[Senate Hearing 111-656]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-656
 
                  PRIMARY HEALTH CARE ACCESS REFORM: 
                   COMMUNITY HEALTH CENTERS AND THE 
                     NATIONAL HEALTH SERVICE CORPS

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                                   ON

  EXAMINING PRIMARY HEALTH CARE ACCESS REFORM, FOCUSING ON COMMUNITY 
                HEALTH CENTERS AND THE NATIONAL HEALTH 
                             SERVICE CORPS

                               __________

                             APRIL 30, 2009

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont         ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio                  LISA MURKOWSKI, Alaska
ROBERT P. CASEY, Jr., Pennsylvania   TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina         PAT ROBERTS, Kansas          
JEFF MERKLEY, Oregon                 
  

           J. Michael Myers, Staff Director and Chief Counsel

     Frank Macchiarola, Republican Staff Director and Chief Counsel

                                  (ii)

  
?



                            C O N T E N T S

                               __________

                               STATEMENTS

                        THURSDAY, APRIL 30, 2009

                                                                   Page
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont, 
  opening statement..............................................     1
Clyburn, Hon. James E., a U.S. Representative from the State of 
  South Carolina.................................................     2
Bascetta, Cynthia, Director of Health Care, Government 
  Accountability Office (GAO), Washington, DC....................     4
    Prepared statement...........................................     5
Hawkins, Daniel R., Jr., Senior Vice President, National 
  Association of Community Health Centers, Bethesda, MD..........    12
    Prepared statement...........................................    14
Hatch, Hon. Orrin G., a U.S. Senator from the State of Utah......    18
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio.......    19
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon......    19
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................    19
Mullan, Fitzhugh, M.D., Murdock Head Professor of Medicine and 
  Health Policy, Washington, DC..................................    20
    Prepared statement...........................................    21
Evans, Caswell A., Jr., D.D.S., M.P.H., Associate Dean for 
  Prevention & Public Health Services, University of Illinois at 
  Chicago College of Dentistry, Chicago, IL......................    33
    Prepared statement...........................................    34
Davis, Yvonne, Community Health Center Board Member, Florence, SC    43
    Prepared statement...........................................    45
Matthew, John D., M.D., The Health Center, Plainfield, VT........    47
    Prepared statement...........................................    48
Nichols, Lisa, Executive Director, Midtown Community Center, 
  Ogden, UT......................................................    54
    Prepared statement...........................................    55
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa..........    70

                                 (iii)

  


  PRIMARY HEALTH CARE ACCESS REFORM: COMMUNITY HEALTH CENTERS AND THE 
                     NATIONAL HEALTH SERVICE CORPS

                              ----------                              


                        THURSDAY, APRIL 30, 2009

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:00 a.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Bernie 
Sanders presiding.
    Present: Senators Sanders, Harkin, Merkley, Hatch, Brown, 
and Casey.

                  Opening Statement of Senator Sanders

    Senator Sanders. Good morning. I am Senator Bernie Sanders 
of Vermont. I want to welcome and thank all of our guests for 
being here. I especially want to thank Congressman Jim Clyburn 
of South Carolina for joining us today. It's important that he 
be here because he has been a leader in the House of 
Representatives on the issues of primary health care and 
community health care centers in particular.
    As I think everybody in this room understands our country 
faces extraordinary problems in terms of health care. They run 
the gamut. But I think one area where there is widespread and 
clear understanding, where we have a major problem, is in terms 
of primary health care. Some of you may have seen a front page 
article in the New York Times just a few days ago highlighting 
that issue.
    The reality is a pretty simple one. At the time when 46 
million Americans have no health insurance, that is not the 
total problem. Because even if tomorrow, by some magical 
circumstance, we were to pass a national health care program 
and provide an insurance card for every American, we would by 
no means solve the health care crisis.
    We have some 60 million Americans, many with insurance, who 
can't find a medical home. They can't find a doctor. They can't 
find a dentist. They can't find mental health counseling. They 
can't gain access to low cost prescription drugs.
    Clearly what all of us understand is that there is not 
going to be real reform or the bringing of cost effectiveness 
to our health care system unless we address that issue.
    I expect that our witnesses will be focusing on that as 
well and what primary health care is all about and what 
community health care centers do to make quality health care 
and dental care and mental health counseling accessible to 
people of all incomes in their community.
    I look forward to hearing what our witnesses have to offer 
about this. And let me just briefly tell you how this hearing 
will proceed. Members, I suspect, will be dropping in and out. 
But we will hear from Congressman Clyburn in a moment. Other 
members, if they come in, will say a few words. Then we will 
just go to brief comments, a couple of minutes each, from 
members of the panel.
    What we have found in general is that it is a richer 
process if we exchange and engage in discussion, rather than us 
giving you lengthy speeches and you giving us lengthy speeches. 
So we will have a dialogue. We will have a conversation, 
informal, and everybody should feel free to pop up and comment 
whenever they want.
    Now in the midst of a lot of bad news in our country, let 
me give you some very good news. This is the result of the work 
done by a lot of people, including many of our panelist, people 
in the House, people in the Senate. Congressman Clyburn played 
a great role in this.
    We have in the stimulus package, taken this country a 
major, major, major, major step forward in terms of improving 
primary health care. At a time when community health care 
centers were receiving about $2.1 billion a year, we basically 
doubled in that package--doubled--it went from $2.1 to $4 
billion, the amount of money going to community health centers.
    Many are aware that President Obama, a month or so ago, 
announced 126 new centers in 1 day, that is extraordinary.
    In addition to that we all understand that we are not going 
to solve the primary health care crisis unless we have far more 
primary health care physicians and dentists and other medical 
personnel.
    Within that same stimulus package we almost tripled the 
amount of money for the National Health Service Corps, going 
from $120 million to $300 million.
    So the good news is I think in a very bipartisan manner, 
people understand the crisis and we are beginning to address 
it.
    Having said that, let me introduce Congressman Clyburn for 
some opening remarks and then we will just take it to the 
panel.
    Jim.

              STATEMENT OF HON. JAMES E. CLYBURN, 
            U.S. REPRESENTATIVE FROM SOUTH CAROLINA

    Representative Clyburn. Let me thank you very much, Senator 
Sanders, for allowing me to be a part of this hearing today. 
Thank you so much for your tremendous leadership on this issue 
that is very, very important to this great country of ours.
    I do have a statement and I heard you when you made your 
opening statement. This PK, this preacher's kid will get on the 
soap box every now and again, so to resist that temptation I am 
going to ask that you allow me to put my statement into the 
record, but let me take a couple of minutes to thank a few 
people.
    I want to thank Ms. Davis for being here. She comes from a 
county in my congressional district, Marion County, I believe. 
Ms. Latian Woodard, comes from the county that I was born in. 
Thank you so much for being here. And I want to say this about 
Ms. Davis' county. Marion County today, as we sit here, is 
situated along what we call the I-95 corridor that many of you 
have heard referred to in recent weeks as the corridor of 
shame. Many of you may recall that President Obama, when he 
spoke to the joint session a few weeks ago, had with him a 
student from Dillon County, next door to Marion, talking about 
the educational problems along that corridor. I think that all 
of us know that a big part of the problem that we have with 
delivering accessible, affordable, quality health care to all 
of our citizens has to do with a lack of education on so many 
fronts, not just what may be garnered from the classroom, but 
the lack of education on many fronts.
    If I might use a personal experience. My wife, about 6 
years ago had 5-vessel bypass surgery. On the night that she 
took ill, we knew from her history, we knew from the symptoms 
what was happening. And when the emergency room medical staff 
wanted to send her back home, my daughters said, ``No. We are 
not taking her back home. We know that there is something else 
wrong. It is not over.''
    Simply because they were educated to what could happen and 
would happen with her history, and a few days later, they found 
three 100 percent blockages, one 90 and one 50. Now what would 
have happened but for the education about her condition that my 
daughter's had when they would not take her back home that 
night? I can think, as I said to the President last week, I can 
think of no better way for us to put prevention at the center 
of this problem than through community health centers.
    We have got to pass H.R. 1296, as I call on the House side, 
Senators Sanders has a different number on the Senate side. 
Whatever it is, they are companion bills. We need to go from 
1,100 health centers that we have now to 4,800, which will give 
us 100 percent coverage, we need to increase the funding up to 
$9 billion per year over a 5-year period of this new budget 
that we just approved yesterday, and we need to do it now.
    It will create not just the prevention measures that we 
need, but it would create or adjust the shortages of the 
deliverance of health care. It would create new employment 
opportunities for people who we know represent services where 
we have tremendous shortages.
    So I am pleased to be here today and to put this in the 
record and to say to Senator Sanders how much I appreciate 
working with him on the bill, and to our staffs, thank you all 
so much for making us look intelligent on these issues, and 
thanks to my constituents for being here to help drive this 
issue home.
    Thank you, Senator Sanders.
    Senator Sanders. Thank you very much Congressman Clyburn.
    I am just looking at--just as one further word. I concur 
with everything that the Congressman said, that at the end of 
the day when we make this $8.5 billion investment, do you know 
what we are also doing? We are saving money. How's that? We are 
keeping people well. We are keeping them out of emergency 
rooms. We are keeping them out of hospitals. And what the 
studies suggest is we are saving substantial sums of money. 
This is a win-win-win situation and we are going to go forward 
and pass this legislation.
    OK. Enough from us. My preference would be that people keep 
their remarks brief so we can engage in a dialogue. Let's begin 
with Ms. Bascetta, who is the director of health care for the 
Government Accountability Office, the GAO. Cynthia, thank you 
very much for being with us.

  STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR OF HEALTH CARE, 
     GOVERNMENT ACCOUNTABILITY OFFICE (GAO), WASHINGTON, DC

    Ms. Bascetta. Thank you, Senator Sanders and Mr. Clyburn. I 
am happy to be here today to discuss our work on community 
health-centered programs, whose mission, as you know, is to 
increase access to primary health care services for the 
medically underserved. More than 6,000 health center sites 
provide comprehensive primary health care services to about 17 
million people through preventative, diagnostic, treatment and 
emergency services, as well as referrals to specialty care. 
Although our work and the work of others has shown problems in 
the referral process.
    Our work focused on the provision of these services for 
people who reside in the federally designated medically 
underserved areas, called MUAs.
    People served by health centers are often Medicaid 
beneficiaries and the uninsured. And because more people in 
employer-based health insurance may need to rely on health 
centers in times of growing unemployment, the Recovery Act 
anticipates a growth in demand for health center services and 
it includes a significant infusion of funds for HRSA to expand 
the program.
    My remarks today are based on our August 2008 report for 
which we analyzed data from HRSA's uniform data system, 
commonly called the UDS.
    We compared the location of health care center sites with 
the locations of MUAs. At the time of our review, the most 
recent UDS data available was for 2006. We also examined how 
new access point grants awarded in 2007 changed the 
distribution of health centers across MUAs.
    Because of the UDS lag time, we contacted agency officials 
this week, who told us that the most recent round of awards did 
not significantly change our findings, which I am about to 
report to you today.
    We found that almost half of MUAs nationwide, 47 percent, 
lacked a health center site. We also reported wide variation 
among the four census regions, and across States and the 
percentage of MUAs that lacked sites. Specifically 62 percent 
of MUAs in the Midwest lacked a health center site compared to 
32 percent in the West.
    The awarding of new access point grants in 2007 was 
modestly successful in reducing the number of MUAs without a 
site to 43 percent, however differences between the regions 
persisted. The West continued to show the lowest percentage of 
MUAs without health center sites, 31 percent, while 60 percent 
of MUAs in the Midwest still did not have health center sites.
    We have a map in our testimony that shows significant 
variation among States within those census regions.
    The 2007 awards had minimal impact on regional variation 
largely because more than two-thirds of the nationwide decline 
in MUAs lacking a health center site occurred in the South 
census region. HRSA awarded grants to 40 percent of applicants 
in the South compared to only 17 percent in the Midwest.
    In our report we also recommended that HRSA collect data on 
the services provided at each site. Currently they only have 
readily available data at the grantee level, which limits their 
ability to place new sites where they are most needed.
    We continue to believe that this information is essential 
for HRSA to use in assessing any potential gaps or overlaps in 
services and that it will more effectively distribute Federal 
resources to meet primary health care needs, especially in 
light of the stimulus.
    [The prepared statement of Ms. Bascetta follows:]

               Prepared Statement of Cynthia A. Bascetta

                                SUMMARY

Why GAO Did This Study
    Health centers funded through grants under the Health Center 
Program--managed by the Health Resources and Services Administration 
(HRSA) of the U.S. Department of Health and Human Services (HHS)--
provide comprehensive primary care services for the medically 
underserved. The statement GAO is issuing today summarizes an August 
2008 report, Health Resources and Services Administration: Many 
Underserved Areas Lack a Health Center Site, and the Health Center 
Program Needs More Oversight (GAO-08-723). In that report, GAO examined 
to what extent medically underserved areas (MUA) lacked health center 
sites in 2006 and 2007. To do this, GAO obtained and analyzed HRSA data 
and grant applications and interviewed HRSA officials.
What GAO Recommends
    In its report, GAO recommended, among other things, that HRSA 
collect site-specific data on services provided at each health center 
site. HHS commented that collecting these data would be helpful for 
many purposes, but would create a burden on grantees and add expense to 
the program. While GAO acknowledges that effort and cost are involved 
in program management activities, this information is essential for 
effective HRSA decisionmaking on placement of new health center sites 
and for evaluating potential service area overlap in MUAs.
What GAO Found
     In its August 2008 report, which is summarized in this 
statement, GAO found the following:

     Grant awards for new health center sites in 2007 reduced 
the overall percentage of MUAs lacking a health center site from 47 
percent in 2006 to 43 percent in 2007.
     There was wide geographic variation in the percentage of 
MUAs that lacked a health center site in both years. (See figure.)
     Most of the 2007 nationwide decline in the number of MUAs 
that lacked a health center site occurred in the South census region, 
in large part because half of all awards made in 2007 for new health 
center sites were granted to the South census region.
     HRSA lacked readily available data on the services 
provided at individual health center sites.



    GAO concluded that from 2006 to 2007, HRSA's grant awards to open 
new health center sites reduced the number of MUAs that lacked a site 
by about 7 percent. However, in 2007, 43 percent of MUAs continued to 
lack a health center site, and the grants for new sites awarded that 
year had little impact on the wide variation among census regions and 
States in the percentage of MUAs lacking a health center site. GAO 
reported that HRSA's grants to open new health center sites increased 
access to primary health care services for underserved populations in 
needy areas, including MUAs. However, HRSA's ability to place new 
health center sites in locations where they are most needed was limited 
because HRSA does not collect and maintain readily available 
information on the services provided at individual health center sites. 
Because each health center site may not provide the full range of 
comprehensive primary care services, having readily available 
information on the services provided at each site is important for 
HRSA's effective consideration of need when distributing Federal 
resources for new health center sites.
                                 ______
                                 
    Mr. Chairman and members of the committee, I am pleased to be here 
today to discuss our work on the extent to which health centers in the 
Federal Health Center Program are located in areas having a shortage of 
health care services. Health centers provide comprehensive primary 
health care services--preventive, diagnostic treatment, and emergency 
services, as well as referrals to specialty care--to federally 
designated medically underserved populations (MUP), or those 
individuals residing in federally designated medically underserved 
areas (MUA).\1\ The people served by health centers include Medicaid 
beneficiaries, the uninsured, and others who may have difficulty 
obtaining access to health care. To fulfill the Health Center Program's 
mission of increasing access to primary health care services for the 
medically underserved, the Health Resources and Services Administration 
(HRSA)--the agency within the U.S. Department of Health and Human 
Services (HHS) that administers the Health Center Program--provides 
grants to health centers.\2\ A health center grantee may provide 
services at one or more delivery sites--known as health center sites. 
HRSA does not require all health center sites to provide the full range 
of comprehensive primary care services; some health center sites may 
provide only limited services, such as dental or mental health 
services. In 2006, approximately 1,000 health center grantees operated 
more than 6,000 health center sites that served more than 15 million 
people. Additional people may need to rely on health centers for their 
care during the current economic period.
---------------------------------------------------------------------------
    \1\ The Health Resources and Services Administration designates 
MUAs based on a geographic area, such as a county, while MUPs are based 
on a specific population that demonstrates economic, cultural, or 
linguistic barriers to primary care services.
    \2\ In 2006, Health Center Program grants made up about 20 percent 
of all health center grantees' revenues. Other Federal benefits include 
enhanced Medicaid and Medicare payment rates and reduced drug pricing.
---------------------------------------------------------------------------
    Beginning in fiscal year 2002, HRSA significantly expanded the 
Health Center Program under a 5-year effort--the President's Health 
Centers Initiative--to increase access to comprehensive primary care 
services for underserved populations, including those in MUAs. Under 
the initiative, HRSA set a goal of awarding 630 grants to open new 
health center sites--such grants are known as new access point grants--
and 570 grants to expand services at existing health center sites by 
the end of fiscal year 2006. New access point grants fund one or more 
new health center sites operated by either new or existing health 
center grantees. In July 2005, we reported challenges HRSA encountered 
during this expansion of the Health Center Program.\3\ In particular, 
we found that HRSA's process for awarding new access point grants might 
not sufficiently target communities with the greatest need for 
services, although we concluded that changes HRSA had made to its grant 
award process could help the agency appropriately consider community 
need when distributing Federal resources. We also reported that HRSA 
lacked reliable information on the number and location of the sites 
where health centers provide care, and we recommended, among other 
things, that HRSA collect this information. In response to our 
recommendation, HRSA took steps to improve its data collection efforts 
in 2006 to more reliably account for the number and location of health 
center sites funded under the Health Center Program.
---------------------------------------------------------------------------
    \3\ GAO, Health Centers: Competition for Grants and Efforts to 
Measure Performance Have Increased, GAO-05-645 (Washington, DC: July 
13, 2005).
---------------------------------------------------------------------------
    By the end of fiscal year 2007, HRSA had achieved its grant goals 
under the original President's Health Centers Initiative and launched a 
second nationwide effort, the High Poverty County Presidential 
Initiative. In fiscal year 2007, HRSA held two new access point 
competitions, one focused on opening new health center sites in up to 
200 HRSA-selected counties lacked a health center site--part of the 
High Poverty County Presidential Initiative--and one that was an open 
competition.\4\
---------------------------------------------------------------------------
    \4\ This new access point competition is described as open because 
applicants were not required to be located in certain geographic areas 
in order to apply, but were required to demonstrate in the proposal 
that the health center and its associated sites would serve, in whole 
or in part, an MUA or MUP.
---------------------------------------------------------------------------
    My statement today is based largely on our August 2008 report 
entitled Health Resources and Services Administration: Many Underserved 
Areas Lack a Health Center Site, and the Health Center Program Needs 
More Oversight.\5\ In the August 2008 report, we examined, among other 
things, (1) for 2006, the extent to which MUAs lacked health center 
sites and the services provided by individual sites in MUAs, and (2) 
how new access point grants awarded in 2007 changed the extent to which 
MU lacked health center sites.
---------------------------------------------------------------------------
    \5\ GAO, Health Resources and Services Administration: Many 
Underserved Areas Lack a Health Center Site, and the Health Center 
Program Needs More Oversight, GAO-08-723 (Washington, DC: Aug. 8, 
2008).
---------------------------------------------------------------------------
    In carrying out the work for our August 2008 report examining the 
extent to which MUAs lacked health center sites and the services 
provided by individual sites in 2006, we interviewed HRSA officials and 
obtained health center site data from HRSA's uniform data system (UDS), 
and then compared the location of health center sites with the location 
of MUAs by census region and State.\6\ We limited our analysis to 
health center sites operated by grantees that received community health 
center funding--the type of funding that requires sites to provide 
services to all residents of the service area regardless of their 
ability to pay.\7\ In addition, because HRSA takes into account the 
location of federally qualified health center look-alike sites--
facilities that operate like health center sites but do not receive 
HRSA funding \8\--when deciding where to award new access point grants, 
we obtained from HRSA the location of health center look-alike sites in 
2006 and compared them with the location of MUAs. To examine how new 
access point grants awarded in 2007 changed the extent to which MUAs 
lacked health center sites nationwide, we obtained data from HRSA and 
compared the location of proposed and funded new health center sites in 
2007 with the location of MUAs in 2007.\9\ As with the 2006 analysis, 
we limited our review to health center sites operated by grantees that 
requested community health center funding, and we obtained from HRSA 
the location of health center look-alike sites in 2007 and compared 
them to the location of MUAs in 2007. We discussed our data sources 
with knowledgeable agency officials and performed data reliability 
checks, such as examining the data for missing values and obvious 
errors, to test the internal consistency and reliability of the data. 
After taking these steps, we determined that the data were sufficiently 
reliable for our purposes. We conducted the performance audit for the 
August 2008 report from 2007 through July 2008, in accordance with 
generally accepted government auditing standards. Those standards 
require that we plan and perform the audit to obtain sufficient, 
appropriate evidence to provide a reasonable basis for our findings and 
conclusions based on our audit objectives. We believe that the evidence 
obtained provides a reasonable basis for our findings and conclusions 
based on our audit objectives. A detailed explanation of our 
methodology is included in our August 2008 report.
---------------------------------------------------------------------------
    \6\ In our report, we considered the District of Columbia a State.
    \7\ 42 U.S.C.  254b(a)(1). In contrast, HRSA grantees that operate 
health center sites targeting migrant farmworkers, public housing 
residents, and the homeless are not required to serve all residents of 
their service areas. 42 U.S.C.  254b(a)(2). Because the UDS does not 
allow separate identification of individual health center sites for 
grantees that receive a combination of community health center funding 
and health center funding to target migrant farmworkers, public housing 
residents, or the homeless (27 percent of all grantees in 2006), we 
could not distinguish sites supported exclusively by community health 
center funding from sites supported exclusively by health center 
funding for migrant farmworkers, public housing residents, or the 
homeless. Therefore, we included all sites associated with health 
center grantees that received, at a minimum, community health center 
funding (90 percent of all grantees in 2006). As a result, some health 
center sites included in our analysis are not sites exclusively 
supported by community health center funding.
    \8\ Some organizations choose not to apply for funding under the 
Health Center Program; however, they seek to be recognized by HRSA as 
federally qualified health center look-alikes, in large part, so that 
they may become eligible to receive other Federal benefits, such as 
enhanced Medicare and Medicaid payment rates and reduced drug pricing. 
For our purposes, federally qualified health center look-alike sites 
are referred to as health center look-alike sites.
    \9\ Because the UDS had not been updated for 2007 at the time of 
our review, we could not determine whether any health center sites that 
were in operation in 2006 were no longer operating in 2007; therefore, 
we assumed that all health center sites operating in 2006 were still 
operating in 2007.
---------------------------------------------------------------------------
    In brief, we found that grant awards for new health center sites in 
2007 reduced the overall percentage of MUAs lacking a health center 
site from 47 percent in 2006 to 43 percent in 2007. In addition, we 
found wide geographic variation in the percentage of MUAs that lacked a 
health center site in both years. We reported that, for 2006, we could 
not determine the types of services provided by individual health 
center sites in MUAs because HRSA does not collect and maintain data on 
the types of services provided at each site. Because HRSA lacks readily 
available data on the types of services provided at individual sites, 
the extent to which individuals in MUAs have access to the full range 
of comprehensive primary care services is unknown. In reporting on 
geographic variation, we found that, for 2007, the West and Midwest 
census regions continued to show the lowest and highest percentages, 
respectively, of MUAs that lacked health center sites. In addition, 
three of the four census regions showed a 1 or 2 percentage point 
decrease since 2006 in MUAs that lacked a health center site, while the 
South census region showed a 5 percentage point decrease. The minimal 
impact of the 2007 awards on geographic variation overall was due, in 
large part, to the fact that the majority of the decline in MUAs that 
lacked a health center site was concentrated in the South census 
region, which received the largest proportion of the awards made in 
2007. To help improve the agency's ability to measure access to 
comprehensive primary care services in MUAs, we recommended that HRSA 
collect and maintain readily available data on the types of services 
provided at each health center site. In commenting on a draft of our 
report, HHS raised concerns regarding this recommendation. HHS 
acknowledged that site-specific information would be helpful for many 
purposes, but said collecting this information would place a 
significant burden on grantees and raise the program's administrative 
expenses.
    While we acknowledge that effort and cost are involved in program 
management activities, we believe that having site-specific information 
on services provided is essential to help HRSA better measure access to 
comprehensive primary health care services in MUAs when considering the 
placement of new health center sites and to facilitate the agency's 
ability to evaluate service area overlap in MUAs.
 almost half of muas lacked a health center site in 2006, and types of 
         services provided by each site could not be determined
    In August 2008, we reported that almost half of MUAs nationwide--47 
percent, or 1,600 of 3,421--lacked a health center site in 2006,\10\ 
and there was wide variation among the four census regions and across 
States in the percentage of MUAs that lacked health center sites. (See 
fig. 1) The Midwest census region had the most MUAs that lacked a 
health center site (62 percent), while the West census region had the 
fewest MUAs that lacked a health center site (32 percent). More than 
three-quarters of the MUAs in 4 States--Nebraska (91 percent), Iowa (82 
percent), Minnesota (77 percent), and Montana (77 percent)--lacked a 
health center site. (See Appendix I for more detail on the percentage 
of MUAs in each State and the U.S. territories that lacked a health 
center site in 2006.) In 2006, among all MUAs, 32 percent contained 
more than one health center site; among MUAs with at least one health 
center site, 60 percent contained multiple health center sites, with 
about half of those containing two or three sites. Almost half of all 
MUAs in the West census region contained more than one health center 
site, while less than one-quarter of MUAs in the Midwest contained more 
than one site. The States with three-quarters or more of their MUAs 
containing more than one health center site were Alaska. Connecticut, 
the District of Columbia, Hawaii, New Hampshire, and Rhode Island. In 
contrast, Nebraska, Iowa, and North Dakota were the States where less 
than 10 percent of MUAs contained more than one site.
---------------------------------------------------------------------------
    \10\ When we included the 294 health center look-alike sites 
operating in 2006, we found that the percentage of MUAs lacking either 
a health center site or health center look-alike site in 2006 was 46 
percent (or 1,564 MUAs).



    We could not determine the types of primary care services provided 
at individual health center sites because HRSA did not collect and 
maintain readily available data on the types of services provided at 
individual sites. While HRSA requests information from applicants in 
their grant applications on the services each site provides, in order 
for HRSA to access and analyze individual health center site 
information on the services provided, HRSA would have to retrieve this 
information from the grant applications manually. HRSA separately 
collects data through the UDS from each grantee on the types of 
services it provides across all of its health center sites, but HRSA 
does not collect data on services provided at each site. Although each 
grantee with community health center funding is required to provide the 
full range of comprehensive primary care services, HRSA does not 
require each grantee to provide all services at each health center site 
it operates. HRSA officials told us that some sites provide limited 
services--such as dental or mental health services. Because HRSA lacks 
readily available data on the types of services provided at individual 
sites, it cannot determine the extent to which individuals residing in 
MUAs have access to the full range of comprehensive primary care 
services provided by health center grantees. This lack of basic 
information can limit HRSA's ability to assess the full range of 
primary care services available in needy areas when considering the 
placement of new access points and can also limit the agency's ability 
to evaluate service area overlap in MUAs.

  2007 AWARDS REDUCED THE NUMBER OF MUAS THAT LACKED A HEALTH CENTER 
              SITE, BUT WIDE GEOGRAPHIC VARIATION REMAINED

    In August 2008, we reported that our analysis of new access point 
grants awarded in 2007 showed that these awards reduced the number of 
MUAs that lacked a health center site by about 7 percent. Specifically, 
113 fewer MUAs in 2007--or 1,487 MUAs in all--lacked a health center 
site when compared with the 1,600 MUAs that lacked a health center site 
in 2006. (See Appendix I) As a result, 43 percent of MUAs nationwide 
lacked a health center site in 2007.\11\ Despite the overall reduction 
in the percentage of MUAs nationwide that lacked health center sites in 
2007, regional variation remained. The West and Midwest census regions 
continued to show the lowest and highest percentages of MUAs that 
lacked health center sites, respectively. (See fig. 2) Three of the 
four census regions showed a 1 or 2 percentage point decrease since 
2006 in the percentage of MUAs that lacked a health center site, while 
the South census region showed a 5 percentage point decrease.
---------------------------------------------------------------------------
    \11\ When we included the 265 health center look-alike sites 
operating in 2007, we found that 1,462 MUAs lacked a health center site 
or health center look-alike site in 2007, which did not change the 
overall percentage (43 percent) of MUAs in 2007 that lacked a health 
center site.



