[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



  THE HEALTH CENTERS RENEWAL ACT OF 2007; THE NATIONAL HEALTH SERVICE 
 CORPS SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS REAUTHORIZATION ACT OF 
          2007; AND THE SCHOOL-BASED HEALTH CLINIC ACT OF 2007

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                                   ON

                    H.R. 1343, H.R. 2915, H.R. 4230

                               __________

                            DECEMBER 4, 2007

                               __________

                           Serial No. 110-76


      Printed for the use of the Committee on Energy and Commerce

                       energycommerce.house.gov
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                    COMMITTEE ON ENERGY AND COMMERCE

            JOHN D. DINGELL, Michigan, Chairman
HENRY A. WAXMAN, California          JOE BARTON, Texas
EDWARD J. MARKEY, Massachusetts         Ranking Member
RICK BOUCHER, Virginia               RALPH M. HALL, Texas
EDOLPHUS TOWNS, New York             J. DENNIS HASTERT, Illinois
FRANK PALLONE, Jr., New Jersey       FRED UPTON, Michigan
BART GORDON, Tennessee               CLIFF STEARNS, Florida
BOBBY L. RUSH, Illinois              NATHAN DEAL, Georgia
ANNA G. ESHOO, California            ED WHITFIELD, Kentucky
BART STUPAK, Michigan                BARBARA CUBIN, Wyoming
ELIOT L. ENGEL, New York             JOHN SHIMKUS, Illinois
ALBERT R. WYNN, Maryland             HEATHER WILSON, New Mexico
GENE GREEN, Texas                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              CHARLES W. ``CHIP'' PICKERING, 
    Vice Chairman                        Mississippi
LOIS CAPPS, California               VITO FOSSELLA, New York
MIKE DOYLE, Pennsylvania             STEVE BUYER, Indiana
JANE HARMAN, California              GEORGE RADANOVICH, California
TOM ALLEN, Maine                     JOSEPH R. PITTS, Pennsylvania
JAN SCHAKOWSKY, Illinois             MARY BONO, California
HILDA L. SOLIS, California           GREG WALDEN, Oregon
CHARLES A. GONZALEZ, Texas           LEE TERRY, Nebraska
JAY INSLEE, Washington               MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
MIKE ROSS, Arkansas                  SUE WILKINS MYRICK, North Carolina
DARLENE HOOLEY, Oregon               JOHN SULLIVAN, Oklahoma
ANTHONY D. WEINER, New York          TIM MURPHY, Pennsylvania
JIM MATHESON, Utah                   MICHAEL C. BURGESS, Texas
G.K. BUTTERFIELD, North Carolina     MARSHA BLACKBURN, Tennessee
CHARLIE MELANCON, Louisiana          
JOHN BARROW, Georgia                 
BARON P. HILL, Indiana               

                                  -----
                           Professional Staff

                    Dennis B. Fitzgibbons, Chief of Staff
                    Gregg A. Rothschild, Chief Counsel
                       Sharon E. Davis, Chief Clerk
                   David L. Cavicke, Minority Staff Director

                                  (ii)


                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
HENRY A. WAXMAN, California          NATHAN DEAL, Georgia,
EDOLPHUS TOWNS, New York                 Ranking Member
BART GORDON, Tennessee               RALPH M. HALL, Texas
ANNA G. ESHOO, California            BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
    Vice Chairman                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine                     MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
ELIOT L. ENGEL, New York             SUE WILKINS MYRICK, North Carolina
JAN SCHAKOWSKY, Illinois             JOHN SULLIVAN, Oklahoma
HILDA L. SOLIS, California           TIM MURPHY, Pennsylvania
MIKE ROSS, Arkansas                  MICHAEL C. BURGESS, Texas
DARLENE HOOLEY, Oregon               MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York          JOE BARTON, Texas (ex officio)
JIM MATHESON, Utah
JOHN D. DINGELL, Michigan (ex officio)







                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     3
Hon. Joseph R. Pitts, a Representative in Congress from the State 
  of Pennsylvania, opening statement.............................     5
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     6
Hon. Tim Murphy, a Representative in Congress from the State of 
  Pennsylvania, opening statement................................     8
Hon. Tammy Baldwin, a Representative in Congress from the State 
  of Wisconsin, opening statement................................     9
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, opening statement.......................................    10
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................    11
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................    12
Hon. Edolphus Towns, a Representative in Congress from the State 
  of New York, prepared statement................................    14
Hon. Tom Allen, a Representative in Congress from the State of 
  Maine, prepared statement......................................    14
Hon. Darlene Hooley, a Representative in Congress from the State 
  of Oregon, prepared statement..................................    15
Hon. Heather Wilson, a Representative in Congress from the State 
  of Mexico, prepared statement..................................    15

                               Witnesses

Dennis P. Williams, Deputy Administrator, Health Resources and 
  Services Administration........................................    16
    Prepared statement...........................................    20
Answers to submitted questions...................................    93
Wilbert Jones, chief executive officer, Greater Meridian Health 
  Clinic, Meridian, MS...........................................    47
    Prepared statement...........................................    49
Steven Miracle, executive director, Georgia Mountain Health 
  Service, Incorporated, Morgantown, GA..........................    55
    Prepared statement...........................................    57
Ricardo Guzman, chief executive officer, Community Health and 
  Social Services Center, Incorporated, Detroit, MI..............    67
    Prepared statement...........................................    69
    Answers to submitted questions...............................    89
Michael Ehlert, M.D., president, American Medical Student 
  Association, Reston, VA........................................    70
    Prepared statement...........................................    73

                           Submitted Material

H.R. 2915, to amend the Public Health Service Act to reauthorize 
  the National Health Service Corps Scholarship and Loan 
  Repayment Programs.............................................   109
H.R. 4230, to amend the Public Health Service Act to establish a 
  school-based health clinic program, and for other purposes.....   111
H.R. 1343, the Public Health Service Act to provide additional 
  authorizations of appropriations for health centers program 
  under section 330 of such Act..................................   104

 
  THE HEALTH CENTERS RENEWAL ACT OF 2007; THE NATIONAL HEALTH SERVICE 
 CORPS SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS REAUTHORIZATION ACT OF 
          2007; AND THE SCHOOL-BASED HEALTH CLINIC ACT OF 2007

                              ----------                              


                       TUESDAY, DECEMBER 4, 2007

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 2:09 p.m., in 
room 2322, Rayburn House Office Building, Hon. Frank Pallone, 
Jr., (chairman) presiding.
    Present: Representatives Gordon, Green, Allen, Baldwin, 
Deal, Pitts, Murphy and Burgess.
    Staff present: William Garner, Katherine Martin, Melissa 
Sidman, Brin Frazier, Bobby Clark, Chad Grant, and Ryan Long.

 OPENING STATEMENT OF HON. FRANK PALLONE JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. I call the meeting to order.
    First let me welcome everybody back from our 2 weeks at 
home. I know we have got a lot to do over the next 2 weeks, so 
I wish us luck on a bipartisan basis. I know it is not going to 
be easy. But today we are having a hearing of the subcommittee 
on three bills, H.R. 1343, the Health Centers Renewal Act; H.R. 
2915, the National Health Service Corps Scholarship and Loan 
Repayment Reauthorization Act; and H.R. 4230, the School-Based 
Health Clinic Act.
     I would now recognize myself initially for an opening 
statement. And let me first mention those who have been the 
sponsors of these bills. The Health Centers Renewal Act was 
introduced by our Vice Chair Mr. Green, the National Health 
Service Corps Scholarship and Repayment Programs 
Reauthorization by Mr. Braley, and the School-Based Health 
Clinic introduced by Ms. Hooley from the committee. And I 
wanted to thank all of them for their hard work in putting 
together these different bills.
    And I also want to call attention to the efforts of two of 
our colleagues on the subcommittee, Representative Bart Gordon 
and Representative Tom Allen. Both Mr. Gordon and Mr. Allen 
have also introduced legislation that reauthorizes the National 
Health Service Corps Scholarship and Loan Repayment Programs. 
Though the hearing today is on H.R. 2915, I wanted them to know 
that the subcommittee will be working very closely with you and 
your staff as we move forward with this legislation, and I laud 
your efforts to address this important public health issue.
    As far as the community health centers, the first bill, 
access to health care obviously has been a priority for this 
Congress, especially since the number of uninsured Americans 
continues to rise. And for the 47 million Americans without 
health insurance, as well as the millions more who are 
underinsured, there are simply too few options for them to 
receive the medical treatment they need. But for the past 40 
years there has been one place that Americans have been able to 
go to receive the medical treatment that they need and deserve 
regardless of their ability to pay, and those are our community 
health centers. Since the mid-1960's our community health 
centers have served as a first line of defense to provide 
quality preventative and primary health care services in 
medically underserved communities.
    But as more and more Americans join the ranks of the 
uninsured, the demands of our States' health centers are 
growing exponentially. Increased demand, coupled with aging 
facilities and difficulties in recruitment and retention of 
health professionals has placed tremendous strain on our health 
centers. Accordingly, it is critical that this Congress act 
quickly to strengthen our community health centers and help 
them fulfill the role they play in guaranteeing access to high-
quality health services.
    The most important step we could take to accomplish this 
goal is to pass this legislation that would reauthorize the 
community health centers program for another 5 years and 
provide them with adequate resources. And I think we can all 
agree that the community health centers provide a vital service 
to all of our communities. We shouldn't waste any time in 
helping them carry out a mission that is of fundamental 
importance to so many Americans.
    Now the second bill on, the National Health Service Corps, 
as I mentioned, this bill would ensure that underserved 
American communities have access to health care through the 
recruitment and support of health service professionals. 
According to the Health Resources and Services Administration, 
which administers the National Health Service Corps programs, 
and we are going to be hearing from Dr. Williams today, 
approximately 50 million people live in communities with no 
access to primary health care. The National Health Service 
Corps works to address this disparity by recruiting and 
retaining health professionals through scholarships, loan 
repayment, and placement programs to serve in those 
communities, and the impact of this program is immeasurable. 
Since 1972, more than 27,000 health professionals have served 
in the National Health Service Corps, including 4,000 current 
Corps members, who are caring for 4 million people in 
underserved urban and rural areas. Many of these Corps members 
will continue to serve in the health professional shortage area 
even after fulfilling their 2-year commitment.
    Ensuring that all Americans have access to quality health 
care is obviously important, but this bill would provide the 
necessary reauthorization and funding in the amount of $300 
million through 2011 to support the National Health Service 
Corps and promote expanded access to care. And again I want to 
thank Mr. Braley, Mr. Allen, and Mr. Gordon for all their 
diligent work in drafting this legislation. And obviously this 
is a collective effort, and we are going to work forward to 
move this legislation in the next few weeks, or I should say 
certainly in the new year. I don't think we are going to be 
doing much in the next few weeks. But in the new year.
    The last bill is the School-Based Health Clinic Act of 
2007. Of the 47 million uninsured Americans, nearly 9 million 
are children. We have spent a lot of time on SCHIP and trying 
to address that, and although some of our programs are aimed at 
insuring children specifically, some of those programs that we 
have are successful, obviously we need to do more. We went 
through all that with the SCHIP, which is still ongoing.
    There still remain too many kids who have no access to the 
basic health care that they need. According to the AMA, 
children between the ages of 13 to 18 have the poorest health 
indicators. And over 70 percent of the children who need 
psychiatric treatment have no access to mental health services. 
We have the opportunity today to tackle this problem head on 
through this act, the School-Based Health Clinic Act.
    School-based health centers treat children in a place that 
is convenient for parents and guardians, and children are seen 
by caregivers they know and trust. These health centers 
identify students at risk for health and behavioral problems, 
and can monitor and treat children with chronic illnesses, thus 
reducing health-related school absences. And school-based 
health centers are currently located in over 1,700 schools 
around the country. There are many in my district. I remember 
dealing with them both here in Congress, as well as a State 
legislator, and they provide health care to children regardless 
of their ability to pay. In fact, 45 percent of kids treated at 
school-based health centers are uninsured, and 44 percent of 
the children treated at these centers are enrolled in either 
Medicaid, SCHIP, or other public coverage.
    Considering these statistics, it becomes clear that these 
health centers provide access to health care professionals to 
children who otherwise would have limited or no access to 
health care services.
    I just want to say that I think all these bills are very 
important. Mr. Green and the others have been asking for this 
hearing for some time. We are going to try to move these bills 
when we come back in January of 2008.
    And I just want to thank everybody for being here today, 
and I would now yield to our ranking member, Mr. Deal.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman. First of all, I would 
like to welcome our witnesses on both of our panels, thank them 
for their attendance today. I would especially like to 
introduce and welcome Steven Miracle, who is the CEO of the 
Georgia Mountains Health Services, which has a health center in 
Morganton, Georgia, which is in my district. I really need to 
send Steven back to medical school because how would you like 
to be able to tell somebody who asked you who is your doctor to 
say Dr. Miracle? You know, he does a great job as an 
administrator, but if we had that ``doctor'' in front of his 
name, that would be great. But thank you for being here today.
    The Community Health Center Program has been a huge 
success, I think, and an asset, as community health centers are 
an integral part of this country's health delivery system which 
provide quality health care services to people and communities 
that would otherwise not have access to that care. Last 
Congress I showed my support for this program by introducing a 
bill that would have extended for 5 years the reauthorization 
of this plan. It did pass the House by a large margin, but 
unfortunately the Senate failed to act on the legislation.
    I understand the measure we are considering today has a 
much higher authorization level than the bill last year, and I 
look forward to hearing a justification for these increases 
because I believe we have to all continue to be good stewards 
of the program and of the taxpayers' dollars that fund the 
program.
    As we evaluate changes to the program during this 
reauthorization, I hope the witnesses will speak to the 
staffing needs of health centers during times of emergency. In 
particular, I know some health centers' medical staff had 
trouble as they sought to serve areas affected by Hurricanes 
Katrina and Rita because of the lack of liability protection. 
Some have also expressed an interest in expanding liability 
protection to physicians who volunteer their services at health 
centers, while others have some concerns about the composition 
of the board requirements for health centers. These are all 
issues that I hope we will have a chance to talk about briefly 
today as we consider reauthorizing this particular program.
    The National Health Service Corps provides an important 
incentive for health care providers to serve an area with a 
shortage of health professionals, it certainly goes without 
question. This is done primarily through scholarships and 
loans. And having had constituent service issues on a 
particular situation, I know that firsthand that at times 
scholarship recipients don't always have the certainty about 
their career path when they accept the scholarship. And so 
therefore I look forward to hearing testimony about the 
effectiveness of the scholarships compared with the loan 
program in encouraging students to serve in shortage areas.
    We also will be looking at school-based health clinics, and 
I hope our witnesses will be able to tell us the most effective 
way to provide services for school-age underserved populations.
    This should be a good hearing as we evaluate these programs 
that help ensure that the medically underserved have access to 
care. I look forward to the testimony of the witnesses, and I 
yield back my time.
    Mr. Pallone. Thank you.
     Next is the gentleman from Tennessee Mr. Gordon, who is 
one of the sponsors on the National Health Service Corps.
    Mr. Gordon. Thank you, Mr. Chairman. As we all know, the 
National Health Service Corps is to provide primary health care 
providers to underserved communities. Unfortunately, when the 
Corps was restructured in 2002, primary eye care was 
unintentionally excluded from the program. As a result, access 
to basic eye-care services at community health centers has been 
severely curtailed. Today less than 17 percent of all centers 
have optometrists on staff. This is concerning, as the 
populations served by the community health centers are at high 
risk for vision loss from blindness caused by glaucoma or 
diabetes. Half of all these cases of blindness in this 
population can be prevented if we can get them screened and 
treated early.
    Earlier this year I introduced legislation to address this 
problem by reinstating optometry as a covered service under the 
National Health Care Service Corps. Importantly, I would also 
note that the Institute of Medicine recognized optometry as a 
primary health care service in its report Primary Care: 
America's Health in a New Era.
    Clarifying that optometry is a primary care service covered 
by the Corps is consistent with the Corps' primary health care 
mission and will prevent much suffering and costs to society. 
The bill has 81 cosponsors, including 15 from this committee, 
and is endorsed by the National Association of Community Health 
Care Centers--and to prevent blindness.
    We have talked about this several times, and I appreciate 
your comments of trying to work together on this issue. I know 
that really the only argument that I have heard against it is 
that if optometry is allowed, or if we correct this error that 
was made with optometry, it could open the door for others. And 
I would just say that is not a good argument against this. I 
think all primary care services ought to stand on their own, 
and if there is other additions, then they should be made.
    So again, Mr. Chairman, thank you for having this hearing, 
and thank you for your willingness to review these arguments.
    Mr. Pallone. The gentleman from Pennsylvania Mr. Pitts.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
            CONGRESS FROM THE STATE OF PENNSYLVANIA

