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for that. But we believe that the job is far from being done, and we need your continued help.

Accordingly, we are requesting-and I know from your warning early on, Mr. Chairman, that it is somewhat precarious to ask for increases, but because of the urgency of this problem, we are going to ask that there be a doubling of the funding for family medicine education to $80 million for the residency programs and $14 million for the departments of family medicine. These funds would provide the necessary doctors that we believe are critical to meet the health care needs of the American people.


We also believe that there ought to be some consideration given to funding the new Agency for Health Care Policy and Research, and we strongly suggest that a consideration be given at this critical time to increase their research appropriations by an additional $20 million so that we can do the community-based health research, which has not been done by the NIH and other kind of research folk.

Senator BUMPERS. Thank you, Dr. Jones.



I am James G. Jones, M.D., Past President of the American Academy of Family Physicians and a member of the National Advisory Council on Health Professions Education. The Academy is the national medical specialty society representing over 70,000 practicing family physicians, family practice residents and medical students. I am pleased to have the opportunity to appear before this committee to discuss with you appropriations for fiscal year 1992 for family practice education.

The Academy is appreciative of your recognition of the need for and the contribution of the specialty of family practice to the nation's health care. Assistance through federal grants targeted to Family Practice Residencies and Departments of Family Medicine help to train more specialists in family medicine and increase access to quality health care for Americans. Your continued support is critical as we again face a budget which would eliminate support for family practice training, as proposed by the Administration.


Approximately 93 percent of family physicians are engaged in direct patient care, serving the range of the nation's population from its children to its elderly, from its urban to its rural areas. It is these physicians who make the initial diagnosis and provide the continuum of care for patients with a variety of health and social problems, such as teenage pregnancy, infant mortality and human immunodeficiency virus, as well as problems involving occupational and environmental health. Because of their multidisciplinary training, family physicians are able to care for the majority of the problems presented in their offices and are particularly adaptable to the diverse needs presented in the various geographic areas. On average 85 percent of all visits are resolved by the family physician without referral or consultation.

Graduates of family practice programs serve the medically needy in remote rural areas as well as impoverished inner-city areas. Family physicians locate in shortage and rural areas in larger proportions than other medical specialties, thus helping to address the national problem of geographic maldistribution.

As the demographics of the U.S. population change, many more family physicians will be needed and must be trained. The population 65 years of age and over will increase about 2 percent a year between now and 2020. These elderly will require a wide range of health care services, including preventive, primary, long-term, hospice, and rehabilitation care. Over the next decade there must be a substantial increase in the number of family physicians to meet the demand for health care.


While the demand for family physicians is high and growing, the supply is not keeping pace. Between the years 1985 and 2000 the U.S. population is expected to increase by 12.3 percent. In contrast, American Medical Association data project that during these years the number of family physicians will increase by only 9 percent. Also of concern is the decrease in the percentage of family physicians of the total physician population from 13.8 percent in 1975 to 11.9 percent in 1986.

There is an adverse trend in primary care career interest among medical and other health professional school graduates. The percent of medical school seniors planning to become board certified in a primary care specialty fell from 37.3 percent in 1981 to 23.6 percent in 1989. This indicates an increasing shortage of family physicians in the future and we believe a cause for great concern.


In fiscal year 1991, with the support of this Subcommittee, Congress appropriated $36.108 million for family practice residency training and $6.8 million for departments of family medicine within medical schools. We have appreciated your past efforts and again come to you requesting that family practice training be a priority for targeted health professions training grants. In order to help meet the ever increasing demand for family physicians, a significant increase in federal support is critical. The American Academy of Family Physicians advocates doubling the current authorizations and appropriations for family practice residency training (Sec. 786) to $80 million and for departments of family medicine (Sec. 780) to $14 million. The Academy is working diligently with the authorizing committees on the reauthorization of the health professions training programs in Title VII for family practice funding at these levels. A renewed and federal commitment of targeted federal support to family practice training is essential to meet the goal of ensuring access to quality health care by the American people.

These funds provide support to train residents to become family physicians, to develop faculty in the specialty of family practice, to create and strengthened departments of family medicine within medical schools to ensure that students are exposed to family practice as a viable career choice. The federal grants help to offset some of the financial disadvantage experienced by family practice education programs.

Over two thirds of family practice residency programs are located in community hospitals, rather than in traditional tertiary medical centers. In addition to the community hospitals, family practice residency programs are exploring affiliation with community health centers, migrant health centers and free clinics. Location in nontraditional training sites, coupled with an ambulatory-based training model which emphasizes training in a family practice center to simulate practice in a physician's office, provide these residency programs with significant financial challenges.