    We found that the minimal impact of the 2007 awards on regional 
variation was due, in large part, to the fact that more than two-thirds 
of the nationwide decline in the number of MUAs that lacked a health 
center site--77 out of the 113 MUAs--occurred in the South census 
region. In contrast, only 24 of the 113 MUAs were located in the 
Midwest census region, even though the Midwest had nearly as many MUAs 
that lacked a health center site in 2006 as the South census region. 
While the number of MUAs that lacked a health center site declined by 
12 percent in the South census region, the other census regions 
experienced declines of about 4 percent. The South census region 
experienced the greatest decline in the number of MUAs lacking a health 
center site in 2007 in large part because it was awarded more new 
access point grants that year than any other region. Specifically, half 
of all new access point awards made in 2007--from the two separate new 
access point competitions--went to applicants from the South census 
region. For example, when we examined the High Poverty County new 
access point competition, in which 200 counties were targeted by HRSA 
for new health center sites, we found that 69 percent of those awards 
were granted to applicants from the South census region. The greater 
number of awards made to the South census region may be explained by 
the fact that nearly two-thirds of the 200 counties targeted were 
located in the South census region. When we examined the open new 
access point competition, which did not target specific areas, we found 
that the South census region also received a greater number of awards 
than any other region under that competition. Specifically, the South 
census region was granted nearly 40 percent of awards; in contrast, the 
Midwest received only 17 percent of awards.

                        CONCLUDING OBSERVATIONS

    In our August 2008 report, we noted that awarding new access point 
grants is central to HRSA's ongoing efforts to increase access to 
primary health care services in MUAs. From 2006 to 2007, HRSA's new 
access point awards achieved modest success in reducing the percentage 
of MUA's that lacked a health center site nationwide. However, in 2007, 
43 percent of MUAs continued to lack a health center site, and the new 
access point awards made in 2007 had little impact on the wide 
variation among census regions and States in the percentage of MUAs 
lacking a health center site. The relatively small effect of the 2007 
awards on geographic variation may be explained, in part, because the 
South census region received a greater number of awards than other 
regions, even though the South was not the region with the highest 
percentage of MUAs lacking a health center site in 2006.
    We reported that HRSA awards new access point grants to open new 
health center sites, which increase access to primary health care 
services for underserved populations in needy areas, including MUAs. 
However, HRSA's ability to target these awards and place new health 
center sites in locations where they are most needed is limited because 
HRSA does not collect and maintain readily available information on the 
services provided at individual health center sites. Having readily 
available information on the services provided at each site is 
important for HRSA's effective consideration of need when distributing 
Federal resources for new health center sites, because each health 
center site may not provide the full range of comprehensive primary 
care services. This information could also help HRSA assess any 
potential overlap of services provided by health center sites in MUAs.
    Mr. Chairman, this concludes my prepared statement. I would be 
happy to answer any questions that you or members of the committee may 
have.
                                 ______
                                 
                               Appendix I

     Number and Percentage of Medically Underserved Areas (MUA) Lacking a Health Center Site, 2006 and 2007
----------------------------------------------------------------------------------------------------------------
                                                              Total no. of       No. of MUAs      Percentage of
                                                                  MUAs        lacking a health   MUAs lacking a
                                                           ------------------    center site      health center
                                                                             ------------------       site
                                                              2006     2007                    -----------------
                                                                                2006     2007     2006     2007
----------------------------------------------------------------------------------------------------------------
Midwest census region.....................................    1,027    1,029      641      617       62       60
  Illinois................................................      146      143       71       63       49       44
  Indiana.................................................       61       61       35       34       57       56
  Iowa....................................................       73       73       60       56       82       77
  Kansas..................................................       66       71       49       52       74       73
  Michigan................................................       89       89       44       43       49       48
  Minnesota...............................................       96       97       74       75       77       77
  Missouri................................................      116      116       62       58       53       50
  Nebraska................................................       82       82       75       73       91       89
  North Dakota............................................       55       55       40       39       73       71
  Ohio....................................................      111      110       48       42       43       38
  South Dakota............................................       65       65       40       40       62       62
  Wisconsin...............................................       67       67       43       42       64       63
Northeast census region...................................      395      400      153      147       39       37
  Connecticut.............................................       17       17        1        1        6        6
  Maine...................................................       30       32       10       11       33       34
  Massachusetts...........................................       40       40       10        9       25       23
  New Hampshire...........................................        5        5        1        1       20       20
  New Jersey..............................................       28       28        1        1        4        4
  New York................................................      115      116       56       53       49       46
  Pennsylvania............................................      137      139       63       61       46       44
  Rhode Island............................................        7        7        0        0        0        0
  Vermont.................................................       16       16       11       10       69       63
South census region.......................................    1,435    1,441      651      574       45       40
  Alabama.................................................       96       96       24       19       25       20
  Arkansas................................................       92       93       38       33       41       35
  Delaware................................................        4        4        0        0        0        0
  District of Columbia....................................        9        8        1        1       11       13
  Florida.................................................       35       35       17       15       49       43
  Georgia.................................................      147      149       88       78       60       52
  Kentucky................................................       78       78       51       45       65       58
  Louisiana...............................................       73       73       39       33       53       45
  Maryland................................................       38       38       11       10       29       26
  Mississippi.............................................       91       91       18       17       20       19
  North Carolina..........................................      107      108       59       55       55       51
  Oklahoma................................................       65       66       34       30       52       45
  South Carolina..........................................       68       69       17       15       25       22
  Tennessee...............................................      101      101       38       35       38       35
  Texas...................................................      282      283      167      145       59       51
  Virginia................................................       92       93       38       34       41       37
  West Virginia...........................................       57       56       11        9       19       16
West census region........................................      485      487      155      149       32       31
  Alaska..................................................       17       17        0        0        0        0
  Arizona.................................................       33       33       13       13       39       39
  California..............................................      165      167       33       31       20       19
  Colorado................................................       42       42        9        9       21       21
  Hawaii..................................................        4        4        0        0        0        0
  Idaho...................................................       35       35       15       14       43       40
  Montana.................................................       44       44       34       33       77       75
  Nevada..................................................        8        8        4        4       50       50
  New Mexico..............................................       36       36        5        4       14       11
  Oregon..................................................       42       42       17       16       40       38
  Utah....................................................       17       17        7        7       41       41
  Washington..............................................       31       31       12       12       39       39
  Wyoming.................................................       11       11        6        6       55       55
U.S. territories..........................................       79       79        0        0        0        0
  American Samoa..........................................        4        4        0        0        0        0
  Guam....................................................        0        0      n/a      n/a      n/a      n/a
  Northern Mariana Islands................................        0        0      n/a      n/a      n/a      n/a
  Puerto Rico.............................................       72       72        0        0        0        0
  U.S. Virgin Islands.....................................        3        3        0        0        0        0
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of Health Resources and Services Administration and U.S. Census Bureau data.


    Senator Sanders. Thank you very much. Dan Hawkins is the 
Senior Vice President with the National Association of 
Community Health Centers in Bethesda.
    Dan, thank you for being here.

  STATEMENT OF DANIEL R. HAWKINS, Jr., SENIOR VICE PRESIDENT, 
 NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS, BETHESDA, MD

    Mr. Hawkins. Thank you, Mr. Chairman. Good morning, 
Majority Whip, Senator, members of the committee, thank you for 
the opportunity to speak with you today about the important 
role of community health centers and health reform.
    Senator Sanders. And if you could pull that mike a little 
closer, please?
    Mr. Hawkins. Sure. Well, it's an honor to share this panel 
with many distinguished colleagues, many of whom are on the 
front lines today delivering quality health care to thousands 
of Americans, as part of the health center family that provides 
care to more than 18 million Americans across the country 
today.
    Mr. Chairman, I have personally seen the power of some 
health centers to lift the health and the lives of communities 
and people all across the country, both as a VISTA volunteer 
and as director of one of the earliest, vibrant community 
health care centers back in the 1970's.
    The beauty is that this patient-directed model thrives 
today in more than 7,000 communities across America, and I am 
honored to share its success story.
    What is the secret of the successful health centers? I 
think there are several key points. No. 1, as was pointed out 
by my colleague a moment ago, every single health center in 
every single one of those 7,000 sites is located in a 
designated underserved area where there are shortages of 
providers and barriers to access to care that cause millions, 
to have to forego care, delay care, get sicker and not be able 
to receive care when it's timely and appropriate.
    No. 2, they occupy the most opportune place in the entire 
health care system, at the entry point, where good quality, 
preventative and primary health care can not only improve and 
maintain health, it can reduce the need for later care for 
illnesses that might otherwise not have been treated, and save 
the system billions.
    Last year we reported together with the Robert Graham 
Center of the American Academy of Family Physicians that health 
centers saved the entire health care system $18 billion a year. 
That is more than twice the total amount of money that they 
spent.
    Senator Sanders. Say that again.
    [Laughter.]
    Mr. Hawkins. I've got even better news for you. Last year, 
health centers saved the health care system more than $2 for 
every dollar they spent. If you look at $2 billion in grant 
funding, they saved $18 billion. That's $9 billion for every 
dollar that this committee and Congress has invested in them, 
and more than $2 for every other dollar that they secured from 
other sources.
    That colleague, from the American Academy of Family 
Physicians, last week noted to another colleague that if every 
person in America received the care that the health care 
centers provide, Senator, are you ready for this, more than 
$500 billion a year could be saved in health care spending 
today.
    Senator Sanders. That is such an important statistic. 
Everybody is wrestling with skyrocketing health care costs. 
Everybody is wrestling with that. We are going to ask you to 
repeat that fact one more time.
    Mr. Hawkins. I will and I know Senator Hatch has been a 
long time champion and believer of health centers, and has 
visited health centers in Ogden and throughout his State of 
Utah, will enjoy this as well. If every person in America 
received the care that is provided by health centers, more than 
$500 billion a year could be saved in health care spending 
today. Today!
    There was an article published just earlier this week that 
said that health center patients receive less specialty care 
than patients seen by other providers. The interesting thing--
there was a worry that health centers are stinting on care, in 
fact, though, even the authors of that study said we don't know 
whether it's because health center patients have less care than 
they need or the patients of other providers get much more care 
than they need.
    We think the answer is probably a combination of those two. 
At any rate, I just want to close by saying that health care 
centers are eager to be full partners and full participants in 
health care reform and know that their role will truly be 
integral because they are the one place in America that can 
turn the promise of coverage into the reality of high quality, 
cost-effective care.
    [The prepared statement of Mr. Hawkins follows:]

              Prepared Statement of Daniel R. Hawkins, Jr.

                                SUMMARY

    Community Health Centers are a 40-plus year unprecedented success 
story. Health center patients have better health outcomes than patients 
in other settings, and they receive this care at a lower cost.

     Health centers improve the health and quality of life of 
their patients through vigorous clinical improvement efforts such as 
the Health Disparities Collaboratives. These efforts result in 
documentable improved outcomes.
     Health centers achieve these outcomes at a lower cost. For 
example, in one study in South Carolina diabetic patients enrolled in 
the State employees' health plan treated in non-CHC settings were four 
times more costly than those in the same plan who were treated in a 
community health center.
     Indeed, literally dozens of studies done over the past 25 
years have concluded that health center patients are significantly less 
likely to use emergency rooms or to be hospitalized for avoidable 
conditions, resulting in large cost savings. A recent national study 
done in collaboration with the Robert Graham Center found that people 
who use health centers as their usual source of care have 41 percent 
lower health care expenditures than people who get their care 
elsewhere. As a result, health centers saved the health care system $18 
billion last year alone.

    Community Health Centers are critical to ensuring access to care.

     As Congress turns its attention to universal health 
reform, health centers are eager to be full and active participants in 
a new and improved health care system.
     Community health centers will be integral to ensuring that 
increased health coverage translates into universal health care access 
for all Americans.
     ``Access'' means a physical place to go to receive high 
quality health care services. But beyond that, to be truly accessible, 
care should be culturally competent, affordable, and nearby.

    Health centers have identified several key principles for health 
reform that we believe will help to guarantee universal access.

     First, health reform should strive to achieve universal 
coverage that is both available and affordable to everyone; second, 
coverage must be comprehensive, including medical, dental, and mental 
health services, with an emphasis on prevention and primary care; 
finally, reform must strive to guarantee that everyone has access to a 
medical or health care home where they can receive high quality, cost-
effective care for their health needs.
     Expanding community health centers is a key to making 
these principles a reality, especially for our most vulnerable 
populations, most of whom live in medically underserved areas. The 
Health Care Safety Net which became law last year, thanks to the 
bipartisan work of this committee, would significantly expand health 
centers program over the next 5 years.
     S. 486, the Access for All America Act introduced by 
Senator Sanders would even more rapidly expand the program and NACHC 
supports that legislation.

    In order to make health care reform a true success, we must ensure 
that access to care is front and center. Community health centers' 40- 
plus year track record of success demonstrates that we are well-
equipped to play a pivotal role in providing this health care access 
and doing so in a way that will ultimately save the health care system 
money. We look forward to that opportunity.
                                 ______
                                 
    Mr. Chairman and members of the committee, my name is Dan Hawkins 
and I am Senior Vice President for Policy and Programs for the National 
Association of Community Health Centers. On behalf of America's Health 
Centers and the more than 18 million patients they serve, I want to 
express my gratitude for the opportunity to speak to you today about 
the importance of the Community Health Centers program to ensuring that 
all Americans have access to high quality, affordable health care. 
NACHC and health centers appreciate the unwavering support of this 
committee over many years, dating back to the original authorizing 
legislation introduced by Chairman Kennedy and approved by this 
committee in 1975. The ongoing, bipartisan support from this committee, 
including through last year's historic reauthorization law, has allowed 
health centers to carry out their important mission, and we look 
forward to continuing to work with you both in health reform and in the 
years to come.
    Mr. Chairman, I have personally seen the power of health centers to 
lift the health and the lives of individuals and families in our most 
underserved communities. As a VISTA volunteer assigned to south Texas 
in the 1960s, the residents of our town asked me to work on improving 
access to health care and clean water in our community. We decided to 
apply for funds through a relatively new, innovative program--the 
Migrant Health program. I stayed on and served as executive director of 
the health center from 1971 to 1977. That health center is still in 
operation today, and has expanded to serve over 40,000 patients 
annually. The community empowerment and patient-directed care model 
thrives today in every health center in America, and I am honored to be 
here to share this success story and how health centers' 40-plus-year 
track record makes them uniquely positioned to be important 
participants in a reformed health care system.

           HISTORY AND OVERVIEW OF THE HEALTH CENTERS PROGRAM

    Conceived in 1965 as a bold new experiment in the delivery of 
preventive and primary health care services to our Nation's most 
vulnerable populations, health centers are an enduring model of primary 
care delivery for the country. The Health Centers program began in 
rural Mississippi and inner-city Boston in the mid-1960s to serve 
rural, migrant, and urban individuals who had little access to health 
care and no voice in the delivery of health services to their 
communities. In the 1980s and 1990s, the Health Care for the Homeless 
and Public Housing health centers were created. In 1996, the Community, 
Migrant, Public Housing and Health Care for the Homeless programs were 
consolidated into a single statutory authority within Section 330 of 
the Public Health Service Act.
    Congress established the program as a unique public-private 
partnership, and has continued to provide direct funding to community 
organizations for the development and operation of health systems that 
address pressing local health needs and meet national performance 
standards. This Federal commitment has had a lasting and profound 
effect on health centers and the communities and patients they serve in 
every corner of the country. Now, as in 1965, health centers are 
designed to empower communities to create locally tailored solutions 
that improve access to care and the health of the patients they serve.
    Federal law requires that every health center be governed by a 
community board with a patient majority, which means care is truly 
patient-centered and patient-driven. Health centers are required to be 
located in a federally designated Medically Underserved Area (MUA), and 
must provide a package of comprehensive primary care services to anyone 
who comes in the door, regardless of ability to pay. In last year's 
reauthorization, this committee strongly endorsed the preservation of 
these core requirements.
    Because of these characteristics, the insurance status of health 
center patients differs dramatically from other primary care providers. 
As a result, the role of public dollars is substantial. Federal grant 
dollars, which make up roughly 22 percent of health centers' operating 
revenues on average, go toward covering the costs of serving uninsured 
patients and delivering care effectively to our medically underserved 
patients. Just over 40 percent of health centers' revenues are from 
reimbursement through Federal insurance programs, principally Medicare 
and Medicaid. The balance of revenues come from State and community 
partnerships, privately insured individuals, and low-income uninsured 
patient's sliding-fee payments.
    Health centers have also been pioneers in improving health care 
quality, particularly in the area of chronic disease management. The 
majority of health centers now participate in the Health Resources and 
Services Administration's (HRSA) Health Disparities Collaboratives. The 
Collaboratives are delivery system improvement initiatives specifically 
designed for health centers, focused on improving the performance of 
clinical staff and strengthened care-giving through the development of 
extensive patient registries that improve clinicians' ability to 
monitor the health of patients both individually and as a group, and on 
effectively educating patients on the self-management of their 
conditions such as cancer, diabetes, asthma, and cardiovascular 
disease. Health centers participating in the Collaboratives almost 
unanimously report that health outcomes for their patients have 
dramatically improved. Published studies have documented these 
outcomes, including one study on the Diabetes Collaboratives where 
evidence showed that over a lifetime, the incidence of blindness, 
kidney failure, and coronary artery disease was reduced.
    Health centers not only improve health and save lives, they also 
cost significantly less money, saving the health system overall. In 
Yvonne Davis' home State of South Carolina, a study showed that 
diabetic patients enrolled in the State employees' health plan treated 
in non-CHC settings were 4 times more costly than those in the same 
plan who were treated in a community health center. The health center 
patients also had lower rates of ER use and hospitalization.\1\ In 
fact, literally dozens of studies done over the past 25 years, right up 
to this past year, have concluded that health center patients are 
significantly less likely to use hospital emergency rooms or to be 
hospitalized for ambulatory care-sensitive (that is, avoidable) 
conditions, and are therefore less expensive to treat than patients 
treated elsewhere.\2\ A recent national study done in collaboration 
with the Robert Graham Center found that people who use health centers 
as their usual source of care have 41 percent lower total health care 
expenditures than people who get most of their care elsewhere.\3\ As a 
result, health centers saved the health care system $18 billion last 
year alone.
---------------------------------------------------------------------------
    \1\ Proser M. ``Deserving the Spotlight: Health Centers Provide 
High-Quality and Cost-Effective Care.'' October-December 2005 Journal 
of Ambulatory Care Management 28(4):321-330.
    \2\ Rust G., et al. ``Presence of a Community Health Center and 
Uninsured Emergency Department Visit Rates in Rural Counties.'' Journal 
of Rural Health, Winter 2009 25(1):8-16; Dobson D., et al. ``The 
Economic and Clinical Impact of Community Health Centers in Washington 
State: Analyses of the Contributions to Public Health and Economic 
Implications and Benefits for the State and Counties.'' Dec 2008 
Community Health Network of Washington and Washington Association of 
Community and Migrant Health Centers; McRae T. and Stampfly R. ``An 
Evaluation of the Cost Effectiveness of Federally Qualified Health 
Centers (FQHCs) Operating in Michigan.'' October 2006 Institute for 
Health Care Studies at Michigan State University. www.mpca.net. Falik 
M., Needleman J., Herbert R., et al. ``Comparative Effectiveness of 
Health Centers as Regular Source of Care.'' January-March 2006 Journal 
of Ambulatory Care Management 29(1):24-35; Proser M. ``Deserving the 
Spotlight: Health Centers Provide High-Quality and Cost-Effective 
Care.'' October-December 2005 Journal of Ambulatory Care Management 
28(4):321-330; Politzer R.M., et al. ``The Future Role of Health 
Centers in Improving National Health.'' 2003 Journal of Public Health 
Policy 24(3/4):296-306; see also, e.g., Politzer R.M., et al. 
``Inequality in America: The Contribution of Health Centers in Reducing 
and Eliminating Disparities in Access to Care.'' 2001 Medical Care 
Research and Review 58(2):234-248; Falik M., et al. ``Ambulatory Care 
Sensitive Hospitalizations and Emergency Visits: Experiences of 
Medicaid Patients Using Federally Qualified Health Centers.'' 2001 
Medical Care 39(6):551-56; Starfield, Barbara, et al., ``Costs vs. 
Quality in Different Types of Primary Care Settings,'' Journal of the 
American Medical Association 272,24 (December 28, 1994): 1903-1908; 
Stuart, Mary E., et al., ``Improving Medicaid Pediatric Care,'' Journal 
of Public Health Management Practice 1(2) (Spring, 1995): 31-38; 
Utilization and Costs to Medicaid of AFDC Recipients in New York Served 
and Not Served by Community Health Centers, Center for Health Policy 
Studies (1994); Stuart, Mary E., and Steinwachs, Donald M., (Johns 
Hopkins Univ. School of Public Health and Hygiene), ``Patient-Mix 
Differences Among Ambulatory Providers and Their Effects on Utilization 
and Payments for Maryland Medicaid Users,'' Medical Care 34,12 
(December 1993): 1119-1137; Health Services Utilization and Costs to 
Medicaid of AFDC Recipients in California Served and Not Served by 
Community Health Centers, Center for Health Policy Studies/SysteMetrics 
(1993).
    \3\ NACHC and the Robert Graham Center. Access Granted: The Primary 
Care Payoff. August 2007. www.nachc.com/access-reports.cfm.
---------------------------------------------------------------------------
            HEALTH CENTERS' ROLE IN ENSURING ACCESS TO CARE

    As Congress turns its attention to shaping universal health reform 
legislation, health centers are eager to be full and active 
participants in a new and improved health care system. We look forward 
to sharing our decades of experience caring for millions of Americans 
in a high quality, cost-effective way. Above all, we know that 
community health centers will be integral to ensuring that the 
increased health coverage we all support translates into universal 
health care access for all Americans.
    What do we mean by ``access''? Well, first, access means a physical 
place to go to receive high quality health care services. However, to 
be truly accessible, that care should be culturally competent, 
affordable, nearby, and without barriers to care. We believe that 
access must be front and center in health reform discussions in order 
to maximize the value of our investments in expanded coverage.
    Health centers have identified several key principles for health 
reform that we believe will help to guarantee universal access. First, 
health reform should strive to achieve universal coverage that is both 
available and affordable to everyone, especially low-income individuals 
and families. Second, coverage must be comprehensive, including 
medical, dental, and mental health services, and it should emphasize 
prevention and primary care. Finally, reform must also strive to 
guarantee that everyone has access to a medical or health care home 
where they can receive high quality, cost-effective care for their 
health needs. Expanding health centers is a key step toward making 
these principles a reality, especially for our most vulnerable 
populations, most of whom live in medically underserved areas.
    For this reason, we believe that health centers will have an 
increased and even more important role in a post-health reform 
environment. Indeed, the Massachusetts experience has born this out: as 
the percentage of insured residents in the State increased, the number 
of health center patients increased as well. Yet, at the same time, 
health centers in that State have also increased the percentage of the 
State's remaining uninsured who they serve.

           PROPOSALS FOR EXPANDING THE HEALTH CENTERS PROGRAM

    Thanks in large part to the work of this committee, last year 
Congress reauthorized the Community Health Centers Program, passing the 
Health Care Safety Net Act of 2008. This legislation preserved all of 
the essential elements of the Health Centers program and reaffirmed 
Congress' support for our successful model. The Health Care Safety Net 
Act also included significantly increased authorizations of 
appropriations. If the authorization levels approved in the 
reauthorization are appropriated, health centers will be on target to 
meet our goal, contained in our Access for All America plan, of serving 
30 million patients by 2015.
    However, community health centers know better than anyone that the 
need right now is greater still. Indeed, a report recently released by 
our Association, entitled ``Primary Care Access, An Essential Building 
Block of Health Reform'' found that there are currently 60 million 
medically disenfranchised Americans--people who lack access to a 
regular source of medical care.
    Given Congress' intention to dramatically improve and reform our 
health care system, and the essential role that health centers will 
play in providing many of the newly insured with access to care, some 
have proposed to grow the health centers program more rapidly. S. 486--
the Access for All America Act introduced by Senator Bernie Sanders and 
co-sponsored by five members of this committee is one such proposal. 
NACHC has endorsed this legislation and the strong message that it 
sends: that growing the Health Centers grant program in conjunction 
with health reform is the most effective way to guarantee that access 
grows along with coverage.
    What will happen if we increase coverage and do not address access? 
One of my health center colleagues came up with this illustration. 
Giving everyone an insurance card without increasing access would be 
like giving everyone in town a free bus pass but not adding any new 
buses. That's a lot of people standing on the side of the road. When it 
comes to people's health, the issue is far more serious and the costs 
are much higher, both in moral and fiscal terms. We must ensure that 
health care access is a part of health reform.

             THE ROLE OF THE NATIONAL HEALTH SERVICE CORPS

    When defining access, I mentioned having a health care home where 
people can go to receive high quality health care services. However, 
patients can't receive these health care services without a health 
professional to provide them. The National Health Service Corps (NHSC), 
also administered by HRSA, plays an essential role in ensuring that 
health centers have the health care providers they need to care for 
their patients.
    Back in South Texas as a health center director, our community 
benefited from the services of one of the first NHSC participants, who 
was placed there in 1972. I can't express what it meant to our center 
and our patients to have the services of that additional physician. 
Today, health centers across the country know what an invaluable tool 
the NHSC is to recruiting and retaining a primary care workforce in 
underserved areas. Without it, the impact of the nationwide problem of 
a diminishing primary care workforce and the maldistribution of 
providers would be devastating to health centers. The Corps is a vital 
tool as health centers work to maintain the workforce they need to keep 
their patients healthy.
    Indeed, between the years 2000 and 2007, health centers 
successfully increased their physician staff by 72 percent, their Nurse 
Practitioner/Physician Assistant staff by 80 percent, and their dentist 
staff by 116 percent, well ahead of their overall 68 percent growth in 
patients during that period. This was accomplished with support, 
assistance, and encouragement from HRSA, NACHC, and the State and 
Regional Primary Care Associations. However, to reach their goal of 
serving 30 million patients, health centers will need an additional 
16,000 primary care providers; to reach 60 million people, they will 
need over 50,000 more primary care providers. Addressing these deficits 
will involve more than a continuation of current workforce policy.
    As we look toward comprehensive health reform and continued growth 
of the Health Centers program, expansion of the Corps is critical to 
ensuring we have a primary care workforce capable of meeting the needs 
of the 21st century. This committee recognized that health centers and 
the NHSC go hand in hand when they included a reauthorization and 
significant expansion of the Corps in the Health Care Safety Net Act. 
The American Recovery and Reinvestment Act also included a landmark 
amount of funding for the Corps: $300 million, essentially doubling the 
program over the next 2 years. We must sustain this investment and grow 
it further in the years to come. S. 486 would accomplish that goal, 
growing the program from its current 4,000 clinical field strength to 
over 21,000 clinicians by 2015.

                               CONCLUSION

    In conclusion, in order to make health care reform a true success, 
we must ensure that access to care is front and center. Providing every 
American with access to comprehensive, affordable care is key to 
achieving a healthier nation. Community health centers' 40-plus-year 
track record of success demonstrates that we are well equipped to play 
a pivotal role in providing this health care access and doing so in a 
way that will ultimately save the health care system money. As you 
consider the myriad challenges facing our health care system, America's 
health centers offer a real, proven solution to many of these complex 
questions. We thank this committee for your years of stalwart, 
bipartisan support and we look forward to continuing to work with you 
as partners in improving the health of all Americans.

