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Question. The details of the Healthy Start proposal have been pretty sketchy so far. What criteria will be used to determine

which cities are funded?

The

Answer. The Department is reviewing the final eligibility criteria which will then be published in the Federal Register. eligibility criteria have been designed to include communities with infant mortality rates approximately 1.5 times the national average with a large enough number of infant deaths to allow the program to have a significant impact on infant mortality. At the same time, communities should not be so large that resources cannot be effectively concentrated and managed.

Question. The Secretary and Dr. Mason also said that rural areas will be eligible to compete for Healthy Start. How much will be available for rural areas, and what characteristics would a successful candidate for these funds have?

Answer. All communities meeting the threshold eligibility criteria, including both rural and urban communities, will be allowed to compete for Heathy Start funding. At this time, no specific dollar amount has been set aside for either rural or urban communities. All communities must meet the same threshold eligibility criteria. In addition, applications will be evaluated according to the principles of the Healthy Start Initiative, including creativity, innovation, integration and collaboration.

Question. Will Indian reservations also be eligible for

funds?

Answer. All communities meeting the threshold eligibility criteria, including those on Indian reservations, will be allowed to compete for Healthy Start funding.

OUTREACH REDUCES INFANT MORTALITY

Consistent with the recommendation of the Secretary's National Advisory Committee on Rural Health to implement federal grant programs to promote integration and coordination of services in rural areas, I set aside $20 million in the FY 1991 Labor-HHS bill for rural health outreach grants. These grants help get health and mental health services to people who aren't getting them now.

The "Healthy Start" proposal in the FY 1992 budget is described as "an aggressive program of outreach, linking health departments, community health centers, State maternal and child health administrators," and so on. It sounds a lot like my rural health outreach grant program.

Question. Would you agree that coordination and outreach can be effective to reach hard-to-serve populations. Could it be useful as a tool to reduce infant mortality and improve birth outcomes?

Answer. We believe that the coordination and outreach activities can be effective in bringing needed services to hard-toreach rural populations. We have announced a special interest in outreach efforts to reduce infant mortality. New models of health care delivery for pregnant women and children can be developed through outreach.

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Question. Might the Rural Health Outreach Grant program be effective in underserved inner-cities as well as rural areas?

Answer. The Rural Health Outreach Grant program has been designed to address the special needs of rural areas where health care resources are often severely limited and distances between providers are great. A program for inner-cities might have different requirements and priorities because providers are more concentrated and travel distance is not a major barrier in providing services. However, the basic concepts of outreach and coordination would be just as applicable to inner-cities as to rural areas.

Question. Given the similarities of the Rural Health Outreach program to "Healthy Start," why are rural health outreach grants zeroed out of your FY 1992 budget?

Answer. "Healthy Start" is a separate initiative that focuses exclusively on reducing infant mortality and improving birth outcomes. We view outreach grant program as a one-time demonstration.

AIDS CARE

Dr. Harmon, would you please give the Committee an update on the Ryan White AIDS Care Act-

Question. How is HRSA going to coordinate funding under Titles I, II, and III to provide the maximum care coverage with minimum duplication?

Answer. The HRSA Administrator holds regular HIV Coordinating Committee meetings to discuss the implementation and the coordination of the Ryan White C.A.R.E. Act and other AIDS related programs throughout the Agency. In addition, the HRSA Bureaus and the Associate Administrator for AIDS hold regular meetings and continue to work closely together to foster coordination with each other to implement the Ryan White C.A.R.E. Act. Implementation plans are submitted and reviewed for each program component. Program notices, guidances, and evaluation and research plans are submitted and reviewed as well.

HRSA has developed a coordinated technical assistance plan and holds regular Technical Assistance Coordinating Committee meetings with programs involved in AIDS services and training to ensure comprehensive and proficient implementation of the AIDS programs through prioritized, timely and coordinated provision of technical assistance to grantees and other organizations supporting their efforts. In addition, the HRSA utilizes an HIV Data Coordinating Committee which discusses the issues of coordinating the data collection activities and is in the process of the developing a data collection plan.

Through the grants mechanism, HRSA encourages and in some cases requires demonstration of the coordination across the various programs locally and statewide as well as with current HRSA grantees. In addition, HRSA has been holding regular meetings with the Centers for Disease Control to coordinate the implementation of the respective components of the Title III programs. HRSA is also

closely coordinating with HCFA to ensure that the requirements for use of other federal dollars are met through the implementation of the Ryan White C.A.R.E. Act.

COMMUNITY HEALTH CENTER FUNDING

This Subcommittee has been very supportive of the Community Health Center program. I want to know how well our funding has affected access to care in underserved communities. Taking into account basic program funds as well as additional funds provided to health centers for the perinatal initiative, health care for the homeless, AIDS treatment, substance abuse, etc.

Question. How much was appropriated, how many centers were supported with those funds, and how many people were served in FY 1981; in FY 1986; and in FY 1991?