    Mr. Pitts. Thank you, Mr. Chairman.
    I strongly support reauthorization of community health 
centers and the National Health Center Services Corporation 
Scholarship and Loan Repayment Program. For more than 35 years, 
the NHSC has been recruiting caring health professionals to 
serve in medically underserved communities where the need is 
the greatest, in rural areas, where the closest provider is 
often many miles away, and in inner-city neighborhoods, where 
economic and cultural barriers prevent people from seeking and 
receiving needed care.
    In the past, the NHSC has made great advances in improving 
access to quality health care services for millions of 
Americans who might otherwise be forced to do without. As we 
all know, the NHSC allows selected health care professionals 
engaged in delivery of primary care services to be reimbursed 
for student loans in return for establishing and maintaining 
their practices in geographic areas designated as medically 
underserved by the Federal Government. However, optometrists, 
the Nation's primary eye- and vision-care providers, are not 
eligible for participation in this program.
    The NHSC program aims to unite communities in need with 
caring health professionals by easing the debt burden 
associated with a professional education, allowing carefully 
selected clinicians, including primary care physicians, nurse 
practitioners, dentists, and other health professionals to 
undertake a multiyear commitment to safeguarding public health. 
However, the exclusion of optometry from the program has had a 
devastating impact on the level and fullness of care with these 
communities which they receive.
    Today, less than 20 percent of community health centers 
have an optometrist on staff, which severely restricts access 
to primary eye- and vision-care services, including 
comprehensive eye exams, detecting and diagnosing eye diseases, 
and treating eye diseases. Nonetheless, doctors of optometry 
have been active in some community and rural health centers 
despite optometry's omission from the NHSC priority.
    Community health centers provide an invaluable service to 
those who need it most and promise to be a growing part of the 
U.S. health care system. They are seen to provide care in a 
more cost-effective manner than hospital emergency rooms, and 
as a result have enjoyed much more Federal support from 
administrators. It is critical that part of the comprehensive 
primary medical services that these centers provide include eye 
and vision care, as these services are central to better 
overall health outcomes.
    Those living in the underserved communities in which CHCs 
are located are significantly more at risk of suffering vision 
impairment from high amounts of preventable vision loss from 
undiagnosed causes, such as diabetic retinopathy and glaucoma. 
And I am joined by the National Association of Community Health 
Centers, the National Rural Health Association, the American 
Optometric Association, and Prevent Blindness America in 
calling for the readmittance of optometry into the NHSC 
program.
    Congressional intent with regard to the inclusion of 
optometrists in the NHSC loan repayment program is clear. 
However, HRSA has indicated that a legislative response, not a 
regulatory response, is needed in order for optometrists to be 
added as eligible providers to the student loan repayment 
program. And so I would commend to my colleagues' attention 
Representative Bart Gordon's bill, H.R. 1884, the National 
Health Services Corporation Improvement Act, which would allow 
optometrists to participate in the National Health Service 
Corps loan repayment program. And I would like to thank our 
witnesses for being here today, and again thank you, Mr. 
Chairman, for setting up this hearing. And I yield back.
    Mr. Pallone. Thank you.
     Our next member is Mr. Green from Texas, who is our vice 
chair. And you should know that he has been lobbying, or 
whatever the word is, for a long time to have this hearing 
because he considers it so important, as we all do. But if it 
wasn't for him, I don't think we would be having this today. So 
thank you.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman. I appreciate your 
patience in putting up with me for months. I know our committee 
had a full schedule with FDA, PDUFA, a host of other things, 
but I appreciate you again not just turning me out the door.
    But thank you for holding the hearings on all three of 
these bills, and they are, all three, great bills. I especially 
am pleased we are discussing the Health Centers Renewal Act, a 
bill that I introduced with my colleague Mr. Pickering from 
Mississippi. We have 230 cosponsors in the full House and 70 
percent of our committee.
    Nearly 40 years after the health centers program began as 
part of LBJ's Great Society, more than 1,000 federally 
qualified health centers operate more than 5,000 sites, located 
in all 50 States, and serving about 16 million people. In order 
to qualify for Federal funding, health centers must be located 
in a medically underserved area, and be majority governed by 
community members utilizing the center for health care. The 
centers must also provide comprehensive primary and 
preventative care to all community residents regardless of the 
patient's ability to pay. Ninety-one percent of health center 
patients are low income; thirty-six percent are Medicaid 
beneficiaries. In 2006 alone, health centers provided services 
to 6 million uninsured individuals, which is 40 percent of all 
health center patients. Without a medical home at which to 
receive treatment, these patients were likely to forego care 
until their medical problems require emergency treatment or 
inpatient hospital care.
    By providing primary, preventative and sometimes specialty 
care, health centers encourage patient treatment before medical 
problems escalate to emergency room visits and inpatient 
hospital treatment. As a result, health centers represent the 
Nation's largest primary care system, with one in nine Medicaid 
beneficiaries and one in five low-income individuals receiving 
care at a health center.
    My State of Texas unfortunately ranks number one in the 
U.S. in the level of uninsured, with 25 percent of the 
population living without health insurance. More than 1 million 
uninsured individuals live in the Houston area, and we have 
fewer than 10 federally qualified health centers. And the 
demand for health centers is growing in our area.
    Houston is not the only area in need of more health 
centers, with studies showing more than 56 million Americans 
lack access to a health care home and primary care. The Health 
Centers Renewal Act would reauthorize the health centers 
program, put the program on the path to meeting this need. In 
fact, our bill would allow health centers to serve 
approximately 23 million patients in the next 5 years. That is 
50 percent more than today. This funding authorized in the bill 
would ensure that care is provided to existing patients as well 
as new patients. It would also allow health centers to provide 
additional service such as mental health and dental care.
    This bill is a true investment in the future of health care 
of underserved communities across the country. And I am sure 
Mr. Pickering joins me in thanking the members of our 
subcommittee and the full committee and the Majority of the 
House who has co-sponsored this bill. Most of you know what an 
important issue this is to me and a number of members of our 
committee. And again, I would like to thank my colleagues, 
thank our witnesses for being here, and I look forward to their 
testimony.
    I yield back my time.
    Mr. Pallone. Thank you.
    Mr. Murphy from Pennsylvania.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
            CONGRESS FROM THE STATE OF PENNSYLVANIA

    Mr. Murphy. Thank you, Mr. Chairman.
    When we hear about the number of the people who are 
uninsured in America, perhaps 45 million is a number often 
thrown out from the Census Bureau, when one begins to dissect 
that number, we find a number of interesting things. First, a 
sizable amount of that 45 million are people who are indeed 
covered by Medicare or CHIP programs, but are not aware of 
that. When you pare them out, then there are several million 
people who remain who actually can afford health care by their 
income, but decide not to, many of them being the invulnerable 
people between 18 and 26 or so who think they will live forever 
and don't need to buy health insurance.
    But there is also a group within that, perhaps 10 to 15 
million, by various estimates, who have no insurance, cannot 
afford it, and do not qualify. They are not old enough for 
Medicare and not poor enough for Medicaid. Interestingly 
enough, that is about the number of people who are served by 
community health centers. But community health centers, we just 
have too few of them. Some of the counties in my district and 
throughout Pennsylvania have no health centers, and so 
therefore someone has no doctor or no health care home. And I 
venture a guess from my many years of working in health care, 
people would much rather refer to their doctor than their 
insurance company as the source of their health care.
    But one huge barrier exists with our community 
healthcenters, and that is there is simply not enough doctors. 
Right now it is estimated that federally funded community 
health centers that provide clinical services, there is a 13 
percent vacancy rate for family physicians, 20 percent for OB/
GYNs, and 22 percent for psychiatrists. Perhaps the numbers are 
even larger.
    We could fill these vacancies and moreso, and expand 
community health centers with volunteers. Unfortunately, there 
is only 100 volunteer clinicians serving in health centers 
nationwide, 100 out of the hundreds of thousands that are out 
there who are specialists in the medical field. The reason is 
if you work in a community health center, you are covered under 
the Federal Tort Claims Act; therefore, your medical 
malpractice insurance is much less, and the clinic can afford 
to pay it. If you volunteer, however, you are not. And 
oftentimes, while characteristically that medical malpractice 
insurance is tens of thousands, perhaps scores of thousands of 
dollars more, then the clinic simply will not take on 
volunteers. They turn them away at the door. And yet there are 
OB/GYNs and family physicians and psychiatrists and dentists 
and podiatrists and others who would like to volunteer, perhaps 
as part of their ongoing practice, or they are nearing 
retirement and would like to dedicate some of their time to the 
community. That is why I introduced a bill last year and 
reintroduced it this year, it is H.R. 1626, to allow Good 
Samaritan doctors to volunteer.
    And as we look at these issues about community health 
centers, yes, they are excellent; yes, they provide good care; 
they are vital parts of the community, and it is a great place 
for someone to have a health care home when they have their 
card saying that is where they get their services from, but I 
hope one of the issues we can address as we move forward in 
this legislation is also allowing medical practitioners to give 
of their time. Many of them have gone to school through 
scholarships and services provided by the government, and many 
of them want to return the favor to the community. We ought to 
open up the doors to them and not close the doors to them, and 
help provide more volunteer services as we deal with these 
issues in community health care. One of the bills we are 
dealing with, too, at this series, is also to provide some loan 
forgiveness. Perhaps we should allow them to have that loan 
forgiveness by giving their time back to the community that 
gave so much to them.
    I yield back.
    Mr. Pallone. The gentlewoman from Wisconsin.

 OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF WISCONSIN

    Ms. Baldwin. Thank you, Mr. Chairman.
    And thank you, Dr. Williams, and the witnesses that are on 
our second panel for joining us today.
    I am very pleased that this subcommittee is taking up such 
an important issue as providinghealth care to those without and 
those in need. The three programs that are the subject of the 
bills we are considering today all play a vitally important 
role in ensuring that those who are uninsured and those who 
live in medically underserved areas receive needed health care.
    As my colleagues all know, almost 16 percent of Americans, 
that is 47 million Americans, are uninsured. And while these 
three programs are not a comprehensive cure for the epidemic of 
uninsurance, they certainly are a treatment. And I am proud to 
be a sponsor of all three programs.
    I really can't say enough good things about the amazing 
work that community health care centers do. The community 
health centers in the district that I represent, which are 
located in Madison and Beloit, Wisconsin, are incredibly vital 
parts of their communities. And I am continually amazed at the 
variety of needed services that they offer. For some people the 
community health center is the only place where they can access 
dental care. For others, it is the only place that they can 
access affordable care. And for yet others it is the only place 
where they can easily communicate with their health care 
providers without interference of language barriers.
    I am proud to be a cosponsor of Mr. Green's bill to 
reauthorize the health center programs, H.R. 1343. This bill 
provides a much-needed increase in the program's authorization 
level, and will put health care centers on a path to serve 23 
million patients within the next 5 years, and that is nearly 50 
percent more than they serve today.
    As we know from our rising number of uninsured Americans, 
the need for care at community health centers is very great. In 
Wisconsin, the number of patients receiving care at community 
health centers has doubled in the past 8 years from 85,000 
annually to 170,000 annually. This level of growth is 
significant, and we need to make sure that the program is 
updated with sufficient authorization levels to ensure that 
community health centers can continue to provide this much-
needed care, continue to grow and provide care to more 
Americans, expand the services they provide to include much-
needed mental and dental health care, and update their health 
services to keep up with changing technology. I thank my 
colleagues for their work on these bills, and I look forward to 
today's discussion.
    Thank you, Mr. Chairman, for holding this hearing.
    Mr. Pallone. Thank you.
     Our ranking member of the full committee is next, Mr. 
Barton.

   OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Barton. Thank you, Mr. Chairman. Thanks for holding 
this legislative hearing on the community health centers, the 
National Health Services Corporation, and school-based health 
clinics.
    Last year the committee reauthorized the Community Health 
Center Program for 3 years. The legislation was endorsed by the 
National Association of Community Health Centers. It was passed 
by a voice vote in the committee, and also passed the House of 
Representatives overwhelmingly. Sadly, the Senate was not able 
to get its act together--what else is new--and the program 
failed to be reauthorized. I am glad to see that the committee 
intends to fulfill its obligation and responsibility this year 
and once again beginning to move forward on a bipartisan basis 
to reauthorize not only that program, but the other two 
programs that are on your legislative hearing agenda today.
    Community health centers have received widespread support 
not only at the Federal level, but at the local level. It is 
important to note that these centers are great sources of 
preventative health care, which helps to control the ever-
increasing health care costs. It is our responsibility as 
Federal representatives to ensure that taxpayers' money is 
being spent efficiently, and community health centers have 
demonstrated that they are effective in achieving this goal.
    As with any program, there is always room for improvement. 
I am going to be interested later in the hearing to hear from 
some of the witnesses how certain aspects of the program can be 
improved. For example, in Tarrant County, which both I 
represent and Dr. Burgess represent, along with Congresswoman 
Kay Granger, that particular county has had a very difficult 
time establishing a community health center. I think that right 
now in a county of well over a million people, approaching 2 
million people, we may have two community health centers that 
have been designated, despite great need for such programs.
    I am concerned that there is a great geographic disparity 
in the establishment of new centers. I am very interested to 
understand the application process and the issues that go into 
those particular reviews of those particular applications.
    Another issue of concern for members of this committee is 
the need for portable liability coverage during times of 
emergency. This need was greatly evidenced during Hurricane 
Katrina. I want to personally thank Mr. Jones for coming here 
from Mississippi to share his personal story with us.
    I am also interested in pointing out the President's 
expansion initiative has been completed, and that there are 
over 1,200 new or expanded centers. The authorization levels 
dramatically spike upwards. I know it is a popular program, but 
it is still the responsibility to be good stewards of the 
taxpayer dollars.
    In addition to community health center reauthorization, we 
are considering legislation to reauthorize school-based health 
centers and the National Health Service Corporation. I have 
some concerns about these bills. I have got a little bit of a 
problem understanding why we want to create a new pot of money 
for a school-based health center program when they are already 
able to access a wide variety of Federal funding streams, one 
of which is the Community Health Center Program that I just 
talked about. There are other concerns inherent in the school-
based health center program that should be explored regarding 
contraceptive distribution, confidentiality, and abortion 
referral, to name just a few noncontroversial items.
    The final bill that we are going to consider today is the 
reauthorization of the National Health Service Corps. The 
authorization amounts for the next 5 years are more than double 
current funding. That seems to me to be a bit much, but I am 
sure there may be a justification in this, so we want to hear 
what that justification is.
    I would like to know where the administration is in the 
process of redefining health professional shortage areas, or 
HPSAs.
    In examining this legislation, we should consider all the 
various sources for loan repayments and how this one is somehow 
unique.
    Again, Chairman Pallone, thank you for holding these 
hearings. They are very important in the oversight work of the 
committee as we move forward to reauthorize these programs. 
Thank you, and I yield back.
    Mr. Pallone. Thank you.
    Mr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman. And I will try to be 
brief, because I know we have heard from everyone already.
    The issue with reauthorizing the federally qualified health 
center program, Ranking Member Barton is quite correct, we did 
do that last year. It unfortunately did not get across the 
finish line. It is an important program. It needs to be 
reauthorized. But Ranking Member Barton has touched upon what 
is a very, very important point: There does seem to be 
geographic disparities. There seem to be winners and losers in 
this program, and this committee, I think, needs to address 
that.
    I represent an area of the city of Fort Worth, TX, that has 
two ZIP Codes with some of the highest infant mortality rates 
in the country. In fact, they rival some of the infant 
mortality rates in other areas of the world that we wouldn't 
normally think of as being medically adequately served. And at 
the same time, we do not qualify, we do not meet the test, we 
do not meet the criteria for a federally qualified health 
center. I have spent the better part of the last 3 years, with 
full support of the hospitals in the area offering financial 
support. I have been unable to get this across the finish line. 
It is personally very troubling to me, and it makes me question 
whether or not the system indeed works as intended.
    One of the other bills before us, H.R. 2915, the National 
Health Service Corps and Loan Payment Reauthorization Act of 
2007, is an attempt to address an issue also about which I 
spend a lot of time worrying and being concerned, and that is 
the issues surrounding the physician workforce for the future. 
The high cost of medical education keeps many qualified 
students from becoming doctors, and indeed keeps many 
interested high school students from even investigating a 
career in health care. But rather than just increasing the 
funding, perhaps we also could look for a way to address some 
of the underlying issues that drive students away from 
practicing primary care medicine in needed areas.
    An alternate bill, H.R. 2584, that was introduced much 
earlier in the year would provide targeted investments into our 
future medical workforce. And I, in fact, would look forward to 
working with the Chairman on this bill before we get to the 
final markup.
    Another issue, as was touched on by Ranking Member Barton, 
with the National Health Service Corps, is how the HRSA defines 
a health profession shortage area. Despite pleading with CMS, 
HHS, and HRSA, Louisiana officials at the highest levels in the 
last 3 years since Katrina just are absolutely baffled as to 
why the most devastated parishes in New Orleans have not been 
classified as health professional shortage areas.
    I know that the National Health Service Corps gives 
preference to sending providers to health profession shortage 
areas. Also these are areas which are still in great need and 
not getting the health professionals that they need.
    Mr. Chairman, I will submit the entirety of my statement. 
It is well written and very important. I encourage Members to 
read it and I will submit it for the record, and I will yield 
back.
    Mr. Pallone. Thank you.
     The gentlewoman from Tennessee.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman. And I thank you 
for our meeting today and for the discussion of what I think 
are three very important public health programs.
    The community health centers really are playing an 
important role in providing adequate care for many of our 
Tennessee families. And by providing health services to those 
in need, such centers are vital to the well-being of our 
Nation's communities, and certainly to the continued quality of 
life of many in these communities. And in my State, we have 
seen growth in these--just tremendous growth, and we are 
pleased with the expanded opportunities that are there for our 
constituents.
    A great example of this is in 2008, Hardiman County 
Community Health Center will receive 1.2 million in grant 
funding to provide discounted medical services in rural west 
Tennessee. This is for a population that is largely unserved or 
underserved. These funds are critical to those in our district. 
In the past year, this center has served over 6,200 patients in 
approximately 20,000 medical visits. Next year a new clinic 
will open in Chester County, Tennessee, to serve 1,000 more 
patients and 2,000 more visits in the first year. And it is an 
important development, and I look forward to working with the 
community health centers as they continue to provide the 
services and to fulfill this need. I do believe they have been 
tremendously successful, and are the right-type idea for 
delivering health services.
    While I appreciate the focus of this hearing on important 
public health programs, I believe this committee should and 
could be using some of this time to work on more critical and 
time-sensitive issues facing our Nation's most vulnerable 
citizens. Those are children and also the elderly. While 
Congress is only scheduled to be in session until the end of 
next week, the House leadership has been unsuccessful in 
forging a compromise that will reauthorize and fund SCHIP in a 
responsible fashion. For many States, SCHIP funding runs out at 
the end of next week. We should get down to business and work 
out differences on SCHIP before moving forward on anything 
else.
    The committee should also focus on the impending 10 percent 
pay cut for physicians under Medicare, which is scheduled to go 
into effect on January 1, 2008. I have repeatedly supported 
congressional efforts to provide physicians with Medicare 
payment relief. It is unfortunate that Congress is waiting 
until the eleventh hour to prevent this payment cut from going 
into effect. The Sustainable Growth Rate, we all hear a lot 
about the SGR, has proven to be a flawed formula that does not 
account for the rapidly increasing volume of Medicare patients, 
and fails to accurately reflect the rising costs of caring for 
these patients. This negative fee schedule update presents an 
unacceptable situation, and I fear that many physicians will 
cease to serve Medicare beneficiaries if a solution is not 
implemented to fix the physician payment reduction. Congress 
should be focusing its efforts to reform Medicare's physician 
payment scheme to ensure both access to care for beneficiaries 
and fair payment to our physicians for the services that they 
are providing, and, I will add, providing in good faith.
    A future Medicare package should not cut the Medicare 
Advantage program, which has expanded choice in the Medicare 
program through partnerships with private-sector plans. More 
choice means more control for beneficiaries over the provisions 
of their own health care.
    First and foremost, this committee has an obligation to 
reauthorize SCHIP with its original intent and to reform the 
Medicare physician payment formula. It is imperative that this 
Congress and the committee act on these critical issues 
immediately and stop playing politics with the issues behind 
closed doors.
    Thank you, Mr. Chairman, and I yield the balance of my 
time.
    Mr. Pallone. Thank you.
    I think that concludes our opening statements. Any other 
statements for the record will be included at this time
    [The prepared statements follow:]