    Senator Sanders. Thank you very much, Mr. Hawkins. We are 
pleased to be joined by Senator Merkley, Senator Hatch and 
Senator Brown, all long time champions of primary health care 
and community health centers.
    Senator Hatch. Mr. Chairman.
    Senator Sanders. Yes.
    Senator Hatch. I have to go to another hearing. Could I 
just make a remark?
    Senator Sanders. You sure can. Please.

                       Statement of Senator Hatch

    Senator Hatch. Very briefly. I am very grateful to all of 
you for showing up and, as you know, I'm a long supporter of 
this. We just had major meetings in the Finance Committee about 
the fact that we don't have enough primary care physicians in 
this country, and yet we have some of the greatest primary care 
in the world through community health centers.
    So I just want to personally congratulate all of you and I 
would like to take this opportunity to welcome Ms. Lisa 
Nichols, the executive director of the Midtown Committee Center 
in Ogden, UT. We are grateful that you would take the time to 
come here and participate with us. I want to thank you for 
being here.
    Midtown Community Health Center has done an excellent job 
providing health care services to residents throughout the 
Ogden community, which is one of our fastest growing 
communities in Utah. I am very proud of you. We are proud of 
all of you. I intend to do whatever I can to help keep 
community health centers strong and expand them. They have to 
be an effective part of total health care reform, in my 
opinion, and I'm just very proud of all of you who work so hard 
and do so much for so many people in the community health 
centers. I want to thank you, Mr. Chairman, for allowing me to 
interrupt, and for having may buddy here, Congressman Clyburn 
from South Carolina, and actually there are some other buddies 
here, too.
    [Laughter.]
    Senator Sanders. Thank you for your support for community 
health centers and we look forward to working with you to 
significantly expand them.
    Senator Brown wanted to say a word and then we will go to 
Senator Merkley and then we will go back to the panel.

                       Statement of Senator Brown

    Senator Brown. Mr. Chairman, thank you very much. I am 
thrilled to see Congressman Clyburn here, who I saw up close 
for many years in the House do such outstanding work on primary 
care and especially on community health centers. Thank you 
panel for all that you do for community health service centers 
and for primary care. There is no better story of health care 
in my State than what community health care centers do.
    A special mention of Dr. Evans, and what dental--we are 
pushing in my State, and I know around the country, 
particularly on primary dental care for children and what a 
difference it makes in their lives, in terms of their health, 
in terms of their appearance when they go out job seeking, and 
just in terms of their going through school; all the kinds of 
things that good dental care at a young age could mean for our 
Nation's children. I want to thank you again for all that you 
do and you make such a difference.
    Mr. Chairman. Thank you, Senator.
    Senator Merkley.

                      Statement of Senator Merkley

    Senator Merkley. Thank you very much, Mr. Chair. I 
certainly want to say that my State legislative experience 
there is wide bipartisan support for community health centers 
in underserved areas, be they urban, be they rural; hugely 
popular recognition that this is a doorway into the health care 
system, both providing significant care but also providing a 
doorway to the other care.
    We need a lot more doorways and we need a lot more primary 
care, and I look forward to hearing and learning additional 
details, and thank all of you for coming to testify.
    Senator Sanders. Thank you.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. Mr. Chairman, thank you very much. I am 
going to be looking forward to engaging in this discussion. We 
had an opportunity over the last couple of months to make 
positive steps forward on health care, in particular with 
regard to children. We finally got that done, but believe it or 
not, there's a lot more to do with regard to children. There 
are still millions who are not covered despite the great work 
that everyone has done. Senator Sanders has been a real 
champion of this issue of community health centers and I know 
the impact that they have had on our State of Pennsylvania, a 
substantial impact, I am proud to be a co-sponsor of the bill 
and we are grateful for Senator Sander's leadership and look 
forward to the discussion.
    Thank you.
    Senator Sanders. Thanks very much.
    OK. Let's go now to Dr. Fitzhugh Mullan, who is the Murdock 
Head Professor of Medicine and Health Policy. We appreciate 
very much your being here. Thank you, Dr. Mullan.

 STATEMENT OF FITZHUGH MULLAN, M.D., MURDOCK HEAD PROFESSOR OF 
           MEDICINE AND HEALTH POLICY, WASHINGTON, DC

    Dr. Mullan. Thank you, Senator Sanders, Congressman 
Clyburn, collaborative colleagues. I am pleased to be able to 
speak with you today about a sister program that is almost as 
old as the health center program, the last day of 1970 signed 
into law by President Nixon, the National Health Service Corps. 
The Corps has grown from that point, but not as one might like 
to see it grow and not as the growth is envisioned in Senate 
bill 486 and House bill 1276. So I am delighted to be able to 
envision with the committee how that might be.
    Just stepping back for a moment, I started my career in 
medicine as a National Health Service Corps physician in New 
Mexico following residency. First generation, first year out of 
the chute, I was privileged to come back and for some years 
thereafter, run the National Health Service Corps. It was the 
early years of the scholarship program. We were very excited. 
We went from 500 to upwards of 2,000 people in the field, this 
being the late 1970's. And I will argue that it was then a 
fabulous demonstration program. Its biggest problem is that 30 
years later, it's still a demonstration program. We need to 
move beyond that.
    A quick word about how to envision or frame the issue. I 
took the liberty of putting up a graphic here in back. I am 
sorry it's--I couldn't figure out where to put it in the room 
so that everybody could see--but in terms of primary care work 
force reform, I would suggest three elements to the life cycle 
of a health worker, a physician in this case: medical school, 
graduate education, and practice.
    The latter, of course is the longest. But the other two are 
formative--the pipeline. And there are a number of instruments 
that are in play and others could be put in play to influence 
that.
    Importantly, we need influence in all three. If you fix the 
pipeline and don't fix practice, or you do something good about 
practice and upscaling reimbursement, but you don't do anything 
about the pipeline, you are going to have far less than a 
satisfactory outcome. So all of this is a framing concept.
    A quick word about where we are about the physician work 
force in general. While we have 280 physicians per 100,000, it 
puts us about in the middle of the pack for developed nations. 
Europe has a few more, Canada and the UK have a few less.
    I think we are in a zone of sufficiency. And folks who are 
yelling about we need more physicians, we need more nurse 
practitioners and more physicians assistants to make more use 
and better use of what we have in the way of a very excellent 
physician work force, but I think roughly we are in a pretty 
good zone in terms of what we are producing.
    We do have enormous distribution problems. And that's where 
health centers, aided by the National Health Service Corps have 
shown the way thus far, but it's no where near the way that it 
might be shown in the future.
    Let me talk just briefly about the Corps and where it sits, 
emphasizing I am not a representative of the program, but I've 
been a fan of it and a participant in it over the years, and I 
did a little homework coming in.
    The essence of the physician distribution problem, is 
shortage areas, which are some combination of local economics 
and local geography that are not sufficiently incentivized to 
get physicians to go there.
    This is a problem throughout the world. Every country has 
it. There is a gradient, docs like well-to-do communities, and 
they like urban areas. So how do we get them to go where they 
don't want to go? That's what democratic incentive programs are 
about and that's what the Corps is.
    In closing, let me just say quickly that one could envision 
under this bill what I've called in the past the muscular 
Samaritan. The Corps is a samaritan--but there are many ways it 
could be developed and more fully impact the country's health 
centers, build them out as we build health centers. There is 
prison health. There is urban health. There is public health. 
There are many ways this instrument could benefit the country.
    And finally the Corps, itself, needs some modest changes. 
It's a great formula. Education for service for things like 
better flexibility in terms of where people serve, teaching 
health centers where there is much more education that goes on 
in health centers, for recruitment purposes, many things could 
be done. The bills proposed would allow that to happen, a real 
revolution in health workforce of the country.
    [The prepared statement of Dr. Mullan follows:]

              Prepared Statement of Fitzhugh Mullan, M.D.

                                SUMMARY

     Improving access to health care in the United States will 
require modifications in the U.S. health care workforce, the foremost 
of which will be the construction of a strong primary care base.
     Two-thirds of the U.S. physician workforce practice as 
specialists and the number of young physicians entering primary care is 
declining.
     The distribution of health care providers in the United 
States heavily favors urban areas. Metropolitan areas have 2-5 times as 
many physicians as non-metropolitan areas and economically 
disadvantaged areas have significant health care access problems.
     Today's physician-to-population ratio is in the zone of 
adequacy and should be maintained with growth in the number of 
physicians trained to parallel growth in the population. Increased 
requirements for patient care due to the aging of the population or the 
inclusion of more Americans in a universal care plan should be met by 
more strategic distribution of physicians, both geographically and 
across the primary care--specialty spectrum, and the expanded use of 
physician assistants and nurse practitioners.

                               STRATEGIES

     Medical Schools.--Medical schools are currently expanding, 
and title VII legislation needs to be re-invigorated and up-funded to 
augment primary care training.
     Graduate Medical Education.--The current number of 
Medicare funded slots is sufficient to maintain workforce numbers. 
However, reforms need to be made in current legislation to prioritize 
and incentivize community-based and primary care training. Serious 
consideration also needs to be given to aligning Medicare GME with the 
workforce needs of the country. This would entail designing a new GME 
allocation system.
     Medical Practice.--Primary care payment reform, support 
for new practice organizations such as primary care medical homes, and 
investment in health information technology are all important reforms 
that will promote a strong primary care practice base in the country.
     National Health Service Corps.--The NHSC is a proven 
program that delivers primary care clinicians to needy communities in 
return for student debt reduction. It is a brilliant and successful 
strategy that has always been under-funded. It is time to radically 
increase its budget toward the end of fully staffing Community Health 
Centers and addressing the oncoming needs for clinical service in the 
United States.
     Teaching Health Centers.--Establishing stable funding for 
both undergraduate and graduate medical education in health centers 
will promote a workforce prepared with skills needed for practice and 
improve recruitment and retention for health centers, which are 
critical providers of health care to underserved communities.
     Data and leadership in the field of U.S. health workforce 
development is insufficient. A National Health Workforce Commission 
would be an important asset at the Federal level in managing health 
care workforce reform.
                                 ______
                                 
                              INTRODUCTION

    Thank you, Mr. Chairman, for this opportunity to testify today. 
During the 40 years since I graduated from medical school, I have 
practiced medicine as a member of the National Health Service Corps in 
New Mexico; I have directed workforce programs including the National 
Health Service Corps; and I have been a student of and commentator on 
U.S. workforce policy in my current role as a Professor of Health 
Policy at The George Washington University.
    Therefore, it is with experience as a practitioner, administrator, 
and scholar that I come before you this morning.
    Current health care access and the expansion of access to all 
Americans are necessarily reliant on both the number and make-up of the 
workforce available to provide care. In my remarks, I will briefly 
review the history, demographics, trends, and problems associated with 
the U.S. health professions workforce. I will focus on the physician 
workforce, which is large, at the center of the delivery system, and 
closely associated with the costs of the health care system. I will 
also talk about nurse practitioners and physician assistants who make 
major contributions to clinical care delivery in the country. I will 
discuss the current and potential future role of the National Health 
Service Corps. Much of my commentary will reference the challenge of 
providing a strong and efficient base to the U.S. health care system--
the sector of practice termed primary care. I will propose a number of 
areas in which legislative action would, in my judgment, support and 
augment the training and practice of primary care providers, thereby 
improving the availability, efficiency and effectiveness of the overall 
health delivery system.

            HEALTH CARE ACCESS AND THE HEALTH CARE WORKFORCE

    Increasing health care access in the United States is necessarily 
dependant upon the current and future status of the health care 
workforce--in absolute numbers, specialty make-up, and geographic 
distribution. Health care reform in Massachusetts provides one 
instructive example of achieving health care reform without 
concurrently addressing the health care workforce. In 2006, 
Massachusetts enacted universal health care measures, increasing the 
number of insured by 340,000. However, within 2 years, reports of 
access problems due to an insufficiency of primary care providers 
emerged, causing the State legislature to scramble to enact primary 
care legislation.
    In addition to the Massachusetts example, many organizations are 
indicating increasing concern over the primary care workforce. The 
National Association of Community Health Centers (NACHC) reports health 
centers currently have a shortage of over 1,800 primary care providers. 
Further, if health centers are to increase their services and access, 
they will need an additional 15,585 primary care providers to reach 30 
million patients by 2015 or an additional 51,299 primary care providers 
to reach 69 million patients.\1\
    Both the Massachusetts experience and the NACHC report remind us 
coverage does not equal access. In order to increase access, we must 
build a high quality, cost-effective, well distributed workforce.

                   THE DEMOGRAPHICS OF THE WORKFORCE

    Today, there are over 800,000 practicing physicians in the United 
States. This number represents a steady increase over the last 50 years 
in both the number of physicians and the physician-to-population ratio 
(see Figure 1). The current density of physicians is 272 per 100,000. 
However, the distribution of physicians in the United States trends 
heavily towards urban and well-to-do areas. Less than 10 percent of 
physicians practice in rural areas while 20 percent of the country's 
population resides in these areas. Metropolitan areas have a primary 
care physician-
to-population ratio of 93 doctors per 100,000 people compared to 55 
primary care doctors per 100,000 people in non-metropolitan areas. 
Specialists are even more concentrated, with greater than three times 
the density of specialists in metropolitan areas versus non-
metropolitan areas.



    American Medicine is highly specialized. Currently, there are 142 
Accreditation Council on Graduate Medical Education (ACGME) recognized 
specialties and combined subspecialties as well as multiple additional 
unrecognized subspecialties. Physicians reporting that they practice 
primarily as specialists comprise 63 percent of practitioners whereas 
those working in the primary care specialties (family medicine, general 
internal medicine and general pediatrics) comprise only 37 percent of 
doctors in practice. This figure is markedly different than it was 50 
years ago when 50 percent of America's physicians were generalists. In 
Canada today, by contrast, 51 percent of physicians are currently 
family physicians and GPs.
    The situation in primary care, however, is more problematic than 
the numbers might suggest. Hard work, low pay, and ``lifestyle'' 
expectations of medical graduates today have resulted in dramatic 
reductions in interest in primary care in U.S. medical graduates (see 
Figures 2 and 3). Between the mid-1990s and today, the number of 
training positions in family medicine has declined 20 percent and the 
percentage of the family medicine residency positions being selected by 
U.S. graduates has fallen from 72 percent to 44 percent. The majority 
of family medicine positions are now filled by international medical 
graduates.





    A recent questionnaire of senior medical students considering 
careers in internal medicine showed that only 2 percent of them wanted 
to be general internists.\2\ These trends have implications for the 
future--a future that will require more primary care services for our 
aging population. A recent study projects that we will be short 
approximately 40,000 primary care doctors in 15 years \3\--and that 
doesn't take into account the millions of Americans who will seek 
primary care when universal coverage is implemented.

              PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS

    The United States is a global pioneer in the creation of new 
categories of health professionals who contribute to the delivery of 
clinical services. Separate pilot programs in the 1960s introduced the 
world to the idea of the nurse practitioner (NP) and the physician 
assistant (PA). Since those early programs, both professions have grown 
enormously in size, stature and public acceptance. Approximately 
125,000 nurse practitioners have been trained in the United States, the 
majority of whom are engaged in clinical practice. There are almost 
70,000 certified physician assistants in the United States and more 
than 100 training programs.
    Both of these professions are associated with primary care and 
practice in rural and underserved areas. About 25 percent of all nurse 
practitioners are located in non-metropolitan areas and an estimated 85 
percent of them practice primary care. Physician assistants are active 
across the spectrum of medical specialties with more than one-third of 
them working in primary care practices and approximately one-fifth of 
them working in rural areas.

                  THE CAREER LIFECYCLE OF A PHYSICIAN

    Before considering questions of the sufficiency of the workforce or 
policy options to modify its direction, I would like to suggest a 
framework for considering physician careers. I call this the career 
lifecycle of a physician. It has three phases--one of which is 
educational, one of which is transitional and the final one of which is 
vocational (see Figure 4). The phases are medical school, graduate 
medical education, and practice. The first two might be considered 
``pipeline phases'' since they determine the quantity and nature of 
physicians prepared for practice. The final phase is the ``payout'' 
phase when the physicians are actually providing health care to the 
Nation.


    This framework allows us to consider capacity, cost and performance 
in three separate but interlinked longitudinal phases of the career 
path of physicians.
    One further clarification is necessary to understand the dynamics 
of the physician lifecycle. The governing sector in the lifecycle is 
graduate medical education (GME). Contrary to popular belief, it is not 
medical schools that determine the ultimate size and specialty 
composition of the physician workforce of the country. Rather it is 
residency programs, taken as a whole, that serve as the final pathway 
into practice and largely govern the numbers and specialty distribution 
of the physicians in practice. In order to practice medicine in the 
United States, one needs a license from a State. All States require 1 
to 3 years of residency in order to obtain a license. It is also 
important to recognize that a significant proportion of practicing 
physicians did not attend U.S. (allopathic) medical schools. Of the 
current first year residents, for instance, 64 percent graduated from 
U.S. allopathic (M.D.) medical schools, 7 percent from U.S. osteopathic 
(D.O.) medical schools, and 29 percent from medical schools abroad 
(International Medical Graduates or IMGs).\4\ Almost all of these 
physicians will complete residency and enter practice in the United 
States. Thus, it is the size and specialty offerings of the aggregated 
residency programs of the country that really determine the future of 
the U.S. physician workforce.

                              SUFFICIENCY

    As we examine the Nation's health care system and as we consider 
options to increase coverage, fairness, quality, and affordability, we 
must wrestle with the question of how many physicians we need. This is 
a central question, not only because it involves the physician 
production process but also because it has important implications for 
training requirements for other health professionals (i.e., nurse 
practitioners and physician assistants). It also has ramifications for 
prospective spending in a number of areas including hospital beds, 
diagnostic testing, medication usage and locations of practice.
    Many policy scholars and analysts have written on this topic with 
strikingly different conclusions. Some have suggested that we are 
training too many physicians while others issue predictions that we are 
entering into a period of dramatic physician shortage. These 
projections are largely dependent on the assumptions made about the 
health care system of the future. If one assumes that the health care 
system will be highly coordinated with the well-organized use of 
physician services, such as is the case in prepaid managed care plans 
like Kaiser Permanente, the case can be made that we might well have a 
surplus of physicians. If one assumes the continuation of a minimally 
organized, specialty dominated, predominantly fee-for-service system 
that is an extrapolation of today's circumstances, one can make the 
case for a perpetually escalating need for physicians. Both cases have 
been argued eloquently.
    My view is that the density of physicians (the physician-to-
population ratio) that we have at the moment is reasonable and the role 
of public policy (financing and regulation at the Federal and State 
levels) should be to maintain a physician workforce of approximately 
the current size. This strategy should take into account projected 
growth in the size of the U.S. population (which is projected at 1 
percent per year) so that the absolute number of physicians would grow 
in a modest but consistent fashion.
    This strategy would be challenged by critics who would raise 
objections in the following areas:

    1. The American population is aging, and by all measures, older 
citizens require more health care;
    2. Physician practice patterns have changed and physicians don't 
work as many hours as they used to;
    3. Technology is advancing and we will need more specialists to 
deliver the fruits of new technologies to the population:
    4. Don't bet on better organization of the health care system.

    These observations are all valid. A response to these concerns 
could certainly be placement of greatly increased numbers of physicians 
into practice--whether from U.S. medical schools or from physicians 
trained abroad at the expense of other nations. However, all evidence 
indicates this would be a very costly response since physicians are 
expensive to train and to compensate in practice. Additionally, 
excellent evidence shows an association of more physicians and, 
especially, more specialist physicians with higher health care costs. 
This is the case because more physicians and, particularly, more 
specialty physicians are associated with higher hospital utilization 
and increasingly costly patterns of practice. Importantly, this 
evidence also shows no benefit in care from this higher intensity of 
physician practice.
    Reforming physician workforce policies in a way that promotes 
quality and constrains costs requires a different strategy. The 
essential elements of that strategy are three:

    1. The revitalization of a primary care workforce that will be able 
to staff an organized system of national primary care delivery that 
needs to be created by reforms in the delivery system. Whether services 
are delivered in primary care medical homes, accountable care 
organizations (ACOs), prepaid group practices, or community health 
centers, the size and skills of the primary care workforce need to be 
robust.
    2. The physician education pipeline needs to produce enhanced 
numbers of primary care physicians prepared to work in hard pressed 
inner city and economically challenged communities, cities and rural 
areas as well as in economically comfortable urban and suburban 
settings.
    3. To the degree that the clinical care workforce as a whole needs 
more providers to address the changing needs of the population, a 
strong strategy of support for nurse practitioners and physician 
assistants should be adopted. The increased use of PAs and NPs should 
not be limited to the primary care sector. Both professions have 
demonstrated excellent functionality as team members in all aspects of 
medical practice from the pediatric office to the operating room. Nurse 
practitioners and physician assistants are trained more quickly, at 
less expense than physicians, cost less in practice, and are not, on 
their own, drivers of ancillary clinical tests and services. Moreover, 
they represent a highly flexible workforce--an important asset 
generally lacking in the physician workforce. In contrast, physicians 
(especially specialty physicians), invest enormous amounts of time, 
money and deferred income in establishing their capabilities and 
credentials. Training, retraining, and/or redirecting them is not 
easily done. Physician assistants and nurse practitioners are, 
comparatively speaking, ``stem cells'' and more able as individuals and 
as professions to focus on areas of emerging or urgent need. NPs and 
PAs provide a well-proven quality, clinical workforce that can 
interdigitate with all aspects of physician practice and whose pipeline 
can be turned up or down as needed to assist in addressing emerging or 
changing clinical needs.

    No discussion of the physician workforce would be complete without 
reference to international medical graduates (IMGs) who constitute 
approximately 25 percent of physicians in practice and 29 percent of 
physicians in residency training. No American policy body--certainly 
not the U.S. Congress--has ever advocated that we ``offshore'' one 
quarter of our medical training or design a system in which our medical 
schools are only capable of training three-quarters of the physicians 
we need. Yet that is what we have done.
    We can be proud that the appeal of our way of life and the prowess 
of our medical institutions that have made the United States a magnet 
for physicians from around the world for the last 50 years. Most have 
arrived under educational visas and, in overwhelming numbers, have 
remained in the United States following residency training. This has 
been an enormous gift to the United States. In steadily escalating 
numbers, these hard working, smart, and ambitious men and women from 
all over the world have staffed our health system. They have also 
allowed us to be casual in our medical education policy. There is no 
need for planning or precision nor, even, adequate funding for medical 
schools since large numbers of foreign graduates are always available 
to fill in the gaps in residency programs and in specialties that are 
out of favor with American graduates. Sixty percent of international 
medical graduates come from poor countries--largely the Indian 
subcontinent, Africa and the Caribbean. In many small countries the 
physician ``brain drain'' is the largest and most destabilizing aspect 
of their health sector. We are not the only country to rely on foreign 
trained physicians, of course. At one point, Nelson Mandela personally 
appealed to Tony Blair to stop ``poaching'' South Africa's doctors. 
Recently, global attention has turned to the question of health system 
strengthening to fight AIDS and end poverty, and yet everywhere one 
turns the brain drain of doctors and nurses stands as an impediment to 
improved health in developing countries. Some have called it ``reverse 
foreign aid.''
    Heavy reliance on international medical graduates to fill residency 
positions and undergird the Nation's physician workforce is neither 
good domestic policy nor good foreign policy. Going forward, public 
policy makers and medical educators should work toward self sufficiency 
in medical education. This boils down to a single simple principle: 
U.S. medical schools should graduate approximately the number of 
students required to fill the first year residency positions offered in 
the country.
    In that regard, the current initiation of new medical schools and 
expansion of class sizes at existing schools is a positive development. 
These new U.S. students will undoubtedly find residency positions upon 
graduation, decreasing our need to draw on the rest of the world to 
meet our medical needs. This will be an asset in our efforts to promote 
the United States as a good global citizen and also provide an overdue 
opportunity for more U.S. students to go to medical school in the 
United States.

         Reform in the Three Sectors of the Physician Workforce

                            MEDICAL SCHOOLS

    The principal Federal legislation impacting medical schools since 
1963 has been the series of programs authorized under Title VII of the 
Public Health Service Act. From 1963 to 1976 the principal investments 
were designed to increase the number of medical schools and medical 
school graduates. Construction grants, capitation funds, and student 
loans were all used as stimuli for medical schools. The result was more 
than a doubling of the Nation's annual medical school graduating class 
from approximately 7,500 students a year in 1960 to 16,000 students a 
year in 1980. This was an extraordinary achievement of public policy 
and medical education.
    The problems with medical education, however, that concerned 
policymakers even in those early years went beyond absolute numbers. It 
was growingly clear that physicians were not equally distributed in the 
country nor were medical students reflective of the diversity of the 
population of the United States. The term ``primary care'' was first 
used in the 1960s to focus on yet another problem with medical 
graduates--the increasing specialization of physicians such that many 
parts of the country had little access to generalist care.
    The result was a new growing set of programs authorized under Title 
VII of the Public Health Service Act to promote community practice, 
rural practice, primary care, and opportunities for minorities and 
disadvantaged students. These included the Area Health Education 
programs, support for family medicine, general internal medicine, and 
general pediatrics, the Health Careers Opportunity Program and funding 
for physician assistants. During this same period, funding for nursing 
and, particularly, new nurse practitioner programs was similarly 
increased under Title VIII of the Public Health Service Act.
    In the early 1970s, the funding for title VII programs reached over 
$2.5 billion (2009 dollars) (see Figure 5). In the mid-1970s, the 
consensus changed with the belief that we were training enough (some 
thought too many) physicians and title VII authorizations and 
appropriations were throttled back. The title VII programs have 
functioned in the very modest $200-300 million/year range from that 
time until the present.



    In the latter years of the Bush administration, serious efforts 
were made to eliminate all title VII funding including support for 
primary care, minorities in medicine, rural placements and workforce 
tracking. During the same period, medical school revenues from NIH 
research funding have risen from $2.4 billion in 1970 to $16.3 billion 
in 2004 (all 2009 dollars), creating a robust culture of research at 
medical schools that dominates medical school finances, faculty values 
and school culture (see Figure 6).



    Any serious proposal to reform medical practice in the United 
States must start with reinventing and reinvigorating title VII funding 
to medical schools for the purpose of creating incentives and 
educational pathways that will select and train students for primary 
care, rural health, diversity, and social mission. Parallel support for 
nurse practitioners and physician assistants is important as well.
    In the past, critics of title VII have proposed high standards of 
measurement, asking, ``how do we know title VII funds make a 
difference?'' This is a difficult problem for programs with small 
funding streams that function within large institutions with many 
contrary incentives. Nonetheless, an impressive series of studies have 
shown that title VII funds affect physician careers positively in 
regard to primary care, rural placement and minority opportunities. 
There are many ways in which title VII could be augmented and 
strengthened. One of those would be an initiative which provides 
incentives for the creation of ``teaching community health centers''--
creating funded linkages between medical schools and Federally 
Qualified Health Centers (FQHCs) for the purpose of training. Another 
area in which title VII needs strengthening is in the ability to 
collect important data and produce useful policy analyses on the 
workforce. A national center for workforce studies should be given 
serious consideration in augmenting title VII authorities and funds.
    Funding for the education of physician assistants and nurse 
practitioners should be continued and augmented to help provide the 
build-up of flexible clinicians for health reform.
    While the National Health Service Corps (NHSC) it is not an 
educational program, it is a brilliant but underfunded asset available 
to redistribute health professionals--physicians, NPs, PAs and others. 
I say brilliant, since it matches the needs of individual health 
science students/professionals with national needs for practitioners in 
underserved areas. The program has been ``tested'' since 1971 and works 
to the benefit of clinicians and communities. Many clinicians have 
remained in their assigned communities for long periods or full 
careers. At times, however, the NHSC has received criticism for not 
having as high ``retention rates'' as some would like. There are 
American communities that for reasons of geography or economy have 
never been able to retain physicians. To the degree that the NHSC can 
meet service needs with serial placements in these communities, the 
program is a success. The principal problem with the NHSC is its size. 
There are many more communities eager for NHSC help and many more 
clinicians interested in scholarships or loan repayment opportunities 
than can be met given the program's budget. Major investment in the 
NHSC would do a great deal to increase access to health services in 
some of our poorest and most rural communities.
    A word should also be said about Community Health Centers which are 
not teaching institutions but have a stellar record of providing 
learning sites and supervision for clinical students--often without 
recompense. Good data now shows that in many communities CHCs are 
struggling to find sufficient primary care providers to meet their 
staffing needs. Expansion of the NHSC and support through title VII and 
Medicare GME for CHC-based teaching activities will be essential to 
allow them to expand to meet the growing needs of the uninsured and 
underinsured populations of our country.