Answer. We do not have information on activities funded with FY 1991 appropriations at this time. The following table represents information on the "basic" community and migrant health centers program from FY 1981 through FY 1990. The information follows:

(Dollars in Millions)

FY 1985

$427

641

Appropriation

Number of Grantees

Number of Delivery Sites

Number of Users (000s)

Percent of Grant to to Total Revenue

FY 1981

$367

765

[blocks in formation]

FY 1990

$506

554

1,500

5,850

43.0

Funding for the Comprehensive Perinatal Program (CPCP), included above, was first awarded in FY 1987. These funds were provided to community and migrant health centers to improve their ability to get women in for care earlier in their pregnancy and; to improve their ability to reach out to persons in need and follow-up on missed appointments to insure compliance.

While preliminary data is beginning to point in the direction of more positive outcomes for the perinatal population served by centers it is too soon to evaluate the effect of community based family oriented perinatal systems and the added value provided by funding under the perinatal initiative. Because perinatal funding was provided to improve outcomes and not necessarily to reach more patients, the user figures shown above for FY 1990 includes those users cared for incorporating perinatal initiative funding.

In addition to the basic community health center grants, shown above, funds are provided under health care for the homeless, 109 grantees were supported with an appropriation of $35 million in FY 1990. Approximately 40 percent of the funding is awarded to community and migrant centers. In FY 1990, approximately 150

thousand homeless users received care with community and migrant health centers out of a total of 350,000 total users. Funding for AIDS treatment in FY 1990 was approximately $12 million. of this amount, $9.1 million was awarded to community and migrant health

centers.

Other additional funding for substance abuse activities in FY 1990 was $9 million. Of this amount $4.5 million was awarded to community and migrant health centers. The remainder went to entities other than community and migrant health centers. As FY 1990 was the first year in which funds were awarded, we do not have utilization data to report for these two programs.

Question. How many new starts have been funded in the last five years?

Answer. The last open competitions for grantees to serve previously unserved areas were in FY's 1986 and 1987 during which 23 new grantees were funded. Since that time there have been no increases to support expansion to unserved areas and therefore no

new starts to new areas.

As previously stated, there have been, over the last several years, significant funding increases for special purposes.

Funding of the CPCP program, AIDS treatment and substance abuse activities have provide significant increases in funding for some centers, but these funds have not been available to support expansions of basic community and migrant health center services to previously unserved areas.

Question. I learned just recently that HRSA has not allowed competitive bidding of community health center funds in spite of a Department requirement for competitive bidding. This letter to you, Dr. Harmon, from the General Accounting Office, dated March 8, 1991, notes that competitive bidding can improve services, increase productivity and the effectiveness of the program, and lower costs. That might free up some funds for new starts.

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What is your response to this letter, and what steps are you planning that will bring the CHC program into compliance with the Department's rules on competitive bidding?

Answer. The Community and Migrant Health Center (C/MHC) Programs are already in compliance with Departmental requirements for competition in assistance programs. Public Health Service (PHS) Grants Administration Manual states that program administrators have the authority to determine the extent of competition, which may be "maximum", "limited", or "single source", subject to the approval of the PHS agency head, or a designee at the agency level who reports directly to the agency head. The decision by the Director of the Bureau of Health Care Delivery and Assistance (BHCDA) to limit C/MHC competition in fiscal years 1989 and 1990 to existing grantees, and my concurrence, were reflected in the program announcements which were cleared through PHS, the Office of the Secretary, and the Office of Management and Budget (OMB).

The promotion of competition must be achieved within the context of fulfilling program goals and objectives, and both the

Congress and the OMB have enunciated this position. The Federal Grant and Cooperative Agreement Act of 1977 encourages competition in the award of grants and cooperative agreements, but only where deemed appropriate. Guidance from OMB also encourages agencies to maximize competition in the award of financial assistance, with the qualification that it be in consonance with program purposes. Thus, the foundation for Federal competition policies contains no absolute requirement for competition, acknowledging that competition would sometimes conflict with the responsible management of programs.

The justification for limiting C/MHC competition has been based on an assessment of Congressional intent coupled with an expert knowledge of the requirements for the operation of a sound health care delivery system. It is statutorily mandated that the comprehensive services provided by health centers to medically underserved populations be available in a manner which assures continuity. Factors which weighed heavily in the decision to limit competition included, but were not limited to:

the FY 1989 Senate Subcommittee report stating the expectation that all funds would be awarded to existing centers;

the continuation of all centers which were performing satisfactorily was consistent with regional, State, and local strategies for addressing weaknesses or failures in the health care service delivery system;

continuity of care is critical to the success of health service activities, and organizational stability is a crucial factor in the recruitment an retention of health care professionals and other center staff;

establishment and maintenance of the strong relationships and shared responsibilities necessary for the achievement of a healthier America requires coordination and coalition-building at the community level, which occurs incrementally over a period of years; and,

turnover is disruptive to the patients and is costly, given the loss of return on the Federal investment in existing centers and start up costs of new centers; some of the most important benefits of technical assistance, consultation and training provided to C/MHCs are obtained years later; and equipment and facilities in which there is a Federal reversionary interest are seldom readily transferable.

There is a collaborative effort now underway within the PHS, which may become Department-wide, to more accurately reflect in the PHS Grants Administration Manual the requirements of responsible grants administration relative to service delivery programs. Competition is one of the elements which is being reviewed, and guidance regarding this matter is being drafted for inclusion in the manual.

TARGETED PERINATAL INITIATIVE NEEDS WORK

We received a report from Inspector General Kusserow last week about the Comprehensive Perinatal Care Program we've funded to combat infant mortality through community and migrant health

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