Prepared Statement of Hon. Edolphus Towns, a Representative in Congress 
                       from the State of New York

     Mr. Chairman and Ranking Member, thank you for your 
leadership in holding this informational hearing, concerning 
these very important pieces of legislation.
     Mr. Chairman, I am a proud co-sponsor of each item that we 
are addressing here, today. I will not waste time, by 
reiterating my previously documented support for this 
legislation. However, I would like to address my committee 
colleagues for the purpose of posing a question regarding H.R. 
2915, ``The National Health Service Corps Scholarship and Loan 
Repayment Programs Reauthorization Act of 2007,'' which will 
continue the valuable program to recruit and retain healthcare 
professionals to work in underserved American communities. This 
program is certainly very worthy of our discussion today, and 
should be reauthorized. As an aside matter, I would like to ask 
this committee why it has chosen to address this piece of 
legislation without also considering H.R. 1134, ``the Physical 
Therapists Student Loan Repayment Eligibility Act,'' which has 
been referred to this subcommittee. H.R.1134 will add physical 
therapists practicing in underserved areas to the list of 
providers eligible to participate in the National Health 
Service Corps Student Loan Repayment Program.
     I believe that H.R. 1134 is worthy of our consideration. 
Therefore, I ask my colleagues why are we neglecting to 
consider this very relevant piece of legislation, today; and 
urge my colleagues to, also, contemplate this legislation, as 
we move forward. Additionally, I have a series of questions 
about the current measures, I am submitting for inclusion in 
the record to be addressed by the witnesses, subsequent to the 
hearing. I, respectfully, ask the chairman to honor this 
request.
    Thank you, Mr. Chairman and Ranking Member for this 
opportunity.
                              ----------                              


Prepared Statement of Hon. Tom Allen, a Representative in Congress from 
                           the State of Maine

    Thank you Chairman Pallone for calling this important 
hearing to consider legislation to reauthorize three important 
programs which are critical to meeting the health care needs of 
millions of American's across the country, and together 
comprise some of the strongest cords in our health care safety 
net.
    I want to thank Representative Green for his work on the 
Health Centers Renewal Act. The 5-year authorization funding 
levels specified in his bill would allow Health Centers to 
serve 23 million patients within the next 5 years, nearly 50 
percent more than today.
    In 2005, federally-funded health centers served 125,255 
individuals in the State of Maine. We have 16 grantees, of 
which 88 percent are rural. The funding targets in H.R. 1343 
represent an investment not only in reaching new patients but 
ensuring that the care provided to new and existing patients is 
comprehensive and sustainable.
    The National Health Service Corps is a vital resource for 
underserved communities experiencing shortages of health 
professionals. Maine has 43 clinicians at 36 sites, many in the 
most remote areas of our State. For over 35 years, National 
Health Service Corps clinicians have expanded access to primary 
and preventive health care, dental care, mental health and 
behavioral health services in underserved areas of the country 
and have improved health outcomes among difficult to reach 
populations.
    During the last reauthorization of the National Health 
Service Corps, this Committee granted Federally Qualified 
Health Centers and Rural Health Clinics automatic facility 
designation as Health Professional Shortage Areas (HPSAs) for 
the purposes of recruiting National Health Service Corps 
clinicians. The intent of this provision was to ensure that all 
such providers, already required to be located in medically 
underserved areas, be eligible to apply for National Health 
Service Corps personnel.
    Despite this, many health centers have continued to face 
difficulty in obtaining NHSC personnel, due to lack of overall 
funding and so-called ``threshold scores'' within HPSA 
designation limiting placements to only those health centers 
with the highest scores.
    Community health centers across the country are finding it 
difficult to recruit and retain clinical staff. And even though 
more than half of National Health Service Corps placements go 
to community health centers, hundreds of those centers, 
representing millions of underserved patients, can't access 
doctors from the National Health Service Corps.
    H.R. 4205, the bill that I introduced on November 15, would 
reauthorize the National Health Services Corps Scholarship and 
Loan Repayment programs, doubling the current investment, and 
also ensure that providers like health centers and rural health 
clinics, those who are serving rural and underserved 
populations, have the first opportunity bringing in these 
National Health Service Corps clinicians to serve.
    The number of new medical residents choosing a primary care 
discipline as a medical specialty is declining, and the 
National Health Service Corps Scholarship and Loan Repayment 
programs provide an important incentive for students to choose 
to pursue a career in primary care.
    I hope that the committee will consider the merits of 
making the HPSA designation permanent for Federally Qualified 
Health Centers and Rural Health Clinics for the purposes of 
recruiting National Health Service Corps clinicians.
                              ----------                              


Prepared Statement of Hon. Darlene Hooley, a Representative in Congress 
                        from the State of Oregon

    Thank you for holding this important hearing, Mr. Chairman.
    I am very excited that the Subcommittee on Health is 
hearing testimony on my legislation, H.R. 4230, the School-
Based Health Clinic Act of 2007, which will authorize funds to 
improve health care access for our Nation's children.
    I also want to thank Congresswoman Shelly Moore Capito for 
working with me on this bill and for her strong leadership on 
school-based health.
    The School-Based Health Clinic Act authorizes a grant-based 
program for the operation and development of school-based 
health clinics (SBHCs), which provide comprehensive and 
accessible primary health care services to medically 
underserved children. My legislation gives priority to schools 
in communities with proven barriers to access to health care 
for children. Resources are thus targeted to schools with the 
greatest need.
    As a former school teacher, I know all too well the 
negative impact that poor health has on a child's ability to 
learn and thrive at school. Unfortunately, far too many of our 
children do not have access to health care. Nearly 9 million 
children in the U.S. are currently uninsured.
    SBHCs bring care right to the child at his or her school--
where it can most easily reach underserved students. This 
allows students to stay in school and prevents their health 
problems from becoming more severe.
    SBHCs play an important role in addressing high uninsurance 
rates by providing care to all children regardless of their 
ability to pay. Nationally 45 percent of children treated at 
SBHCs have no insurance and 44 percent are enrolled in 
Medicaid, SCHIP, or other public coverage. In Oregon, surveys 
indicted that 60 percent of clients are unlikely to receive 
care outside their school-based health clinic. SBHCs are 
therefore a critical lifeline for many of the approximately 2 
million children currently attending a school with a clinic.
    The School-Based Health Clinic Act will help increase the 
number of clinics and expand their ability to reach even more 
children by providing much needed Federal funding. Because 45 
percent of SBHC patients are uninsured, SBHCs need Federal 
funding to fill the gap between the cost of providing care and 
revenue collected from billing Medicaid, SCHIP, and private 
insurers. Although Federal funds are critical to expanding 
SBHCs, clinics will continue to effectively utilize resources 
by leveraging State and local government funds, private 
contributions, and Medicaid, SCHIP, and private insurance 
payments where possible.
    This legislation is a good start toward a brighter future 
for our youth by keeping them healthy and in school.
    Thank you Mr. Chairman.
                              ----------                              


Prepared Statemetn of Hon. Heather Wilson, a Representative in Congress 
                      from the State of New Mexico

     Mr. Chairman, I would like to thank you for holding this 
hearing today on these bills before the committee. Today, we 
are meeting to discuss important issues regarding programs that 
improve access to health care for people in the United States, 
and particularly in New Mexico. House Resolution 1343, the 
Health Centers Renewal Act, would reauthorize the community 
health center program for the next 5 years, with funding 
increases each fiscal year. This funding would allow the 
Community Health Centers to establish new sites, add services 
such as mental health and dental care, and undertake other 
measures that will improve the quality and cost-effectiveness 
of delivery. I am proud to be a cosponsor of this legislation.
     Last year, I cosponsored House Resolution 5573, which 
renewed the health centers program grant for 5 additional 
years. The legislation was passed in the House but there was no 
action in the Senate regarding this legislation.
     Health centers are a beacon of hope for the most 
vulnerable populations- low income, uninsured, or underinsured 
individuals. Many of whom are struggling with chronic diseases, 
teen pregnancy, substance abuse, and HIV/AIDS infection. A 
large portion of these same people cannot afford even the most 
basic medical care. I proudly cosponsor this legislation, and 
believe that by reauthorizing this program, we can put 
community health centers on the path toward serving 30 million 
patients by the year 2015.
     In New Mexico, we have 15 federally qualified health 
center grantees, 79 percent of which are in rural areas. The 
centers serve predominantly low-income and uninsured patients. 
These centers provide a medical home for many, and for most, 
the community health center is their only point of access to 
primary care. In 2005, federally-funded health centers were the 
family doctor and medical home for approximately 223,000 
individuals in New Mexico.
     I have visited community health centers in my district, 
and I have been impressed with the concept of ``health 
commons'' where low income patients can go to get medical, 
dental, mental health, substance abuse, and pharmacy benefits 
all in one location. These health centers help reduce health 
disparities and provide cost effective care in the most 
medically underserved communities.
     Health centers have both immediate and long-term benefits. 
Health centers reduce the need for more expensive hospital in-
patient and specialty care, which result in significant savings 
for taxpayers. We are also here to discuss H.R. 2915, the 
National Health Service Corps Scholarship and Loan Repayment 
Programs Reauthorization Act of 2007. I support reauthorization 
of the program. It is vital to improving access to health care 
in rural and underserved parts of New Mexico by encouraging 
doctors and other health care providers to practice in Health 
Professional Shortage Areas. Thank you, Mr. Chairman.
                              ----------                              

    Mr. Pallone. We will now turn to our witness on our first 
panel, which consists of Dr. Dennis P. Williams, who is Deputy 
Administrator for the Health Resources and Services 
Administration. We will recognize you for a 5-minute opening 
statement. And as I think you know, the statements are made 
part of the hearing record, but you may, in the discretion of 
the committee, submit additional brief and pertinent statements 
in writing for inclusion in the record. And thank you for being 
here, Dr. Williams.

 STATEMENT OF DENNIS P. WILLIAMS, DEPUTY ADMINISTRATOR, HEALTH 
             RESOURCES AND SERVICES ADMINISTRATION

    Mr. Williams. Thank, Mr. Chairman. Good afternoon. And good 
afternoon to the members of the subcommittee. Thank you for the 
opportunity to meet with you today on behalf of the Health 
Resources and Services Administration to discuss the health 
center and National Health Service Corps programs. I appreciate 
your support and awareness of the importance and critical role 
these safety net programs play in ensuring the access to care 
for millions of Americans.
    I want to recognize the outstanding effort of the 
clinicians and the staff of the Nation's health centers. Their 
contributions to remedying the problems of the underserved and 
uninsured are undeniable and significant. Their patients and 
communities know and rely on them.
    Health centers are community-based and consumer-directed 
organizations that serve populations with limited access to 
health care. These include low-income populations, the 
uninsured, those with limited English proficiency, migrant and 
seasonal farm workers, individuals and families experiencing 
homelessness, and those living in public housing.
    Health centers provide comprehensive primary and 
preventative health services, as well as supportive services 
that promote access to health care. Services are available with 
fees adjusted based on one's ability to pay.
    Health centers must also meet performance and 
accountability requirements regarding administrative, clinical, 
and financial operations.
    Health centers are located in medically underserved areas 
and/or serve medically underserved populations. Nearly 82 
percent of health center funding is awarded to community health 
centers, with the remaining 18.5 percent divided across 
migrant, public housing, and homeless health centers. This 
community-based primary care service delivery model has worked 
effectively over many years. We thank the committee for their 
efforts in reauthorizing this program.
    Let me update you on the success and growth of the program 
to date. By any measure, we have been enormously successful in 
implementing the President's Health Center Expansion 
Initiative. In 2001, the President committed to create 1,200 
new or expanded health center sites to increase access to 
primary health care across the country. By 2006, these centers 
were serving over 15 million patients, an increase of 46 
percent since 2001. The final fiscal year 2007 congressional 
appropriation included an increase of more than $203 million 
for health centers. These additional funds are supporting the 
establishment of over 330 new and expanded health center sites. 
Of these awards, 80 are supporting new health center sites in 
counties with high rates of poverty that currently do not have 
access to health center services. These centers are part of the 
President's initiative to provide a health center in every poor 
county that lacks a health center site and can support one, 
thus extending the benefits of health centercare to the 
hardest-to-reach, poorest areas of the country. As a result, 
health center sites will exist in more low-income counties than 
ever before, and some 300,000 people in some of the poorest 
communities in the country will gain access to primary care, 
many for the first time. These expansion efforts continue to be 
a priority, because we know these funds go to provide direct 
health care services for our neighbors who are most in need.
    Health centers provide comprehensive, culturally competent, 
high-quality primary health care services to a diverse patient 
population. In 2006, health centers served 15 million 
individuals at an average cost of about $538 per patient, and 
provided over 59 million patient visits. The proportion of 
uninsured patients of all ages held steady at nearly 40 
percent, while the number of uninsured patients increased from 
4 million in 2001 to 6 million in 2006.
    A key goal of HRSA is to transform the systems of care for 
safety net populations through the effective use of health 
information technology. In order to improve the quality and 
safety of health care, HRSA awarded in fiscal year 2007 a total 
of 46 grants, worth $31.4 million, to expand the use of health 
information technology at health centers. And 2 years ago HRSA 
created an Office of Health Information Technology within our 
organization in order to help deploy this new technology not 
only to health centers, but to all of our grantee service 
delivery programs. We partnered with the Agency for Health Care 
Research and Quality in order to provide information to our 
grantees so that they can make good business decisions as they 
consider the use of this technology, and we have also been 
partnering with the Office of the National Coordinator for 
Health Information Technology so that as he and his group sets 
health information technology standards for the country, that 
he understands the needs of the health care safety net in this 
country, and we have worked very closely together over the last 
2 years.
    HRSA is also currently involved in an agencywide effort to 
improve quality and accountability in all of HRSA-funded 
programs that deliver direct health care. One of the steps we 
have taken in this area is to establish a core set of clinical 
outcome measures for all health centers. In the past, we have 
measured how many patients we serve. We have measured and kept 
track of what kind of services we provide to them. But it is 
important to us to understand what is the outcome of all of 
these services that we are providing? What is the health 
outcomes of these services?
    In our view, help for the poor should not be poor health 
care, so we have identified a core set of measures related to 
immunization, prenatal care, cancer, cardiovascular disease and 
hypertension, and diabetes, and these measures will help us 
assess how well our patients are doing relative to national 
norms and national statistics.
    Let me now talk briefly about the National Health Service 
Corps. The National Service Corps was created to place 
clinicians in areas of need. In 2002, the National Service 
Corps was reauthorized by Congress through fiscal year 2006, 
and was given greater flexibility to distribute funds between 
the scholarship and loan repayment programs. This change in the 
law enabled the National Health Service Corps to direct more 
funding to loan repayment.
    By 2006, the National Health Service Corps field strength 
grew to 4,109, a nearly 50 percent increase in the field 
strength since reauthorization in 2002. This is due in part to 
the increased flexibility the program now has to shift more 
funding to help meet the immediate needs of underserved 
communities and vulnerable populations, and in response to 
communities' demand for services.
    In 2006, as throughout the history of the program, 
approximately 60 percent of National Health Service Corps 
clinicians served in rural areas----
    Mr. Pallone. Dr. Williams, sorry to interrupt you, but you 
are up to 7 minutes, and I know you are about halfway through, 
so if you can kind of summarize because we want to ask you 
questions. But go ahead, but maybe just summarize.
    Mr. Williams. I will finish the one paragraph.
    As a significant source of highly qualified, culturally 
competent clinicians for the health center program, as well as 
other safety net providers, the National Health Service Corps 
can build on its success in ensuring access to residents of 
health professional shortage areas, removing barriers to care, 
and improving the quality of care to these underserved 
populations. The National Service Corps program is working with 
many communities in partnership with State, local, and national 
organizations to help address their health care needs, and to 
help reduce the health disparities gap.
    We are proud of the accomplishments of the Health Center 
Program and the National Service Corps. These programs are 
delivering care to millions of underserved Americans with few 
health care alternatives. We look forward to working with the 
committee in reauthorizing these programs, and I would be happy 
to answer any questions you might have.
     Thank you, Mr. Chairman.
    [The prepared statement of Mr. Williams follows:]