                       GRADUATE MEDICAL EDUCATION

    Graduate medical education (GME) grew significantly through the 
1980s and early 1990s and leveled off at about 100,000 residents and 
fellows a year in GME from the late 1990s to the early 2000s. In recent 
years there has been a small increase in the total number of residents 
and fellows. Residency programs are unevenly distributed throughout the 
country, with history playing an important role. The locations of the 
earliest residency programs 100 years ago are the areas of the largest 
residency concentrations today including Boston, New York City, 
Philadelphia and Washington, DC. In general, the resident physician-to-
population ratio is highest in cities in the Northeast, lower in 
Southern and Western States, and lowest in rural areas.
    The most important financial policy and educational instrument in 
graduate medical education is Medicare GME. While Medicare has paid for 
a portion of GME since its inception, the current system was 
established in 1983 as part of the prospective payment reforms of 
Medicare. The current system reimburses hospitals that train residents 
for two costs:

    1. Direct costs (DGME) associated with residents, such as salaries, 
teaching time of faculty, administrative costs; and
    2. Indirect costs (IME), which are intended to subsidize the higher 
cost of patient care in teaching hospitals related to both higher 
patient care acuity and the presence of residents in the hospital.

    The calculation for direct and indirect payments is different, but 
both are based on the number of residents at a given teaching hospital 
and, as such, are a form of capitation payment--the more residents, the 
higher the payment. In 2006, direct GME payments totaled $2.8 billion 
and indirect GME payments totaled $5.8 billion, a total of $8.6 
billion. This total amount represents only 2 percent of Medicare's 
expenditures in 2006 and, perhaps, receives less public debate than it 
might. On the other hand, $8.6 billion is far and away the largest 
Federal expenditure related in any way to medical education.
    As part of Medicare, these funds function as an entitlement and are 
allocated based on established formulas. Medicare legislation requires 
no community or regional physician needs assessment to qualify a 
hospital for GME payments, sets no targets for the number or type of 
resident physicians that a hospital trains and requires no 
accountability for the type or sufficiency of physicians in the 
hospital's city, county or State. Concerned with the cost of the 
program and its potential to escalate, Congress capped the number of 
federally funded residents in the Balanced Budget Act of 1997. In the 
last 5 years, the total number of residents in the country has grown 
slowly presumably due to the addition of ``off-cap'' residents and the 
selection of specialties with longer training periods.
    While Medicare GME in its current form has provided a large and 
stable source of income for teaching hospitals that is understandably 
of enormous value to those important institutions, it is effectively a 
Federal payment without a deliverable--a subsidy. The resident 
compliment of any given hospital is determined by the staffing needs of 
that particular hospital with, presumably, the input of the chiefs of 
the clinical services. There is no requirement that the particular 
hospital or the medical school with which it is affiliated make any 
judgments about the workforce needs of their community, region or 
State. The result is that the annual graduates of the over 9,000 
residency programs at nearly 1,100 teaching hospitals in the United 
States comprise the workforce of the country with no regard to 
specialty selection, practice location or regional needs.
    Effectively, we are addressing the health care needs of the country 
with a physician staffing pattern based on hospital needs. This is a 
core problem for workforce reform. There are many ways in which 
Medicare GME could be reconceptualized and redirected. For the purpose 
of this testimony, let me suggest two levels of reform that might be 
considered. The first I will entitle ``modest'' and the second 
``major''.
    Modest reforms to current Medicare GME would entail modifications 
in the rules governing the use of GME funds. Currently, there are a 
variety of financial disincentives to offsite training. Hospitals stand 
to lose GME payments, both DGME and IME, for residents who spend time 
offsite (for instance in Community Health Centers, office-based 
practices, or local public health departments.) The sites, in turn, 
face either complicated negotiations to obtain GME pass-through funds 
or the prospect of training residents without receiving the benefit of 
GME financing.
    There is much that could be done to make Medicare GME more user-
friendly to primary care and community-oriented training. Reforms in 
this area would be helpful but would do little to change the basic 
problem of hospital staffing patterns dictating the Nation's physician 
workforce.
    A major reform would require reconstituting the current policy 
thinking that governs Medicare GME. Rather than seeing GME as a 
convenient vehicle for teaching hospital support, Medicare GME should 
be seen as the principal instrument to shape the physician workforce of 
the country. This perspective would require teaching hospitals to 
undertake community or regionally oriented analyses of physician 
workforce needs and make application for training positions based on a 
fiduciary responsibility to train a complement of residents that 
corresponds to agreed upon regional needs. This approach might also 
call for rebalancing regional and sectional allocations of GME funding 
and therefore physicians to provide a more balanced landscape of GME 
training.
    One problem with envisioning a system of this sort is that many 
teaching hospitals who are current recipients of GME funding are not 
large and do not have a large number of teaching programs. In fact, 
many larger hospitals have specific foci such as cancer or children or 
surgery that do not equip them to address regional needs. An answer to 
this problem is the formation of independent consortia of teaching 
institutions that would, when working together, represent training 
capacity that could address regional needs in a much more comprehensive 
fashion. A variant approach would be State-based GME organizations that 
might (or might not) have a link to State government. In either case, 
the consortium would be able to represent regional needs and work with 
the Center for Medicare and Medicaid Services (CMS) on residency 
training targets and GME funding.
    A consortium system would require the establishment of many new 
arrangements within the medical teaching sector. It might also mean 
that teaching hospitals would have to modify their complement of 
residency programs in ways that might not be popular with the chiefs of 
service or the hospital administration. Strong political objection 
would predictably be mounted against any such reform, but if this most 
crucial link in the construction of the physician workforce in the 
United States--graduate medical education--is to be modified to meet 
the needs of an efficient and effective health system in the future, 
changes will need to be made in the way the Federal Government does 
business with the teaching hospitals of the country.

                            MEDICAL PRACTICE

    Re-incentivizing and re-directing primary care in the pipeline 
(medical schools and GME) will amount to little if parallel reforms are 
not achieved in support for primary care practice. Physicians are smart 
and ambitious enough that, if the current reimbursement inequities and 
structural disincentives to primary care practice remain in place, many 
will abandon primary care during their practice years despite excellent 
primary care education and support for primary care in their training 
years. The key areas in the practice environment that will help are 
practice reimbursement, practice organization, and health information 
technology.
    Primary care physician average annual incomes are currently less 
than half those of their specialty colleagues. Given high medical 
school debt, late entry into an economically productive life and 
demands of the job, it is not hard to understand why primary care 
careers are severely disadvantaged in comparison to more lucrative 
specialty options that often have more controlled lifestyles. While 
physicians receive payment from many sources, the Medicare fee schedule 
is the primary determinant of physician reimbursement and is a 
candidate for major restructuring.
    The organization of primary care practice is another area of major 
reform potential. The preponderance of primary care providers still 
work in solo practice or small groups. This minimizes the opportunity 
to develop a full-service primary care team benefiting from new 
information technologies or relating in an effective way to specialty 
consultants. Larger team-based practices with excellent information 
systems such as medical homes or accountable care organizations offer 
the promise of a new platform for health care delivery. Incentivizing 
and supporting these forms of practice stands to do a great deal to 
improve the overall health system, particularly promoting primary care, 
whose currency is patient well-being over time linked to episodes of 
care provided by other practitioners. Health IT will organize and 
empower the primary care practitioner in ways that will make the 
practice of primary care much more effective. Investments in these 
areas are crucial.

                              ACTION ITEMS

    In closing, I want to emphasize three areas for legislative action 
that would move the healthcare workforce of the United States in the 
direction needed to provide universal coverage built on a strong 
primary care base. The areas are the following:

1. The 1 percent National Health Service Corps
    Increase investments in NHSC scholarships and loan repayment such 
that there are 8,000 physicians and others in the field by 2012--
something approaching 1 percent of the physicians currently practicing 
in America. A field strength of this size would help staff the 
expanding network of community health centers and other community sites 
and begin to address the medical needs of many newly insured Americans. 
Additionally, modifications will need to be made in the current NHSC 
law to allow NHSC clinicians to engage in teaching and medical 
leadership functions.

2. Teaching Health Centers
    A reform effort focused on all three sectors of the physician 
workforce is the Teaching Health Center. Patient care in the United 
States increasingly occurs in ambulatory settings. Yet medical 
education (both undergraduate and graduate) is overwhelmingly based in 
hospitals--creating a mismatch between the skills obtained during 
training and those needed in practice, promoting specialization over 
primary care careers and inhibiting recruitment and retention in 
ambulatory sites, particularly those serving rural and underserved 
communities. Establishing Teaching Health Centers would address all of 
these by augmenting the current training system with increased training 
directed by and occurring in health centers (including FQHCs, FQHC 
look-alikes and public health department). While education does 
currently occur in these settings, current laws and regulations are 
prohibitive. Legislation to support the Teaching Health Center could 
include:

     Medicare GME funding paid directly to health centers to 
support these training programs.
     Title VII and title VIII grants to support faculty and 
curriculum development.
     Section 330 grants to support facility expansion and 
faculty time costs.
     Changes in National Health Service Corps to support a 
teaching role within the NHSC service obligation.

3. A National Health Workforce Commission
    Underlying reform efforts in all three sectors of the physician 
workforce is the need for national level analyses and guidelines for 
workforce policies. Policy changes aimed at reforming the three sectors 
to address the health care needs of the Nation can not be successful 
without clear workforce objectives, which require the ability to 
collect important data and produce useful policy analyses on the 
workforce. A National Health Workforce Commission, established as an 
independent congressional agency, could serve in this function and 
advise Congress and the Secretary on the alignment of Federal programs 
including Medicare GME with national health workforce goals. Also 
recognizing the complexities of data collection and the varying 
geographic needs at the local level, State Level Health Workforce 
Councils could support the National Commission--collecting and 
analyzing State level data and implementing national level policies at 
the local level.

                               CONCLUSION

    In order to reform the delivery of health care in the United States 
in a way that is more effective and constrains costs, a number of 
changes need to be made in the workforce since the workforce is an 
essential governing component of the functionality, quality and cost of 
the system as a whole.
    The number of physicians entering practice in the United States 
currently is in a zone of adequacy. Many of these physicians are 
trained abroad and measures should be taken to increase U.S. medical 
school output so as to decrease our dependence on foreign-trained 
physicians. The training and use of nurse practitioners and physician 
assistants should be augmented to absorb increased demand in the system 
due to an aging population.
    The current system heavily favors fragmented specialty care, making 
it inefficient and expensive. Moreover, it is unevenly distributed, 
raising serious concerns of access and equity. Major investments in the 
pipeline at the medical school and GME level will be essential to 
rebalancing the system. At the GME level, in particular, where a large 
investment already exists, modifications need to be made in the system. 
In the practice sector, primary care is currently severely 
disadvantaged and reforms in payment systems and practice support will 
be needed to re-incentivize and restructure the practice of primary 
care across the country.
    It goes without saying that this is an important moment in the 
history of health care in the United States. The Congress has an 
unprecedented opportunity to lead in the reform of the system for the 
benefit of all Americans. I very much appreciate the opportunity to 
testify before you and I remain available to provide assistance in 
whatever way I can.
    Thank you.

                               References

    1. National Association of Community Health Centers, Robert Graham 
Center, George Washington University. Access Transformed: Building a 
Primary Care Workforce for the 21st Century. August 2008.
    2. Hauer KE, Durning SJ, Kernan WN, et al. Factors Associated with 
Medical Students' Career Choices Regarding Internal Medicine. JAMA. 
2008;300:1154-64.
    3. Colwill JM, Cultice JM, Kruse RL. Will Generalist Physician 
Supply Meet Demands of an Increasing and Aging Population. Health 
Affairs. 2008;27:232-241w.
    4. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR. 
U.S. Residency Training Before and After the Balanced Budget Act. JAMA. 
2008;300:1174-1180.

    Senator Sanders. Thank you very much, Dr. Mullan. When we 
talk about health care, sometimes we forget dental care, which 
is a huge problem in my State of Vermont. We are very pleased 
to have Caswell A. Evans, Jr., who is the Associate Dean for 
Prevention & Public Health Sciences, University of Illinois, at 
Chicago College of Dentistry.
    Dr. Evans, thanks very much for being here with us.

 STATEMENT OF CASWELL A. EVANS, Jr., D.D.S, M.P.H., ASSOCIATE 
  DEAN FOR PREVENTION & PUBLIC HEALTH SCIENCES, UNIVERSITY OF 
     ILLINOIS AT CHICAGO COLLEGE OF DENTISTRY, CHICAGO, IL

    Mr. Evans. Senator Sanders, thank you very much for having 
me and Senator Brown, very nice to see you again and I 
appreciate your comments, and our other distinguish elected 
leaders. It is a pleasure to be here with you.
    I am here this morning representing the American Dental 
Education Association, which represents the dental education 
network and 58 dental schools in the United States, all its 
faculty and residency programs and other training programs.
    It's important to point out and I want to echo your 
comments, Senator, that we often overlook the fact that oral 
health is inextricably linked to general health and the jaw 
bone is connected to the toe bone. It's a connection we 
unfortunately miss, and infections that occur in the jaw bone, 
in effect, eventually will affect the toe bone and all in 
between.
    I want to point out that academic dental institutions are 
significant safety net providers in their communities. They 
provide care to populations that unfortunately do not have 
access otherwise to the health system, with the exception of 
our community health centers. And we know these populations 
well. They are low income, racially and ethnically diverse, 
disabled, institutionalized patients, HIV/AIDS patients, and a 
long list of those who did not have access to care.
    We know that vulnerable populations are more at risk for 
unmet oral health needs compared to other populations and the 
same populations that, again, make up the service community and 
recipients of services at community health centers, also seek 
care in our schools of dentistry.
    One of the issues facing dentistry is its lack of diversity 
of the workforce. While we take African-Americans and Hispanics 
collectively, they represent approximately 25 percent currently 
of the U.S. population. Only 3 percent of dentists are Hispanic 
and only 3 percent of dentists are African-American. So we look 
at that as a potential barrier to access to care, much less the 
issue of role modeling in terms of profession and recruiting 
individuals into the profession.
    I want to take just a moment to illustrate some of the 
things we are doing at the University of Illinois at Chicago 
College of Dentistry, because I think they are illustrative to 
this particular issue.
    In a course that is requisite and for credit and for all of 
our senior students, we have 64 students per class. All senior 
students now spend between 60 and 80 days in community centers, 
in terms of gaining their clinical experience. We have a group 
of specifically selected students, 16 in all, who spend half of 
their senior year in community-based sites. These sites include 
community health centers, FQHCs, Federally Qualified Health 
Centers in both rural and urban environments. They also include 
philanthropically supported health centers, a clinic serving 
the developmentally disabled only, local health departments, a 
union run clinic, Veterans Administration Hospital, and other 
hospitals.
    These clinical rotations are intended to provide an 
experience in terms of access to care and health disparities 
for these students and we find that they are resonating well to 
that and many of them are seeking employment in community 
health centers and we think that's a very significant model for 
training and sensitizing our dental student cadre.
    Thank you.
    [The prepared statement of Dr. Evans follows:]

       Prepared Statement of Caswell A. Evans, Jr., D.D.S, M.P.H.

                                SUMMARY

    Good morning, Mr. Chairman and members of the committee. I am Dr. 
Caswell Evans, Associate Dean for Prevention and Public Health 
Sciences, at the University of Illinois at Chicago College of 
Dentistry.
    The American Dental Education Association represents all 58 dental 
schools in the United States, in addition to more than 700 dental 
residency training programs and nearly 600 allied dental programs, as 
well as more than 12,000 faculty who educate and train the nearly 
50,000 students and residents attending these institutions.
    Academic Dental Institutions as safety net providers. Academic 
dental institutions are the dental home to a broad array of vulnerable 
and underserved low-income patient populations including racially and 
ethnically diverse patients, elderly and homebound individuals; 
migrants; mentally, medically or physically disabled individuals; 
institutionalized individuals; HIV/AIDS patients; Medicaid and State 
Children's Health Insurance Program (SCHIP) children and uninsured 
individuals. These dental clinics serve as key referral resources for 
specialty dental services not generally accessible to Medicaid, SCHIP, 
and other low-income uninsured patients. ADIs provide care at reduced 
fees and millions of dollars of uncompensated care is provided each 
year.
    Vulnerable populations are more at risk for unmet oral health 
needs. The same people that make up the largest proportion of Community 
Health Center patients, namely low-income families, members of racial 
and ethnic minority groups, the uninsured and rural residents, 
experience more unmet oral health care needs than other groups and 
suffer greater losses to their overall health and quality of life as a 
result.
    Multiple approaches are needed to improve access to dental care, 
including improving access to community health centers. Evolution in 
dental education to involve a more diverse student body, greater 
attention to public health, and collaboration with other oral health 
providers as well as primary care providers will help improve access to 
oral health care in the long term.
    Health centers are important providers of oral health care to 
vulnerable populations who otherwise would go without. In 2005, 73 
percent of existing federally funded health centers provided oral 
health services onsite and all new federally funded health centers are 
now required to assure the availability and accessibility of oral 
health care services. About half of all NHSC providers are at community 
health center sites. In order to meet the medical staffing needs of 
underserved communities, including hundreds of vacancies at community 
health centers, the NHSC must be expanded. Scholarship and loan 
repayment programs ease provider shortages with approximately 20 
percent of loan repayment awards currently going to dentists.*
---------------------------------------------------------------------------
    * Ruddy G ``Health Centers'' Role in Addressing the Oral Health 
Needs of the Medically Underserved. ``Report'' National Association of 
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
    University of Illinois at Chicago College of Dentistry. The 
University of Illinois at Chicago College of Dentistry (UIC COD) has 
made an unwavering commitment to community-based service-learning as a 
fundamental element of its curriculum. The average class size is 
approximately 64 students. In the context of a requisite and for-credit 
course structure, all fourth-year (senior) students spend at least 60 
days in community sites providing care. A specifically selected group 
of 16 students gain half of their clinical education and training 
experience in community settings. The community sites include FQHC's 
(Federally Qualified Health Centers) in urban and rural locations, 
philanthropically supported health centers, a clinic serving the needs 
of developmentally disabled patients only, local health departments, a 
union-run health clinic, a Veterans Administration hospital and other 
local hospital-based clinics. These clinical rotation experiences are 
intended to expose students to issues of access to care, health 
disparities, practice models beyond private practice, and the ``real 
world'' of health care delivery and the related challenges. The 
didactic aspect of the course provides an opportunity to explore these 
issues in a scholastic manner as well. These educational experiences 
have also proven to be an opportunity as more students, upon 
graduation, have sought to initiate their careers in community health 
centers, the Indian Health Services, or through the National Health 
Service Corps supported positions.
    In conclusion, Mr. Chairman, I thank the committee for considering 
the American Dental Education Association's recommendations regarding 
Primary Care Access Reform. A sustained Federal commitment is needed to 
meet the challenges oral disease poses to our Nation's citizens 
including children, the vulnerable and disadvantaged. Congress must 
address the growing needs in educating and training the oral health 
care and health professions workforce to meet the growing and diverse 
needs of the future. ADEA stands ready to partner with you to develop 
and implement a national oral health plan that guarantees access to 
dental care for everyone, eliminates oral health disparities, bolsters 
the Nation's oral health infrastructure, eliminates academic and dental 
workforce shortages, and ensures continued dental health research.
                                 ______
                                 
    Good morning, Mr. Chairman and members of the committee. I am Dr. 
Caswell Evans, Associate Dean for Prevention and Public Health 
Sciences, at the University of Illinois at Chicago College of 
Dentistry. I currently serve on the Legislative Advisory Committee of 
the American Dental Education Association (ADEA) on whose behalf I am 
honored to appear before you to offer recommendations with regard to 
primary health care access reform.
    The American Dental Education Association represents all 58 dental 
schools in the United States, in addition to more than 700 dental 
residency training programs and nearly 600 allied dental programs, as 
well as more than 12,000 faculty who educate and train the nearly 
50,000 students and residents attending these institutions. It is at 
these academic dental institutions that future practitioners and 
researchers gain their knowledge, where the majority of dental research 
is conducted, and where significant dental care is provided. ADEA 
member institutions serve as dental homes for a broad array of racially 
and ethnically diverse patients, many who are uninsured, underinsured, 
or reliant on public programs such as Medicaid and the Children's 
Health Insurance Program for their health care.
    U.S. academic dental institutions (ADI) are the fundamental 
underpinning of the Nation's oral health. As educational institutions, 
dental schools, allied dental education, and advanced dental education 
programs are the source of a qualified workforce, influencing both the 
number and type of oral health providers. Academic dental institutions 
play an essential role in conducting research, educating and training 
the future oral health workforce. All U.S. dental schools operate 
dental clinics and most have affiliated satellite clinics where 
preventative and comprehensive oral health care is provided as part of 
the educational mission. All dental residency training programs provide 
care to patients through dental school clinics or hospital-based 
clinics. Additionally, all dental hygiene programs operate on-campus 
dental clinics where classic preventive oral health care (cleaning, 
radiographs, fluoride, sealants, nutritional and oral health 
instruction) can be provided 4 to 5 days per week under the supervision 
of a dentist. All care provided is supervised by licensed dentists as 
is required by State practice acts. All dental hygiene programs have 
established relationships with practicing dentists in the community for 
referral of patients.
    As safety net providers, academic dental institutions are the 
dental home to a broad array of vulnerable and underserved low-income 
patient populations including racially and ethnically diverse patients, 
elderly and homebound individuals; migrants; mentally, medically or 
physically disabled individuals; institutionalized individuals; HIV/
AIDS patients; Medicaid and State Children's Health Insurance Program 
(SCHIP) children and uninsured individuals. These dental clinics serve 
as key referral resources for specialty dental services not generally 
accessible to Medicaid, SCHIP, and other low-income uninsured patients. 
ADIs provide care at reduced fees and millions of dollars of 
uncompensated care is provided each year.

                             DENTAL ACCESS

    Access to oral health care is a growing challenge in the United 
States. As many as 130 million American adults and children lack dental 
insurance, nearly three times as many as lack medical insurance. Now 
more than ever, academic dental institutions are a critical source of 
oral health services to those with the highest burden of disease and 
unmet need. The disparities in oral health care are stark: 100 million 
Americans lack adequate fluoridated drinking water and only 10 percent 
of the highest risk children have dental sealants. Yet, fluoridation 
and sealants have been shown to prevent dental disease and reduce 
health care costs over time. Dental caries remains the single most 
common disease among children in America, with five times as many 
sufferers as asthma. Half of all children have untreated tooth decay by 
age 9 and 70 percent have at least one cavity by 18. Thirty percent of 
Americans over the age of 65 have no teeth. In the face of these 
alarming realities, academic dental institutions are working to reduce 
the burden of oral health disease.\1\
---------------------------------------------------------------------------
    \1\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health 
Needs of the Medically Underserved. ``Report'' National Association of 
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
    Many Americans do not have access to dental services given a lack 
of dental providers in their areas, or a lack of dentists who are 
willing to accept insurance. Over 2,000 counties or partial counties 
have been designated dental Health Professions Shortage Areas (D-HPSA), 
where individuals suffer from an absolute lack of dental providers. 
Less than half of these are served by safety net providers. Many 
dentists do not accept patients insured by public insurance, such as 
Medicaid.\2\ This was the case of a 12-year-old Maryland boy whose 
untreated infected tooth resulted in his death. His death could have 
been avoided by simply removing his tooth, a procedure costing about 
$80. Though covered by Medicaid, the boy's family was unable to find a 
dentist willing to take new Medicaid patients. The implications of not 
having access to oral health care can be severe and even fatal.
---------------------------------------------------------------------------
    \2\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health 
Needs of the Medically Underserved. ``Report'' National Association of 
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
    Currently a number of dental schools are taking it upon themselves 
to address dental workforce issues around the lack of diversity and 
lack of providers for underserved communities. The Arizona School of 
Dentistry and Oral Health at A.T. Still University is a new school with 
a focus toward social responsibility. Students spend their fourth year 
in a residency at a health center, Indian Health Service site, or 
Veterans Affairs facility.\3\ The school was founded to help meet the 
staggering need for dental care in Arizona and to avert a significant 
shortage of dentists--given that 2,000 more dentists are retiring each 
year than entering practice in the State.\4\ Some 200 applicants vie 
for 62 spots each year. The dental school graduated its first class in 
2007. Graduates are specifically trained to be culturally competent, 
community-responsive general dentists who are able and willing to serve 
as a resource in their community for dental public health issues.
---------------------------------------------------------------------------
    \3\ 3 Krause B. ``State Efforts to Improve Children's Oral 
Health,'' Issue Brief, Center for Best Practices, National Governor's 
Association, Washington, DC, November 20, 2002.
    \4\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health 
Needs of the Medically Underserved. ``Report'' National Association of 
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
    Additionally, other dental schools in California, Kentucky, 
Missouri, New Mexico, and Oklahoma are exposing students during their 
training to patients covered by Medicaid or the State Children's Health 
Insurance Program (SCHIP). The Illinois at Chicago College of 
Dentistry, the University of Michigan School of Dentistry and the 
College of Dental Medicine Columbia University go further and link 
students to underserved communities in an effort to encourage 
subsequent work with low-income and other vulnerable populations.\5\
---------------------------------------------------------------------------
    \5\ Ryan J. Improving Oral Health: Promises and Prospects. National 
Health Policy Forum Background Paper. Washington, DC, June 2003.
---------------------------------------------------------------------------
    Pipeline, Profession and Practice is a 3-year-old program funded by 
the Robert Wood Johnson Foundation that now involves 27 percent of U.S. 
dental schools. Each school is slated to establish a community-based 
clinical education program and develop recruitment and retention 
programs directed at underrepresented minorities and those from low-
income backgrounds. Even before graduation, students are in a position 
to improve access to oral health care.

