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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.

HEALTH PROFESSIONS

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, physician population ratios rose almost three times faster for the Nation tha for rural areas, despite overall rapid growth in physician supply.

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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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a/ Cluster authority - includes previously funded individual programs.

HEALTHY START INFANT MORTALITY INITIATIVE

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.

and

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?

Answer. The Department is reviewing the final eligibility criteria which will then be published in the Federal Register. The 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.

funds?

Question. Will Indian reservations also be eligible for

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:

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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

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