    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Pallone. Thank you. And we will submit your whole 
statement for the record.
    I apologize for interrupting, but we do want to ask you 
some questions, and I will recognize myself initially for 5 
minutes.
    I cannot stress enough how important these community health 
centers are nationally, as well as in my own district. We have 
quite a few in my district. And with the increased number of 
uninsured, and with a lot of people who are undocumented, the 
needs of these health centers have just grown dramatically in 
my district, and I am sure that reflects the rest of the 
country.
    I want to commend the Bush administration for its 
initiative, which began when the President was first elected, 
to try to provide money for new centers, the infrastructure. I 
think, as you said, that has been very successful. But my 
questions really kind of go back to the same thing in some ways 
that Dr. Burgess mentioned.
    If I could use my own hometown as an example, we a few 
years ago built a new community health center which is 
federally qualified, unlike, I guess, some of the ones that Dr. 
Burgess mentioned which are not, but yet they have been denied 
the grants under the Section 330 program several times. So I 
guess, as you know, in this bill, in Mr. Green's bill, we have 
increases in the authorized funding levels. The administration 
has not commented on those so far. So my question really 
relates to whether or not you or the administration would take 
a position on these authorized funding levels. I think they are 
needed, because I know that even though I have a qualified 
health center, we haven't been able to get any money. And 
obviously Dr. Burgess is talking about those who haven't even 
qualified. So if you could tell us what the administration's or 
your position is on the authorizing levels and what the need 
is, because clearly there is a need for a lot more money, in my 
opinion.
    Mr. Williams. Well, there certainly is a lot of demand for 
health centers. When the President's initiative started 6 years 
ago, and the amount of money devoted to the expansion of these 
health centers began to grow, I think a lot of us felt at that 
time that the--it might be difficult to attract the number of 
applications we would need to spend the money that was given to 
us and to get the quality of applications that we wanted in 
order to make these health centers successful. But as the 
initiative went on, to our surprise we got rapidly a very large 
number of increases in the number of applications every year. 
And as the initiative went on, the quality of those 
applications has also grown substantially over the 6-year 
period, so that by this time we are in a very--it is a very 
competitive market.
    About a third of all of the people who apply to us for a 
health center are successful, and many of them are not 
successful on the first try, but are successful after two or 
three attempts. And we, through the primary care associations 
and also through State governments, have been providing a lot 
of technical assistance to communities in order to prepare them 
to be successful applicants.
    Mr. Pallone. So clearly you do see a need for additional 
funding?
    Mr. Williams. Well, I can say to you there is a demand for 
additional funding. Quality is important. But in any budget 
situation like this, it is a matter of priorities and balances. 
There are a lot of things which this government supports, and 
what is the proper amount really comes down to a question of 
establishing a balance in one's priorities.
    Mr. Pallone. All right. Let me ask you this, because I only 
have 5 minutes. You mentioned HIT, and I understand that the 
authorization under this bill or maybe under existing law 
doesn't specify grants specifically for HIT. But I think that 
is very important.
    I visited one of my community health centers that in many 
ways is a model. I am not going to mention the name right now. 
But one of the things that I noticed is that they were not--
they had no--you know, their records were still paper. Half of 
the building was devoted to the records, which seemed such a 
waste.
    It seems to me if you have more HIT, you can really save 
some money and use the money for other things. So would you 
advocate that we specifically provide in the legislation 
authorization for HIT, or how do you decide when you are 
dealing with these grants, how to allocate your funds for HIT 
versus other things?
    Mr. Williams. I don't think it is a question of 
authorization. I think we have the ability to support health 
information technology in our grantees. It is a question--
again, it is a question of how you wish to spend the money 
available to you. And we have worked hard to try to make money 
available within the appropriations given to us to support this 
new technology.
    Now, I think in our view it is not--we would like to 
support broader networks of grantees. We have what are called 
Health Center Controlled Networks. These are collections of 
grantees who come together for the purpose of managing this 
technology either as practice management systems or electronic 
health records. By coming together and pooling their resources, 
they are much more successful because this technology is 
expensive, and by coming together it makes it cheaper for 
people to afford it. But even more important than the cost is 
that the knowledge, the people who know how to use the 
technology, is as scarce or even more scarce than the money. So 
by becoming part of a network, that scarce knowledge base can 
be made available to a lot more of our grantees. That makes 
investment in health care technology a lot less risky because 
you have got--you are working with people who know how to use 
this technology.
    But we are never going to be probably in a position to buy 
all this technology for everybody, so we are also trying to 
provide information to our grantee base through ARC. We have 
set up a Web site dedicated to community health centers, and we 
have brought our health center community together in that Web 
site. They can talk to each other. They can learn from each 
other's experiences. And we make available on that Web site 
information about electronic health records and other 
technology to help educate those who are going to buy this 
technology so they can make a good business decision. So those 
are some of the things we are trying to do.
    Mr. Pallone. Thank you.
    Mr. Deal?
    Mr. Deal. Thank you.
    Dr. Williams, I want to talk primarily about the National 
Health Service Corps. As I understand, about half of the people 
who go through that program wind up working in community health 
centers. Is that generally true?
    Mr. Williams. That is about right, yes.
    Mr. Deal. All right. Is the Department currently examining 
ways in which changes can be made to the health professions 
shortage areas? And if so, what changes would you anticipate 
there?
    Mr. Williams. We are looking at that regulation. The 
regulation in place has been around for many years, and we are 
in the process of reviewing that regulation. And we hope in the 
short period of time to be putting out a proposal that the 
public can comment on with respect to that regulation.
    Mr. Deal. Could you elaborate as to the kind of changes you 
are anticipating?
    Mr. Williams. I can't at the moment because it is still on 
the decision side of the Department. We are talking with OMB 
about it, but we do expect to soon put it before the public as 
a notice of proposed rulemaking. And we will give the public 
the opportunity to comment, and then we would see whether the 
ideas are good or not.
    Mr. Deal. OK. Would you explain the breakdown that exists 
now between the scholarship side of the program and the loan 
side? And which of those programs yields the best results?
    Mr. Williams. Under current law, we are required to provide 
a minimum of 10 percent of the National Service Corps 
recruitment dollars for scholarships. So we have a floor, which 
gives us actually a lot of flexibility as to how the money 
might be allocated between loan repayments and scholarships. 
There is a real trade-off that one has to think about here. On 
the one hand, when you invest in a scholarship, you might be 
investing a fair amount of money, let us say 4 years of medical 
school, and then that person would graduate from medical 
school, go off into residency, and 6, 7, 8 years later are 
available for service in an underserved area. That is a very 
long wait time to get the benefit of the money that we really 
put up front.
    The other dimension to that is--that you alluded to is 
somebody who is just starting medical school at the age of 22, 
by the time they are 30 and have to go out and serve, they may 
look at the world differently. Their circumstances might be 
different than they were when that individual was 22. So with 
that long lead time, people's willingness to serve sometimes is 
different at the end than at the beginning.
     The advantage of a loan repayment is that they have 
already gone through--the individual has already gone through 
all that process. They have finished their medical school, they 
have finished their residency, they are ready to go to work. So 
we can give them incentives to come to work in underserved 
areas by buying--helping to buy down their loans, pay back 
their loans; and the service is immediate.
    There is a big advantage, in order to maximize the number 
of people you have in the field, to use loan repayment. 
Scholarships can also be useful to some extent to support those 
who might otherwise not go to medical school because of their 
income, but they can't get a scholarship until they have 
already been admitted to medical school. They would have wanted 
to have gone anyway.
    But there is some use to scholarships, I think, to promote 
the diversity in our workforce, but the long lead time has to 
be considered.
    Mr. Deal. But in addition to having an available workforce, 
make your dollars buy up front as you have talked about, isn't 
there also a difference in the retention rates that you see 
between a scholarship and a loan program?
    Mr. Williams. Yes. We--well, I don't know the exact 
statistics on that, but certainly most people going into loan 
repayment are well committed to the work that they are going to 
do. In the overall program, our retention rate of scholars and 
loan repayers is very, very good. Fifty percent of the people 
we put into medically underserved areas are there many years 
after their commitment is over. It is a very cost-effective 
program either way you look at it.
    Mr. Deal. Do you feel that the legislation before us today, 
which would require $30 million to be dedicated to 
scholarships, would that hurt or help your program?
    Mr. Williams. I think, in our view, it would reduce the 
flexibility that we have now. Right now, we have a floor of 10 
percent for scholarships. That gives us a lot of room to 
maneuver and balance between scholarships and loan repayers.
    At the present time, we are devoting about 20 percent of 
our money to scholarships and 80 percent to loan repayers, so 
we are actually giving scholarships a little bit higher than 
the floor requires. $30 million, depending on the amount of 
money available, can be a substantial amount. Right now, we 
are--in 2007, we had $85 million for recruitment. If we would 
have had to devote $30 million of that to scholarships, then we 
would have had to put 35, 36, 37 percent of our money into 
scholarships.
    That reduces our ability to put our money where we think we 
can get the best return.
    Mr. Deal. Thank you, Mr. Chair.
    Mr. Pallone. The gentleman from Tennessee.
    Mr. Gordon. Thank you, Mr. Chairman.
    Dr. Williams, in 2005, the House and Senate appropriators 
directed HRSA to include optometry in the National Health 
Service Corps loan forgiveness program.
    Per this directive, do you believe that HRSA has the 
authority to include optometry in the Corps?
    Mr. Williams. No, I don't believe we do.
    Mr. Gordon. Well, you are consistent with your statement. I 
don't agree with it, but you are consistent, which I think 
demonstrates much more why we need to have legislation to 
accomplish that need.
    Thank you.
    Mr. Pallone. Mr. Pitts.
    Mr. Pitts. Thank you, Mr. Chairman.
    Dr. Williams, what types of providers are eligible for the 
National Health Service Corporation loan repayment program?
    Mr. Williams. Doctors, dentists, nurses, a range of 
midlevel providers, psychiatrists--an exhaustive list.
    Mr. Pitts. Is that list exclusive?
    Mr. Williams. I think that is most of them, but I could 
give you an exhaustive list for the record.
    Mr. Pitts. In your opinion, what would be the effect of 
adding additional skills to this list?
    Mr. Williams. Again, I think it is a matter of priority and 
trade-offs. Right now, I think if you listen to community 
health centers, half our national service corps are going to 
community health centers, for example. That represents probably 
somewhere in the range of--I don't know--10, 15, 20 percent of 
their clinicians.
    They buy a lot of health professionals outside of the 
National Health Service Corps in order to manage their program. 
They have increased their total staffing by about 50 percent in 
the course of this growth in the Health Center Initiative, so 
there is opportunity for health centers and others to make 
decisions about whether they buy an optometrist, which they are 
perfectly free to do, or to buy a clinician.
    What people tell us is that they need clinicians, they need 
doctors, they need dentists, they need nurses. I think, given 
the demand for those skills, adding additional professions to 
this list may not serve the purpose that it is designed to do.
    Mr. Pitts. I understand that only 17 percent of community 
health centers have an optometrist on the staff. In my home 
State of Pennsylvania, only 6 of our 29 community health 
centers have an optometrist on the site.
    Wouldn't including optometric care in an HSC help achieve 
the goals of the program and HRSA's public health goals?
    Mr. Williams. Well, I don't think it would necessarily help 
the health center who wants an optometrist. If a health center 
wants an optometrist, and an optometrist is willing to serve, 
they can pay an optometrist to provide services in their health 
center.
    If the National Health Service Corps were to make an 
optometrist available, they would also have to pay the salary 
to that optometrist, so the question is, I think really in the 
end, are there optometrists willing to serve in medically 
underserved areas on their own, or would they need to be 
provided some additional incentive? I don't think I know the 
answer to that question.
    Mr. Pitts. Are there any providers not on the list that you 
think should be added?
    Mr. Williams. Not at the moment, no.
    Mr. Pitts. Let me shift to H.R. 4230, the School-Based 
Health Clinic Act. Are school-based health clinics reimbursed 
for prescription contraception or the morning-after pill?
    Mr. Williams. I have no idea. We don't manage school-based 
health clinics as you are describing it in this legislation.
    Some of our health centers do run--have sites that are 
located in schools, but they are part of the community health 
center normal operations. They just happen to have a site 
located at a school.
    But the school-based health clinics you are talking about 
authorizing in this program are freestanding. They are not 
associated with a community health center program, they would 
be a separate activity, a business that we don't have any 
association with.
    Mr. Pitts. With the ones that you are involved in, are 
there any age restrictions or parental consent requirements for 
reimbursement?
    Mr. Williams. To the extent that we--that a community 
health center manages one of its--has a site in a school, it 
would be subject to the same State and local rules, laws, as 
any other health care provider would be. That is going to vary 
by every State and local jurisdiction.
    Mr. Pitts. But as far as the Federal Government is 
concerned, there are no age restrictions or parental consent 
requirements?
    Mr. Williams. In terms of primary care services, no. In 
fact, we fund about--30, 35, 36 percent of the people we serve 
in health centers are kids under the age of 19. About 23 
percent of the people we serve are school-aged kids, mostly in 
primary care settings outside of the school, but about 10 
percent in school settings.
    Mr. Pitts. My time is up.
    Thank you, Mr. Chairman.
    Mr. Pallone. Mr. Green.
    Mr. Green. Thank you, Mr. Chairman.
    Dr. Williams, I understand that HRSA provided funding for 
roughly 700 new community health center sites and more than 500 
expanded sites since the beginning of the health center 
expansion initiative in 2002. I know President Bush and this 
Congress and I supported that bipartisan effort to secure this 
increase.
    During that same time, however, I understand that upwards 
of 1,000 additional applications were submitted and met all the 
program requirements, but were not approved due to the lack of 
available funding; is that correct?
    Mr. Williams. Well, some were certainly not funded because 
of the lack of available funding, but some did not meet our 
quality standards also.
    Mr. Green. Even though they met the program requirements, 
the quality standards are different from the program 
requirements?
    Mr. Williams. Well, it is a competitive situation; to be in 
the competition, you have to meet the standards of the law. 
After that, it then becomes a matter of what is the degree of 
need, how good is the program relative to others who are 
applying.
    It is a competitive environment in that sense, and about a 
third of the people who apply to us get funded in any given 
year.
    Mr. Green. What I am saying, I guess, I am trying to get 
to, is that there were 1,000 additional applications that were 
submitted and met all the program requirements, but they didn't 
score as high because of the funding availability.
    I would assume my colleague from Tarrant County, maybe his 
FQHC they were seeking may have been in those 1,000 
applications. I don't know either.
    Mr. Williams. Possibly, it is; possibly, yes.
    Mr. Green. But when you have upwards of 1,000 that were 
submitted and met the program requirements, but weren't funded 
because of the competition, it stands to reason that we might 
need more funding.
    Mr. Williams. Well, I am not saying that the program 
couldn't use more funding.
    Mr. Green. That is fine.
    Mr. Williams. You have to be concerned about the quality of 
the applications that you end up funding. Again, it is a 
question of budget priorities.
    Mr. Green. Oh, sure. I understand that. That is why I wish 
I could say we appropriate money in this committee, but we 
don't. We just authorize it, and we still have to fight within 
the appropriations process to do that.
    I was looking at the numbers. Fiscal year 2008, the 
President requested $1,988,467,000, which is a little more than 
$400 million more than the year before for fiscal year 2007. 
The House actually appropriated--although again Labor-H didn't 
pass, wasn't signed, but about another $200 million. The House 
passed $2,188,000,000.
    Again, no matter what we authorize, we are still going to 
be struggling with getting $2,188,000,000. We are dealing with 
authorizations, and I think your point was made.
    Mr. Williams. Let me correct your numbers a little bit. The 
President's budget in 2008 was actually--it was about $200 
million more than the 2006 level, but it was about the same as 
the actual enacted level in 2007.
    Mr. Green. OK. But again, getting back to the original one, 
there were 1,000 additional applications that were submitted 
that met the program requirements, but because of 
competitiveness, they couldn't be funded.
    While we support the expansion of the community health 
centers, it is no surprise to members of our committee that the 
need remains high for affordable and effective community 
centers. Earlier this year, a study found that 56 million 
Americans are medically disenfranchised, that is, without a 
regular source of care or lack a community health center. As we 
plan for the future, it is critical we know how many would-be 
health centers are out there that still haven't received grant 
funds and, as a result, how many more patients we could reach 
through this successful program.
    What I would ask you, and I know you don't have it today, 
if you could provide the committee with the total number of 
applications submitted for each year, beginning in fiscal year 
2002, and the number that were scored as fully acceptable or 
higher, and the number that were actually funded, so we can 
look at it and base our authorization levels, hopefully, on the 
number of clinics that weren't--that meet the requirements, but 
because of budget constraints, couldn't qualify.
    Mr. Williams. We would be happy to do that.
    Mr. Green. Your testimony mentioned HRSA's goal of 
improving quality health care at centers throughout with 
expanded health information technology. I agree with you.
    I am pleased that the agencies awarded grants to health 
centers for health IT expansion. Despite the increased emphasis 
on health IT in HRSA, we know that health IT adoption is not 
widespread among our centers.
    A recent ``Health Affairs'' article published the results 
of a national survey of FQHC's foci on health IT. A study found 
that a quarter of health centers have some capacity for 
electronic health records, but only 13 percent of health 
centers have truly functional electronic health records.
    It should be no surprise that the lack of capital is a 
cited as a top barrier to the health center adoption of IT. 
With more than 100 health centers in this country and with only 
13 percent truly functional for electronic health records, I 
can only imagine that HRSA has more than 46 centers in need of 
health IT grants.
    Can you speak to HRSA's needs for health resources for 
those health IT grants?
    Mr. Williams. Yes. Let me say one thing. I think the health 
center community is a very diverse community, and it ranges 
from very small health centers and isolated rural areas to 
larger, one would say, almost big businesses.
    If you look at the very best of what we have--and not all 
of them are just the biggest, but if you look at the very best 
of our health center operations, especially with respect to 
health information technology, they are--our best health 
centers are on the cutting edge in the use of this technology, 
especially for clinics and medical operations of the size that 
we are talking about.
    A lot of--we are not a big hospital center where a lot of 
this technology is now deployed. But if you look at doctors' 
offices or clinics, the best of our health centers do very well 
with this technology.
    There is more that we can do, and we are trying to 
encourage them to be wise in their business decisions, to come 
together as networks so that they can reduce the risk of the 
implementation of this technology. And we have also been 
working with--going around the country talking with 
foundations.
    States are also now investing in this technology and trying 
to make marriages, so to speak, between foundations that want 
to invest in the safety net and promote this technology, States 
that want to do the same thing and bring our health center 