                            DENTAL WORKFORCE

    The representation of minorities in the health care workforce has 
not increased in over a decade. Black, Hispanics and American Indians 
represent more than 25 percent of the U.S. population, yet comprise 
less than: 9 percent of nurses, 6 percent of physicians and 5 percent 
of dentists. The U.S. Bureau of Labor Statistics (BLS), which placed 
the number of practicing dentists at 161,000 in 2006,\6\ projects a 9 
percent growth in the number of dentists through 2016. This rate would 
bring the total number of practicing dentists to 176,000.
---------------------------------------------------------------------------
    \6\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
content/ocos072.stm, accessed February 5, 2008.
---------------------------------------------------------------------------
    About 80 percent of dentists are solo practitioners in primary care 
general dentistry while the remaining dentists practice one of nine 
recognized specialty areas: (1) endodontics; (2) oral and maxillofacial 
surgery; (3) oral pathology; (4) oral and maxillofacial radiology; (5) 
orthodontics; (6) pediatric dentistry; (7) periodontics; (8) 
prosthodontics; and (9) public health dentistry.
    The vast majority of the 176,634 professionally active dentists in 
the United States are White non-Hispanic. At the present time the U.S. 
population is 303,375,763.\7\ At the time of the last census, when 
there were 22 million fewer people, the largest segment of the U.S. 
population was White (75 percent), but an increasing percentage was 
minority with 35.3 million (13 percent) Latino, and 34.6 million (12 
percent) Black or African-Americans.
---------------------------------------------------------------------------
    \7\ U.S. Bureau of the Census, http://www.census.gov/population/
www/popclockus.html, accessed February 5, 2008.
---------------------------------------------------------------------------
    The allied dental workforce, comprised of dental hygienists, dental 
assistants and dental laboratory technologists, is central to meeting 
increasing needs and demands for dental care. About 167,000 \8\ dental 
hygienists, 280,000 \9\ dental assistants and 53,000 \10\ dental 
laboratory technologists were in the U.S. workforce in 2006. Both 
dental hygiene and dental assisting are among the fastest growing 
occupations in the country with expected growth of 30 percent and 29 
percent respectively through 2016, bringing the total numbers of dental 
hygienists to about 217,000 and dental assistants to 361,000. Only 
about 2,000 dental laboratory technologists will be added to the 
workforce by 2016. The ability to increase the number is limited. At 
the present time there are only 21 accredited training programs.
---------------------------------------------------------------------------
    \8\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/pdf/
ocos097.pdf, accessed February 5, 2008.
    \9\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos163.htm, accessed February 5, 2008.
    \10\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos238.htm, accessed February 5, 2008.
---------------------------------------------------------------------------
    We must acknowledge that the current dental workforce is unable to 
meet present day demand and need for dental care. If every man, woman 
and child were to have a dental home and were covered by dental 
insurance, the Nation would clearly have an insufficient number of 
dentists to care for the population. We are not close to being at this 
point but we aspire to get there as quickly as possible so everyone who 
needs and wants dental care is able to achieve optimal oral health.
    The need and demand for dental services continues to increase; in 
large measure this is due to the population explosion. Also, Baby 
Boomers as well as the geriatric population, are retaining more teeth 
and there is a growing focus on increasing access and preventative 
dental care.
    Each year academic dental institutions (dental schools, allied 
dental programs and postdoctoral/advanced dental education programs) 
graduate thousands of new practitioners to join the dental workforce. 
About 4,500 predoctoral dental students graduate annually. About half 
of these new graduates immediately sit for a State licensure exam 
before beginning private practice as general dentists, or they join the 
military, the U.S. Public Health Service, or advance their education in 
a dental specialty. Approximately 2,800 graduates along with hundreds 
of practicing dentists apply to residency training programs. Nearly 
23,000 allied dental health professionals graduate from ADIs each year 
and join the dental workforce. Approximately 14,000 dental hygiene 
students, 8,000 dental assistants, and 800 dental laboratory 
technologists graduate annually.
    According to the U.S. Surgeon General, the ratio of dentists to the 
total population has been steadily declining for the past 20 years, and 
at that rate, by 2021, there will not be enough active dentists to care 
for the population. The number of Dental Health Professions Shortage 
Areas (D-HPSAs) designated by the U.S. Health Resources and Services 
Administration (HRSA) has grown from 792 in 1993 to 4,048 in 2008. In 
1993, HRSA estimated 1,400 dentists were needed in these areas; by 
2008, the number grew to 9,432. Nearly 48 million people live in D-
HPSAs across the country. Although it is unknown how many of these 
areas can financially support a dentist or attract a dentist by virtue 
of their infrastructure or location, it is clear that more dentists are 
needed in these areas.

                ORAL HEALTH AND COMMUNITY HEALTH CENTERS

    Over 2,000 counties or partial counties have been designated dental 
Health Professions Shortage Areas where individuals suffer from an 
absolute lack of providers in addition to all of the other barriers 
facing the uninsured and publicly insured. Less than half (875) of 
these dental HPSAs are served by federally qualified health centers 
(837), FQHC look-alikes (6), or rural health clinics (32). Many 
counties eligible for dental HPSA status have not applied for the 
designation, whether because of the administrative burden or for other 
reasons.
    There are over 7,000 community health centers (CHC); 52.8 percent 
are in rural communities.\11\ In calendar year 2007 16 million patients 
were served. The CHC dental workforce includes 6,899 oral health 
professionals: 2,107 dentists, 806 hygienists and 3,986 assistants.\12\
---------------------------------------------------------------------------
    \11\ Health Resource Service Administration. Accessed May 2007.
    \12\ Uniform Data System, 2007 Data.
---------------------------------------------------------------------------
    Currently, community health centers are providing dental services 
to over 2.3 million patients, a growth of 77 percent since 2000. Most 
new dental care patients are likely to be those who lacked access to 
care prior to seeking it at a health center, therefore more likely to 
suffer from caries and periodontal disease and require more intensive 
services than simple preventive care. The people who make up the 
largest proportion of community health center patients, namely low-
income families, members of racial and ethnic minority groups, the 
uninsured and rural residents, experience more unmet oral health care 
needs than other groups, and suffer greater losses to their overall 
health and quality of life as a result. Research shows that the 
provision of preventive dental care is cost-effective.\13\
---------------------------------------------------------------------------
    \13\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health 
Needs of the Medically Underserved. ``Report'' National Association of 
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
    Of existing community health centers 73 percent provide oral health 
services and all new community health centers are now required to 
provide comprehensive oral health care. But challenges persist as these 
centers continue to expand their capacity to better meet the oral 
health needs of their patients. Community health centers cannot bridge 
the gap between the supply and demand for oral health care alone. They 
will continue to depend on the important contributions of the large, 
private dentistry workforce as they work to provide dental care for the 
medically underserved.

                      CHC STATE-BY-STATE ANALYSIS

    Appendices A, B, and C provide state-by-state data on the 
proportion of community health centers providing oral health services, 
community health center dental staff, and related patients and visits 
in 2005. As Appendix A demonstrates, 100 percent of community health 
centers in Vermont and Nevada provide all four major dental service 
categories--preventive, restorative, emergency, and rehabilitative, and 
100 percent of the community health centers in three other States 
(Delaware, Missouri, and New Mexico) provide three out of the four 
services (preventive, restorative, and emergency).
    Appendix B provides for each State information on patients who rely 
on community health center dental services. Not surprisingly, these 
centers in eight large States (California, Florida, Massachusetts, 
Michigan, New York, Pennsylvania, Texas, and Washington) account for 
half of all community health center dental patients. While nationally 
17 percent of all health center patients use health center dental 
services, more than 25 percent of health center patients in six States 
(Connecticut, Michigan, Missouri, Nebraska, Vermont, and Washington) 
receive health center dental services.
    Last, Appendix C provides a close look at community health center 
dental services staffing and visits per dentist and dental hygienist by 
State. Although nationally the average dentist provided 2,719.5 visits 
last year, health centers in three States (California, Florida, and 
Wyoming) provided over 3,000. In addition, the average dental hygienist 
in four States (Connecticut, Maryland, Michigan, and Oregon) and Puerto 
Rico provided over 1,600 visits, compared to the national average of 
1,279.8.

           ORAL HEALTH AND THE NATIONAL HEALTH SERVICE CORPS

    The National Health Service Corps (NHSC) has been important to the 
oral health of the underserved for more than 26 years as it positively 
addresses two public health concerns:

    (1) enabling underserved populations to access qualified, high-
skilled health care practitioners; and
    (2) facilitating continued interest in serving these special 
populations after participants have left NHSC. It is more important 
than ever that the NHSC embrace a bold proactive health agenda. Due to 
the increased focus on children's oral health, the findings reported in 
the U.S. Surgeon General's Report on Oral Health, and increasing 
research data linking oral health to systemic health, the NHSC is of 
paramount importance.

    The National Health Service Corps dispatches clinicians to urban 
and rural communities with severe shortages of health care providers. 
Currently, more than 4,000 NHSC clinicians, including dentists, 
physicians, nurse practitioners, physician assistants, nurse midwives, 
and behavioral health professionals, provide health care services to 
nearly 5 million Americans. About half of all NHSC providers are at 
community health center sites. In order to meet the medical staffing 
needs of underserved communities, including hundreds of vacancies at 
community health centers, the NHSC must be expanded. Scholarship and 
loan repayment programs ease provider shortages with approximately 20 
percent of loan repayment awards currently going to dentists.\14\
---------------------------------------------------------------------------
    \14\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health 
Needs of the Medically Underserved. ``Report'' National Association of 
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
    There are several straightforward steps that Congress can take to 
immediately address the challenges we face. The answer lies in 
prioritizing resources both in terms of manpower and funding to tackle 
these challenges. Some are fairly simple and pragmatic while others, 
admittedly, will require coordination among multiple interested parties 
and compromise. The American Dental Education Association stands ready 
to work with Congress and our colleagues in the dental community to 
ameliorate the access to dental care problems the Nation faces and to 
meet the needs of the future dental workforce. Specifically, we 
recommend:

     Evolution in dental education to involve a more diverse, 
representative student body, greater attention to public health, and 
collaboration with dental hygienists as well as primary care providers 
will help improve access to oral health care in the long term;
     Financial, administrative and clinical support incentives 
will increase the likelihood that dentists at both ends of their 
careers will choose to care for the underserved. Reimbursement and 
remuneration may also need to more closely reflect those in the private 
sector if more dentists are to choose to care for the underserved;
     Innovative programs involving public-private partnerships 
in several States have improved dentist participation in Medicaid and 
increased take-up by eligible persons. These programs provide templates 
for other States to devise solutions to challenges around use;
     Maintain Support and restore adequate funding for Title 
VII General and Pediatric Dentistry Residency Training programs;
     Strengthen and Improve Medicaid;
     Prioritize Dental Access in Rural Health Clinics;
     Bolster Prevention to Eradicate Dental Caries; and
     Establish Dental Homes for Everyone.

                               CONCLUSION

    In conclusion, the American Dental Education Association thanks the 
committee for considering our recommendations with regard to addressing 
access and dental workforce issues. A sustained Federal commitment is 
needed to meet the challenges oral disease poses to our Nation's 
citizens including children, the vulnerable and disadvantaged. Congress 
must address the growing needs in educating and training the oral 
health care and health professions workforce to meet the growing and 
diverse needs of the future. ADEA stands ready to partner with you to 
develop and implement a national oral health plan that guarantees 
access to dental care for everyone, eliminates oral health disparities, 
bolsters the Nation's oral health infrastructure, eliminates academic 
and dental workforce shortages, and ensures continued dental health 
research.
                                 ______
                                 
  Appendix A.--Percent of Community Health Center Grantees Providing 
                 Dental Services Onsite* by State, 2005


----------------------------------------------------------------------------------------------------------------
                                                               Dental       Dental      Dental        Dental
                                                   # Health  preventive  restorative   emergency  rehabilitative
                      State                         center      onsite      onsite      onsite         onsite
                                                   grantees   [percent]   [percent]    [percent]     [percent]
----------------------------------------------------------------------------------------------------------------
Alabama..........................................        15        73.3         73.3        66.7          40.0
Alaska...........................................        24        66.7         58.3        58.3          25.0
Arizona..........................................        14        92.9         85.7       100.0          64.3
Arkansas.........................................        12        75.0         75.0        75.0          50.0
California.......................................        97        74.2         72.2        72.2          44.3
Colorado.........................................        15        80.0         80.0        80.0          73.3
Connecticut......................................        10        90.0         90.0        90.0          70.0
Delaware.........................................         3       100.0        100.0       100.0          33.3
District of Columbia.............................         3        66.7         33.3        33.3          33.3
Florida..........................................        36        69.4         66.7        69.4          47.2
Georgia..........................................        23        65.2         52.2        52.2          34.8
Hawaii...........................................        11        54.5         54.5        54.5          27.3
Idaho............................................        10        70.0         70.0        70.0          60.0
Illinois.........................................        33        75.8         66.7        69.7          45.5
Indiana..........................................        13        61.5         61.5        53.8          53.8
Iowa.............................................         9        77.8         77.8        77.8          66.7
Kansas...........................................         9        55.6         33.3        44.4          33.3
Kentucky.........................................        14        64.3         64.3        57.1          28.6
Louisiana........................................        18        66.7         66.7        55.6          44.4
Maine............................................        16        75.0         62.5        62.5          50.0
Maryland.........................................        13        76.9         69.2        69.2          46.2
Massachusetts....................................        33        72.7         69.7        66.7          51.5
Michigan.........................................        26        76.9         73.1        73.1          61.5
Minnesota........................................        12        66.7         66.7        66.7          33.3
Mississippi......................................        19        84.2         78.9        84.2          36.8
Missouri.........................................        17       100.0        100.0       100.0          82.4
Montana..........................................        12        75.0         66.7        58.3          41.7
Nebraska.........................................         5        80.0         80.0        80.0          20.0
Nevada...........................................         2       100.0        100.0       100.0         100.0
New Hampshire....................................         8        62.5         62.5        50.0          50.0
New Jersey.......................................        17        76.5         70.6        70.6          64.7
New Mexico.......................................        14       100.0        100.0       100.0          78.6
New York.........................................        47        91.5         89.4        85.1          63.8
North Carolina...................................        24        75.0         75.0        75.0          37.5
Oregon...........................................        21        61.9         52.4        57.1          28.6
Pennsylvania.....................................        29        86.2         79.3        82.8          62.1
Rhode Island.....................................         7       100.0        100.0        85.7          42.9
South Carolina...................................        21        33.3         28.6        33.3          28.6
South Dakota.....................................         7        57.1         42.9        42.9          28.6
Tennessee........................................        22        50.0         45.5        50.0          27.3
Texas............................................        43        88.4         86.0        88.4          48.8
Utah.............................................        11        90.9         72.7        72.7          63.6
Vermont..........................................         3       100.0        100.0       100.0         100.0
Virginia.........................................        21        57.1         47.6        57.1          28.6
Washington.......................................        23        95.7         95.7        87.0          52.2
West Virginia....................................        27        44.4         37.0        37.0          22.2
Wisconsin........................................        15        80.0         73.3        73.3          73.3
Wyoming..........................................         5        80.0         20.0        20.0           0.0
----------------------------------------------------------------------------------------------------------------
  United States**................................       952        73.4         68.7        68.8          46.4
----------------------------------------------------------------------------------------------------------------
North Dakota.....................................         4        25.0         25.0        25.0           0.0
Ohio.............................................        23        73.9         69.6        73.9          56.5
Oklahoma.........................................         9        44.4         44.4        44.4          22.2
----------------------------------------------------------------------------------------------------------------
* ``Onsite'' includes services rendered by salaried employees, contracted providers, National Health Service
  Corps Staff, volunteers, and others such as out-stationed eligibility workers who render services in the
  health center's name. Grantees may also provide these services through formal referral arrangements.
** U.S. totals include American Samoa, Fed. States of Micronesia, Guam, Marshall Islands, Virgin Islands, and
  Palau.
Note: Includes only federally-funded health centers, and therefore may underreport the volume of health care
  delivered by health centers.
Source: Bureau of Primary Health Care, HRSA, DHHS, 2005 Uniform Data System.

    Appendix B.--Community Health Center Dental Services Patients, 
    Visits per Patient, and Percent of Total Patients by State, 2005


----------------------------------------------------------------------------------------------------------------
                                                                                          Total patients  using
                State                   Total dental services    Average dental visits       dental services
                                               patients            per dental patient           [percent]
----------------------------------------------------------------------------------------------------------------
Alabama..............................  42,057.................  1.6....................  15
Alaska...............................  16,243.................  1.9....................  21
Arizona..............................  40,353.................  2.2....................  14
Arkansas.............................  18,565.................  1.7....................  15
California...........................  285,460................  2.8....................  14
Colorado.............................  65,018.................  1.9....................  16
Connecticut..........................  58,046.................  1.7....................  29
Delaware.............................  3,874..................  2.1....................  18
District of Columbia.................  13,851.................  1.9....................  18
Florida..............................  102,464................  1.9....................  16
Georgia..............................  24,137.................  1.4....................  10
Hawaii...............................  13,480.................   2.1...................   16
Idaho................................  13,599.................  2.0....................  15
Illinois.............................  66,582.................  1.9....................  9
Indiana..............................  22,089.................  1.8....................  14
Iowa.................................  16,715.................  2.0....................  18
Kansas...............................  4,689..................  1.5....................  8
Kentucky.............................  21,424.................  1.7....................  11
Louisiana............................  27,780.................  1.7....................  22
Maine................................  20,604.................  1.5....................  16
Maryland.............................  27,574.................  1.6....................  16
Massachusetts........................  86,305.................  2.4....................  20
Michigan.............................  113,385................  1.5....................  27
Minnesota............................  29,804.................  1.9....................  24
Mississippi..........................  41,031.................  1.7....................  15
Missouri.............................  71,510.................  2.1....................  24
Montana..............................  18,287.................   1.5...................  24
Nebraska.............................  5,989..................  2.2....................  17
Nevada...............................  Data Unavailable.......  Data Unavailable.......  Data Unavailable
New Hampshire........................  4,550..................  1.1....................  8
New Jersey...........................  57,914.................  2.0....................  22
New Mexico...........................  53,839.................  2.1....................  24
New York.............................  196,811................  2.1....................  18
North Carolina.......................  52,196.................  1.9....................  17
North Dakota.........................  3,726..................  1.8....................  17
Ohio.................................  53,171.................  1.9....................  17
Oklahoma.............................  10,184.................  1.9....................  12
Oregon...............................  41,620.................  1.8....................  21
Pennsylvania.........................  72,543.................  2.1....................  16
Puerto Rico..........................  27,699.................  1.7....................  7
Rhode Island.........................  19,724.................  1.7....................  21
South Carolina.......................  11,319.................  1.6....................  4
South Dakota.........................  7,353..................  2.0....................  15
Tennessee............................  29,648.................  1.7....................  12
Texas................................  117,025................  1.9....................  18
Utah.................................  13,169.................  1.8....................  16
Vermont..............................  10,526.................  1.6....................  30
Virginia.............................  21,803.................  1.8....................  11
Washington...........................  174,972................  2.2....................  30
West Virginia........................  23,653.................  1.5....................  8
Wisconsin............................  37,513.................  1.9....................  24
Wyoming..............................  4,779..................  1.6....................  25
                                      --------------------------------------------------------------------------
  United States*.....................  2,340,710..............  2.4....................  17
----------------------------------------------------------------------------------------------------------------
* U.S. totals include American Samoa, States of Micronesia, Guam, Marshall Islands, Virgin Islands, and Palau.
Note: Includes only federally-funded health centers, and therefore may underreport the volume of health care
  delivered by health centers.
Source: Bureau of Primary Health Care, HRSA, DHHS, 2005 Uniform Data System.

   Appendix C.--Community Health Center Dental Services Staffing and 
                         Visits by State, 2005


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                        Dental
            State               Dentist visits    Visits per FTE       hygienist      Visits per FTE    Dental support    Total dental     Total dental
                                                      dentist           visits           hygienist        staff* FTE      services FTE   services visits
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama......................  67,204..........  2,941.1.........  19,945..........  1,360.5.........  36.8...........  74.3...........  87,149
Alaska.......................  31,210..........  2,100.3.........  3,429...........  546.0...........  29.2...........  50.3...........  34,639
Arizona......................  88,994..........  2,604.4.........  21,737..........  1,232.3.........  96.5...........  148.3..........  110,731
Arkansas.....................  31,030..........  2,800.5.........  5,486...........  1,284.8.........  24.3...........  39.7...........  36,516
California...................  808,672.........  3,239.2.........  28,780..........  1,100.6.........  497.6..........  773.4..........  837,452
Colorado.....................  122,860.........  2,642.7.........  22,624..........  1,147.3.........  102.9..........  169.1..........  145,484
Connecticut..................  100,335.........  2,837.5.........  45,555..........  1,867.0.........  58.6...........  118.4..........  145,890
Delaware.....................  8,278...........  1,851.9.........  1,646...........  1,266.2.........  5.7............  11.5...........   9,924
District of Columbia.........  25,756..........  2,846.0.........  0...............  0.0.............  11.8...........  20.8...........  25,756
Florida......................  195,566.........  3,177.9.........  34,402..........  1,284.1.........  126.2..........  214.5..........  229,968
Georgia......................  34,186..........  2,387.3.........  8,682...........  1,205.8.........  22.2...........  43.7...........  42,868
Hawaii.......................  28,702..........  1,807.4.........  2,122...........  742.0...........  28.0...........  46.8...........  30,824
Idaho........................  26,655..........  469.2...........  5,342...........  1,077.0.........  19.2...........  35.4...........  31,997
Illinois.....................  128,316.........  3,050.1.........  12,073..........  1,223.2.........  73.0...........  124.9..........  140,389
Indiana......................  39,730..........  2,579.9.........  11,668..........  1,511.4.........  29.0...........  52.1...........  51,398
Iowa.........................  34,056..........  2,742.0.........  5,985...........  1,031.9.........  31.5...........  46.7...........  40,041
Kansas.......................  7,177...........  2,648.3.........  1,866...........  790.7...........  6.0............  11.1...........  9,043
Kentucky.....................  37,280..........  2,782.1.........  9,184...........  1,111.9.........  24.6...........  46.2...........  46,464
Louisiana....................  48,409..........  2,384.7.........  2,746...........  888.7...........  30.4...........  53.8...........  51,155
Maine........................  31,140..........  2,077.4.........  25,309..........  1,202.3.........  30.4...........  66.4...........  56,449
Maryland.....................  45,259..........  2,935.1.........  5,994...........  1,927.3.........  24.3...........  42.9...........  51,253
Massachusetts................  205,754.........  2,870.1.........  37,419..........  1,514.3.........  94.8...........  191.2..........  243,173
Michigan.....................  174,784.........  2,703.5.........  79,163..........  1,663.1.........  114.1..........  226.4..........  253,947
Minnesota....................  56,932..........  2,564.5.........  14,316..........  944.3...........  28.6...........  66.0...........  71,248
Mississippi..................  68,943..........  2,496.1.........  7,991...........  1,225.6.........  40.9...........  75.1...........  76,934
Missouri.....................  148,374.........  2,582.2.........  20,709..........  1,320.7.........  108.0..........  181.1..........  169,083
Montana......................  27,351..........  2,811.0.........  7,146...........  1,791.0.........  16.5...........  30.2...........  34,497
Nebraska.....................  13,359..........  2,515.8.........  1,332...........  672.7...........  11.7...........  19.0...........  14,691
Nevada.......................  Data Unavailable  Data Unavailable  Data Unavailable  Data Unavailable  Data             Data             Data
                                                                                                        Unavailable.     Unavailable.     Unavailable
New Hampshire................  5,145...........  2,198.7.........  3,969...........  1,160.5.........  2.5............  8.3............  9,114
New Jersey...................  116,724.........  2,824.2.........  6,497...........  1,486.7.........  65.6...........  111.3..........  123,221
New Mexico...................  110,404.........  2,455.1.........  28,684..........  1,221.6.........  92.2...........  160.7..........  139,088
New York.....................  408,533.........  2,468.0.........  78,776..........  1,558.1.........  251.2..........  467.3..........  487,309
North Carolina...............  96,581..........  2,530.3.........  18,872..........  1,217.5.........  71.2...........  124.8..........  115,453
North Dakota.................  6,777...........  2,823.8.........  1,337...........  568.9...........  5.6............  10.3...........  8,114
Ohio.........................  103,027.........  2,762.9.........  15,728..........  1,012.7.........  72.4...........  125.3..........  118,755
Oklahoma.....................  19,325..........  2,049.3.........  3,233...........  829.0...........  15.9...........  29.2...........  22,558
Oregon.......................  73,311..........  2,260.6.........  24,353..........  1,742...........  63.4...........  109.8..........  97,664
Pennsylvania.................  154,850.........  2,517.5.........  33,388..........  1,239.8.........  97.1...........  185.5..........  188,238
Rhode Island.................  32,567..........  2,649.9.........  19,375..........  1,490.4.........  31.4...........  56.7...........  51,942
South Carolina...............  18,227..........  2,112.1.........  4,494...........  1,129.1.........  13.6...........  26.2...........  22,721
South Dakota.................  14,358..........  2,033.7.........  3,845...........  1,248.4.........  14.7...........  24.8...........  18,203
Tennessee....................  49,224..........  2,507.6.........  4,359...........  736.3...........  26.4...........  51.9...........  53,583
Texas........................  224,858.........  2,543.6.........  46,622..........  1,185.4.........  186.1..........  313.8..........  271,480
Utah.........................  23,232..........  2,242.5.........  3,176...........  1,549.3.........  17.8...........  30.2...........  26,408
Vermont......................  16,881..........  2,718.4.........  10,030..........  1,297.5.........  12.1...........  26.1...........  26,911
Virginia.....................  40,317..........  2,599.4.........  2,660...........  537.4...........  33.4...........  53.9...........  42,977
Washington...................  391,782.........  2,893.3.........  30,543..........  1,000.4.........  333.3..........  499.2..........  422,325
West Virginia................  36,623..........  2,886.0.........  10,689..........  1,138.3.........  26.9...........  49.0...........  47,312
Wisconsin....................  72,454..........  2,575.7.........  17,672..........  979.1...........  57.3...........  103.5..........  90,126
Wyoming......................  7,779...........  3,758.0.........  4,065...........  2,032.5.........  4.1............  8.2............  11,844
Puerto Rico..................  45,797..........  2,346.2.........  5,382...........  2,152.8.........  28.3...........  50.3...........  51,179
                              --------------------------------------------------------------------------------------------------------------------------
  United States*.............  4,728,590.......  2,719.5.........  834,042.........  1,297.8.........  3,268.2........  5,649.6........  5,562,632
--------------------------------------------------------------------------------------------------------------------------------------------------------
FTE = Full-time employed.
* Includes Dental Assistants, Aids, and Technicians.
** U.S. totals include American Samoa, States of Micronesia, Guam, Marshall Islands, Virgin Islands, and Palau.
Note: Includes only federally-funded health centers, and therefore may underreport the volume of health care delivered by health centers.
Source: Bureau of Primary Health Care, HRSA, DHHS, 2005 Uniform Data System.


    Senator Sanders. Dr. Evans, thank you very much. Yvonne 
Davis is a board member with the Community Health Center in 
Florence, SC. And one of the interesting aspects about 
federally qualified community health centers is they are run by 
the community, itself, and Ms. Davis, thank you so much for 
being with us.

   STATEMENT OF YVONNE DAVIS, COMMUNITY HEALTH CENTER BOARD 
                      MEMBER, FLORENCE, SC

    Ms. Davis. Thank you, Mr. Chairman. To my own Congressman 
Clyburn, and members of the committee as well, for the 
invitation to speak to you today. This is a topic that I care 
deeply about and I appreciate the chance to share my thoughts 
with you.
    My name is Yvonne Davis, I'm from Florence, SC. I have been 
employed at Francis Marion University as a Resource and 
Acquisitions Coordinator for about 28 years. Today I am here as 
a community health center patient, advocate and consumer board 
member. I have been a part of the community health center 
movement for about 18 years now, as both a health center 
patient and a community board member at Health Care Partners of 
South Carolina, Incorporated.
    I have never been more excited for the world to witness and 
hear what our community health center is and to learn what it 
is all about.
    I come from Marion, SC. It's my home, which is a very small 
town about 45 miles north of Myrtle Beach. Communities there 
are close knit, and of course, gatherings there are still alive 
and well. My home town, at one time, was booming with many 
jobs, and life was good. Then as years passed, they all seemed 
to just disappear; no jobs, no insurance, no unemployment 
benefits means no health care.
    Having the health center in our community has made it 
possible for people who have lost their jobs to still receive 
access to quality care, purchase medicine at a reduced price, 
and be educated about preventive measures they can take to live 
a normal and productive life.
    The story I would like to share with you is about my 
brother, Dwayne. After being laid off from his job of 20-plus 
years, and suffering a series of personal tragedies, as if he 
had no reason to live, Dwayne went into a state of depression. 
One day I went to visit him and found him in a condition I 
couldn't believe.
    I took him to our community health center for a complete 
examination. The doctor called me and informed me that my 
brother had suffered a heart attack. What a shocker. Luckily, 
he survived.
    Now my brother receives health care at the health center 
and is sharing the information about the center with his 
friends who are in need as well. And he says to me quite often, 
``Thank you.''
    Since that time I have vowed to advocate for community 
health centers. We are truly blessed to have access to a place 
like Health Care Partners in our community and receive the 
comprehensive care that they provide.
    Now, my role as a community health center board member. 
Consumer board members in my center go out to church services, 
civic meetings, and town functions and share information about 
the services provided by our health center. We don't want 
anyone to go without care simply because they're not aware of 
our health center.
    I am thinking about an instance I am particularly proud of, 
and that is when we worked with one of our local high schools 
there--we housed a school-based plan and saw their numbers of 
teenage pregnancy, STD's, and other conditions decrease. That 
pride turned to disappointment when we could no longer provide 
the services due to limited funds.
    There is an emergency call from the community for us to 
return. So we must find a way to answer their call.
    I have witnessed the power of community health centers 
firsthand, and I know that all across the country America's 
health centers are ready to lead the way in health reform by 
providing high quality, affordable, accessible primary and 
preventive care to anyone in need. Thank you.
    [The prepared statement of Ms. Davis follows:]

                   Prepared Statement of Yvonne Davis

                                SUMMARY

    I'm here as a community health center patient, advocate and 
community board member.