In 1970 there were 49 approved residency programs with 290 residents. Tremendous growth in family practice followed and then peaked in 1983 with 388 residency programs and 7,409 residents. Today there are slightly fewer program and family physicians being trained, 382 programs and 7,268 residents. The growth curve in family practice education closely parallels federal support of these training program.


The AAFP supported the establishment of the Agency for Health Care Policy and Research (AHCPR) under the Omnibus Budget Reconciliation Act of 1989. The purpose is to enhance the quality, effectiveness and appropriateness of health care services and access to such services. In carrying out this mission, the agency is to conduct and support research and guideline development on health care services and systems for services delivery. The law specifies clinical practice research is to include primary care and practice-oriented research. This focus has given hope to many in family practice that primary care practice-based research would receive federal support and attention long given to traditional biomedical and health services research. Primary care research has not had a traditional base of support and developing this capacity requires a defined and sizable investment. As family physicians provide one third of office visits to the elderly population, the work of the agency will have a significant impact on patients.

Research in family practice primary care is strengthened by an exciting new research paradigm that has been pioneered by family practice researchers. Practice based research combines the wisdom of the practitioner in defining relevant_research questions with the scientific rigor of a multi-disciplinary research team. This type of research has clearly demonstrated that the bulk of current medical knowledge generated from research in the highly selected population of the academic med

ical center does not generalize well to the care of health problems that most people experience most of the time. If primary care physicians are to practice medicíne based on informed clinical policy a great deal of additional support for practicebased research is required.

In order to support this critical line of research we request that an additional $20 million be appropriated to the Agency for Health Care Policy and Research. We note that while the President's budget requests additional budget support for AHCPR in 1992 this comes largely from an increase in the contribution from one percent evaluation funds, and actually requests $60 million less (compared to the current year) for AHCPR from basic budget authority." Thus appropriating an additional $20 million for research in family practice and primary care can be accomplished while maintaining overall budget neutrality.

The Academy believes the committee has the opportunity to invest in practicebased primary care research through the restoration of funds from the budget authority appropriation amount. We believe that if the agency is provided with the resources and incentives to address primary care research, it holds the potential to improve the health of Americans.


The federal support of family practice training programs has helped to bring qual ity health care to many people who otherwise might not have a physician in their communities. However, while the demand for family physicians is growing, there has been a standstill in funding for these programs and in their growth.

We are, therefore, seeking increased funding for these programs. We encourage your support of this funding and look forward to continuing to work with you on appropriations for fiscal year 1991.



Senator BUMPERS. Mr. Kelehan.

Mr. KELEHAN. Good morning, Mr. Chairman. My name is Jim Kelehan, and I am the AARP vote coordinator for the Fourth Congressional District in Des Moines, IA. Thank you for this opportunity to comment on spending next year for programs which affect older Americans.

While time will not allow for a thorough discussion of the association's recommendations in this regard, we do want to express our gratitude for the subcommittee's continuing support of these activities which include Older Americans Act programs, aging research, nursing home inspections, and geriatric health care training. We also deeply appreciate the subcommittee's support of programs which help the Nation's elderly poor, such as the Low-Income Home Energy Assistance Program, better known as LIHEAP, and the Community Service Employment for Older Americans Program. The need for providing adequate resources next year for both programs remains critical.

The President's total funding request for LIHEAP is $600 million below the CBO baseline for 1992. A reduction of this magnitude would have a devastating impact on this already hard-pressed program, Mr. Chairman. In its analysis of the President's budget request, CBO reports that heating assistance benefits, which represent the program's largest component, were provided to only 5.5 million households last year, compared to 6.6 million households in 1985 when program spending was at its peak.

In the past it has been suggested that alternative funding sources for LIHEAP would be available, but they have never materialized. Total oil overcharge moneys spent on LIHEAP have not been sufficient to offset the total reduction in Federal funds. The

association recommends current services funding next year for this essential program.

We also urge the subcommittee to fully fund community services employment for older Americans.


Thank you again for this opportunity to present our views regarding programs of interest and concern to older Americans. We trust the recommendations included in our complete statement will receive the subcommittee's favorable consideration.

Senator BUMPERS. Mr. Kelehan, I want to, on behalf of Senator Harkin, apologize for his not being here to greet you. He was sorry. I think he is going to see you later in the day, is he not? Mr. KELEHAN. Thank you very much, Senator.

[The statement follows:]


On behalf of the American Association of Retired Persons (AARP), thank you for this opportunity to testify concerning fiscal year 1992 funding for programs under this subcommittee's jurisdiction. My name is Jim Kelehan and I am the AARP vote coordinator for the 4th congressional district in Iowa.

