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year 1992 at the level of $66 million. The ANA has established as priorities the following programs within the NEA:

Special Projects: This program provides grants to schools and other entities for projects that improve access to nursing service and encourages geographic and specially distribution of nursing manpower. Projects authorized under this program include long-term care and geriatric training for nurses, assistance for development of innovative hospital nursing practice models to reduce vacancies in professional nursing positions, and funds to assist licensed vocational or practical nurses, nursing assistants, and other paraprofessional nursing personnel toward achievement of professional nursing degrees.

Advanced Nurse Education and Professional Nurse Traineeships: These two programs provide support for schools of nursing and individual nursing students for advanced preparation of nurses at the graduate level. The professional traineeships are designed to encourage full-time study and increase the supply of advanced practitioners at a more rapid rate by lowering financial barriers and supplementing tuition support for recipients. These iwo programs are a priority because of the need for additional faculty in nursing schools to handle the increased number of nursing students who are enrolling in nursing programs. In its annual survey, the American Association of Colleges of Nursing (AACN) reported that faculty shortages were cited by more than 56 percent of its respondents as a reason for not accepting students for enrollment. They found that 2,292 prospective qualified bachelors degree students were not admitted in the 1990-91 academic year to their member schools of nursing because of insufficient resources to accommodate all the potential students. These reports indicate that while nursing has done a good job of getting the message to potential students about nursing as a career, we have not addressed the need to increase the resources needed to educate future nurses. We cannot allow the gains we have made in the past few years to be lost because of our inability to respond to increased enrollment. The priority on advanced education and professional traineeships will not only ensure an adequate supply of faculty but will additionally provide advanced practitioners for clinical practice.

ANA would additionally recommend that funding for the National Center for Nursing Research (NCNR) be increased to a level of $58.8 million. The purpose of the Center is to foster adequate funding for nursing research and to ensure an adequate supply of qualified nurse researchers. NCNR priorities include : HIV-related nutritional problems, frailty in older adults, long-term care requirements of older persons, low birth: prevention and neonatal nursing care, management of Alzheimer's disease symptoms, minority health, women's health interventions and rural health care for vulnerable populations. Although appropriations for NCNR have continued to increase, the Center is still not funded at the same level as other NIH institutes and centers. In FY 1990, NCNR had an award rate of 18 percent as compared to the overall NIH award rate of 24 percent. An appropriation of $58.8 million in FY 1992 would permit a award rate of 20 percent for the NCNR. Given that many of the research studies funded by NCNR are providing outcomes that will alter nursing interventions and improve the quality of patient care, the investment is minor compared to the potential cost-savings that will be realized.

Mr. Chairman, I appreciate the opportunity to appear before you today on behalf of nursing. We appreciate the support you and your committee have given us in the past and hope that you will continue to recognize the important contribution that nurses make to the health care system in America. I would be pleased to answer any questions.

Senator HARKIN. Thank you very much. That is a great story. You say you now pay as much in taxes as you received in welfare?

Ms. WHITEHEAD. Per year.

Senator HARKIN. That is a great success story, one that ought to be retold. You ought to be very proud of that. Ms. WHITEHEAD. Thank you.

Senator HARKIN. What did we have last year? We had National Center for Nursing at $43.7 million is the request. You are requesting $58.8 million for that and $66 million for the nurse training.

Ms. WHITEHEAD. That is correct. It is an increase of about 10 percent.

Senator HARKIN. It was $39 million last year. And the administration was asking for $43 million this year. I see. I just want to get my figures straight here.

How can we encourage more nurses to practice in underserved areas?

Ms. WHITEHEAD. Increase the salaries.
Senator HARKIN. Makes sense to me.

Ms. WHITEHEAD, In Pennsylvania, I work in Philadelphia and I make a very good salary. But you can go about one-half an hour away from Philadelphia and I am probably making about 25 to 30 percent more than nurses in those areas, the small rural communities.

Senator HARKIN. How much do nurses learn now in their training about health prevention, disease prevention, and health promotion?

Ms. WHITEHEAD. Over the years it has been increasing. When I went to school in 1979, 1980, 1981 range, that probably was the focus of maybe about 40 percent of our education. And I know over the years i know a lot of it was to help people through patient teaching and education to either minimize the problems they were experiencing or to prevent them.

I work in a coronary care unit. I do a lot of preventive education while I am taking care of these people, like how to prevent further heart attacks and things like that.

Senator HARKIN. Thank you very much for your testimony. It was very good. I appreciate it.

