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Question. Given the work established for the Division of Organ Transplant, how can you justify a funding cut?

Answer. The Division of Organ Transplantation has coordinated the establishment of a consortium of organizations interested in organ donation with the goal of consolidating and coordinating organ donor awareness activities. This collaboration is expected to be a most effective mechanism for ensuring consistency in organ donation efforts and in reducing costly and often confusing public and professional education efforts.


Question. Specifically, how is the Division of National Health Service Corps implementing the requirement to spend 10 percent of funds on non-physician health providers?

Answer. The Department will comply with the legislative requirement by allocating at least 10 percent of the funding for new scholarships for non-physicians such as nurse practitioner, nurse midwife, and physician assistants.

Question. How many scholarships will be given to nonphysician providers in FY 1991, and how many are proposed for FY 1992?

Answer. In FY 1991 and FY 1992 we estimate that approximately 160 and 180 non-physician health providers, respectively, will be supported.



The Committee has requested an evaluation of the two nursing loan repayment programs funded over the past two years, those authorized by Sections 836(h) and 847 of the Public Health Service

Question. Please provide that report for the Committee, and summarize its findings.

Answer. The report is currently being finalized and will be submitted soon. In summary, an evaluation of the two programs indicates that the direct loan program would only require about $100,000 of the $700,000 recommended for this program in FY 1991. With regard to the 836 (H) program, as of April 25, 1991 we have approved applications totalling $794,973. Applications are still being received, with one more review cycle planned for on/about July 1, 1991.


Question. Dr. Harmon, how much money did HRSA request of the Assistant Secretary for HIV programs, as compared to the final level

forwarded in the President's budget? If it was more, what program

areas were cut to meet the President's level?

Answer. Our request to the Assistant Secretary for the HIV programs was $197,649,000 which was less than the President's Budget.

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Question. Dr. Harmon, in your professional judgment have the shortages of trained health care professionals, such as nurses, been eliminated? If not, how can the elimination of the majority of health professions training program be justified?

Answer. The overall National supply of physicians appears to be more than adequate. However, there appear to be shortages of general and family practitioners as well as obstetricians. Rural and inner cities are also having difficulties obtaining physician services.

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The latest available data from surveys of employers in various fields of registered nurse employment suggest a continuing high level of budgeted vacant positions. Based on these data there may be about 126,000-158,000 additional full-time equivalent registered nurses needed, although in March 1988, more nurses were employed than ever before 1.627 million (1.363 full-time equivalent registered nurses). Also, proportionately more nurses, 80 percent, were in the work force more than ever before. Secretary Bowen's Commission on Nursing assessed the cause of the nursing shortage as stemming from the increases in employer demand which could not be satisfied by the available supply.

Data for allied and public health disciplines is much less reliable. However, the available data do point to shortages of many of the allied and public health occupations. Shortages of physical therapists, occupational therapists, epidemiologists, biostatisticians, environmental health personnel and public health physicians are especially acute.

Very difficult choices among priorities for Federal funds must be made in order to meet budget targets for the FY 1992 budget request. The FY 1992 proposed budget request would provide a well balanced approach to addressing the disparities in the health status of minorities and their underrepresentation in the health professions and represents BHPr's highest priority.


Question. Dr. Harmon, last year the Conference Committee provided your agency with $600,000 to establish a pilot program to address the shortage of organ donation. Would you summarize for the Subcommittee what specific steps you have taken to implement this program?

Answer. The House Appropriations Committee did refer to a specific pilot program in its July 12, 1990 Report on an FY 1991 Appropriations Bill and proposed an amount for it. The Conference Committee's Report was broader, noting that the $600,000 was for special projects to increase the supply of donated organs. Although we have not taken steps to implement the pilot program mentioned in the House Report we continue to address organ donation awareness issues. The focus is on organ donation awareness and education activities for both the public and for health and health related

professionals, through grants to Organ Procurement Organizations and other non-profit private entities for projects that are both local and national in scope. Increasing minority awareness of organ donation and transplantation is a program priority.


Question. Are funds included for this initiative in the President's FY92 budget? If how much?

Answer. The FY 1992 request includes $250,000 for organ donation awareness activities. It does not include funds for a pilot program.

Question. In your professional judgment, is there an organ shortage and are additional funds to the Division of Organ Transplantation necessary to effectively address the problem?

Answer. Yes, there is an organ shortage. More than 23,000 people are currently on the transplant waiting list, however, there are only about 4,000 cadaveric donors each year. Many people wait years for a transplant and many others die while waiting. For example, between January 1, 1990 and September 30, 1990, 1,601 patients on the waiting list died before receiving an organ transplant. While it can be said that additional funds could be used to address the issue of organ donation, nevertheless, the President's FY 1992 Request is based on the limited resources available and competing program needs.