AARP's recommendations can be summarized as follows:

One, provide, at a minimum, current services funding ($1.68 billion) to the low income home energy assistance program (LIHEAP).

Two, provide an increase for title III programs under the Older Americans Act, in recognition of rapid growth in the 75+ age group. Also fund OAA outreach to increase participation in public benefit programs.

Three, raise the fiscal year 1992 appropriation for the senior community service employment program (SCSEP, title V of the OAA) by an amount adequate to accommodate minimum wage increases for 65,000 authorized permanent positions at the new per unit cost of $6,061.

Four, provide a realistic level of funding for Medicare contractors.

Five, provide sufficient funding to maintain current services in the geriatric health care training program and no less than the current level of research services by the National Institutes of Health, particularly in the field of aging.


The association supports a current services budget of $1.68 billion for this program which is so critical to low income older Americans. The administration is requesting a total of $1.025 billion, of which only $925 million would be made available for the regular program. The remaining balance of $100 million would be set aside in a special contingency fund for release later if energy prices escalate.

The association is deeply concerned about the administration's proposal to impose a $685 million spending cut next year. A reduction of this magnitude could eliminate more than 2 million households from the program, or require a comparable 45 percent reduction in benefits that are already too low. Moreover, the proposal to include a contingency fund would divert critical resources from this already hard pressed program. While we fully recognize the value of providing additional resources for exceptional circumstances, in our judgment it makes no sense to construct such a fund at the expense of the regular program.

The association's strong support of LIHEAP is a matter of record with the subcommittee, and we are grateful for your past efforts to keep the program viable. Energy prices have not declined since the substantial increase in the price of heating oil and propane during the record-breaking cold wave of December 1990. Several states, routinely those in the Northeast and even those in the Mid-Atlantic region, allocated most of their LIHEAP funds before winter ended this year. The nation is in a recession. Unemployment is at its highest rate since 1982. States across the country are reporting increased demand for public assistance.

In the past it has been suggested that alternative funding sources for LIHEAP would be available, but they have never materialized. Total oil overcharge moneys spent on LIHEAP have not been sufficient to offset the total reduction in federal funds.


Funding for title III services should be increased. Over the past decade, funding for title il programs has declined, in real terms. In addition, the population age 75 and older, which is the group most likely to need services, has increased rapidly and will continue to do so. Today many aged persons are able to live independently in their own homes because of effective and innovative supportive services, meals, programs, training, research and demonstrations provided by the act.

AARP also believes that funds should be provided for conducting outreach designed to help older persons gain access to public benefit programs. We recognize that action by the authorizing committee is necessary prior to final passage of the fiscal year 1992 spending bill. However, we trust sufficient resources will be available to fund this essential activity.


The association urges the subcommittee to provide at least $394 million for the senior community service employment program. This amount reflects new, mandated wage increases for more than 65,000 low income older Americans at the cost of $6,061 per unit. Those who participate in this essential activity rely heavily on these resources. The association appreciates the subcommittee's strong support of this program over the years. AARP also urges current services funding for the Job Training Partnership Act.


AARP urges the subcommittee to provide a realistic level of funding for Medicare contractors in fiscal year 1992. Contractors are responsible for reimbursing Medicare beneficiaries and providers, and provide technical assistance and information about changes in the Medicare program. Without reasonable funding, we can expect further delays and errors in processing payments for beneficiaries and physicians.


AARP opposes the proposal to establish a survey and certification revolving fund to charge facilities for costs associated with federally required surveys in Medicare and Medicaid. Charging providers such "user fees" could weaken state survey agencies at a critical time when major long-term care reforms are being put in place in the survey area. We are also concerned that such a proposal could motivate providers to shift costs onto non-Medicare patients and could open the door to "deemed status" of long-term care facilities by private accreditation organizations in lieu of the normal Medicare survey and certification process.


AARP supports funding sufficient to maintain current services for federal programs in geriatric health care training. The rapidly aging population and the estimated shortage in health care professionals underscore the need for federal support of geriatric training.


AARP supports continued funding at the current services level for research conducted by the National Institutes of Health (NIH). The thirteen research centers which comprise NIH have played important roles in advancing not only aging research, but research to benefit all generations. As the population ages, crucial policy decisions will have to be made in every sector. It is essential that these decisions be grounded in solid research. The association appreciates the impressive work done by the National Institute on Aging in this regard.

AARP deeply appreciates the subcommittee's continuing support of programs serving older Americans. We stand ready to work closely with members and staff as the fiscal year 1992 appropriations bill works its way through Congress.


Senator BUMPERS. Michele.

Ms. BEST. Thank you, Mr. Chairman. My name is Michele Best. I am the director of laboratory quality assurance and human resources at the Washington Hospital Center. I am pleased today to

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