community to the table and say we are a vehicle where this 
technology can be deployed to the very good benefit of the 
people we serve.
    Mr. Green. I agree, and I know my time is running out and 
ran out, Mr. Chairman, but that is the beauty of our community 
health center program, that they can draw money from lots of 
other sources, including foundations; but we are only dealing 
with authorization level.
    Mr. Chairman, I would like to submit that our increased 
authorization level fits the future needs of the health center 
program; and also the health IT adoption is a perfect example 
of the growth tool that our bill seeks and needs to provide to 
health centers. We can go to foundations, and I know lots of 
centers do that, but they still need that basic assistance from 
the Federal Government.
    I have one other question I will submit, basically on Dr. 
Williams' testimony that driving the health centers program is 
cost-effective. I would like to follow up on that, but we will 
do that to show they are cost-effective, particularly with 
Medicaid.
    Mr. Pallone. So ordered.
     Mr. Murphy.
    Mr. Murphy. Thank you, Mr. Chairman.
    Dr. Williams, good to have you here. I saw a study that was 
reported a while ago from the National Association of Community 
Health Centers that stated that the community health centers 
even save Medicaid about 30 percent per Medicaid patient, or 
about $17 billion annually, due to reduced specialty referrals 
and fewer hospital admissions.
    Does that number sound about right, or do you think it is 
higher than that now?
    Mr. Williams. I don't have any other information that would 
say it is any different, so I would guess that is probably 
correct.
    Mr. Murphy. I am just thinking in terms of it not only 
saves people money when they don't have any insurance, but it 
even saves money, the government money, on Medicaid.
    Also, a question with those professionals who participated 
in the National Health Service Corps: They are paid for their 
services?
    Mr. Williams. They are paid by the people who employ them, 
yes.
    Mr. Murphy. They are employed by the community health 
centers, and I am assuming they are covered under the Federal 
Torts Claim Act. And you heard my earlier comments.
    Mr. Williams. Yes.
    Mr. Murphy. Were aware of the issue out there, that 
volunteers are not covered by that?
    Mr. Williams. Yes.
    Mr. Murphy. Do you know, has the Government in any way--
looked in any way at what the cost savings would be if we 
allowed people to volunteer at these centers?
    Mr. Williams. Volunteer at community health centers?
    Mr. Murphy. Yes.
    Mr. Williams. I don't know the answer to that question. The 
statute clearly requires us to employ physicians. It doesn't 
allow us to provide tort coverage to volunteers.
    Mr. Murphy. The law would allow us to change that.
    Mr. Williams. There is, though, and this is worth looking 
at--the Congress authorized a program a couple of years ago, 
free clinics program. Their volunteers, if the clinic itself 
accepts no payment, and the physicians who practice there 
accept no payment, they can--if they apply to us and meet 
certain criteria, can get FTCA tort coverage.
    Mr. Murphy. I always thought it was ironic that a community 
health center, if you are paid, you are covered by the Federal 
Torts Claim Act, and if you are volunteering, not. If you 
volunteer at a free clinic, you are covered, but if you are 
paid, you are not.
    Maybe we should look at what is the best way to help the 
patients out. I mean, only government could figure out that 
kind of a mess, how to do that. Yet if we recognize that just 
the savings alone from Medicaid may be upwards of $17 billion--
and that was a couple of years ago--and we are trying to 
provide other open direct access of care for patients without 
even having to go through insurance carriers alike--without 
having to go through Medicare, Medicaid, everything, but 
directly with the physicians--it seems to me that it is an 
issue whose time is due. I hope that is something you all can 
look at.
    My understanding in the past--unfortunately, our CBO 
doesn't score savings. Any time a Member tries to present 
legislation that saves the government money, the government 
says. We don't know how to score that. And we hope that is 
something you can address to the chairman of the subcommittee 
and the full committee too.
    I wanted to ask, of those who are part of the National 
Health Service Corps, those are generally people right out of 
school too?
    Mr. Williams. Right out of medical school and usually right 
after their residency--they complete their residency.
    Mr. Murphy. You need just to draw attention that those who 
might want to volunteer--sometimes it is a physician who, 
oftentimes because of the cost of medical malpractice 
insurance--you may be aware of this--there may be an OB/GYN who 
declares it is too costly to deliver any more babies, so they 
stop doing prenatal care. They stop deliveries.
    I see many of these folks who say, I would love to 
volunteer some of my time somewhere. But, of course, if they do 
that, then their insurance climbs back up again and they can't 
do it. It is a way of getting people who are highly experienced 
at these centers as well.
    I think we all agree in this community, these centers are 
just a tremendous asset for communities. It is sad, though, 
when I read an article that came out the other day in way off, 
faraway Anchorage, Alaska, that they are struggling to hire. 
They don't have enough physicians there, and some funding 
issues. But again, it is an issue if someone could volunteer, 
they could do well, and I can save some money.
    I just want to leave my questions with the part of I hope 
that is something you will take a careful look at and provide 
some information back to the chairman of this committee.
    Mr. Williams. We would be happy to do that.
    Mr. Murphy. I yield back.
    Mr. Pallone. Thank you.
    Ms. Baldwin.
    Ms. Baldwin. Thank you, Mr. Chairman.
    Dr. Williams, I have a couple of questions that actually 
relate pretty closely to the first question that Mr. Murphy 
just asked, basically the interrelationship between the 
Medicaid program and the community health centers.
    First, I just want to recall that obviously Congress a few 
years ago passed a Deficit Reduction Act which included cuts to 
the Medicaid program, giving the States the authority to figure 
out how they would extract those savings, but including 
increasing the amount of cost-sharing that Medicaid 
beneficiaries would have to pay for their health care.
    I know that during the debate those several years ago, many 
of my colleagues and I argued that we expressed our concerns 
about the cost-sharing provisions and how it could make health 
care unaffordable to some Medicare beneficiaries and 
potentially force them to forgo needed care.
    I am curious to know whether we are seeing any pivot of 
these people, turning to community health centers.
    As the representative of the agency that administers the 
grants for the health--for community health centers, has HRSA 
evaluated the data from community health centers of late, to 
measure the impact that increased Medicaid cost-sharing 
provisions have had on utilization of community health centers 
and the people they serve?
    I would invite you also, if any of the other DRA 
requirements that were put in have increased utilization--I 
know there were numerous provisions, obviously, in the DRA.
    Mr. Williams. I can go back and take a look. I am not aware 
of any research that we have done that would pinpoint the 
answer to the question that you raised.
    Certainly, health centers are by law obligated to serve 
whoever comes to them. Whether more people are coming because 
they have higher copayments outside of Medicaid, I don't know. 
Certainly, as the number of uninsured has grown, there are more 
people, I think, coming to health centers because they have no 
alternative.
    I will see what information we may have, but I am not sure 
that we can answer your question precisely.
    Ms. Baldwin. OK.
    Also, following directly on Mr. Murphy's first question, we 
certainly as a committee struggle with ensuring that American 
people have access to quality health care, but also maintaining 
fiscal discipline in our entitlement programs such as Medicare 
and Medicaid.
    In your testimony, you described health centers and their 
programs as cost-effective. I certainly and wholeheartedly 
agree with that, but I wonder if you could elaborate on the 
relationship between health center programs and the Medicaid 
programs, particularly with regard to the savings that the care 
provided in health centers translate into for the Medicaid 
program.
    Mr. Williams. A lot of the Medicaid reforms have shifted 
decision-making to the State level, so States have a lot more 
flexibility on how to design their programs and how to operate.
    That has been, actually, an incentive for our community 
health centers to talk and come to their States to lay out what 
they can do, demonstrate what they can do in the context of 
providing a value for the Medicaid services which they provide.
    Incidentally, health information technology, electronic 
health records, actually is a good tool to document the 
services you are providing and the results that people get. 
Chronic disease management with diabetes, for example, a lot of 
health centers are very good at controlling chronic disease. 
For Medicaid, it is a real value.
    I think, as we go around and talk to State Medicaid 
directors, a lot more of them are now conscious of the fact 
that health centers actually produce very good results and are 
willing to work with health centers as part of their managed 
care or other operations at the State level.
    I think it is beginning to penetrate that health centers 
are a very good deal.
    Ms. Baldwin. That is great, and that is a really 
interesting point you raise about health centers actually 
approaching Medicaid administrators at the State level.
    Are there any States that have provided a role model for 
others to look at in terms of that collaboration and the cost 
savings that are generated from that?
    Mr. Williams. Well, let me take that back, and I will give 
you some feedback on that question.
    I know in some States--Texas, for example, understood early 
on that health centers were a very good investment and they 
actually created what is called an incubator program in Texas 
and they worked with communities, States, that invested in the 
development of FQHC, what are called FQHC look-alikes. They 
would then apply for FQHC status, and that would give them good 
experience to apply to us for a section 330 grant.
    Other States, Louisiana and others, have picked up this 
idea and are also investing in their communities to try to 
develop good, competitive applications for the health center 
program because they have understood that it is a good 
investment.
    But I will see what other additional information I can give 
you that might point to some States that are very good at this.
    Mr. Pallone. Thank you.
    Mr. Burgess.
    Mr. Burgess. Thank you.
    Dr. Williams, you heard me reference Orleans Parish and 
Jefferson Parish in my opening remarks. As far as the National 
Health Service Corps is concerned, do you think that during the 
public health emergency that existed in the fall of 2005 and, 
really, to my understanding, persists to this day, do you think 
the National Health Service Corps has adequately addressed the 
needs of Orleans Parish and Jefferson Parish in Louisiana?
    Mr. Williams. Absolutely. We have worked--from the 
immediate aftermath of Hurricane Katrina in Louisiana, we 
worked very closely with the State as they provided us 
information for designating geographic areas in Louisiana as 
health professional shortage areas.
    The State has a very good mechanism. We gave it a high 
priority, and we told them that as they assembled information, 
brought applications to us, that we would turn them around in a 
very short period of time, and we have kept that promise.
    If you look at the number of health percentage--health 
professional shortage areas designated in Louisiana today, 
versus prior to Hurricane Katrina, you will see that we have 
kept our word.
    With respect to Orleans Parish, a lot of the health care 
providers live there. It is difficult to identify some 
geographic areas as health professional shortage areas, and 
actually I think Orleans is one, because there are so many 
providers that are there. We have tried to work with the State 
to actually identify shortage populations and other ways to try 
to make these designations available to the State.
    Mr. Burgess. I don't want to interrupt you.
    Mr. Williams. They have done a very good job working with 
them, and I think the State would say we have too.
    Mr. Burgess. Well, but every time we have a hearing on 
either Oversight and Investigations, or this committee, that 
deals with health care in Louisiana, we hear about the fact 
that it is not working as it was intended.
    I will just tell you my own observation from being down 
there. In October of 2005 I met with groups of doctors in both 
Jefferson Parish and Orleans Parish, and they were struggling 
to keep the doors open. They were spending their kids' college 
money to keep their doors open, and they couldn't get any help 
out of Washington. I heard it over and over and over again.
    Then our committee, the Subcommittee on Oversight and 
Investigations, went back down in January. It was pretty clear 
to me then that doctors were leaving the area in large numbers. 
If the doctor was not married to someone who was born and 
raised in the area, they were not very likely to stay there.
    Now--again just my personal observation, but again, it has 
been borne out by testimony we have had before this committee 
on numerous other occasions. I would just ask, in the interest 
of time, if you could detail some of those things for me in 
writing.
    Mr. Williams. We are not the only ones involved in this. 
CMS and others have also been very much engaged. Secretary 
Leavitt has been very much engaged in trying to make resources 
available.
    Mr. Burgess. I understand. I will just tell you the level 
of frustration that is coming before this committee time and 
again does not indicate that a good job has been done. Quite 
honestly, I don't know, really it been several months since we 
have had another hearing, and perhaps we need to go back down 
there, Mr. Chairman. I would be very interested in doing that.
    Let me just ask you a question, because we are going to run 
out of time. You talked a little bit about not having the 
availability to tie into the kinds of things that a big 
hospital system would and that you would rely on foundations 
and States that want to invest in the health care, the 
federally qualified health care system.
    What about partnering with some of the integrated health 
systems that are out there like Ascension Health, Covenant 
Health out in West Texas. What are the barriers that prevent 
the federally qualified health center from partnering with some 
of those groups?
    Mr. Williams. Partnering in the investment and information 
technology.
    Mr. Burgess. Well, trying to get a specialist, trying to 
get a patient referred to a specialist, for example, when their 
primary care is a federally qualified health center--difficult 
to get them referred to a specialist, might be difficult to get 
them into a hospital.
    You have groups like Ascension Health and Covenant Health 
out in Lubbock that would welcome the opportunity to work with 
a federally qualified health center and that would be a win-win 
situation for both sides.
    Mr. Williams. Sure.
    Mr. Burgess. Yet, they have had no success in getting past 
the starting blocks.
    Mr. Williams. Well, I think what Ascension--if you are 
talking about a health center making referrals for specialty 
care to Ascension Health, I don't see that there are any 
barriers to that. If what you mean is that Ascension Health 
itself wishes to become designated as a FQHC, that is a 
different matter.
    It really has to do not with Ascension Health's ability 
or--it could qualify. It does nothing about Ascension Health 
and its clinics that couldn't qualify if it met all of the 
requirements of the statute. For a big hospital system like 
Ascension, traditionally the biggest stumbling block has been 
governance requirements, that the requirement for a majority, 
consumer-based board has been one of the biggest obstacles to 
big hospital systems.
    Mr. Burgess. But, in concept, you would not be averse to 
that type of partnering if the governance issues could be 
worked out.
    Mr. Williams. I think the governance issues are very 
important.
    Mr. Burgess. If they can be worked out, then an amendment 
to our reauthorization bill that addressed that would be in 
accordance with HRSA's desires.
    Mr. Williams. No. I think if Ascension Health can qualify 
for the section 330 health center requirements as they exist 
today, we would obviously like that. We wouldn't necessarily 
propose to change those.
    Mr. Burgess. Let me ask you this. Would it be possible for 
you to provide the committee with a map where the federally 
qualified health centers are located across the country?
    Mr. Williams. Yes. In fact we do have such a map. We have 
geospatial data capability. We can do that.
    Mr. Burgess. You can provide that to the committee?
    Mr. Williams. Yes.
    Mr. Burgess. When Congressman Green talked to you about the 
scoring and that some facilities might not score as high as 
others, do you ever look at the maps to see that you have six 
clinics in Chairman Pallone's district and five in Congressman 
Green's and none in Ranking Member Barton's district and none 
in Congressman Burgess' district?
    Mr. Williams. We don't look at things that way.
    We do look at the maps and see where we have gaps. We have 
done that. One of our motivations for the President's 
initiatives on high poverty counties was our recognition that 
some of the poorest counties in the country were not as 
competitive in the Presidential initiative, and so we felt the 
need to try to create a competition that would allow those poor 
counties to better compete. That was the motivation for that by 
looking at the map.
    Mr. Burgess. The counties themselves are not amorphous. 
There can be pockets, deep pockets, of poverty within a county 
that otherwise just demographically can look quite affluent.
    Mr. Williams. Yes, people have pointed that out to us. I 
think that is a fair comment.
    Mr. Burgess. Let me ask you this. You talked about 
performance and accountability standards within the federally 
qualified health center. Who draws up the business plan? Is 
that entirely drawn up by the board?
    Mr. Williams. They are responsible for doing that, yes.
    Mr. Burgess. You have oversight over the business plans as 
they are drawn up?
    Mr. Williams. We do have oversight. We need to make certain 
that they meet statutory requirements and that they are doing 
what they are telling us what they are going to do in their 
applications.
    Mr. Burgess. Decisions like the ratio of the number of 
administrators to the number of practitioners, who makes those 
decisions?
    Mr. Williams. That is a local board decision.
    Mr. Burgess. Who makes the decisions about how many 
patients per day are seen by a given practitioner?
    Mr. Williams. We have some standards that we like to hold 
people--give people objectives to try to meet. In the end, it 
is a board decision.
    Mr. Burgess. I have got to tell you, in trying to work 
through some of these problems locally in Fort Worth, thinking 
back to my days of having run a clinic, looking at the 
guidelines that were provided by the existing federally 
qualified health center, I don't know how in the world the 
thing could cash flow with the number of constraints they put 
on themselves.
    But those are entirely local board decisions and not 
decisions coming out of HRSA?
    Mr. Williams. We have some of productivity standards that 
we lay out for people, and we want them to try to meet them. 
They are not absolutes, but we do set some goals for them. We 
don't want to subsidize very expensive health care.
    If you look at the cost per patient that I have cited to in 
my testimony, I think we are, by and large, a very productive 
system.
    Mr. Burgess. Now, in a community where you have a federally 
qualified health center and a private practitioner side by 
side, a Medicaid patient comes to each facility, is the 
reimbursement rate different in a federally qualified health 
center than it would be for a private practitioner who is just 
out trying to earn a living next door?
    Mr. Williams. FQHCs do have some cost reimbursement 
advantages.
    Mr. Pallone. Dr. Burgess, I am going to have to stop you, 
even though I like your questions, but you are 4 minutes over, 
so let's wrap up.
    Mr. Burgess. I guess what I am getting at is, would there 
ever be a situation where we would reimburse the actual 
physician in a neighborhood that doesn't have a federally 
qualified health center?
    Why don't we encourage the participation of physicians in 
those neighborhoods who are out there doing our work for us, 
seeing the Medicaid patient, seeing the SCHIP patient, seeing 
then insured patient? Why do we favor the physician who is 
working in a federally qualified health center when the 
physician who is working in a private practice in a similarly 
poor neighborhood is doing just as much good work?
    Mr. Pallone. We will let you answer that, and that is going 
to be it.
    Mr. Williams. I think the underlying argument here is that 
in a health clinic setting such as we have, we are providing 
health care and a lot of wraparound support services for that 
individual and for the patients who come to that clinic; and 
the return for that is very good.
    Mr. Burgess. Mr. Chairman, I would just submit if we paid 
physicians in poor areas fairly to begin with, maybe we 
wouldn't have had to create this entire other bureaucratic 
structure. But that is another day's question.
    Mr. Pallone. Fair question. I know you are going to get 
back to us with some materials, particularly that map is of 
great interest to me as well.
    Mr. Williams. We would be happy to do that.
    Mr. Pallone. Thank you very much. We appreciate your 
responses, and it has been very helpful in what you have been 
doing.
    Thank you.
    Mr. Williams. Thank you.
    Mr. Pallone. I will ask the next panel to come up.
    Our second panel--I will go from the left here: We start 
with Mr. Wilbert Jones, who is chief executive officer of the 
Greater Meridian Health Clinic in Meridian, Mississippi.
    Then we have Steven Miracle, who is executive director of 
the Georgia Mountain Health Service, Inc., in Morgantown, 
Georgia. I like that name, ``Miracle.''
    We have Mr. Ricardo Guzman, who is chief executive officer 
of the Community Health and Social Services Center in Detroit, 
Michigan.
    Finally, Dr. Michael Ehlert, president of the American 
Medical Student Association. He is from Reston, Virginia.
     As I said before, we have 5-minute opening statements from 
each of you. They will be made part of the record. We may ask 
you to submit additional statements in writing for inclusion 
into the record.
    I recognize, first, Mr. Jones for an opening statement or 
for a statement. Thank you.