     I've been a part of the community health center movement 
about 18 years now, as both a health center patient for 16 years and a 
community board member for 18 years at Health Care Partners of South 
Carolina, Inc.
     I come from a very small town about 45 miles north of 
Myrtle Beach, SC. My hometown at one time was booming with many jobs 
for the citizens of Marion as well as the connecting counties, and life 
was good. Then as years passed they all just seem to have disappeared; 
no jobs, no insurance, no unemployment benefits, means no health care.

    Having the health center is critically important to our community 
and it has been to me personally.

     I've had allergy problems since I was a kid. It was our 
physician at the community health center who taught me how to live a 
more comfortable life during the high allergy season. I no longer felt 
like it was a waste of time to seek a physician's help when my eyes 
were always running and red all the time and I spent little or no time 
outside.
     My brother Dwayne was very ill and actually suffered a 
heart attack after years of not seeing a doctor. His experience 
motivated me to advocate for community health centers because there are 
many more cases just like my brother's: people who, if they had access 
to the right care at the right time, could avoid the pain and cost of 
hospitalization.

    As a board member, I make it a priority to get out in the community 
and spread the word on health centers.

     Volunteer consumer board members at my center make it a 
point to get out to church services, civic meetings and town functions 
and share information about the services provided by our community 
health center.
     We don't want anyone to go without care simply because 
they aren't aware of the health center.
     Funding constraints have limited our ability to advertise, 
but the good news is that there is no better advertisement than 
recommendations coming from community leaders that are now patients of 
the center.
     Because of the recession we're facing serious problems 
with providing coverage for the higher demand. Patients are constantly 
calling asking for more office hours.

    I have witnessed the power of community health centers first hand 
as a patient and board member. I know that all across the country, 
America's Health Centers are ready to lead the way in health reform, 
providing high-quality, affordable, accessible primary and preventive 
care to anyone in need.
                                 ______
                                 
    Good morning. Thank you, Mr. Chairman and members of the committee, 
for the invitation to speak to you today. This is a topic that I care 
deeply about, and I appreciate the chance to share my thoughts with 
you.
    My name is Yvonne G. Davis of Florence, SC. I've been a State 
employee for 28 years at Francis Marion University as the Resource & 
Acquisitions Coordinator for the library.
    Today I'm here as a community health center patient, advocate and 
community board member. I've been a part of the community health center 
movement about 18 years now, as both a health center patient for 16 
years and a community board member for 18 years at Health Care Partners 
of South Carolina, Inc. I have never been more excited for the world to 
witness and hear what community health centers are all about.
    I come from a very small town about 45 miles north of Myrtle Beach, 
SC. Communities there are close knit and family gatherings are still 
alive and well. My hometown at one time was booming with many jobs for 
the citizens of Marion as well as the connecting counties, and life was 
good. Then as years passed they all just seem to have disappeared; no 
jobs, no insurance, no unemployment benefits, means no health care.
    Having the health center in our community has made it possible for 
people who have lost their jobs to still receive access to quality 
care, purchase medicine at a reduced price, and be educated about 
preventive measures they can take to live a normal and productive life.
    You see, I've had allergy problems since I was a kid, and if any of 
you suffer from them, then you know where I'm coming from. It was our 
physician at the community health center who taught me how to live a 
more comfortable life during the high allergy season. I no longer felt 
like it was a waste of time to seek a physician's help when my eyes 
were always running and red all the time and I spent little or no time 
outside. What a difference it makes when your doctor makes you feel as 
if he or she really cares. The service at my health center is excellent 
and I would recommend the center to any of my family members. My mother 
who at the time lived in St. Petersburg, FL had a serious stroke and 
could no longer take care of herself; once we relocated her to the 
Carolina's, we immediately registered her as a patient at the health 
center.
    She was diagnosed with several serious conditions: hypertension, 
renal failure, diabetes, congestive heart failure, etc. This was a big 
adjustment for my family and we really didn't know what to expect. It 
was the assistance of the center's staff and other specialists that 
made life a little easier for us and we're so grateful. The quality of 
care she received was just unreal. If you can please my mother, then 
you must be doing something right.
    But the real story is about my brother Dwayne. I remember so 
clearly the day when Dwayne, who is just 11 months older than me, was 
laid off from his job of 20+ years. Not only did he lose his job, but 
within a 16-month timeframe, his only son was killed in a car accident, 
our oldest brother who was a disabled veteran died of medical problems, 
our mother had a stroke, and Dwayne's wife was diagnosed with a lung 
disease then later died. It was if he had no reason to live. Dwayne 
went into a state of depression like never before, and it was like we 
had lost another family member.
    In August 2007, I attended the National Association of Community 
Health Center's (NACHC) annual Community Health Institute conference in 
Dallas, TX and had invited my brother Dwayne to travel with me just to 
get him away. For a life-long Dallas Cowboy fan to quickly turn me down 
was shocking. I immediately went to visit him and found him in a 
condition I couldn't believe. I promised myself and him that he was my 
candidate for take a love one to the doctor day, and I did just that.
    After a complete examination and several tests the Doctor called me 
in and informed me that he thought my brother suffered a heart attack 
and the ambulance was on its way. What a shocker. I saw the look on his 
face from the news and knew that he was afraid. He was afraid for 
several reasons, one, because he didn't have any insurance and wasn't 
sure what would happen because he had no money. After completing 
applications for public assistance, patient care services, etc., he was 
finally admitted to the hospital then immediately put into the 
intensive care unit. A quadruple bypass operation was recommended after 
a series of tests. He had 96.5 percent blockage.
    After spending about 14 days in the hospital, we all know who ended 
up paying for that bill: yes, taxpayers. His excuse for not seeing a 
doctor earlier was after paying his utility and other bills he just 
didn't have the money. My brother is now sharing the information about 
the community health center with his friends that may be in the same 
shape he was in, and says to me, thank you. ``That Health Center is 
alright with me,'' I didn't know they had it like that.
    Since that time I have vowed to advocate for Community Health 
Centers because there are many more cases just like my brother's: 
people who, if they had access to the right care at the right time, 
could avoid the pain and cost of hospitalization. We truly are blessed 
to have access to a place like Health Care Partners in our community, 
and to receive the comprehensive care they provide, regardless of the 
ability to pay.
    I would also like to speak a little about my role as a community 
board member. Volunteer consumer board members at my center make it a 
point to get out to church services, civic meetings and town functions 
and share information about the services provided by our community 
health center. We don't want anyone to go without care simply because 
they aren't aware of the health center. Funding constraints have 
limited our ability to advertise, but the good news is that there is no 
better advertisement than recommendations coming from community leaders 
that are now patients of the center. Because of the recession we're 
facing serious problems with providing coverage for the higher demand. 
Patients are constantly calling asking for more office hours. With your 
help we can make that happen. The need of our people is why we're here.
    In thinking about an instance I am particularly proud of, I think 
one example is when one of the local high schools where we housed a 
school-based clinic saw their numbers of teenage pregnancy, STDs, and 
other conditions decrease during the time we were on campus. That time 
of being proud turned to disappointment when we could no longer provide 
these services within the school. There is an emergency call from the 
community for us to return, so we must.
    I have witnessed the power of community health centers first hand 
as a patient and board member. I know that all across the country, 
America's Health Centers are ready to lead the way in health reform, 
providing high-quality, affordable, accessible primary and preventive 
care to anyone in need.

    Senator Sanders. Thank you very much, Ms. Davis.
    John Matthew is a physician and the director of the health 
center in Plainfield, VT. In Vermont, we have gone, in the last 
6 years, from two community health centers, FQHCs, to eight. 
And John, at Plainfield, is doing an outstanding job. Dr. 
Matthews, thank you very much for being here.

    STATEMENT OF JOHN D. MATTHEW, M.D., THE HEALTH CENTER, 
                         PLAINFIELD, VT

    Dr. Matthew. Thank you, Senator Sanders, Representative 
Clyburn and members of the committee. Thank you for having us 
here today.
    I have been practicing primary care medicine in rural 
Vermont for 36 years. When good, accessible primary care is 
available, it still is most costly when provided in a 
multispecialty setting. It's almost as expensive in the hands 
of internal medicine physicians, and is much less costly in 
family medicine practices. The care is most economical, with 
equal outcomes, in community health centers, just published in 
Health Affairs, this very week, same as it was a decade ago. 
When care is unavailable, those who lack access pay the price 
and society pays the bill.
    Rural communities, suburbs and city neighborhoods, all 
would do well to have accessible good health care through 
FQHCs. These services, I want to emphasize, are not only for 
the poor, the uninsured or the Medicaid population. FQHCs 
provide care to all persons, regardless of their ability or 
inability to pay. We do not discriminate against those who are 
insured.
    At our health center, we have a motto, we do ``Health Care 
the Way it Ought to Be,'' everyday for every one.
    Our organization, The Health Center in Plainfield, 
functioned for years as a freestanding nonprofit rural health 
center. It was a struggle to keep the organization afloat. We 
had to scrimp and save all the time to break even at each 
year's end. We were always restrained by very tight finances.
    Since becoming an FQHC 2 years ago, we've been able to 
expand the number of uninsured persons we see, and our active 
patient population has increased from 7,800 to 9,400 persons. 
By this fall, our staff will have grown from 34 full-time and 
19 part-time employees to 47 full-time and 30 part-time 
employees. We anticipate that we will be able to take care of 
1,200 to 1,800 more medical patients, 2,000 more dental 
patients and 2,400 kids and adolescents around the State with a 
mobile dental program. We have consolidated our fiscal position 
and are poised to do more in behavioral health, mental health, 
dental health, access to 340b pharmacy and physical therapy, 
which is now in-house.
    It is an enormous relief as head of the agency to be on a 
more solid financial footing. And as a physician, it's 
extremely gratifying to be able to provide a broader scope of 
services and to care for all of our patients, and to offer more 
sliding scale and nominal charge care to the unfortunate, the 
downtrodden and the marginalized, and now with the newly 
unemployed and uninsured who are suffering in the current great 
recession.
    Many of these improvements and our ability to address our 
community's needs would be impossible without our having become 
a FQHC. Others would have occurred only slowly and 
incrementally because tight finances would constrain innovation 
and the starting of new or expanded services, despite these 
being badly needed by the population.
    Expansion of funding for FQHCs and for the National Health 
Service Corps has the potential to help reverse the decline of 
primary care and bring excellent, accessible care to all in all 
of our communities.
    This is the essence of health care reform. This is what 
America needs, not just for the poor and uninsured, but for all 
of us. Health care for all.
    [The prepared statement of Dr. Matthew follows:]

              Prepared Statement of John D. Matthew, M.D.

                                SUMMARY

    Good, accessible primary care is the essential foundation of all 
health care and for any hope of constraining the costs of health care 
for the Nation. But primary care is, and has been for a decade or more, 
in precipitous decline, with some 60 million Americans now unable to 
find a personal physician. Arresting and reversing this decline must be 
a matter of the highest priority.
    When primary care is available, it is most costly when provided in 
multi-specialty settings. It is almost as expensive in the hands of 
Internal Medicine physicians, and it is much less costly in Family 
Medicine practices. But care is most economical, with equal outcomes, 
in Community Health Centers (Federally Qualified Health Centers or 
FQHCs).
    When care is unavailable, those who lack access pay the price and 
society pays the bill.
    Rural communities, suburbs, and city neighborhoods, to have 
accessible care for all, need to have an FQHC in their area. These 
services are not only for the poor, the uninsured, or the medicaid 
population. FQHCs provide care to all persons regardless of their 
inability--or ability--to pay. We do not discriminate against those who 
are insured or economically better off.
    We do ``Health Care the Way it Ought to Be'' every day, for 
everyone.
    Our organization, The Health Center in Plainfield, VT, functioned 
for years as a freestanding nonprofit Rural Health Clinic. It was a 
struggle to keep the organization afloat, We had to scrimp and save all 
we could to break even at each year's end. We were always restrained by 
very tight finances.
    Since becoming an FQHC 2 years ago, we have been able to expand the 
number of uninsured persons we serve on sliding scale and our active 
patient population has increased from 7,800 persons to 9,400 persons. 
By this fall our staff will have grown from 34 full-time and 19 part-
time employees to 47 full-time and 30 part-time staff members. We are 
consolidating our fiscal position and are poised to do much more, with 
more medical, dental, and behavioral health patients and more persons 
accessing our 340b pharmacy program, all with sliding scale discounts 
for uninsured persons with incomes below 200 percent of the federally 
determined level of poverty.
    To accommodate the unmet need, we will add a physician and a 
physicians assistant this summer. We anticipate taking care of about 
1,200 to 1,800 more medical patients with this summer's staff 
additions, with eventual growth to 12,000 patients. Adding two dentists 
this fall and another in December will allow our staffing a dental care 
mobile in six locations around the State and will allow our caring for 
about 2,000 more patients in the dental service of the center. We will 
also see substantial growth in our behavioral health and 340b pharmacy 
services.
    It is an enormous relief as head of the agency to be on a more 
solid financial footing. And as a physician it is extremely gratifying 
to be able to provide a broader scope of services and care to all our 
patients and to offer more sliding scale and nominal charge care for 
the unfortunate, the downtrodden, and the marginallized--and now for 
the newly unemployed and uninsured who are suffering in the current 
great recession.
    Many of these improvements in our ability to address our 
community's needs would be impossible without our having become an 
FQHC. Others would only occur slowly and incrementally, because tight 
finances would constrain innovation and the starting of new or expanded 
services, despite those being badly needed by the population.
    Expansion of funding for FQHCs and for the NHSC has the potential 
to help reverse the decline of primary care and to bring excellent, 
accessible care to all--in all of our communities.

          This is the essence of health care reform.
          This is what America needs.
          Not just for the poor or the uninsured--but for all of us.
          Health Care for All.
           The Coming Crisis in Primary Care is Soon Upon Us
    Vermonters were pleased recently to have been told we live in the 
healthiest State in the Nation. The State launched the new Catamount 
health plan, an ambitious effort to reduce the number of persons 
without health insurance in the State. The UVM School of Medicine was 
rated very highly for its education of primary care physicians. The 
past 2 years have seen the expansion in Vermont of Federally Qualified 
Health Centers chartered to serve all persons in their geographic area, 
regardless of their ability to pay.
    But these recognitions, innovations, ratings, and successes have 
occurred in circumstances that, beneath the radar of most of the public 
and many policymakers, threaten to undermine our collective efforts to 
make health care available to all, especially in rural areas. In fact, 
the very structure of our health care system, if it should be called a 
system, is threatened by the coming collapse of primary care, which is 
the foundation of quality and any hope of economy in this realm.
    There is a substantial and worsening lack of physicians and 
dentists to work in primary care nationwide, with rural areas suffering 
disproportionate shortages. While our need for these essential 
professionals is projected to grow by as much as 40 percent in the 
coming decade, the number of medical students moving on to primary care 
residencies after graduation has fallen by about 50 percent in the last 
10 or 12 years. Our cadre of primary care providers, both medical and 
dental, is aging and not being replaced. If this trend continues--and 
it appears to be accelerating--we will find ourselves in a circumstance 
with 50 percent of our present supply trying to provide care for 140 
percent of our present demand. This may understate the problem, since 
the aging population, in little more than 20 years, will need about 
seven times the present number of geriatric physicians, a group already 
available at half of current need.
    About half of the estimated 56 million Americans who now have no 
primary care doctor have health insurance but still can find no source 
of primary care. We are already seeing many practices in Vermont closed 
to new patients and the professionals working longer hours to take care 
of those enrolled in their practices. In Vermont, and across the 
Nation, increasing numbers of patients are being seen and experiencing 
worsening delays in our emergency rooms. This trend has been aggravated 
in other States by the closure of many ERs by for-profit hospitals 
which have discovered that these services lose money, particularly as 
they attract the uninsured and the down and out. The care that people 
without a regular source of primary care receive, if they do receive 
care, is almost certain to be much more costly, in both the short and 
the longer run, in financial and in human terms.
    Primary care is one of the most challenging disciplines in 
medicine, requiring broad scientific knowledge and exceptional 
interpersonal ``soft'' skills. It is also one of the most rewarding, 
involving long-term relationships with individuals and families which 
many other specialties do not offer. It is also the most cost-effective 
component of our system. But primary care is in trouble.
    Many primary care physicians, feeling under appreciated and under 
reimbursed compared to their professional colleagues in other fields, 
report diminished satisfaction with their professional work. After 
working more and more un-reimbursed hours contending with Medicare 
pharmacy program companies and an unending stream of prior approval 
forms, changing formularies, and barriers to care, some are getting out 
of practice. They are not recommending similar careers to their 
children or others, and increasingly report feeling undervalued, 
overworked, and taken for granted.
    There are many disincentives to choosing primary care that devolve 
from our medical education system, including what sort of person is 
chosen to be admitted to medical school, how they are influenced by the 
role models and practice organizations in academic medical centers, and 
the great costs they confront to get through college, medical school, 
and residency training before starting practice. Medical students 
graduate with substantial debt after 4 years of college and 4 years of 
medical school, so they are apt to opt for specialties that provide 
higher incomes after residency training. For the same time in training 
and no less work, primary care incomes are often half or a third of 
what other specialists earn.
    We not only have half as many graduating doctors choosing primary 
care post-graduate training but also find that half of the new 
residents in family medicine programs are graduates of foreign medical 
schools, half of whom are foreign nationals. We do not seem to be able 
to manage to attract and educate enough of our own bright young people 
to take care of our own population.
    Unlike attorneys, physicians can not bill for telephone work or 
most paperwork, so roughly 35 percent of the regular working hours of 
primary care physicians are not reimbursed. The average family 
physician, prior to the extra hours demanded by managed care and 
pharmacy benefits management companies, worked a 54-hour week, not 
including the hours on call with a beeper on their belt or a phone on 
the bedside table. More and more ``free'' work is the result of 
companies, often for profit companies, requiring physicians and their 
staff to complete forms, answer questionnaires, or make telephone calls 
to justify their decisions in order to have their patients receive 
care.
    The private physicians still attempting to survive in unsubsidized 
situations are trying to make ends meet with increasing numbers of 
persons in the expanded Medicaid program, which nickels and dimes 
providers at every turn. Medicaid also has its own formulary program, 
which adds to the difficulty of caring for these patients. Quite a 
number of these physicians are limiting or ceasing enrollment of 
Medicaid patents in their practices, because of the poor reimbursement.
    One of the great ironies of our present circumstance is that State 
government, the State colleges, and some of our leading and more 
successful companies reduce their operating costs by insuring with 
Cigna, which, when patient management fees are taken into account, pays 
primary care providers in the fee-for-service sector less than Medicaid 
pays. The State and some employers often appear to be surprised and 
even mystified by the shrinking supply of doctors for their 
beneficiaries and employees, but some simple accounting would solve the 
mystery. (It's the reimbursement, stupid.)
    The public, where primary care is still available, seems unaware of 
the accelerating crisis in access that faces all of our citizens. If 
they knew the true situation, there might be a clamor for solutions, 
but any of these, when adopted, will take years to change the supply of 
doctors for the population. Things are virtually certain to get much 
worse before getting better, if that is going to happen. The primary 
care system, with dwindling numbers of providers contending with 
increasing patient loads and expanding mandates, dictates, expectations 
and demands, including those of such laudable quality initiatives as 
the Vermont Blue Print for Health, is much closer to breaking down than 
most people realize.
    Those leading the march to health care reform run the risk of 
turning around to discover that there are no primary care physicians 
and dentists behind them in the parade. Those who do continue in the 
work--some would say the calling--of taking care of the sick will all 
be entirely too busy with patients who are aging and have more complex 
illnesses, while trying to get pharmaceuticals and tests approved by 
companies which increase their profits--or non-profit insurers which 
must try to compete with those companies--by reducing access to care.
    Also missing from the parade will be the numerous Physician's 
Assistants and Nurse Practitioners who are essential and capable 
components in our primary care efforts. They too will be overwhelmed as 
more and more need confronts our shrinking numbers, physicians and 
``physician extenders'' alike.
    There will be increasing numbers of foreign medical graduates 
filling out the ranks of America's primary care providers, but leaving 
their native lands with even less care in a global brain drain to the 
more affluent United States. Hospitals will increasingly employ primary 
care providers, subsidizing their practices by shifting income from 
imaging and surgery services to attract and retain primary care 
doctors, whose value is not as obvious until they are not available in 
their communities.
    President Bush may be proven to have been inadvertently prescient 
when he stated recently that all Americans have access to health care 
because they can go to the emergency room. More and more, this will be 
the health care entry point of necessity: crowded, expensive, and 
poorly suited to attend to the tasks of primary care. It is a chaotic 
and worrisome picture to contemplate.
                                 ______
                                 
    Mr. Chairman, members of the committee, my name is John Matthew. I 
am a primary care physician. I have been practicing primary care 
medicine in rural Vermont for the past 36 years. I appreciate the 
opportunity to offer to you my insights and opinions concerning the 
crisis in primary care access and the potential that Community Health 
Centers and The National Health Service Corps offer to address this 
core challenge in our present circumstances and to any health care 
reform program the Nation may undertake.
    Good, accessible primary care is the essential foundation of all 
care and for any hope of constraining the costs of health care for the 
Nation. But primary care is, and has been for a decade or more, in 
precipitous decline, with some 60 million Americans now unable to find 
a personal physician. The causes and consequences of this situation are 
multiple and complex. I addressed some of these last year in the 
appended article, ``The Coming Crisis in Primary Care is Soon Upon 
Us,'' which provides some detail concerning the dynamics of this 
accelerating calamity.
    Arresting and reversing this decline must be a matter of the 
highest priority. Without an adequate supply of primary care providers, 
located and organized to make accessible, high quality care available 
to all residents in all of our communities, good health care is in 
jeopardy. Care will not just be less and less available, it will, when 
accessed, be of lower quality and of much greater cost, in human and in 
economic terms. Without primary care the population delays care, visits 
emergency rooms as sources of basic care, and often uses medical sub-
specialists in lieu of those trained to provide primary care.
    When primary care is available, it is most costly when provided in 
multi-specialty settings. It is almost as expensive in the hands of 
Internal Medicine physicians, much less costly in Family Medicine 
practices, and most economical, with equal outcomes, in Community 
Health Centers (Federally Qualified Health Centers or FQHCs). There are 
also short- and long-term impacts on health and on health care costs 
that devolve from primary care quality and availability, or the lack of 
these, played out in other settings and for years to come. Early 
intervention, preventive medicine, and risk factor control are key 
parts of good primary care. Those who lack access pay the price and 
society pays the bill.
    The days of physicians setting up shop in small communities and 
suburbs, even if we did train a sufficient number to care for the 
population, are going fast, if not gone. No primary care physician has 
set up a private practice in Central Vermont in many years. Most 
physicians now are not entrepreneurs: they seek employment in which 
they can practice on a salary and without investing in buildings, 
equipment, and staff. Rural communities, suburbs, and city 
neighborhoods, if they are to have accessible care would do very well 
to have an FQHC in their area, providing an organizational structure, 
economies of scale, economies of scope, efficient use of providers 
organized in teams of physicians and mid-level practitioners, 
integration of behavioral health services, well-equipped dental units, 
community outreach and social services, and access to less costly 
prescription medications. With a community board of directors in 
charge, the program of each FQHC can be tailored to the needs of its 
particular community. These services are not only for the poor, the 
uninsured, or the medicaid population. FQHCs provide care to all 
persons regardless of their inability--or ability--to pay. We do not 
discriminate against the insured or better off in our population. We 
take pride in providing care as good as or better than that which 
insured persons might find anywhere else to everyone, whatever their 
insurance status.
    Just as all politics is local, so is all health care, whether in an 
exam room or in the community. Every community is different in some 
way. We need flexible, locally controlled institutions such as FQHCs to 
organize and operate the structures which can tailor their programs to 
meet local needs. These established agencies can then better attract 
professionals to provide the primary health services--medical, dental, 
mental health, and medications--needed in every community, rural or 
otherwise. FQHCs are the prototypical patient-centered medical homes, 
committed to patient participation in their care and viewing health 
care as far more than a series of episodic or periodic office visits. 
Informing and empowering people are key concepts of the community 
health center movement.
    Our organization's evolution and the value of our becoming a 
Federally Qualified Health Center to the people whom we serve is 
illustrative. At the start we established The Health Center as a non-
profit corporation, which employs the staff and owns the practice. We 
have always had a board of directors made up of community members and 
it has always been our mission to provide care for everyone from our 
area who wants to come to the center, whatever their insurance status. 
We functioned for years as a freestanding Rural Health Clinic (RHC). 
The RHC caps for cost-based reimbursement were always too low. We lost 
money on every Medicare and Medicaid office visit and it was a struggle 
to keep the organization afloat, though we always did. Our sliding 
scale was self-funded, in the sense that we had no outside monies to 
support the un-reimbursed care we provided for the less fortunate. We 
had to know where every nickel was and to scrimp and save all we could 
to pay our staff and operating costs and still break even at each 
year's end. We were always constrained by very tight finances. But for 
a very dedicated core staff putting in extraordinary hours, we might 
well have floundered and folded up shop. We did good work, but in a 
very crowded facility, and our margin was far too tight for comfort. I 
spent as many sleepless nights concerned about our finances as I did up 
admitting patients to the hospital and taking after hours calls.
    When we became an FQHC--after once having our application receive a 
grade of ``95'' but not be funded--higher reimbursement caps provided 
more income than we had received as an RHC for the very same work. We 
reduced our losses on Medicare visits, though the caps still cause us 
to receive less than our costs, and were able to recoup our costs for 
Medicaid visits. Our 330 grant has allowed us to have community 
resources persons on staff, to expand the hours of our operations 
manager to coordinate fund raising for and construction of an expanded 
facility, to have the luxury of time free for program development, and 
to expand the number of uninsured persons we serve on a sliding scale. 
We are enabled to provide not just one-on-one care in a series of 
office calls and hospital visits, but also to innovate, to collaborate, 
and to reach out to our community and to other agencies and local 
systems that compliment the provision of these services.
    In the past 2 calender years our active patient population has 
increased from 7,800 persons to 9,400 persons. By this fall our staff 
will have grown from 34 full-time and 19 part-time employees to 47 
full-time and 30 part-time staff members. We are consolidating our 
fiscal position and are poised to do more, with more medical, dental, 
and behavioral health patients and more persons accessing our 340b 
pharmacy program, all with sliding scale discounts for uninsured 
persons with incomes below 200 percent of the federally determined 
level of poverty.
    We are expanding our medical and our dental staff to meet the unmet 
medical and dental needs in the area. All of the local medical 
practices, other than the Health Center, have been closed to new 
patients for most of the past few years. And no local dental practice 
accepts medicaid patients except on a very limited basis. Our medical 
practice has about 45 percent medicare and medicaid patients. Our 
dental practice does 65 percent or more of total work for medicaid 
patients. There is a region-wide need for more dental care for medicaid 
and uninsured patients.
    To accommodate the unmet need, we will add a physician and a 
physicians assistant this summer. We anticipate taking care of about 
1,200 to 1,800 more medical patients with this summer's staff 
additions, with eventual growth to 12,000 patients, or 20 percent of 
the county population as we find another physician and another PA or 
nurse practitioner.
    We have moved from five to nine dental chairs and are now going to 
add four more. We are expanding our in-house dental program and 
cooperating with other FQHCs in an innovative mobile dental program for 
rural kids and youth. Adding two dentists this fall and another in 
December will allow our staffing the dental care mobile in six 
locations around the State and will allow our caring for about 2,000 
more patients in the dental service of the center.
    Our ``mental health'' staff, with added counseling, PTSD treatment, 
behavioral neurology, rehabilitation, and onsite psychiatric skills is 
growing to meet a large unmet need. We have teamed with other FQHCs to 
set up a tele-psychiatry link for consultations with the University of 
Vermont child and adolescent psychiatrists. We have submitted a request 
for a Change of Scope to allow our contracting for child and 
adolescent, general, and geriactric psychiatric consultations for our 
medicaid and uninsured patients who otherwise have substantial problems 
receiving this care.
    We have been able to bring 340b pharmacy services to our patients 
in a collaborative effort with four other FQHCs, including an automated 
dispensing unit--effectively a branch of the pharmacy--in our center.
    We have brought two staff members on to expand our outreach and 
case management efforts. We are taking on more medical students for 
teaching in the practice, improving continuing education for our 
professionals, and strengthening our community health education 
efforts.
    This fall we will, through a cooperative agreement with the local 
transportation agency, start to offer transportation to patients who do 
not have reliable private transportation. We are already open 60 hours 
a week. We will add another evening medical clinic and more evening 
dental hours this fall.
    It is an enormous relief as head of the agency to be on a more 
solid financial footing and to have more adequate support staff in the 
business and operations components of the center, necessary to our 
addressing the needs of those whom we serve.
    It is an equal relief as a physician to be able to provide more 
sliding scale and nominal charge care for the unfortunate, downtrodden, 
and marginallized--and now for the newly unemployed and uninsured who 
are suffering in the current great recession. We wish that we could 
provide a sliding scale fee schedule to persons or families with 
incomes under 300 percent of FLP, as we did when we were a Rural Health 
Clinic.
    It is heartening to be able to expand our dental program. We have 
become the de facto dental practice for those seen in our local 
emergency room with dental pain. We draw dental patients from a large 
geographic region. This includes many persons who have medicaid dental 
coverage but no other practice which will see them. We have always 
understood dental care to be an integral part of the promise of good 
heath care. To be able to deliver on this promise is very heartening.
    We have always been very comfortable and capable, nearly unique 
amongst practices in our region, caring for behavioral heath problems 
in our practice, but we have always recognized the need for other 
skills in this domain. We are very pleased to have been able to offer 
more services on site, where they are more accessible and affordable 
for our patients.
    And it is a very substantial benefit to providers and patients 
alike to have access to more affordable medications through the 
collaborative 340b program. For some patients the postal delivery of 
these medications is about as helpful as the lower prices, since 
getting to the drug store, often several times a month due to PBM 
restrictions, and waiting for overworked pharmacists has been a burden 
and a barrier that we did not recognize before we had the 340b option 
in house and by mail.
    And, I am sleeping better, concerned with service delivery rather 
than with survival.
    Many of these improvements in our ability to address our 
community's needs would be impossible without our having become an 
FQHC. Others would only occur slowly and incrementally, because tight 
finances would constrain innovation and the starting of new or expanded 
services, despite these being badly needed by the population.
    To staff the FQHCs that we envision being established across the 
Nation, as well as other primary care settings in every corner of the 
country, we will need to attract a very much larger proportion of the 
graduates of our medical schools to work in primary care. Slowing and 
then reversing the trend to fewer and fewer graduates entering primary 
care will require a multifaceted and multi-year effort. One important 
step will be to relieve physicians who undertake primary care training 
of some of the substantial debt that they accumulate as they pursue 
their professional education and post graduate studies. It is telling 
that our community, with most practices closed to new patients and 
having lost three primary care doctors in the past year, has been 
unable to recruit replacements. The last primary care M.D. brought to 
our area by the local hospital and the new physician who will join our 
organization this summer are both veterans with years of practice and 
experience, not the 30-year-olds fresh out of residency training. These 
veterans will not practice forever, nor will my physician colleagues at 
The Health Center, nor will I, as much as we enjoy most aspects of our 
practice lives. The same limits apply to the very fine Physicians 
Assistants and nurses who work with us every day.
    Expansion of the National Health Service Corps will be one 
mechanism to address the need to replace the Nation's aging cadre of 
primary care medical and dental providers. Knowing that NHSC loan 
forgiveness or scholarships are available will help attract students to 
primary care. Having the NHSC professionals located in various 
communities will provide professional staffing for the interval of the 
professional's commitment. And some will remain to dedicate their 
professional lives to the communities which they get to know as NHSC 
members.
    Expansion of funding for FQHCs and for the NHSC has the potential 
to help reverse the decline of primary care and to bring excellent, 
accessible care to all--not just the poor or uninsured--in all of our 
communities. This is the essence of health care reform. This is what 
America needs. Not just the poor or the uninsured--all of us. All 
Americans.

