000 persons as rural counties (8.7 compared to 5.5). In 1988, all of the 111 counties (with a resident population of 325,000) with no M.D. or D.O. were rural. In that year 29 percent of all rural residents were living in federally designated primary care Health Manpower Shortage Areas, compared with only 9.2 percent of urban residents. Moreover, from 1979 to 1988, when the number of active physicians increased 35 percent in the U.S., primary care physicians practicing in the most vulnerable rural communities (those with 10,000 or fewer people) only increased 20 percent.


Dr. Harmon, I want to ask you some questions about the National Health Service Corps. I spent a lot of time last year on the legislation reauthorizing the Corps, and in my position as Chairman of this Subcommittee, provided the Corps its largest funding increase in the last decade. This program means a lot to rural states like mine, and I want to make sure it's fulfilling its mission:

Question. Dr. Harmon, I've been told that the single most important factor that influences where doctors choose to practice has to do with where they are trained. Do you agree?

Answer. It is probably the most important single factor, yes.

Question. What are the implications for states like mine of spending most of the scholarship funds at just a few East Coast schools?

Answer. Although most scholarship awardees did attend schools on the east coast, by no means did all students, and certainly not in just a few schools. For example, of the 13,800 scholars receiving support, 800 attended schools in California. The school which had the largest number of NHSC scholars is Meharry Medical College in Tennessee. The top ten schools trained only about 20 percent of the total number of obligors.

However, because scholarship obligors must be assigned to areas of highest need, they select assignment from a list of sites developed by the NHSC based on an assessment of need. These sites are usually remote rural or underserved urban areas. Therefore, during the period of obligated service, where the individual is trained is of lesser influence than when physicians are able to make choices without consideration of a service obligation. The long term solution to the problem of health professional shortages in States like yours depends on finding ways to retain practitioners after their obligation is complete.

Question. With the large funding increase we provided, how many positions do you expect to fund in FY 91, and how can this Subcommittee make sure that Iowa and other rural states get their fair share?

Answer. We expect to fund over 400 scholarships and 285 loan repayment agreements in FY 1991. With regard to ensuring that Iowa and other rural States have proportional representation in scholarship awards and loan repayment agreements, it must be recognized that such awards are the result of successful individual applications. Such applications are evaluated on individual merit, with an emphasis on a commitment to primary care and service to the underserved. The NHSC program supports many activities designed to make all medical students aware of opportunities in the NHSC including advertising in professional journals; supporting relationships with professional organizations, especially health professions student organizations; and mail campaigns which are directed to most medical students across the country by name. Neither the recruitment nor the selection process favors any State or geographical area over another, but depends on the individual student making a commitment to providing the kind of health care required by the NHSC in underserved areas and successfully competing for available funding, which as you mention, in FY 1991 is significantly higher than in recent years.


Dr. Harmon, for years there have been severe shortages of health professionals in many inner-city and rural areas. And I think it's no coincidence that our worst infant mortality problems occur in those same places.

I raised this point with Dr. Sullivan, too. It seems clear to me that "Healthy Start" can't have a 'healthy finish' unless we supply enough primary care doctors, nurse practitioners and midwives, and physician assistants to make prenatal care available to women who need it.

So it's curious to meet that, once again, no funds are proposed for most health professions and nurse education programs.

Question. Dr. Harmon, do you think the problem of having too many health professionals in some places and too few in others will sort itself out; or can government intervention help?

Answer. The overall supply of health professions has been increasing over the last twenty years. However, not all areas of the country have benefitted equally. Shortages of health professionals remain in many inner-city and rural areas. Shortages also remain for some specialties and occupations, especially primary care physicians, nurses and several allied health disciplines.

Physician supply has increased rapidly since the mid-1960s. Several studies by researchers at RAND and others argued that many of the less well served counties would be adequately served in the future as the results of the increased overall supply ("diffusion theory"). Although there is some evidence of the "diffusion theory," many of the underserved rural and inner-city areas remain underserved. For example, over the period of 1975-1985, physicianpopulation ratios rose almost three times faster for the Nation than for rural areas, despite overall rapid growth in physician supply.

Support for health professions and nursing education has produced a large growth in overall supply, but has not solved these

rural and inner-city problems to any large degree.

Our budget request reflects the need for government intervention to address these rural and inner-city problems through programs such as the National Health Service Corps, the Health Professions Student Loan Program, and assistance to minority health professions students. We are also putting emphasis on service programs for the underserved and disadvantaged through Community Health Centers and several rural health initiatives.

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

Answer. No. The following table reflects HRSA's original budget request to the Public Health Service for FY 1992:

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Dr. Harmon, the budget proposes a new "targeted infant mortality initiative," for 10 cities. When the Secretary testified last week, he told us to expect a reprogramming request for this initiative, known as "Healthy Start." I'm opposed to reprogramming MCH block grant and community health center funds, but I certainly do support addressing the infant mortality problems in cities in rural areas, too.



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