 STATEMENT OF WILBERT JONES, CHIEF EXECUTIVE OFFICER, GREATER 
              MERIDIAN HEALTH CLINIC, MERIDIAN, MS

    Mr. Jones. Mr. Chairman, good afternoon, Chairman Pallone, 
Representative Deal and members of the subcommittee.
    I am honored to speak with you about health center programs 
and several pieces of Federal Tort Claims Act legislation that 
would help centers to deliver better care for the systems for 
the underserved communities.
    As chief executive director of the Greater Meridian Health 
Clinic, I am grateful to this subcommittee for supporting 
health center programs.
    I want to thank my Congressman, Representative Pickering, 
and Representative Green for introducing H.R. 1343, the Health 
Centers Renewal Act. All the health centers in my area support 
this bill and wish to renew the core elements of this program. 
This program would also authorize much-needed additional 
funding so that we can serve even more individuals in our 
communities.
    Mr. Jones. The Greater Meridian Health Clinic was 
established in 1986 to serve medically underserved residents in 
five counties in our rural areas. We operate six sites and a 
mobile health unit, and we pride ourselves on being a one-stop 
shop for the provision of primary care, preventive care, on-
site dental, pharmacist services and important enabling 
services.
    I am very proud of the board of directors, who make sure 
that we are connected to our community, and I am equally proud 
of our staff, which now number over 100 employees, including 
health care providers, administrative staff, to support patient 
care in over seven sites.
    As the health center program has grown over the past 5 
years, Congress has recognized key challenges that could keep 
health centers from maximizing delivery of health services to 
the medically underserved individuals. With this in mind, in 
1992, Congress enacted legislation that would allow health 
centers to be covered under FTCA in order to expand the 
availability of care and ensure that our providers are 
accountable for the care they provide.
    In the wake of Hurricane Katrina, the urgent need for 
further clarification of the FTCA statute came to light. The 
number from medically underserved individuals in our community 
has swelled as Greater Meridian Health Clinic served not only 
our regular patients, but a tremendous number of evacuees that 
were fleeing the storm. Three of our sites were directly 
affected by the hurricane, and our main site went off land for 
a short period of time. We estimated that we sustained over 
half a million dollars in damage and revenue losses.
    A number of health centers from outside of Mississippi were 
glad to come down to help relieve my staff. Unfortunately, the 
Health Resource and Service Administration clarified, in a 
program information notice, that health center medical staff 
would not be covered under the FTCA once they crossed State 
lines even if they were serving in a covered health center.
    Our center is located 14 miles from the Alabama border, and 
I am concerned that this process severely affected the health 
center response in my State and other States. I don't want to 
see the same situation arise in other emergencies, potentially 
preventing health centers from going where patients need their 
services.
    H.R. 870, sponsored by Representatives Diana DeGette and 
the late Paul Gillmor, would cover health centers under FTCA to 
help in disaster situations, and I urge the committees to 
support it.
    Additionally, Greater Meridian Health Clinic would welcome 
a clarification to the FTCA statute that would allow volunteer 
physicians to serve at health centers and become accountable to 
our patients. As specified in H.R. 1626, this bill was 
sponsored by Representative Tim Murphy and Representative Susan 
Davis.
    We have been very pleased to have several physicians who 
have donated their time to see our patients, and we would like 
to accommodate more providers who want to volunteer at Greater 
Meridian Health Clinic. However, the confusion surrounding 
medical liability coverage often makes this a very challenging 
situation.
    At our center, we take pride and volunteerism to heart. We 
believe that extending the FTCA coverage, as outlined in H.R. 
1626, would provide an incentive for clinicians who would 
volunteer to deliver critically needed health services to our 
patients at our health centers.
    Health centers look forward to working with members of the 
subcommittee to ensure that centers can continue to deliver 
high-quality, cost-effective health care services, and we thank 
this committee for your work and would be happy to answer any 
questions from this committee.
    [The prepared statement of Mr. Jones follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Pallone. Thank you, Mr. Jones.
     Next we have Steven Miracle.

   STATEMENT OF STEVEN MIRACLE, EXECUTIVE DIRECTOR, GEORGIA 
          MOUNTAIN HEALTH SERVICE INC., MORGANTOWN, GA

    Mr. Miracle. Thank you.
    Mr. Chairman and members of the subcommittee, thank you for 
the opportunity to speak about the health centers bill and H.R. 
1343, the Health Centers Renewal Act. I appreciate the 
unwavering support that this subcommittee has offered to health 
centers as we seek to expand and enhance access to health care 
services for medically underserved individuals and their 
families.
    The health centers program should be swiftly reauthorized. 
A special thank-you to Representative Green and Representative 
Pickering for introducing H.R. 1343, which provides for a 
straightforward 5-year reauthorization of the program with 
funding authorization levels which will allow centers to serve 
additional individuals.
    With 230 cosponsors, including a majority of the members of 
this subcommittee and the full committee, I believe that 
passage of H.R. 1343 is the best way to guarantee the 
successful renewal of the program. In this reauthorization, 
nothing is more important than retaining the patient majority 
board governance of health centers and ensuring the enactment 
of the funding authorization levels included in the bill.
    I also applaud Chairman Pallone and my Representative, 
Congressman Deal, for their leadership this year in authoring a 
letter to the Appropriations Committee in support of a $200 
million increase in fiscal year 2008 funding for the health 
centers program equal to the initial year funding in H.R. 1343, 
which will help fuel the next phase of the program's growth. 
This expansion is supported by the funding levels in the bill 
and will put health centers on a path to eventually serve 30 
million patients by 2015.
    The community empowerment and patient directed care model 
that began over 40 years ago is alive and well in my health 
center. Georgia Mountain Health began in 1984 as a result of a 
public-private initiative, in part to provide primary care 
services to residents of the Appalachian area in the northern 
part of our State.
    The first provider at our health center worked in a 
trailer, which, incidentally, doubled as her home as well as 
the medical office. Since then, that trailer has been replaced 
with a building with five exam rooms and our corporate office.
    We have grown to five service sites, including one site 
that provides dental services. We currently employ over 30 
full-time employees. We have 11 health care providers and a 
bilingual staff to address the needs of our Spanish-speaking 
patients.
    Georgia Mountain Health provides services to over 6,500 
individuals and over 16,000 total patient encounters. Almost 55 
percent of our patients are uninsured. Nearly 27 percent are 
Medicaid recipients. The Latino population in our community is 
rapidly growing and accounts for nearly 15 percent of our 
patients today.
    Our patient majority board is made up of retired people, 
small business owners, Latinos and Caucasians, and is a good 
reflection of both our service area and our patient population.
    Our board is committed to ensuring that the care we provide 
to our patients is community driven. Our board has been 
centrally involved in developing our strategic plan and 
identifying new service areas needing local access to medical 
services. In addition, individuals on our board are active 
volunteers and supportive of various outreach efforts in which 
our organization is engaged.
    We are proud of the high-quality, cost-effective care we 
provide, including basic family and geriatric medical care, 
dental services and key enabling services that make our care 
truly accessible.
    Nationally, the health centers program wins top marks for 
efficiency and performance from the Office of Management and 
Budget, the Institutes of Medicine, and the GAO. Our success 
and the success of health centers nationally is due to the four 
statutory requirements of the health centers programs: openness 
to all regardless of the ability to pay; location in medically 
underserved areas; provision of comprehensive, preventive and 
primary care services; and lastly and importantly, the 
governance of patient majority boards.
    We are making a difference in rural north Georgia. H.R. 
1343 will ensure continued access to quality care for residents 
of our area and for millions nationwide.
    Thank you once again, and I would be happy to answer your 
questions.
    [The prepared statement of Mr. Miracle follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Pallone. Thank you. Mr. Guzman.

STATEMENT OF RICARDO GUZMAN, CHIEF EXECUTIVE OFFICER, COMMUNITY 
      HEALTH AND SOCIAL SERVICES CENTER, INC., DETROIT, MI

    Mr. Guzman. Good afternoon, Mr. Chairman, ranking member 
and members of the subcommittee. Before I go into my little 
speech, I wanted to again thank the committee for being able to 
make this presentation.
    It was interesting, listening to Dr. Williams and the 
members of the committee. We don't always get kudos in terms of 
the work that we do in the community. So thank you very much.
    The second item, though, is Mr. Jones, Mr. Miracle and 
myself represent 81 years of providing services in community 
health centers to the citizens and the residents of the United 
States.
    My name is Ricardo Guzman, and I am chief executive officer 
of the Community Health and Social Services Center, a 
comprehensive, federally qualified health center with two 
community health centers and one school-based health clinic in 
Detroit, Michigan. I want to thank you for the opportunity to 
speak today on behalf of the Nation's health care safety and 
our providers and to emphasize the importance of your support 
of school-based health clinics, which we refer to as SBHCs. The 
National Assembly of School Health Care, which I represent 
today, supports the continued growth of the consolidated health 
center program.
    As Congress moves towards reaffirming its support for a 
health care safety net system, it is incumbent upon each of you 
not to leave children and youth behind in this process. As a 
manager of health centers, I am here today to tell you that 
SBHCs are an important health care safety net provider for 
children and adolescents, and it is time for Congress to 
support the life-altering work that they do every day.
    Therefore, I want to thank Representatives Hooley and 
Capito for their leadership in introducing H.R. 4230, the 
School-Based Health Center Act of 2007, which authorizes a 
grant program to support and expand SBHCs nationwide, the only 
medical model solely dedicated to meet the health needs of 
children and adolescents in schools.
    For members who are here today who might not be as familiar 
with this model of health care, let me tell you more about 
SBHCs and the comprehensive care and mental health support they 
offer.
    These programs are like doctors' offices in schools. There 
are 1,700 school-based health centers in 44 States and the 
District of Columbia and Puerto Rico. These programs provide 
services ranging from acute medical care, chronic disease 
management, preventive medical care, health education, mental 
health and, in some programs, oral health services. They serve 
as a medical home and as a secondary access point for the 
students they see. When a medical home already exists, the 
relationships between the two has been documented as 
complementary, not duplicative.
    The daily educational experience of children and 
adolescents can be optimized by reducing obstacles to learning 
created by poor health. Providers have the advantage of 
proximity and time with students to create substantive 
relationships with high-risk youth throughout their academic 
career.
    A nationwide poll found that voters looked to the Federal 
Government to set aside specific funds for SBHCs, yet only 36 
percent of programs are eligible to receive funds from the 
Federal Government to support their efforts.
    In fact, in my SBHC we do not receive section 330 funds. 
The mental health of students, particularly the need for 
assistance with grief, peer pressure, bullying and suicide 
prevention is of special concern to voters and SBHCs are 
responding to this need.
    As an example, in our center, a young girl came to our SBHC 
requesting aspirin because of a headache. As the nurse 
practitioner spoke with the student, it became apparent that 
the student really came because she needed to talk with 
someone. She was thinking of killing herself. In our SBHC, we 
were lucky to have our social worker on staff who was able to 
see her immediately.
    In spite of the tremendous advantages afforded by SBHCs, 
significant policy and financial barriers threaten the 
sustainability of the model and prevent widespread replication. 
While we are fortunate in Detroit to sponsor and fund our 
program through our community health center, only 22 percent of 
the current programs nationwide are eligible for this funding.
    You heard from the government witness, funding exists for 
this segment of the school-based health center population. 
However, three-quarters of the field can't receive these funds. 
Access to these funds is severely limited. Therefore, the vast 
majority of SBHCs operating throughout the country do not have 
access to the same sources of funding that we have.
     There is no specific Federal funding program for SBHCs. 
Because of inadequate funding forpreventive and mental health 
care services in primary care settings, SBHCs experience great 
difficulty in integrating and sustaining their comprehensive 
scope of services.
    SBHCs have had great difficulty being recognized as 
Medicaid service providers. Even when the clinics are 
recognized as providers, services outside of the traditional 
doctor-patient visit that are central to the success of the 
model are not reimbursed by Medicaid.
    Therefore, as the committee enters into discussions 
regarding the various models of health care currently 
administering to populations in need, I urge you to include 
H.R. 4230 in this discussion. The authorization of a grant 
program to support and expand SBHCs nationwide is an urgent 
need if we are to allow all students an opportunity to grow up 
healthy, strong, and achieving their educational potential.
    Our Nation is hungry for change. Americans are no longer 
willing to accept their ineffective health care system, the 
kind of system where a child can die from something as 
treatable as a dental abscess. School-based health clinics must 
be front and center as we transform our Nation's health care 
system to gain equity, access, and opportunity for all 
children.
    Thank you very much.
    [The prepared statement of Mr. Guzman follows:]