Dr. Harmon, the programs in your agency are very important in my state of Mississippi. We have one of the highest infant mortality rates, one of the highest teenage pregnancy rates, and a severe shortage of health professionals.

We derive substantial benefits in our state from the programs administered by your agency to deal with these problems.

I am concerned about some of the proposals of the Administration that come under your jurisdiction. Mississippi's infant mortality rate has been improving over the past few years because of initiatives that are working. Other states are achieving success as well.

I understand that you intend to use the "target cities" approach in the infant mortality initiative to develop prototypes that can eventually be used on a national scale.

Question. Do you feel that the programs currently being administered by states are not effective enough to use on a national scale?

Answer. The infant mortality rate in the United States declined significantly during the 1960's and 1970's. Part of this decline was due to state programs such as those supported by the Maternal and Child Health Block Grant. During the 1980's however,

the infant mortality rate leveled off, and the maternal mortality rate actually increased slightly. In addition, the nature of the infant mortality problem changed. For example, substance abuse among pregnant women has become a primary factor in infant mortality today, which was not the case twenty years ago. Therefore, we believe business as usual is not enough. We plan to utilize a targeted, heavily intensive approach to delivering comprehensive perinatal services in the selected communities in order to achieve further reductions in the U.S. infant mortality rate.

Question. Will rural areas with high infant mortality rates be allowed to compete for these additional funds, or is the new program restricted to large cities?

Answer. Rural areas with high infant mortality are most certainly allowed to compete for Healthy Start funding. The Healthy Start eligibility criteria have been designed in the least restrictive manner possible, including both rural and urban areas while at the same time maintaining the ability of the program to have a significant impact on infant mortality.


Question. Could you give us a progress report on the State Offices of Rural Health?

Answer. There are currently 25 State offices of "focal points" for rural health. We regularly provide these offices with a wide range of information and technical assistance on rural health issues. In turn, we actively seek their hands-on expertise to improve our insight into these issues. We had our first annual state office meeting last year which was very successful. We plan to continue this year and into the future. We are also planning to support a newsletter which will focus on ongoing state programs and policies that are designed to improve access to care in rural communities. We are currently implementing a matching grant program with States to establish State Offices of Rural Health. Approximately $1.5 million is currently available for grants in FY 1991. The law requires that they perform a number of activities and achieve certain goals. We are working closely with both existing and new state offices to help them accomplish this mission.

Question. What resources do you plan to allocate to the establishment and support of these offices in fiscal year 1992?

Answer. The President's budget would provide approximately $700,000 to support the State Offices of Rural Health grant program in FY 1992.


Question. A number of Senators, who are members of the Senate Rural Health Caucus, wrote to the Secretary last month to express our concern over the criteria that were used last year to fill vacancies in the National Health Service Corps. Apparently, the Department was including particular pathologies as a requirement for placement, although the law specified other criteria to be used. I understand you are currently considering the criteria for this year's replacements in the NHSC. Could you tell us your rationale

for including those criteria last year and what your plans are for this year?

Answer. The High Priority Opportunity List or HPOL (used for scholarship obligors), the loan repayment list and the volunteer list are developed and used over an eighteen month period. It is made available in the summer preceding the fiscal year for which it used for placements. Therefore the list currently in use was developed prior to the enactment of the current legislation, which contains specific criteria to use in deciding on sites which apply for inclusion on the lists. The criterion employed in evaluating applicant sites for the current list included as one criteria the percent of special populations such as homeless, migrant, perinatal, persons with HIV/AIDS, substance abusers, and the elderly. Additionally, the criteria were that: the site must be part of a system of care; be located in a currently designated Health Professions Shortage Area or HPSA (required by law); must need at least one FTE; the rate of poverty, infant mortality, population to primary care physician ratio, and the percent of minority population; vacancies as a percent of total budgeted staff; and the degree of rurality. The criteria specified in the new law are: the ratio of available health professionals to the number of individuals in the area or population group involved or served by the medical facility or other public facility involved; and indicators of need such as the rate of low birth weight, infant mortality, poverty, and access to primary health services taking into account the distance to such services. The new criteria are currently being employed in the development of lists that will be used beginning July, 1991.

The distribution of sites currently in use which were selected under the old legislation resulted in a HPOL to be used in placing scholarship obligors that is 73 percent rural and a loan repayment list that is also 73 percent rural. It is not likely that the lists issued this past summer would be more rural in their distribution if the new legislation had been in place. Furthermore, there is no reason to expect that the list now under development would be significantly more rural under the new criteria.

It is widely acknowledged that there are shortages of doctors in rural areas and one program that can contribute to a solution of this problem is an expanded NHSC. However, redoing the current placement lists is not a solution and would only have adverse affects on the process (which is at about the midpoint at this time), the obligors and volunteer selecting sites, the sites themselves, and the continuity and integrity of the program.

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