    Senator Sanders. Dr. Matthew, thank you very much.
    Lisa Nichols, who is the Executive Director of Midtown 
Community Center, Ogden, UT. Ms. Nichols, thanks very much for 
being with us.

    STATEMENT OF LISA NICHOLS, EXECUTIVE DIRECTOR, MIDTOWN 
                  COMMUNITY CENTER, OGDEN, UT

    Ms. Nichols. Thank you. Thank you for having us here today. 
I'm very proud to be part of the community health center 
movement and to tell you all about our health center and health 
centers in general.
    My name is Lisa Nichols. I am the Executive Director of 
Midtown Community Health Center, and a board member of the 
Association for Utah Community Health.
    Midtown serves underserved community residents from Weaver, 
Morgan and Davis counties located in northern Utah. Midtown has 
experienced tremendous growth fueled by community need, Federal 
funding opportunities and private partnerships.
    In 1999, Midtown served 6,500 patients from a single site. 
Services were limited to comprehensive primary care. Oral 
health care services and mental health services were not 
provided. We now operate from six sites in four different 
cities, providing comprehensive primary, oral and mental health 
services to nearly 26,000 patients.
    The most dramatic growth has come over the past 3 years. 
Midtown relocated its Ogden site to a new facility in 2006. 
This $3.2 million facility was funded through Federal funds and 
private dollars, with $2.9 million raised from our community.
    The new facility is more than twice the size and should 
have allowed for 5 years of growth. We were turning an average 
of 20 patients away because demand exceeded resources daily. 
The patient population has grown by over 11,000, and we still 
turn an average of 20 patients away daily.
    Midtown received new Federal access point funding in 2007 
to open a site in Davis County. Over 1,000 residents from Davis 
County were traveling to Midtown's Ogden site to receive 
subsidized services. We opened in 2007 with a goal of adding 
4,300 users by 2010. Over 5,800 patients are served and the 
need continues to grow.
    One of Midtown's most successful partnerships is with 
Weaver State University's Oral Hygiene Program. Midtown 
provides a dentist to supervise the students, while providing 
dental services to Midtown patients. The University provides 
space, equipment and students to care for the oral hygiene 
needs of patients. This arrangement allows 2,500 individuals to 
receive care annually at an average cost of $62 compared to the 
national benchmark of $139.
    Federal funding to Midtown has grown by 685,000 since 2006, 
allowing for $62 per user. This is a cost-effective model, 
giving that the average cost of serving a patient in other 
settings ranges upwards to $700.
    Midtown, along with other community health centers, 
decreases overall health care costs. Midtown's work with 
InterMountain Health Care, our local hospital, to transfer 
uninsured patients seeking non-emergent care through the 
emergency department to a community health center. A decrease 
from an average of six visits per patient to less than one per 
year has been realized.
    Midtown's largest challenge is in medical provider 
staffing. It is difficult to compete with the generous wage and 
benefits packages of larger organizations. The National Health 
Service Corps' loan repayment program has been vital to our 
success. We have retained medical providers hired in 1994 
through this program.
    Community needs continue to grow beyond our resources to 
meet it. An additional 37,000 individuals in Weaver, Morgan and 
Davis counties have limited health care access. We will strive 
to meet this need through new Federal funds and new community 
partnerships. Thank you.
    [The prepared statement of Ms. Nichols follows:]

                   Prepared Statement of Lisa Nichols

                                SUMMARY

    The following written statement contains an overview of community 
health centers in Utah. It includes a profile of each of the 11 
federally qualified health centers along with their 2008 data, as 
reported in the Federal Bureau of Primary Health Care Uniform Data 
System. My remarks to the committee will focus primarily on specifics 
related to the Midtown Community Health Center (MTCHC), of which I am 
the executive director.
    MTCHC has operated in northern Utah since 1970 serving underserved 
community residents from Weber, Morgan and Davis Counties. MTCHC has 
experienced tremendous growth fueled by community need, Federal funding 
opportunities and private partnerships over the past 10 years. In 1999, 
MTCHC served 6,504 patients from a single site located in Ogden, UT. 
Currently, MTCHC operates from six sites in four different cities, 
providing comprehensive primary health care, oral health care services 
and mental health services to 25,969 individuals.
    Midtown relocated its Ogden site to a new facility in the spring of 
2006. This facility, at a cost of $3.2 million, was funded through a 
combination of Federal funds and private dollars. Nearly $2.9 million 
was raised from the residents of northern Utah. The new facility is 
more than twice the size of the former facility. It was anticipated 
that the site would allow for 5 years of growth. Midtown added a 
pharmacy and radiology services along with additional medical 
providers. The patient population has grown by over 11,000 and we still 
turn an average of 20 patients away daily.
    Sixty-eight percent of the patients served by MTCHC are uninsured. 
This is in contrast to the national benchmarks for urban health centers 
of 41 percent. Only 31 percent of Midtown's funding comes from the 
Bureau of Primary Health Care. Midtown is able to serve such a large 
uninsured population and manage tremendous growth by managing resources 
cost-effectively and developing community partnerships.
    Midtown's largest challenge in meeting the on-going needs of the 
underserved is in finding adequate medical provider staffing. Midtown 
competes with larger health care facilities in recruiting efforts. It 
is through the National Health Service Corps loan repayment program 
that Midtown is able to keep the clinic fully staffed. Midtown has 
retained medical providers hired in 1994 through this program. It is 
vital to our success.
    Community need continues to grow despite MTCHC's efforts to meet 
it. It is estimated that an additional 37,000 individuals in Weber, 
Morgan and Davis Counties have limited health care access. MTCHC will 
strive to meet this need through new Federal funds and new community 
partnerships.
                                 ______
                                 
    Mr. Chairman and members of the committee, my name is Lisa Nichols. 
I am the executive director of the Midtown Community Health Center in 
Ogden, UT and a board member of the Association for Utah Community 
Health (AUCH). On behalf of Utah's 11 not-for-profit community health 
center corporations (CHCs), we appreciate the opportunity to 
demonstrate the cost-effective provision of comprehensive primary and 
preventive medical, dental, and mental health services being offered at 
29 health care home delivery sites in Utah. While the National 
Association of Community Health Centers (NACHC) speaks to the 
contribution of the Nation's CHCs providing service in more than 7,000 
communities nationwide, AUCH will present information on Utah CHCs. The 
CHC response to Utah health care reform efforts is also included.

                    COMMUNITY HEALTH CENTERS IN UTAH

    The first health center established in Utah was the Wayne Community 
Health Center in the rural town of Bicknell (January 1978), followed by 
the Salt Lake Community Health Center in 1979. The contrast in the two 
locations is striking--one, a relatively isolated rural setting and the 
other within the large metropolitan area of the State. Fourteen of 
Utah's counties are classified as ``Sparsely Populated/Frontier,'' with 
less than six persons per square mile. There are 14 health center 
delivery sites within these counties. Approximately 89 percent of Utah 
residents live in metropolitan areas where 15 health center delivery 
sites are located. The diverse nature of the populations/locations 
served by CHCs in Utah is a testimony to the versatility and 
suitability of the model to successfully provide comprehensive, high 
quality primary care in a reformed health care system. Appended to this 
document are profiles of Utah's CHCs together with 2008 data as 
reported to the Federal Bureau of Primary Health Care (BPHC). Important 
in describing CHCs in Utah is the comprehensive nature of the services 
provided to over 100,000 individuals, which include the following:

     Pediatric, adult and family medicine, including chronic 
disease management;
     Obstetrics/gynecology;
     Dental care;
     Supporting social services;
     Specialty referrals;
     Immunizations;
     School-based health locations;
     Laboratory services;
     Mental health/substance abuse counseling;
     In-patient care;
     Pharmacy (including access to 340B pricing);
     Smoking cessation and prevention; and
     Public health programs.

    Additionally, CHCs in Utah are connected through video technology, 
helping to mitigate the considerable geographic distances between the 
29 sites. This capacity allows for educational/informational 
presentations for both CHC providers and patients from a variety of 
sources, e.g., Moran Eye Center and other University of Utah 
departments, the Utah Department of Health, Utah Women's Information 
Center, private providers. Teleophthalmology services for diabetic 
retinopathy screenings are provided collaboratively between all Utah 
CHCs and contracted screening providers. Teleradiology services are in 
place for most Utah CHCs, as well.
    Utah CHCs have quantified the economic impact on the communities 
they serve. A 2006 report by Capital Link and AUCH found that the CHCs 
had an overall impact of $71.1M and supported more than 846 jobs during 
the 2005 study period. The impact included $42.6M in operational 
expenditures injected into local economies and $28.5M in indirect and 
induced economic activity. Additionally, the report estimated that the 
economic output on Utah's CHCs included $39.2M in aggregate gain of 
household incomes within the communities that CHCs served.
    Staffing of CHCs with adequate numbers of primary care providers 
remains a challenge, however. Currently, there are 10 CHC-posted 
vacancies in Utah with the National Health Service Corps, a primary 
recruitment source.
 community health center role in a reformed health care delivery system
    Utah's CHC presented the following response to a United Way's 
Financial Stability Council Straw Man Reform Proposal in 2008. The 
response includes a number of cost-effective CHC practices that 
highlight the appropriateness of community health centers as 
centerpieces within health care reform efforts.


------------------------------------------------------------------------
            Guiding principles                 Health center alignment
------------------------------------------------------------------------
Contain Costs:
  We must make difficult choices that will  An emphasis on preventive
   make health care more affordable and      care, such as
   equitable, stem rapidly rising health     immunizations, disease
   care costs, simplify administration and   screenings, and health
   encourage the implementation of health    education provides for
   information technology. Incentives in     screening and early
   the system must be realigned to focus     identification of
   on quality, value, best practices, and    conditions that are
   personal responsibility.                  considerably more expensive
                                             to treat if not addressed
                                             early.
                                            Evidence-based chronic
                                             disease maintenance and
                                             monitoring slow the
                                             progression of conditions
                                             such as diabetes and heart
                                             disease, and minimize the
                                             need for costly
                                             hospitalization for these
                                             conditions. For example, if
                                             everyone with diabetes were
                                             screened for eye disease
                                             and received the
                                             recommended care and
                                             treatment, a savings of
                                             $470 million could be
                                             created for the health care
                                             system nationally.\1\
                                             Utah's health centers
                                             currently provide retinal
                                             screenings for their
                                             diabetic patients.
                                            Many of Utah's health
                                             centers provide primary
                                             care services using Nurse
                                             Practitioners or Physician
                                             Assistants, which is a cost-
                                             effective method of care
                                             delivery that has proven
                                             results.
                                            The total medical care
                                             services cost per medical
                                             encounter in Utah health
                                             centers averages $110. This
                                             compares with the average
                                             encounter charge in an
                                             emergency department for a
                                             medical condition which
                                             could more appropriately
                                             have been treated in a
                                             primary care setting of
                                             $347-$572,\2\ depending on
                                             the degree of delay by the
                                             patient and subsequent
                                             severity.
                                            Following Federal health
                                             information technology best
                                             practice guidelines, health
                                             centers in Utah monitor
                                             health outcomes and track
                                             key measures. CHCs are
                                             adopting integrated
                                             electronic medical records
                                             technology, and many sites
                                             have also implemented
                                             telehealth technology.
Shared Responsibility:
  Individuals, employers, providers,        The model of health centers
   insurers, State government and the        has always been based on
   Federal Government share responsibility   shared responsibility. The
   to make high-quality, cost-effective      clinics do not provide
   health care available to everyone.        charity or free care, but
   Within this framework, Utahns should      provide a reasonable fee
   decide what health care solutions work    schedule that is based on
   best for them.                            an individual's ability to
                                             pay for the services. In
                                             2006, $4.4 million was
                                             collected directly from
                                             health center patients for
                                             care rendered.\3\
                                            In addition to patient
                                             revenue, the health center
                                             model leverages a
                                             combination of contract and
                                             grant funding from Federal,
                                             State, local, and private
                                             sources to ensure adequate
                                             access to high-quality care
                                             for all health center
                                             patients. Shared
                                             responsibility is inherent
                                             in the diverse funding
                                             sources that are brought
                                             together to serve each
                                             community in which health
                                             centers operate.
Support For Market-Based Solutions:
  Effective and fair competition in a       CHCs are full participants
   responsibly regulated free-market         in the existing health care
   system will deliver greater value for     market. Patients are
   both employers and individuals.           rigorously screened for
   Competition should be focused on          insurance eligibility.
   effectiveness, outcomes, efficiency,      Health centers participate
   and overall quality and value.            in all available health
   Consumers should have the information     plans. Insurers, including
   and incentive to choose health care       Medicare and Medicaid, are
   options based on value.                   billed according to
                                             established methodologies.
                                            The quality of care at CHCs
                                             is assured by the rigorous
                                             standards required to
                                             annually maintain their
                                             Federal designation and
                                             Joint Commission on
                                             Accreditation of Healthcare
                                             Organizations (JCAHO)
                                             ambulatory care
                                             accreditation.
Endorse Wellness and Prevention:
  Healthy lifestyles and preventive care    Health centers receive
   form the cornerstone of good health.      significant UDOH funding
   Individuals must take responsibility      ($348,000) to engage in
   for their health and be provided with     preventive care activities,
   incentives that reward responsible        including funding from
   behavior.                                 Heart Disease and Stroke
                                             Prevention, Immunization,
                                             and Tobacco Control to
                                             implement programs in their
                                             patient base.
                                            Health centers adhere to
                                             national quality measures
                                             in the treatment of
                                             individuals with chronic
                                             conditions such as diabetes
                                             and heart disease.
                                            Health centers leverage
                                             funding sources to improve
                                             access for preventive
                                             screening technology, such
                                             as the use of a shared
                                             retinal camera for diabetic
                                             screenings.
                                            Health centers continue to
                                             emphasize wellness
                                             practices as an essential
                                             component of good health
                                             care. Services offered may
                                             include health education,
                                             parenting education, and
                                             lifestyle change practices.
                                            Through the services offered
                                             by health centers, patients
                                             gain an understanding of
                                             the impact that current
                                             decisions have on their
                                             subsequent health status.
Be Compassionate:
  Society must devote appropriate           Health centers in Utah and
   resources to care for the most needy in   nationally have continued
   our community. In addition, population-   to follow a vision that
   specific differences in the presence of   places the patient first,
   disease, health outcomes and access to    regardless of their
   health care should be eliminated.         economic, insurance, or
                                             geographic situations.
                                            As an example, Utah's health
                                             centers provided care to
                                             over 53,000 uninsured
                                             Utahns in 2006 (61 percent
                                             of the total patient base,
                                             and 17.6 percent of the
                                             total uninsured in the
                                             State). Utah's health
                                             centers also provided care
                                             to over 83,000 individuals
                                             living at or below 200
                                             percent of the poverty
                                             level. (94.4 percent of
                                             total patient base)\4\
                                            Access to health center
                                             services is designed to
                                             accommodate any person in
                                             need of health care
                                             services. The use of a
                                             sliding fee scale based on
                                             income provides one
                                             indication of the
                                             commitment to access that
                                             health centers share.
                                             Significant resources are
                                             expended in health centers
                                             to assist patients.
------------------------------------------------------------------------
\1\ National Association of Chronic Disease Directors, An Urgent
  Reality: The Need to Prevent and Control Chronic Diseases, undated.
\2\ Utah Office of Health Care Statistics, Utah Department of Health.
  Primary Care Sensitive Emergency Department Visits in Utah, 2001.
  April, 2004. http://health.utah.gov/hda/Reports/
  Primary_Care_ERvisits_Utah2001.pdf.
\3\ U.S. Department of Health and Human Services, Health Resources and
  Services Administration, Bureau of Primary Health Care, Uniform. Data
  System Calendar Year 2006 Utah Rollup Report, available on request.
  AUCH Health Care Reform Action Plan--April 2008.
\4\ U.S. Department of Health and Human Services, Health Resources and
  Services Administration, Bureau of Primary Health Care, Uniform. Data
  System Calendar Year 2006 Utah Rollup Report, available on request.

  
  
  
  
  
  

    The following information includes a brief profile of each health 
center organization in Utah.

                BEAR LAKE COMMUNITY HEALTH CENTER, INC.

    The mission of BLCHC is to provide access to quality primary and 
urgent health care for the residents and visitors of the Bear Lake 
Valley and surrounding communities on an ability-to-pay basis. The 
center takes a holistic approach to maintaining a healthy community 
through education, prevention, and a community networking system.
    In 2008, the clinics of BLCHC served 5,138 individual patients, and 
provided 15,819 patient visits during the year while supporting 28 
full-time equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 33........................  100 percent or < FPL:    Age 0-4: 11............  Hispanic/Latino: 7
                                        10.
CHIP: 0..............................  101-150 percent FPL: 2.  Age 5-19: 25...........  Not Hispanic/Latino: 93
Medicaid: 9..........................  151-200 percent FPL: 1.  Age 20-44: 38..........  Asian/Pl: < 1
Medicare: 6..........................  > 200 percent FPL: < 1.  Age 45-64: 19..........  Black: < 1
PCN/Other: 0.........................  Unknown: 87............  Age 65+: 7.............  NA/AI: < 1
Private: 52..........................    .....................    .....................  White: 92
                                                                                         > One race: 7
                                                                                         Unreported: < 1
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

               Carbon Medical Services Association, Inc.

    Carbon Medical Services Association, Inc. (CMSA) was originally 
founded in 1952 to serve the needs of the local coal miners and their 
families. Since 1992, CMSA has been operating as a Federally Qualified 
Health Center. CMSA operates two clinic sites, and serves Carbon County 
and the northeast region of Emery County.
    In 2008, the clinics of CMSA served 3,058 individual patients, and 
provided 9,651 patient visits during the year while supporting over 19 
full-time equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 33........................  100 percent or < FPL:    Age 0-4: 5.............  Hispanic/Latino: 15
                                        33.
CHIP: 1..............................  101-150 percent FPL: 11  Age 5-19: 14...........  Not Hispanic/Latino: 85
Medicaid: 12.........................  151-200 percent FPL: 3.  Age 20-44: 37..........  Asian/PI: < 1
Medicare: 18.........................  > 200 percent FPL: 2...  Age 45-64: 30..........  Black: <
PCN/Other: 0.........................  Unknown: 51............  Age 65+: 14............  NA/AI: < 1
Private: 36..........................    .....................    .....................  White: 92
                                                                                         > One Race: 0
                                                                                         Unreported: 7
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                     Community Health Centers, Inc.

    The mission of CHC, Inc. is to provide quality patient-centered 
primary health care services to individuals regardless of their ability 
to pay. It is CHC's vision that culturally relevant primary health care 
is available, affordable, appropriate, adequate and acceptable to all 
community members, particularly for individuals, families and groups 
who are vulnerable and underserved.
    In 2008, the clinics of CHC, Inc. served 31,096 individual 
patients, and provided 99,432 visits during the year while supporting 
152 full-time equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 63........................  100 percent or < FPL:    Age 0-4: 20............  Hispanic/Latino: 73
                                        61.
CHIP: 2..............................  101-150 percent FPL: 18  Age 5-19: 32...........  Not Hispanic/Latino: 27
Medicaid: 18.........................  151-200 percent FPL: 5.  Age 20-44: 33..........  Asian/PI: 3
Medicare: 2..........................  > 200 percent FPL: 1...  Age 45-64: 12..........  Black: < 1
PCN/Other: 0.........................  Unknown: 15............  Age 65+: 3.............  NA/AI: 3
Private: 15..........................    .....................    .....................  > One Race: < 1
                                                                                         Unreported: 5
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                    Utah Farm Worker Health Program

    In 1990, Community Health Centers, Inc. (CHC) received Federal 
funding to provide health services to Utah's migrant and seasonal farm 
workers and their families. CHC provides medical, dental, health 
education, and outreach services through the Utah Farm Worker Health 
Program (UFWH). UFWH also refers patients to other existing health care 
providers and resources.
    In 2008, UFWH served 5,531 individual patients, and provided 7,088 
patient visits during the year through the Brigham City clinic site 
(Clinica de Buena Salud) and mobile van services.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 92........................  100 percent or < FPL:    Age 0-4: 13............  Hispanic/Latino: 98
                                        92.
CHIP: 1..............................  101-150 percent FPL: 5.  Age 5-19: 78...........  Not Hispanic/Latino: 2
Medicaid: 4..........................  151-200 percent FPL: 1.  Age 20-44: 6...........  Asian/PI: 2
Medicare: < 1........................  > 200 percent FPL: < 1.  Age 45-64: 2...........  Black: 1
PCN/Other: 0.........................  Unknown: 2.............  Age 65+: < 1...........  NA/AI: 1
Private: 3...........................    .....................    .....................  > One Race: 0
                                                                                         Unreported: 11
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                    Enterprise Valley Medical Clinic

    The Enterprise Valley Medical Clinic (EVMC), established in 1983, 
provides primary and preventive care to a service area spanning a 40-
mile radius in rural southwest Utah. EVMC serves individuals living in 
the Washington County towns of Enterprise, Central, Brookside, and Veyo 
and the Iron County towns of Beryl, New Castle, Modena, and Lund.
    In 2008, the EVMC served 2,465 individual patients, and provided 
6,619 visits during the year while supporting over nine full-time 
equivalent positions in its clinic community.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 45........................  100 percent or < FPL:    Age 0-4: 11............  Hispanic/Latino: 14
                                        29.
CHIP: 2..............................  101-150 percent FPL: 17  Age 5-19: 29...........  Not Hispanic/Latino: 86
Medicaid: 10.........................  151-200 percent FPL:     Age 20-44: 29..........  Asian/PI: < 1
                                        100.
Medicare: 9..........................  > 200 percent FPL: 37..  Age 45-64: 19..........  Black: < 1
PCN/Other: 1.........................  Unknown: 7.............  Age 65+: 12............  NA/AI: 1
Private: 33..........................    .....................    .....................  White: 89
                                                                                         > One Race: 0
                                                                                         Unreported: 9
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                       Green River Medical Center

    The Green River Medical Center (GRMC) provides a full range of 
healthcare services to eastern Emery and northern Grand counties in 
southeastern Utah. GRMC not only provides care to the local residents 
but also provides the bulk of emergency medical services for those 
individuals traveling on the isolated stretch of Interstate 70 running 
through central Utah.
    In 2008, GRMC served 1,527 individual patients, and provided 4,804 
patient visits during the year while supporting almost seven full-time 
equivalent positions in its clinic community.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 38........................  100 percent or < FPL:    Age 0-4: 6.............  Hispanic/Latino: 17
                                        41.
CHIP: 2..............................  101-150 percent FPL: 11  Age 5-19: 26...........  Not Hispanic/Latino: 83
Medicaid: 14.........................  151-200 percent FPL: 3.  Age 20-44: 33..........  Asian/PI: < 1
Medicare: 13.........................  > 200 percent FPL: 3...  Age 45-64: 22..........  Black: < 1
PCN/Other: 0.........................  Unknown: 42............  Age 65+: 14............  NA/AI: 22
Private: 33..........................    .....................    .....................  White: 75
                                                                                         > One Race: 0
                                                                                         Unreported: 1
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                    Midtown Community Health Center

    Midtown Community Health Center's (MTCHC) mission is to provide 
excellent and safe health care to the residents of northern Utah, 
especially those with economic, geographic, cultural, and language 
barriers. MTCHC is recognized for its high level of cultural competency 
and ability to provide affordable, quality health care.
    In 2008, the clinics of MTCHC served 25,969 individual patients, 
and provided 60,060 visits during the year while supporting over 76 
full-time equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                 Ethnicity/Race (2007)
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 68........................  100 percent or < FPL:    Age 0-4: 16............  Hispanic/Latino: 60
                                        36.
CHIP: 2..............................  101-150 percent FPL: 12  Age 5-19: 26...........  Not Hispanic/Latino: 40
Medicaid: 13.........................  151-200 percent FPL: 3.  Age 20-44: 38..........  Asian/PI: < 1
Medicare: 3..........................  > 200 percent FPL: < 1.  Age 45-64: 16..........  Black: 1
PCN/Other: 0.........................  Unknown: 48............  Age 65+: 4.............  NA/AI: < 1
Private: 15..........................    .....................    .....................  White: 35
                                                                                         > One Race: < 1
                                                                                         Unreported: 62
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                 Mountainlands Community Health Center

    The mission of MCHC is ``Health professionals providing and 
collaborating with other partners to assure high-quality health care 
for everyone in our community.'' MCHC is the only provider in Utah 
County that offers comprehensive primary medical, dental, and mental 
health services on a sliding fee scale.
    In 2008, MCHC served 10,111 individual patients, and provided 
32,397 patient visits during the year while supporting almost 51 full-
time equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 75........................  100 percent or < FPL:    Age 0-4: 14............  Hispanic/Latino: 78
                                        64.
CHIP: 2..............................  101-150 percent FPL: 20  Age 5-19: 19...........  Not Hispanic/Latino: 22
Medicaid: 11.........................  151-200 percent FPL: 3.  Age 20-44: 46..........  Asian/PI: 1
Medicare: 3..........................  > 200 percent FPL: 1...  Age 45-64: 16..........  Black: 3
PCN/Other: 0.........................  Unknown: 11............  Age 65+: 5.............  NA/AI: < 1
Private: 9...........................    .....................    .....................  > One Race: 0
                                                                                         Unreported: < 1
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                 Southwest Utah Community Health Center

    The mission of the SWUCHC is to make lives better in southwest Utah 
by providing accessible, quality health care, regardless of financial, 
language, or cultural barriers. SWUCHC serves a five-county area in 
southwestern Utah, and is the only provider of care in the St. George 
area that offers medical, dental, and mental services on a sliding fee 
scale.
    In 2008, the SWUCHC served 4,805 individual patients, and provided 
13,585 visits during the year while supporting over 18 full-time 
equivalent positions in its clinic community.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 57........................  100 percent or < FPL:    Age 0-4: 17............  Hispanic/Latino: 66
                                        64.
CHIP: 2..............................  101-150 percent FPL: 18  Age 5-19: 17...........  Not Hispanic/Latino: 34
Medicaid: 24.........................  151-200 percent FPL: 5.  Age 20-44: 44..........  Asian/PI: 1
Medicare: 4..........................  > 200 percent FPL: 3...  Age 45-64: 18..........  Black: 1
PCN/Other: 0.........................  Unknown: 11............  Age 65+: 5.............  NA/AI: 2
Private: 13..........................    .....................    .....................  White: 48
                                                                                         > One Race: 51
                                                                                         Unreported: < 1
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                  Wayne Community Health Centers, Inc.