                     Statement of J. Ricardo Guzman

    Good afternoon Mr. Chairman and Members of the 
Subcommittee,
    I am Ricardo Guzman, the chief executive officer of the 
Community Health and Social Services Center, a comprehensive 
federally Qualified Health Center with two community health 
centers and one school-based health clinic in Detroit, 
Michigan. I want to thank you for the opportunity to speak 
today on behalf of our Nation's health care safety net 
providers and to emphasize the importance of your support of 
school-based health clinics. The National Assembly on School-
Based Health Care, which I represent today, supports the 
continued growth of the consolidated health center program. As 
this committee begins its consideration of H.R. 4230, The 
School-Based Health Clinic Establishment Act of 2007 and the 
Health Centers Renewal Act of 2007, I urge you to consider the 
needs of underserved populations throughout the country.
    As Congress moves toward reaffirming its support for a 
health care safety net system, it is incumbent upon each of 
you, not to leave children and youth behind in this process. As 
a manager of health centers, I am here today to tell you that 
school-based health clinics are an important health care safety 
net provider for children and adolescents and it is time for 
Congress to support the life altering work they do every day. I 
want to thank Congresswoman Hooley for her leadership in 
introducing, H.R. 4230, The School-Based Health Clinic 
Establishment Act of 2007, which authorizes a grant program to 
support and expand school-based health clinics nationwide.
    For Members here today who might not be as familiar with 
this model of health care, let me tell more about school-based 
health clinics and the comprehensive care and mental health 
support they offer. These programs are like doctors offices in 
the schools. There are 1,700 school-based health clinics in 44 
states, DC and Puerto Rico. These programs provide services 
ranging from acute medical care, chronic disease management, 
preventive medical care, health education, mental health and in 
some programs, oral health services. They serve as a medical 
home and as a secondary access point for the students they see. 
When a medical home already exists the relationship between the 
two has been documented as complementary not duplicative.
    The daily educational experience of children and 
adolescents can be optimized by reducing obstacles to learning 
created by poor health. In our school-based health clinics, we 
work closely with teachers, parents, and school administrators 
to serve students in the best possible manner.
    A nationwide poll found that:
    Voters look to the Federal Government to set aside specific 
funds for the clinics. Yet only 36 percent of programs report 
receiving any funds from the Federal Government to support 
their efforts.
    Voters also believe that school-based health clinics should 
provide a wide range of services including prevention and 
treatment of chronic diseases such as asthma and diabetes. They 
are also supportive of providing students in school with health 
education on eating right and exercising, treatment of acute 
illness and sudden trauma. The great majority of existing 
programs provide these services.
    The mental health of students particularly the need for 
assistance with grief, peer pressure, bullying and suicide 
prevention is of special concern to voters, and school-based 
health clinics are responding to this need as well.
    School-based health care is vital to my community--and many 
like mine--because it provides unprecedented access to health, 
mental health and oral health services. The programs are 
designed with input from the community and school. Providers 
have the advantage of proximity and time with students, 
creating substantive relationships with high risk youth 
throughout their academic career.
    In spite of the tremendous advantages afforded by school-
based health clinics, significant policy and financial barriers 
threaten the sustainability of the model and prevent widespread 
replication. While we are fortunate in Detroit to sponsor and 
fund our program through our community health center, only 22% 
of programs nationwide are eligible for this funding. Therefore 
the vast majority of clinics operating throughout the country 
do not have access to the same sources of funding that we have. 
There is no specific Federal funding program for school-based 
health clinics. Because of inadequate funding for preventive 
and mental health care services in primary care settings, 
school-based health clinics experience great difficulty in 
integrating and sustaining their comprehensive scope of 
services. For example since the proliferation of Medicaid 
managed care, school-based health clinics have had greater 
difficulty being recognized as Medicaid service providers. Even 
when the clinics are recognized as providers, services outside 
of the traditional doctor patient visit are not reimbursed by 
the Medicaid program. These services are central to the success 
of the model and are identified by sponsors and insurers alike 
as the model's added value.
    Therefore, as the committee enters into discussions 
regarding the various models of health care currently 
administering to populations in need, I urge you to include 
H.R. 4230, The School-Based Health Clinic Establishment Act of 
2007 in this discussion. The authorization of a grant program 
to support and expand school-based health clinics nationwide is 
an urgent need if we are to allow all students an opportunity 
to grow up healthy, strong and achieving their educational 
potential.
    Our Nation is hungry for change. Americans are no longer 
willing to accept their ineffective health care system--the 
kind of system where a child can die from something as 
treatable a dental abscess. Momentum is building around 
improving children's health access and quality in states across 
the country and in the halls of Congress. School-based health 
clinics must be front and center as we transform our Nation's 
health care system to gain equity, access, and opportunity for 
all children.
    Thank you.
                              ----------                              

    Mr. Pallone. Thank you. Dr. Ehlert.