Ms. WHITEHEAD. Thank you. STATEMENT OF DR. CHARLES R. WALLACE, NATIONAL ASSOCIATION

OF COMMUNITY HEALTH CENTERS Senator HARKIN. Next is Dr. Charles Wallace, Lee County Cooperative Clinic from Marianna, AR, representing the National Association of Community Health Centers.

Dr. WALLACE. I am substituting for Dr. Payne who was suddenly ill. I came in his place.

Senator HARKIN. Sorry to hear that.

Welcome, Dr. Wallace to the subcommittee. We have your statement. Please proceed.

Dr. WALLACE. Thank you, Mr. Chairman.

Good morning, Mr. Chairman and members of the subcommittee. For the record, I am Dr. Charles R. Wallace. I am a clinic physician and surgeon at the Lee County Cooperative Clinic in Marianna, AR. I am here today in place of my colleague, as I just mentioned.

I am also here today on behalf of the National Association of Community Health Care Centers which represents over 600 community and migrant health centers and homeless health care programs.

I deeply appreciate the opportunity to present to you the problems which these health centers face and the current climate and the issues of the fiscal year 1992 funding for these programs.

Mr. Chairman, these health centers are community-based systems which provide high quality prevention-oriented primary health care services to patients who are impoverished, disabled, rural, or have no other places to have health care or health education. By law, these health centers are placed in medically underserved areas, deteriorating neighborhoods of major cities, are in rural areas too isolated or too poor to attract private physicians.

A written statement is submitted for the record, but I would like to touch on some of my own personal experiences at the Lee County Clinic in Marianna, AR.

The clinic population is basically large, rural, mixed with many farmers and laborers. Most of the patients I see are not necessarily poor, but because of economic situations in the country today they find themselves with no place to go for health care except this clinic.

I have seen in the past month alone three teenagers under 15 years pregnant because of inability of the health care system to provide outreach.

I have dealt with sickness and death throughout my career and practice, but have not been so devastated until a 9-month old was brought in dead because the family was too poor to go to a doctor and waited until the last minute. By then it was too late.

Yes; teenage pregnancy and infant mortality is a real problem and health centers today are really helping to curb this problem.

I see many people in Marianna who are temporarily out of work and some homeless whose medical problems would become catastrophic if the health center were not there to provide services which are relatively inexpensive.

In summary, there are three key points I would like to reiterate. First, is the lack of physicians. Second, the basic underfunding of these health centers. And third, the number of patients keep growing.

PREPARED STATEMENT

For these reasons, I ask you to support the recommended funding level submitted in the record for health, happiness, and stronger moral guide consciousness.

Thank you, Mr. Chairman. [The statement follows:)

STATEMENT OF DR. CHARLES R. WALLACE

Mr. Chairman and Members of the Subcommittee:

My name is Earnest Payne, Jr., Medical Director of the Lee County Cooperative Clinic, based in Marianna, Arkansas. Today, I am speaking behalf of the National Association of Community Health Centers which represents over 600 Community and Migrant Health Centers and Homeless Health Care Programs throughout our nation. As you know, these health centers provide basic comprehensive primary health care to America's poorest, most disadvantaged people from inner-city ghettos to rural migrani farmworker labor camps and isolated, resourcepoor communities.

I dceply appreciate the opportunity to present to you today the problems which these health centers face in the current climate, and the issues of fiscal 1992 funding for the federal programs which support the health center activities.

Overview of Health Centers

Health centers are community-based systems of care which provide high quality prevention. oriented, comprehensive case-managed primary health care services to patients who, because of poverty, disability, geographical, occupational and cultural barriers would otherwise have little or no health care. By law, health centers are placed in medically underserved areas, usually in the inner, deteriorating neighborhoods of major cities or in rural areas that are too isolated or too poor to attract private physicians.

Twenty five years ago, prior to the advent of Medicare, Medicaid, and the federally funded health centers, low-income patients or persons living in remote areas were forced to choose between the hospital emergency room, local public health services, or the teaching clinic of medical schools, if and where they existed and if the patient were accepted. These services were and still are inadequate both in scope and size, or inappropriate for the level of care needed. Health centers' achievements over the past 25 years show how much is known about how to make a difference in the health of the poor and how far even a modest investment will go.

Health centers understand their communities' most urgeot needs: As the primary, is not sole, source of health care for the medically underserved, health centers respond to a host of needs. Their strong community ties have made health centers extremely sensitive to emerging community needs. Their community-based nature means that health centers tailor their services to meet those needs. Centers provide a broad array of comprehensive primary and preventive health services in settings that are appropriate for their patients and accessible. They charge for their services only in accordance with patients' ability to pay.