STATEMENT OF MICHAEL EHLERT, M.D., PRESIDENT, AMERICAN MEDICAL 
                STUDENT ASSOCIATION, RESTON, VA

    Dr. Ehlert. I think we are still on.
    Mr. Chairman, members of the committee, my name is Dr. Mike 
Ehlert. I am president of the American Medical Student 
Association and a recent graduate of Case Western School of 
Medicine in Cleveland, Ohio.
    I have taken a year off from my clinical training, and I am 
proud to represent my members and offer the following testimony 
on the shortage of primary care physicians in the United States 
and on H.R. 2915 to reauthorize the National Service Corps.
    As background, AMSA is the Nation's oldest and largest 
independent, student-governed organization of physicians-in-
training. With a membership of more than 68,000 medical 
students, premedical students, interns, and residents, AMSA 
continues its commitment to improving medical training and the 
Nation's health.
    We have proudly testified for each of the National Service 
Corps reauthorizations since our 1970 championing of the 
Emergency Health Personnel Act, the origin of the Corps. In 
academic medical centers, urban hospitals, and community based 
clinics, physicians-in-training are at the forefront of 
providing care to a wide range of patients, including the 
Nation's most vulnerable.
    Through our rotations in emergency rooms, we see the impact 
of inadequate access to primary care daily. Our Nation is in a 
crisis of reliable primary and preventive care for all 
Americans. The absence of primary care physicians endangers not 
only the individual health of our patients but the community as 
well.
    For individual patients, primary care doctors can see a 
wide range of health problems, provide a place where patients 
can expect to have their problems resolved, as well as 
coordination of care where necessary. This teamwork allows 
patients to rely on a consistent and informed provider to take 
a greater role in decisions about their health.
    Primary care also allows appropriate attention to be given 
to health promotion and creates opportunities for early 
prevention of disease. The majority of health costs in America 
are incurred by preventable and reversible health risks, as 
well as easily detectable and treatable conditions.
    According to a report by the Institute of Medicine, Primary 
Care: America's Health in a New Era, primary care reduces the 
cost and increases access to appropriate medical services. 
Health outcomes improve because primary care enables 
individuals to obtain services before the illnesses become 
severe, to better control their chronic conditions, and 
ultimately reduce the inefficient use of emergency rooms. This 
all decreases the cost of care in America.
    The shortage of primary care physicians is, however, a 
problem that is not distributed evenly. Over 50 million 
Americans reside in areas designated as HPSAs, health 
professional shortage areas, by the Bureau of Health 
Professions. In 2000, HRSA estimated that an additional 26,000 
physicians were needed to meet the desired clinician-to-
population ratio in these shortage areas.
    There are currently over 4,000 professionals participating 
in the National Service Corps, and throughout its history over 
27,000 professionals were placed in underserved areas. As you 
have heard, retention rates usually hover around or greater 
than 50 percent. Those eligible for Corps funding include 
primary care physicians, which by definition include 
pediatricians, internists, OB/GYNs, psychiatrists and family 
physicians and the other members of the primary care team, 
including nurse practitioners, physician assistants, midwives, 
dentists, dental hygienists, and mental/behavioral health 
professionals.
    The premise of the National Service Corps is a financial 
incentive for those clinicians who practice in locations not as 
rewarding as others. It is no secret that our financing system 
for health care does not reward those who prevent or coordinate 
care but rather those who perform procedures or provide 
hospital-based critical interventions. Further, student debt is 
at an all-time high. According to the most recent report by the 
Association of American Medical Colleges, the average medical 
student graduates with $120,000 in educational debt. My fiancee 
and I will have over $300,000--$300,000--to repay.
    Primary care is the lowest-paying physician profession. It 
is no wonder that the number of U.S. graduates entering primary 
care fields has steadily decreased over the last decade.
    The Corps provides a crucial incentive to care for 
Americans who are most vulnerable and least likely to have 
access to care. Both the scholarships and loan repayments are a 
much-needed investment in our health care workforce and the 
health of these communities. The Corps allows committed and 
driven and compassionate physicians to follow their interests 
to provide care to the Nation's neediest, instead of being 
forced to make career decisions based on high debt loads. 
Central to this service are the Nation's federally qualified 
health centers; and, as you have heard, over 54 percent of 
Corps recipients work in community health centers.
    In a recent article published by JAMA, and as statistics 
quoted today, the average health center has a family physician 
staff vacancy of more than 13 percent. In rural areas, the rate 
approaches 16 percent.
    As a physician-in-training and as the AMSA president, I 
strongly believe that continued support and increased funding 
for the Corps is crucial to improve the Nation's health. There 
are a number of bills before this committee that would 
reauthorize the Corps. We emphasize, however, the importance to 
authorize increased funding for the program. The Corps turned 
away half of the 1,800 physicians who applied last year, an 
even lower acceptance rate for students who apply for 
scholarships, with over 11 applicants for each available 
scholarship.
    As my time is up, I will just summarize to say that an 
immediate increase in funding for the Corps is crucial for an 
already proven vacancy rate, a paucity of primary care 
physicians, and a ballooning of student debt that push young 
physicians away from primary care and away from underserved 
areas. This would recognize the crucial role physicians play in 
coordinating and managing the health of their patients.
    Thank you, and I look forward to answering any questions.
    [The prepared statement of Dr. Ehlert follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    
    Mr. Pallone. Thank you all, and we will start with 
questions. We will start with me. I will recognize myself for 5 
minutes.
    I wanted to ask Mr. Guzman, we heard Ranking Member Barton 
raise concerns about creating a new pot of money for school-
based clinics when other pots already exist. And you touched on 
this in your testimony, but I was going to ask you to comment 
further on why authorizing a new grant program is necessary and 
why relying on existing or other revenue streams is not 
adequate.
    And I, just from my own experience in New Jersey, I believe 
that most of the school-based clinics in my district or in our 
State are primarily State-funded. But I don't know--knowing the 
situation in the State, I am sure that that money is not--there 
is not a lot to go around. So if you would talk about that.
    Mr. Guzman. Yeah. We are in the same boat in Michigan.
    I think there are two questions here. The first one is the 
funding. We need dedicated dollars to that. There are different 
models. This model of school-based health centers works, and it 
allows us to have different models that would include health 
departments, that would include hospitals. But I think that if 
you look at--if you accept the concept that there are no real 
dedicated dollars with the exception of FQHC dollars, which are 
very, very limited----
    In our particular case, we did not get any encouragement by 
the Bureau to submit for a school-based clinic. There was 
several issues related to whether or not we had to provide the 
array of services required, have certain hours of operation 
that would have been contrary to--not contrary, but counter to 
the school and the local school district's wishes in our 
particular case.
    Mr. Pallone. Again, I don't know if it was Mr. Murphy or 
one of my colleagues on the Republican side pointed out that 
everything we are talking about here is preventative; and, 
unfortunately, we don't get it scored. But, I mean, we all 
believe that all these things save money in the long run; and 
it is unfortunate that we can't score them.
    The other question I wanted to ask, I guess I could ask of 
Mr. Jones and Mr. Miracle, obviously, as was mentioned earlier 
with Dr. Williams, the authorization levels provide for 
increased--higher authorization, more funding in Mr. Green's 
bill that is before us and if you wanted to indicate whether 
you are supportive of the authorized funding levels included in 
the bill. Do you think they are adequate to sustain the 
community health centers program over the authorization period, 
and is there sufficient increased demand to justify the 
increased authorization levels? Obviously, I think so, but I 
would like to hear from you.
    Mr. Jones. On two parts. The demand is definitely--at our 
health center, located in the State of Mississippi, not only 
are we dealing with the patients, our current patients, but 
continued growth in patients and relocation because of Katrina. 
We are still receiving patients, new patients in our clinic. 
The demand--because of the downturn of the economy, we have 
many of our patients that are not able to afford health 
insurance that are seeking the health center and seeking the 
availability of health center services. We are--in our most 
rural counties, we are seeing more and more patients that are 
not able to travel a long distance to work. They are again 
seeking our services.
    So, yes, there is a demand. To meet that demand, we must 
have increased funding to not only sustain our existing base, 
our existing patients' care and facilities but also to expand 
to meet the demand, the new demand.
    Mr. Pallone. Mr. Miracle?
    Mr. Miracle. I would concur with that. In our community in 
rural north Georgia, we are a very tourist economy; and we also 
are a second-home-construction economy. We are having problems, 
and I foresee in the next 6 months that the unemployment rate 
in our area will skyrocket. Those folks that are employed 
because of the tourist economy are employed by small businesses 
who don't typically provide insurance, and so we have a 20-plus 
uninsured rate in our community, and I envision that that will 
continue.
    We need the dollars to help us take care of the greater 
demand that I foresee in our community. We also need dollars to 
expand our services. We don't currently provide mental health 
services at our center. There is a serious need in our 
community for that, and I see increased funding levels being 
able to help us to provide those additional services.
    And, lastly, there is just a general increase in the cost 
of supplies our organization faces as well as other providers. 
And with the large percentage of uninsured that we see, it 
would be very helpful to have additional funding to help us 
just keep up with the health care inflation.
    Mr. Pallone. Thank you.
    Mr. Murphy?
    Mr. Murphy. Thank you; and thank you, panelists. This is 
very enlightening to have you all here. But I know your jobs 
require a great deal of services above and beyond the call of 
duty, so I thank you for that.
    I should first relay a message, Mr. Miracle, from Ranking 
Member Deal. He is on the floor managing part of the debate on 
the Norwood organ donor bill, so he sends his apologies. He 
wishes he could be here. He may be back.
    But a question for Mr. Jones and Mr. Miracle on the issue I 
mentioned before about the medical malpractice costs for people 
under the Federal Torts Claim Act versus volunteers. Mr. Jones, 
you made specific reference to that. Do you have any idea what 
it costs your clinic to pay some of these medical malpractice 
costs under the Federal Torts Claim Act versus physicians who 
volunteer in clinics? Do you have any direct knowledge of what 
those difference in costs would be?
    Mr. Jones. Per physician I really would need to do some 
research on that, but I can tell you that prior to FTCA 
coverage our cost per physician, which was more than 5 years 
ago, exceeded $5,000 annually per provider. With 20-plus 
providers, you can see that is a substantial amount of money. 
OB/GYN and other services considerably higher in providing 
costs. In today's market I would say it would be considerably 
higher per provider.
    Mr. Murphy. And in some other States those numbers might 
even be----
    Mr. Jones. Much higher. Much higher.
    Mr. Murphy. Do you agree with that, Mr. Miracle, too?
    Mr. Miracle. I don't have any direct knowledge of 
professional liability insurance outside of our organization. 
But I know that it would be substantial, and it would be a 
burden to Georgia Mountain Health.
    Mr. Murphy. And among the three of you involved with these 
clinics, too, your overall administrative costs, have you done 
any analysis of what the administrative costs would be compared 
to if you--other kinds of clinics or hospitals that would not 
be based upon this sort of like the clinic model that you use?
    Mr. Jones. At the current time, I don't have those numbers 
for you, but I can tell you that, from observation, our 
administrative costs are much lower than what you would find in 
the private sector.
    Mr. Murphy. That is helpful.
    Mr. Jones. But I would be glad to get those figures for 
you.
    Mr. Murphy. Thank you. I appreciate it.
     Mr. Guzman, in your testimony, you said you are fortunate 
in Detroit to have other funding, but you said only 22 percent 
of programs nationwide are eligible for some specific funding. 
What kind of funding were you talking about and why is only 22 
percent eligible for that?
    You need the microphone.
    Mr. Guzman. I am sorry. I think the mike is on.
    What I know about that is, of the FQHCs, only 22 percent is 
my understanding are eligible for funding for school-based 
health centers. The balance of that, which is over three-
quarters of the 1,700 school-based health centers, do not 
receive any Federal dollars.
    Mr. Murphy. Is that something that you see there is some 
legislative corrections in some of the bills we are dealing 
with here?
    Mr. Guzman. Well, that would be the hope.
    When we were talking just a moment ago, when you were 
talking about malpractice insurance, because the school-based 
health center that our organization runs at the local high 
school, which is out of our scope, our Section 330 scope, we 
have to pay malpractice insurance. Even though we have FTCA 
coverage within the clinic physicians and medical providers as 
well as the other staff, we have to pay her malpractice 
insurance because she is not deemed--I guess she is out of 
system.
    Mr. Murphy. Thank you.
    And, Doctor, thank you for not only your testimony but 
giving your time. Can I ask what it pays to be a family--or a 
primary practitioner under this program?
    Dr. Ehlert. Under the National Service Corps or in general?
    Mr. Murphy. Under National Service Corps.
    Dr. Ehlert. It depends on the individual clinics, actually, 
but the Corps provides for each year, depending on the 
scholarship that it covers, but the loan repayment is $25,000 
per year. And then there has been a focus--as Dr. Williams 
mentioned, there is actually--HRSA has decided to also increase 
that $35,000 for people that meet requirements and stay on 
past.
    Mr. Murphy. But there is a salary, too. You get paid, 
correct?
    Dr. Ehlert. Correct. The payers, I think, are here. They 
would be better to comment on how much they are able to pay 
their physicians.
    Mr. Murphy. You are doing it now?
    Dr. Ehlert. No, I have graduated from medical school, but--
--
    Mr. Murphy. Can someone tell us how much they get paid?
    Mr. Guzman. Sure. Primary care docs, and again depending 
upon the region of the country, but in the Midwest primary care 
docs are averaging somewhere in the area of between $175,000 
and probably 225.
    Mr. Murphy. To the ones at the clinic or ones in private 
practice?
    Mr. Guzman. The ones in the clinics.
    Mr. Murphy. And in private practice what would they make?
    Mr. Guzman. Private practice they are probably averaging a 
little bit more than that.
    Mr. Murphy. Mr. Jones? You are not paying that?
    Mr. Jones. Pretty much depending upon experience and 
specialists, the range in our clinic is from $125,000 to 
$140,000.
    Mr. Murphy. So quite a dramatic difference between what the 
private sector would be----
    Mr. Jones. That is still much lower than the private 
sector.
    Mr. Murphy. And people who, as you mentioned, Doctor, may 
have several hundred thousand dollars of debt in the family to 
deal with.
    Well, thank you so much for your testimony. I appreciate 
that.
    Mr. Pallone. Costs more in the urban areas. Cost of living.
    Mr. Guzman. That is what we say, yeah.
    Mr. Pallone. Sure.
    Mr. Green.
    Mr. Green. Thank you, Mr. Chairman.
    My staff just told me that in our clinics in Texas we have 
never heard the numbers, but, knowing doctors' costs, I would 
say that is probably a little higher than what would be paid in 
urban Houston. But it is a benefit because you have the the 
loans payback.
    Mr. Miracle and Mr. Jones, I read several studies that 
point to the role of health centers in reduction of health care 
disparities. Specifically, it has been shown that these 
disparities don't exist among health center patients even after 
controlling for socioeconomic factors. These are impressive 
health outcomes, especially given that health care center 
population is 23 percent African American, 36 percent Hispanic, 
much higher proportions of minority representation than the 
Nation at large.
    Can you speak to how health centers have achieved such 
success at eliminating these health disparities? And what role, 
if any, does the community board play in helping health centers 
to tailor their preventative and primary health care services 
to address the most pressing health needs of the minority 
populations within these communities? Like I said, I think some 
of these numbers are very good compared to the numbers we 
normally hear about health care disparities.
    Mr. Jones. One of the things that is part of our planning, 
our board participates in our planning. It begins from the 
board, the clinical staff, and the office of the corporation. 
We plan yearly, annually, and have strategic plans.
    But the main thing is making sure that we are very 
sensitive to the population group that we serve, making sure 
that we have interpreters when needed but also making sure that 
we listen to our consumer board. They are there, they are 
patients of the clinic, they see the need of the clinic, and 
they report to us and make sure that we listen.
    And we try to respond. We are located in areas where our 
population is located, and we make sure that our facilities' 
doors are open to everyone, and that is a part of our staff 
training, from our housekeeping staff to our doctors. We make 
sure that every patient is respected, and after 20 years of 
service, the community knows this. They know that they can come 
there.
    And it was evident of Katrina. The community health 
centers, all six of my community health centers were avenues 
for care; and from the mayor to the sheriff, they knew they 
could refer patients to our clinic because we were accustomed 
to dealing with patients that were homeless, patients that were 
disenfranchised. We have the experience to deal with those 
patients. And all of a sudden, when Katrina hit, everybody was 
homeless. So we became a site, an open-door site for the 
patients.
    Mr. Green. OK. Mr. Miracle?
    Mr. Miracle. I think from the health disparity standpoint, 
two things to make comment about.
    Number one is, where it relates to our Latino population, 
we deliver culturally competent care. I mean, we have a 
bilingual staff, and we have gone through separate training to 
help those folks, our staff communicate with our patient 
population. And I think that is very important to be able to 
talk to folks in a way, or--to talk to folks where they are, as 
opposed to from some other standpoint. So that has helped a 
lot. In fact, our organization was recognized recently, one of 
four health centers in Georgia to be recognized as a culturally 
competent health center.
    The other thing is, as a participant in HRSA's disease 
collaborative program, we monitor, track, and communicate 
outcomes to our providers, and we hold ourselves accountable to 
specific outcome measurements. By identifying how well we are 
doing on A1C levels, for example, is very important, and that 
helps to make sure that we are providing the care that we need 
for those chronic disease cases.
    Mr. Green. OK.
    Mr. Guzman. If I could just add one other point, we are 
also required as FQHCs to provide a wide array of other 
services, wraparound services that encompass social work, 
nutrition, health education, et cetera. And I think that if you 
encompass that in the role in how we do things, that is why you 
see much of the differences along with all of the other things 
that have taken place.
    One of the things that in school-based health centers we 
have been trying to do is mirror that concept of not just a 
physician and/or provider being in a location but the provider 
being there along with social workers and the availability of 
nutrition and health education programs.
    Mr. Green. Mr. Chairman, I know I am out of time. I had one 
more question for Mr. Miracle about the dental services he 
offers for adults and children, and our bill that Mr. Pickering 
and I have would authorize the funding for expanding those 
services, including mental health, dental, and pharmacy 
services at every health center.
    And with that I won't take up any more time, particularly 
since you said we would have the markup in early January when 
we come back.
    Mr. Pallone. We don't come back in early January.
    Mr. Green. Well, late January. Well, early and late January 
when we come back.
    Mr. Pallone. We will do it as quickly as we can. I don't 
think we come back until after the 15th of January, actually, 
but--OK.
    Mr. Burgess?
    Mr. Burgess. Thank you, Mr. Chairman.
    Mr. Jones, I guess I was a little startled to hear your 
story about Katrina and individuals across the border in 
Alabama who could not come and help because they wouldn't be 
covered under the Federal Tort Claims Act. Is that correct?
    Mr. Jones. Yes. We received an opinion, clarification from 
HRSA once we began to explore the idea. Which once they 
crossed--although they were deemed in their health facility, if 
they crossed State lines or if they moved from another health 
center you are only deemed at the health center that you are 
contracted to work for.
    Mr. Burgess. So that was strictly encompassing that 
population of individuals who were covered at a health center 
under the Federal Tort Claims Act?
    Mr. Jones. That is right.
    Mr. Burgess. Because the information was exactly different 
than I was given near Dallas. I am licensed but not insured; 
and, obviously, when we started taking in large numbers of 
displaced persons, they said--I called the Texas Medical 
Association for clarification. They said, well, you can't go to 
Reunion Arena or you will be exposed to liability, but you 
could go to Louisiana and you wouldn't.
    So it is just an odd situation where we find you got one 
set of information and I got a completely different set. But I 
guess it only encompassed that universe of people who are 
employed by the federally qualified health center and had their 
coverage as an employee, is that correct?
    Mr. Jones. Correct. Again, we are asking for clarification.
    Mr. Burgess. It seems--we are the Federal Government. We 
don't pay any attention to State boundaries anyway in so many 
things, so I am just surprised that we do in this one.
    Mr. Jones. Right. We were surprised, too.
    Mr. Burgess. Maybe an educational program needs to be 
undertaken before our next end-of-the-world occurs.
    Dr. Ehlert, you testified very eloquently about the 
reauthorization of the National Health Service Corps 
scholarship and loan forgiveness. Is the scholarship and loan 
forgiveness under the National Health Service Corps, is that 
the only avenue that a medical student would have available to 
them for this type of help or are there other entities that 
might provide assistance?
    Dr. Ehlert. I don't have a detailed list but certainly I 
know that there are regions, counties, and States that have 
designed repayment programs, as well as certain centers that do 
provide similar incentives for people to go and work there. And 
certainly scholarships, there is a myriad of scholarships for 
student.
    Mr. Burgess. When I started medical school in 1974, and 
they had just phased out at that time what was called the Berry 
Plan, which the Armed Services would pay for your education, 
books, and a stipend on which to live. Do the Armed Services 
provide any type of stipend or loan forgiveness program that 
you are aware of?
    Dr. Ehlert. There is a tremendous opportunity for people 
that includes both scholarship and stipend. However, your 
commitment through that is to serve in the military and at 
military health centers, not at community health centers.
    Mr. Burgess. But it is a similar one-for-one trade, 1 year 
in for training and 1 year in repayment?
    Dr. Ehlert. I am not a scholar, but that is my 
understanding through my colleagues that have done it.
    Mr. Burgess. And is that the type of help that is 
available, is it comparable?
    Dr. Ehlert. I feel it is more robust.
    Mr. Burgess. Which is more robust?
    Dr. Ehlert. The military one, because they encompass more 
long-term benefits of having been in the military.
    Mr. Burgess. I see.
    Dr. Ehlert. That is the same as anyone who served in the 
military.
    Mr. Burgess. OK. But that is still a trajectory that is 
available to a medical student.
    Dr. Ehlert. Certainly. And my association supports those 
opportunities for students as well.
    Mr. Burgess. Well, now, have you done the math as to if the 
funding increase--and do bear in mind--and this is something I 
did not know before I got here--we have got authorizers, and we 
have got appropriators, and we are talking about an 
authorization limit here that is extremely--then there is 
another hurdle to cross to actually get the appropriations.
    I found this out at the National Institutes of Health when 
I went out there--I have been out there for several field 
trips--and every building is named after an appropriator. There 
is none named after an authorizer. But if we authorize it at 
the level that is in the Braley bill, how many new scholarships 
will be created as a result of that?
    Dr. Ehlert. Again, there is discretion in HRSA. I don't 
know how many.
    But I would just like to point out what I said in my 
testimony of 11 applicants for each scholarship recipient and 
about half of the physicians who apply for the stipend while 
they work in the centers has been turned down.
    Mr. Burgess. But from the standpoint from the government 
side that is good because then we are getting the most 
qualified and highly motivated individuals. A lot of 
competition to get those scholarships?
    Dr. Ehlert. Certainly. And some of the greatest leaders I 
know that have come out of medical school have been denied 
these scholarships, which is ironic. So, true, it does drive 
quality, but there is still that need.
    Mr. Burgess. Are they awarded on a competitive basis?
    Dr. Ehlert. Yes.
    Mr. Burgess. Grade point average and national boards and--
they still do all that stuff?
    Dr. Ehlert. The last people I talked to who applied, there 
is a formula. I don't know the details of the formula, but, 
yeah, there is a formula involved.
    Mr. Burgess. So your opinion that the National Health 
Service Corps scholarships and loan forgiveness programs are a 
good deal for medical students or is it like the court of last 
resort?
    Dr. Ehlert. No, I think it is a tremendously good deal.
    Mr. Burgess. And do you think that us increasing the 
authorization limit, you think that need, that pressure is 
still going to be there, still going to remain there?
    Dr. Ehlert. Absolutely. I didn't include it in my oral 
testimony but in my written testimony. Medical tuition went up 
11.1 percent last year. So there is actually less and less--if 
funding stays the same, it becomes less and less incentive.
    Mr. Burgess. Yeah, but you have so much more to learn now.
    I just want to thank you for taking the time to come up 
here today. I know it is time you could have given to something 
else.
    And, Mr. Chairman, I yield back.
    Mr. Pallone. Thank you.
    Mr. Deal.
    Mr. Deal. Thank you, Mr. Chairman; and I think you have 
been told where I went. I was handling the Charlie Norwood 
organ transplant bill on the floor. As all of you know, that is 
an important piece of legislation honoring my good friend from 
Georgia, the late Congressman Charlie Norwood. I do apologize 
for missing your testimony.
    Let me be quick. Mr. Miracle, how long did it take for your 
center to qualify for the Section 330 funds and how difficult a 
process was that?
    Mr. Miracle. I don't know how long it took because it 
happened before I got there. I can tell you that we applied in 
2003 for an expansion for a new start-over in Union County, and 
we were denied. I can tell you that we tried again in this most 
recent round with the high poverty counties for Murray County, 
and we were successful.
    What happened between then and now partly was my maturity 
as a manager of an FQHC but also the help that was provided by 
the State PCA, the organization that community health centers 
in Georgia belong to. And the technical support that they 
provided, with help from HRSA, to our organization to put 
together a quality grant was tremendously helpful.
    Mr. Deal. OK. What part of the process was the most 
onerous, do you think?
    Mr. Miracle. Writing 200 pages of--I think the most onerous 
part was understanding the community. It was onerous, but it 
was important. I mean, we, in putting that grant together, 
required not just sitting in the office in Morgantown and 
saying, oh, let's do a community health center grant for 
Chatsworth, but I and my staff actually went to the community 
several times, met with the hospital there, with community 
leaders.
    We understood from resources that were available the need 
in the community in terms of the underserved population, and I 
ended up where I felt that I know that community as well as I 
know the community where our home center is. And although it 
was onerous and difficult, it was the most important part of 
the process, as far as I was concerned.
    Mr. Deal. OK. Do you know offhand how many community health 
centers we have in the State of Georgia?
    Mr. Miracle. I can give you an estimate. I think there are 
some 22 organizations. My guess is that there is some 35 or 40 
service sites. But I will have to get back to you with the 
exact number.
    Mr. Deal. OK. Obviously, since the one in Union County was 
denied I assume you think there is still a need for some more 
in our State?
    Mr. Miracle. Well, I do; and some of that is--as we talked 
about earlier, there are pockets of needs. And Union County is 
one of those areas where on the surface it may look like there 
is no need but there are certainly--as you know, there are 
certainly some serious pockets of underserved areas in that 
county. We have 159 counties in Georgia. There are many that 
would be deserving of a community health center.
    Mr. Deal. Is there any kind of geographical bias in the 
process, in your opinion?
    Mr. Miracle. Well, not that I can tell. We serve--we are in 
north Georgia. We see patients from Tennessee and North 
Carolina. When we were denied the grant for Union County, my 
opinion was, well, we needed to just go back and do a better 
job next time.
    Mr. Deal. OK. Anybody disagree with any of those 
assessments? Mr. Guzman?
    Mr. Guzman. Yes, Congressman, I would disagree with that.
    I think there appears to be some type of bias. In Michigan, 
as an example, and specifically in Detroit, we have a 
significant population. You only have four community health 
center organizations that represent probably another 10 
clinics, points of access for a population of almost 900,000 
people. In our particular center, as an example, we see about 
78 percent of the folks are uninsured. So that is clearly a 
need, and we are not quite sure what the status is at the 
Bureau, but we don't think we got our fair share.
    Mr. Deal. Yours is a metropolitan area.
    Mr. Guzman. Correct.
    Mr. Deal. Mr. Jones, yours is a rural area.
    Mr. Jones. Very rural.
    Mr. Deal. What do you see?
    Mr. Jones. I would not say there is a bias. I am concerned 
about the formula. I am concerned about a county not looking at 
the--looking at the county as being a county of economic growth 
when in fact there are pockets in that county that the--there 
is created a situation where there is a few with a tremendous 
amount of wealth, but the majority of the county is poor. 
Unfortunately, that county is not a high priority. The majority 
of the population in that county has tremendous need, but it is 
not rated because of the formula.
    Mr. Deal. In a rural area, that percentage of wealth tends 
to distort it even more than it would in a metropolitan area.
    Mr. Jones. Very much so.
    Mr. Deal. OK. My time is up. Thank you all very much, and I 
apologize again for not hearing your testimony. Thank you.
    Mr. Pallone. Well, let me thank all of you for 
participating. This is obviously a very important issue with 
all three of these bills; and I know, as I said before, Mr. 
Green is pushing us to move quickly on trying to markup the 
legislation and move it. We are certainly cognizant of the fact 
that we need to get moving because of the need, and your 
testimony has helped us a great deal in that respect. So thank 
you all.
    Let me mention that members may submit additional questions 
to you to be answered in writing. Those should be submitted to 
the clerk within the next 10 days, and then we will notify you 
if we have some additional questions.
    But thank you again; and, without objection, this meeting 
of the subcommittee is adjourned.
    [Whereupon, at 4:37 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]


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