Health ceoters care for those whom other providers cannot or will not serve: Perhaps the greatest testament to the unique ability of health centers to design services that are accessible to their patients is that, ironically, health centers report that for every ten currently served there are another three on waiting lists who seek care. And the individuals and families on waiting lists do not even begin to take into account the far larger number of persons who need the services of health centers but who do not have a center within reach.

Health ceoters offer high quality medical care: Because health centers exist to provide comprehensive care they are staffed to offer ongoing medical treatment as well as preventive and diagnostic services, through a staff that includes primary care physicians plus an array of other health professionals who have been particularly recognized for the quality and impact of their work on low-income and medically underserved communities, such as nurse midwives, nurse practitioners, and physicians assistants.

Health centers have had a major impact on the health of their communities aod provide care in a highly cost-effective fashioo: Numerous studies have shown the impact or health centers on the health status of their communities:

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More Effective Care: Community health center patients have been shown to have lower hospital admission rates, shorter lengths or stay and make Icss inappropriate use of emergency room services.

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Fewer Infant Deaths: Communities served by health centers have bcen shown to have infant mortality rates from ten to forty percent lower than communities not served by health centers. The provision of health center services also has been linked to improvements in the use of prenatal care and reductions in the incidence of low birth weight.

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Less Preventable Illness: Community health centers have been shown to reduce rheumatic rever and untreated middle ear infections in children and have significantly increased the proportion of children who are immunized against preventable discase.

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Beller Use o Preventive Care: Health centers have increased the use or preventive health services such as Pap smcars and family planning services.

However, the need to strengthen the capacity of health centers has grown more urgent in recent years. And yet, although demand for services has increased significantly, federal funding for centers has actually decreased by up to 30 percent over the past ten years, when compared with virtually any measure of increased costs, as shown in the attached chart. What is most remarkable is that the centers have increased the number of patients served by nearly one million over that same period, despite the inadequacy of federal support. Cleariy, this canner be allowed to continue.

The simple fact is that, after 25 years of experience, and despite their remarkable record of achievement. The health centers today serve only one of every sive Americans who lack access 10 a regular source of continuous, high-quality primary health care. For 24 of the 30 million medically underserved Americans, the ability to get health care when they need it is still only a dream · • and their struggle to obtain any kind of care is a regular nightmare. It is well past time that we, as a nation, made the commitment to assuring available, accessible, affordable health care for every American. Our recommendations, which are made with the full awareness of the severe economic, fiscal, and political constraints you face in crasting the fiscal 1992 appropriations, are nevertheless absolutely essential to put us on the path or realizing that commitment by the end of this decade.

Recommendations

I.

Community Health Centers - $620.0 million
This amount would continue current funding as well as allow health centers to serve an
additional 1.2 million medically underserved individuals in the neediest unserved
communities through existing health centers and by establishing another 120 health
centers in the neediest communities. In addition, this amount would continue to provide
and enhance health care services to high-risk pregnant women and children. Current
perinatal care funding for health centers meets less than one-third of the service needs
of low income pregnant women. A recent study of the perinatal program indicated that
at least $ 100 million was needed to meet the basic maternity and insani care needs in
health center communities last year compared to the $35 million currently available.
We wish to note that, in 1989, health centers provided perinatal care to over 200,000
low-income, pregnant women one out of every 15 American women who gave birth
that year -- including more than one of every four pregnant teenagers under the age of
15. It goes without saying then, that we care for many of the highest-risk pregnancies
in this nation.

II.

Migrant Health - $80.0 million
This amount would continue current services as well as provide for an additional
300,000 migrant and scasonal farm workers and their family members -- still only 20%
of the migrant population who need health care.

III.

National Health Service Corps
Because they are located in areas with significant shortages of health care providers,
health centers depend on the NHSC for manpower. However, as I have already noted,
centers face a severe loss of critically-nceded physicians. There is currently a vacancy
of 930 physicians at health centers of which 600 are NHSC physicians who will
complete their scholarship obligation at health centers this year. Approximately one-
half (300) of thc NHSC physicians will leave for reasons which health centers can do
little about c.8., rural isolation, lack of medical peer interaction, "burn-out" from heavy
cascloads. Currently, there are 360 scholars and loan repayment assignces available for
all medically underserved areas. Only about 288 of these will be available to health
centers. Although scholarships will be awarded this year, these recipients will not be
available for service until 1996. In order to provide for the expansion of the
Community and Migrant Health Center programs, an additional 500 physicians are
needed. This means that health centers face a need to recruit nearly 850 physicians in
FY 1992. Furthermore, most rural health centers and those in high priority areas are

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