    WCHC has been offering full-time primary health care services in 
Wayne County since 1978. Deep canyons and high mountains separate this 
service area from any other primary or emergency care provider for 60 
to 120 miles. WCHC has built a strong reputation for delivery of high 
quality services to this economically depressed and isolated area.
    In 2008, WCHC served 3,899 individual patients, and provided 15,068 
patient visits during the year while supporting almost 26 full-time 
equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 42........................  100 percent or < FPL:    Age 0-4: 8.............  Hispanic/Latino: 2
                                        29.
CHIP: 7..............................  101-150 percent FPL: 13  Age 5-19: 29...........  Not Hispanic/Latino: 98
Medicaid: 5..........................  151-200 percent FPL: 10  Age 20-44: 27..........  Asian/PI: < 1
Medicare: 7..........................  > 200 percent FPL: 39..  Age 45-64: 22..........  Black: < 1
PCN/Other: 0.........................  Unknown: 9.............  Age 65+: 14............  NA/AI: < 1
Private: 39..........................    .....................    .....................  White: 96
                                                                                         > One Race: 0
                                                                                         Unreported: 2
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

        Wasatch Homeless Health Care, Inc. Fourth Street Clinic

    The Fourth Street Clinic helps homeless Utahns improve their health 
and quality of life by providing high-quality health care and support 
services. WHHC principles include the fact that good health is 
necessary for maintaining a job and stable housing; that affordable 
health care and housing are basic human rights; that compassionate and 
respectful health care is delivered to all Fourth Street Clinic 
patients; and that ensuring affordable health care, housing and other 
basic life necessities will break and prevent the cycle of 
homelessness.
    In 2008, the Fourth Street Clinic provided health care to 5,723 
individuals.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                   Ethnicity/Race  [
         Insurance  [percent]                 [percent]          Age groups  [percent]           percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 84........................  100 percent or < FPL:    Age 0-4: 4.............  Hispanic/Latino: 19
                                        93.
CHIP: < 1............................  101-150 percent FPL: 1.  Age 5-19: 6............  Not Hispanic/Latino: 81
Medicaid: 13.........................  151-200 percent FPL: <   Age 20-44: 50..........  Asian/PI: 1
                                        1.
Medicare: 3..........................  > 200 percent FPL: < 1.  Age 45-64: 39..........  Black: 8
PCN/Other: 0.........................  Unknown: 5.............  Age 65+: 2.............  NA/AI: 4
Private: < 1.........................    .....................    .....................  White: 70
                                                                                         > One Race: 0
                                                                                         Unreported: 17
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level

                    Utah Navajo Health System, Inc.

    The mission of UNHS is to make a difference in the quality of life 
for all community members by providing high quality, comprehensive 
primary and preventive health care in a culturally and linguistically 
competent manner while maintaining fiscal viability. UNHS operates 
clinics in San Juan County, Utah and Tonalea, AZ, and is a major 
provider of health care to Navajo Tribal members living in southeast 
Utah and adjacent ``Four Corners'' locations.
    In 2008, UNHS served 11,760 individual patients, and provided 
53,660 visits during the year while supporting over 129 full-time 
equivalent positions in its clinic communities.

                                              2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
                                            Poverty level                                     Ethnicity/Race
         Insurance  [percent]                 [percent]          Age groups  [percent]          [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 44........................  100 percent or < FPL:    Age 0-4: 12............  Hispanic/Latino: < 1
                                        62.
CHIP: 1..............................  101-150 percent FPL: 11  Age 5-19: 28...........  Not Hispanic/Latino: 99
Medicaid: 20.........................  151-200 percent FPL: 12  Age 20-44: 26..........  Asian/PI: < 1
Medicare: 8..........................  > 200 percent FPL: 13..  Age 45-64: 24..........  Black: < 1
PCN/Other: 0.........................  Unknown: 2.............  Age 65+: 9.............  NA/AI: 76
Private: 28..........................    .....................    .....................  White: 24
                                                                                         > One Race: 0
                                                                                         Unreported: < 1
----------------------------------------------------------------------------------------------------------------
 FPL = Federal Poverty Level


    Senator Sanders. Ms. Nichols, thank you very much.
    We have been joined by Senator Harkin of Iowa, and I want 
him to say a few words because he has perhaps, more than 
anybody else in the Senate over the years, been the leading 
exponent for disease prevention and primary health care. 
Welcome, Senator Harkin.
    Senator Harkin. Thank you very much, Mr. Chairman.
    Senator Sanders. Do you want to say a few words?
    Senator Harkin. No. I don't want to interrupt. I am sorry I 
am late. I had a previous engagement. I wanted to be here. This 
is so important.
    Senator Sanders. Let's just begin the discussion. Let's all 
take a deep breath and we will do it informally. We're among 
friends here.
    [Laughter.]
    Let me start off. I want to go to Dan Hawkins for a minute 
because he made a very profound statement a few moments ago. He 
talked about the potential of the saving of hundreds of 
billions of dollars through the expansion of community health 
centers as we keep our people well. People are healthier. The 
system spends less money. It's kind of a no-brainer in terms of 
wanting to go forward. Dan, why would we save so much money by, 
if Representative Clyburn and I are successful, putting a 
community health center in every underserved area in America? 
Where does the savings occur?
    Mr. Hawkins. Senator, where they occur most profoundly is 
in the quality management of the care and the health of each 
individual patient that they serve. Health centers, No. 1, 
emphasize prevention, both for children, childhood check-ups, 
immunizations, for women who are pregnant, good, quality 
prenatal care, they have lower low-birth weight rates and lower 
infant mortality rates. Studies have shown that rates are 40 
percent lower in communities that have a health center than 
they are in similarly situated communities that do not have a 
health center.
    And perhaps most importantly in this day and age, when 
chronic illness is such a major cause of health care spending, 
health centers have learned to engage the people they serve. I 
don't like the word patient because it implies dependency. It's 
really a co-dependency in a collaborative relationship between 
a provider of care and the individual receiving care. The 
individual receiving care has to understand their condition, 
has to take charge of that condition, embrace it, and 
understand if they have diabetes or high blood pressure, 
congestive heart failure, they may well have--now HIV and many 
forms of cancer, which instead of being a fatal diagnosis now 
are more likely to be a lifelong condition diagnosis. Take 
charge, embrace that condition, understand how to manage it, to 
self-manage their care. Health centers provide glucometers to 
diabetics, blood pressure cuffs to hypertensives, tell them to 
go home and measure your particular indicators, call us every 
day, provide that information, and come back for regular 
planned visits and group visits. Actually, I think that John 
Matthew and Lisa could probably speak more profoundly to this 
from the real world, but this is what we know health centers 
do. By doing that, they avoid the need for much of the 
specialty care and repeat services that are needed. They avoid 
the need for in-patient hospitalization and they take people 
out of the emergency room, which is the absolute worst place 
for people to receive primary or preventive care, most costly 
and least effective.
    Senator Sanders. OK. Why don't we stay on this issue.
    Ms. Bascetta. I have a comment.
    Senator Sanders. Yes.
    Ms. Bascetta. I want to make three comments. One is that 
there was a study done a few years ago that noted that while 
health centers provide care that is equivalent to other 
providers across the country, that in some situations in 
chronic care, they weren't performing as well as some 
integrated systems such as the VA, and the hypothesis was that 
better health IT at the health centers would enable them to 
perform better because that was the competitive advantage that 
the VA has. So I would like to note that the stimulus does 
provide money for IT. It's not a panacea, necessarily, but it's 
a very important piece for measuring outcomes across the course 
of a chronic disease.
    The second thing I want to mention is that, and I sort of 
hesitate to say this, but prevention--everybody wants to do 
prevention. It's absolutely what you want to do. You do want to 
avert the cost of failing to take care of people early in the 
disease, but from a system perspective, overall, most of the 
studies show that when you prevent certain diseases, people 
eventually will live to develop something else. So it doesn't 
necessarily control costs in the long run.
    Senator Sanders. We all hope at 100 to develop something 
else. I don't know if that's a criticism?
    [Laughter.]
    Ms. Bascetta. No, it's not. I just want to point it out. 
The other thing that I would point out is that on the cost-
saving issue, it's correct that many of the studies show 
important costs from things like emergency room diversion. We 
have some concerns that the more that health centers expand, 
the more Medicaid costs will increase. Now that's a good thing, 
because it means people are getting care. So rather than think 
only about the cost savings over all to the system, I would 
prefer thinking about the importance of building on the 
infrastructure that community centers have established to be a 
vehicle for using the public insurance that we have, Medicaid 
and Medicare.
    Senator Sanders. Thanks very much. Further discussion?
    John.
    Dr. Matthew. Senator, I would make the point that I have 
been around in medicine long enough to see preventive medicine 
work. We now have a radically reduced rate of strokes and a 
radically reduced rate of coronary heart disease, heart attacks 
because of risk factor control. It's not a short term 
phenomenon. It is years of good blood pressure control, good 
cholesterol control, and salt control in the diet. The American 
Heart Association says if everybody ate a no-added salt diet in 
the whole Nation, we'd have 25 percent less cardiovascular 
disease and stroke. If everybody ate fish twice a week or fish 
oil every day, we would have 20 percent additional reduction in 
cardiovascular disease and stroke. Middle-aged men who ate two 
grams of fish oil a day reduced their risk of sudden death to 
one-sixth of what it would be. Men with highest levels of 
vitamin D who have prostate cancer, have one-sixth the chance 
of dying from that cancer compared to men who have the lowest 
levels. There is a lot of room to do preventive medicine.
    Senator Sanders. And you feel that community health centers 
are in a position to do that?
    Dr. Matthew. Absolutely.
    Mr. Evans. Senator, may I add an oral health point here? It 
is somewhat indirect but it is rather pertinent.
    Senator Sanders. Yes.
    Mr. Evans. A recent study in California, indicated that in 
California emergency rooms, there were over 200,000 dentally 
related emergency visits. The cost translation to that 
emergency room system of California hospitals was in the 
multimillions of dollars. Again, were there are better points 
of access, that would be a major cost savings.
    I would also like to point out that that study indicates 
that there are 51 million school days lost by children for 
dentally related issues in our system and 146 workdays lost by 
workers in the United States over dentally related issues. Were 
there more access points in the system, many of those being 
provided by community health centers, those statistics also 
represent major savings in the United States, and in terms of 
the workforce, increase the productivity of that workforce.
    Senator Sanders. Representative Clyburn.
    Representative Clyburn. Thank you very much, Senator. I 
would like to make two quick points before I go back to the 
other side. I don't want to wear out my welcome over here.
    [Laughter.]
    Two things. First of all is this. I am a former public 
school teacher. I started out my career as a public school 
teacher and I know dental care is something that we have to be 
very concerned about. There is something we never talk about, 
but that I have seen a profound impact on students being able 
to do well in school. It's called vision care, and I think we 
never talk about it. If you talk to any public school teacher, 
especially first or second grades, they will tell you that a 
lot of time students fall behind and never catch up simply 
because they don't know that they can't see or don't see well. 
So I want us to start a discussion, and community health 
centers would be great with that.
    Second, on yesterday, I met with my hospital association, 
and I was shocked when they told me how much they are 
supporting our efforts here, Senator Sanders. And they tell me 
the main reason is because Federal law currently dictates that 
their emergency centers must provide primary care for those who 
can't afford it. And they said to me that is the worst possible 
thing to take place. And they would love to get these people 
out of the emergency rooms and out into the community health 
centers. So my hospital association told me they are ready for 
us to get these bills passed. Thank you, Mr. Chairman.
    Senator Sanders. Other discussion?
    Yes, Dr. Mullan.
    Dr. Mullan. If I could say just say a word about the future 
that we might envision with these bills passing. The 
relationship between training and careers in community health 
centers in the past has been a little shaky. For a long time 
the National Health Service Corps and community health centers 
ran on totally separate tracks. It's only been more recently 
where there has been a vigorous effort to use the National 
Health Service Corps to staff health centers.
    The notion that we had far more National Health Service 
Corps people in health centers, and that in fact, training 
could take place in health centers, so it becomes not just 
something that you do to pay off a loan, it's something that is 
seen as a career, as a culture of medicine, not as a side bar, 
but as a main line activity, is very, very important. And I 
think running it at very low levels--National Health Service 
Corps, as I mentioned before, I've always called it a pilot 
program even though it is 40 years old. There are today 4,000 
people in the field serving in that National Health Service 
Corps, about half of those are physicians.
    There are 800,000 physicians in America. So right now, one-
quarter of 1 percent of physicians are in the National Health 
Service Corps. That is a pilot. That is a demonstration, and 
that's after 40 years of proven effectiveness.
    So what you envision in taking this out of the nice 
experiment into the main line, with teaching, with residency 
programs, with careers, with leadership training, really is 
revolutionary and terribly important. I commend you for it, and 
if we can get it, it would be terrific.
    Senator Sanders. Thank you. Let me tell you a funny story. 
Senator Harkin, you will be interested in this.
    David Reynolds, who is sitting behind me, founded the first 
federally qualified community health center in Vermont, and is 
now on my staff. He and I went to Dartmouth Medical School a 
few weeks ago, and our purpose was to explain to the medical 
school that we tripled the funding for the National Health 
Service Corps, and we would like them to do everything they 
could to advertise that fact to their students to get them 
involved in primary health care.
    What we learned from some of the young students, medical 
students was, they said that when they told their fellow 
students that they were going into primary health care, their 
fellow students looked at them in shock and assumed that they 
were dummies doing bad on their tests. They could not 
understand why would you go into primary health care and earn 
substantially less money than those who were going into 
specialties?
    That's where we are today. The most important work is 
disparaged. So I did want to mention that and certainly agree 
with you, Dr. Mullan, we've got to get out of the pilot project 
phase, which has now gone on for 40 years.
    I would be remiss in not mentioning, obviously that the 
founder of the whole concept of community health centers is not 
with us today, but is the Chairman of this committee, Senator 
Kennedy. His work is so greatly appreciated.
    So getting physicians and getting dentists, of course, out 
into areas where we need them is a major priority that many of 
us are working on.
    Senator Harkin.

                      Statement of Senator Harkin

    Senator Harkin. Thank you very much, Mr. Chairman. And 
thank you for calling this hearing. As we have discussed many 
times, this is an intense area of interest of mine. As we are 
looking ahead to having a health care reform bill this year, if 
you could draft--not the whole bill perhaps--but if you could 
draft a part that would be for prevention and wellness, which 
is what I am doing with the working group, how would you fit in 
these two elements: federally qualified community health care 
centers and the National Health Service Corps? How would they 
fit? How would they be structured so they could continue to not 
only get operational money, but expansion money?
    That's always been a battle, as you know, the money we 
provide--if it's for new construction, then we don't put enough 
money in there for the operational requirements for existing 
centers. So how do we structure that to make sure that we can 
grow federally qualified community health care centers, and 
also keep the operational structure intact and supporting those 
that are there? The ones that are there are going to need 
increases every year, not just cost-of-living, but a lot of 
them now need to expand their services to dental and a lot of 
other things that they did not have in the past. That's one 
element.
    The second is just what we just touched on, and that's the 
National Health Service Corps. How do you structure that in 
health care reform?
    I think that these are just two elements which we've got to 
address. We are wrestling with it right now, on exactly how we 
structure it.
    So you are the experts. How would you structure it?
    Dan.
    Mr. Hawkins. Thank you, Senator. I have to say I know you 
struggle every year, but I marvel at your success, in managing 
to produce additional resources to grow these and many other 
vital public health programs across the board, so my hat's off 
to you, and the hard work that you do.
    First of all, I think an important way to look at this, and 
this in the context of health reform, is we are talking about 
investments that produce a return. I mentioned earlier that 
health centers last year saved the health care system $18 
billion. I did point out that their expenditures at that point 
were $8 billion. That's still a two-for-one return on 
investment.
    And by the way, more than a third of that was Medicaid 
spending, that Ms. Bascetta mentioned, of which health centers 
pulled down $3 billion in Medicaid revenues last year, and sent 
back to Medicaid through State agencies and to the Federal 
Government more than $6.5 billion. Again, a two-for-one return 
on the payments that Medicaid agencies made for care provided.
    We have to think about this. Our centers provide personal 
health care. National Health Service Corps clinicians, by and 
large, provide personal health care. But as I know you both 
know, Senators Sanders and Harkin, and everyone at the table, 
it's got to be about more than personal health. It's community 
health. It's population health.
    Right now, the first confirmed case of swine origin flu 
was--a confirmed case now--was identified at a health center. 
But I know my own health center in Brownsville, TX is sitting 
on 30 cases of suspected flu. They are linked at the hip with 
the local health department down there, ensuring that the 
community is going to get preventive measures that they need to 
avoid spreading that contagion further than it has already 
spread, to track and contain it. You have to be about 
population health.
    One of the most important things Jack Geiger, one of the 
founders of community health centers, said was, ``Yes, it's 
care patient by patient, but it is so much broader than that. 
It's got to be about the whole community.'' There are resources 
you have to put in, Senator, but what you also look at is the 
return you get.
    Senator Harkin. I want to ask Dr. Mullan about this too, 
the National Health Service Corps, and anyone else who has a 
thought on this. We are going to have a national health 
program. We are obviously going to have a lot of price plans 
out there and whether there is a connector or not, like the 
Massachusetts system, we don't know. But it's been my thinking 
that we must insist that any plan that anyone might want to get 
that comes into this system must provide that they can exercise 
that plan at a community health center.
    Mr. Hawkins. Oh, absolutely.
    Senator Harkin. And that services are fully reimbursable at 
any community health center--as it is now. As you know, anyone 
can go to a federally qualified community health center now, 
under a private plan, or whatever, and they will pay for that. 
But we have to insist that somehow that's part of every plan 
that is allowed into the system.
    Mr. Hawkins. You are absolutely right. I mean I suspect 
that reform would have network adequacy standards. And one of 
the worst things that could be allowed in the absence of those 
strict standards, is that some plans may choose not to contract 
with community health centers as a way of redlining the very 
people we are working----
    Senator Harkin. You see, that's why we have got to have 
that.
    Mr. Hawkins. That's right. We can't allow that to happen. 
It's a form of discrimination that occurs too much today in the 
private insurance system. With insurers looking for young 
healthy folks and avoiding in every way they can, folks who are 
sicker and in need of greater care. That's one of the things 
that we've got to do, and as you said, full participation and 
adequate payment. Folks have got to recognize the kinds of 
services health centers provide--I know John's center does, 
Lisa's center does, Yvonne's center does--services like 
outreach into the community, health and nutrition education. I 
am talking about making the medical care they get effective. 
Making it work. For a pregnant woman, understanding how to take 
care of herself during pregnancy, in order to ensure a positive 
outcome. That costs money. That's care management, it's patient 
management, but oftentimes insurers, especially private 
insurers, won't reimburse it.
    So full participation is required and adequate payment, 
that is vitally important. The only programs that do that 
today, Senator, in response to your point about a public plan, 
the only payers today that recognize the unique needs of the 
people that health centers serve, and provide benefits 
accordingly, and the only payers that recognize the unique 
safety net role that health centers play and reimburse them 
accordingly, are Medicare, Medicaid, and SCHIP, public 
programs.
    To me, and to all of us, there is great value.
    Senator Harkin. Dan and Mr. Chairman, I would like to work 
with you, to work together to make sure that in this health 
reform it is adequately reimbursed, for any plan that comes in 
has to have that in its plan.
    I want to get into the National Health Service Corps. 
That's another part.
    Yes, Dr. Matthew.
    Dr. Matthew. I would make the point that you have to invest 
in efforts of community education. I put up on the dias behind 
you sir--we have a newsletter, we have a series of the public 
classes on topics of importance to the public. We have people 
on our staff called community resources. We have always had a 
dietician. You can not do all of the medical care on a one-on-
one encounter in an exam room or the one person who is in the 
hospital. We have an effort by the staff to get people a ride, 
to be sure they are signed up for their insurance. That sort of 
thing. But on the other side, the public education and patient 
education are terribly important.
    Senator Harkin. Of course, I have another idea for that 
that I am thinking of incorporating. And that is that we should 
have a federally qualified community health center establish an 
outreach program at every public school within its region. But 
that's for another time. I hate to take any more time, but the 
National Health Service Corps, how do we incorporate them in 
this health care reform bill?
    Mr. Mullan. The question is a good one because standard 
medical education, as we all know, and dental education, is 
fairly narrow and it tends less to the issues of prevention, 
population health, and community health, both at the medical 
school level and in residency. What the opportunity of an 
enhanced National Health Service Corps, community health center 
initiative affords is really impacting that education system in 
several ways.
    One is that traditionally it's been hard for the National 
Health Service Corps to work with the people it gives awards to 
until they actually come on site. But going back into the 
pipeline, and doing a lot more power education where there 
would be summer clerkships, and there would be residency 
opportunities for people who are headed to health centers even 
along the way.
    The building of teaching community health centers where 
population health would be part of what they learn, would be 
essential to creating the kinds of doctors that we need.
    And this finally gets to this whole notion of changing the 
culture of medicine. This is the specialty, community health, 
and this puts air under the wings of the idea that we would 
really have a major part of health education in medicine, 
dentistry, and nursing in this country, focusing on prevention, 
outreach, population health for folks who are headed into that 
practice setting with prestige. This gives you the opportunity 
to really put a brand on what they're doing and not at 
something, again, that they did just to pay the bills--it's 
something they did because that's where they want to serve.
    Senator Harkin. A cardiologist friend of mine said just 
recently, ``Look, we really need more primary care doctors. And 
the only way we are going to get them is you have got to pay 
them more.''
    There are two ways of payment, there's back-end payment and 
front-end payment. We can control and we can do something about 
the front-end payment. And that is, if you want more primary 
care doctors, why don't we just pay for their education? Pay 
for the whole thing? Pay for everything. That's front-end 
payment.
    That, I think is something else I would like to see 
incorporated, but my time is up.
    Senator Sanders. Senator Merkley.
    Senator Merkley. Thank you very much, Mr. Chairman. I 
wanted to explore a couple other points.
    One is how the health care centers serve as a gateway to 
more complicated medical treatment that might involve 
specialists. Ms. Davis, your story may provide an example of 
this. Your brother had a heart attack, if I understood 
correctly?
    Ms. Davis. Yes.
    Senator Merkley. So he got care for that heart attack. I'm 
imagining he did not have insurance. If that's the case, how 
did the health center work with heart specialists to ensure 
that he got the treatment that he needed, and how did the 
finances around that work?
    Ms. Davis. Actually, what happened was, when my brother was 
diagnosed that he had had a heart attack, I immediately went to 
the emergency room. I knew, he knew that he was uninsured. We 
had no idea what was about to happen. I went there and asked 
for the patient assistance program, and we had to sign 
documents and complete the paperwork because they didn't want 
to dismiss him. Well, actually, I was not going to take him 
home--let him go home. And it turns out that he had a quadruple 
bypass. He had a 96.7 percent blockage. The doctors told them 
he would have lasted about 48 hours, but when they told him 
what surgery he had to have, family members came in because we 
knew he was only eligible for a certain amount of patient 
assistance.
    So instead of having to mortgage his home, his siblings--we 
in turn--had to borrow money to help. But the rest of it, more 
or less, was paid for by taxpayers because, unfortunately he 
was in the intensive care unit for 6 days, and then in the 
hospital for an additional 5 days. But that was the way--we had 
no other choice. We had to put our necks on the line in order 
to make the payment.
    Senator Merkley. Yes, I want to broaden the discussion to 
the issue of how--thank you very much for your personal 
example. I think it really helps illuminate the issues that we 
face and to broaden the question to other folks who would like 
to comment on how this works, how it should work, how it can 
work, how it does work currently?
    Ms. Davis. I would also like to add that when he was 
discharged from the hospital, the community health center made 
arrangements for him to see a local internal physician, and 
then he himself had a personal connection with a cardiologist, 
and then they got it set up so that he could be treated by him 
as well.
    So it was this ongoing effort by the community health 
center that helped him get what was locally available to him in 
Marion. Because Marion County is without a lot of specialists, 
so we had to do what we had to do to make it happen.
    Ms. Nichols. We provide comprehensive primary care, but as 
you might imagine, we often detect people who need specialty 
care services. Our community has been enormously generous. We 
have 370 specialty care providers in a volunteer provider 
network who have each agreed to donate one to three visits 
monthly and donate about $2 million in care annually. That's 
wonderful, but that generosity can only go so far. For example, 
we have an orthopedic surgeon, who spends 2 days a month in our 
office and another 2 days of surgery donated by the hospital, 
donated by him. We still have to pay his malpractice insurance. 
It's a great benefit for the community, but we would love to 
see services somehow expanded to include FTCA for specialty 
care providers. That would just help us enormously.
    Senator Merkley. The health care center plays a huge role 
in facilitating donated services, and an individual, a poor 
individual, would have no chance of knowing how to reach that 
gateway, if you will, to access care for a complicated medical 
circumstance.
    Ms. Nichols. Exactly. We have case managers who do that. We 
have to have them placed in the emergency department and in the 
local school system.
    Senator Merkley. Now, Ms. Nichols, I think you mentioned 
that you had to turn away patients. How do you make decisions 
as a health care center, who you provide services to, and who 
you do not provide services to, when the demand exceeds the 
capacity?
    Ms. Nichols. It's very difficult. We have created some 
priority groups. We always take children under the age of 19, 
pregnant women, individuals with HIV/AIDS, individuals with 
mental health issues. We are pleased that in August, because of 
the stimulus funding, that we will be able to open our doors 
again. We hope! We don't know how soon we will be turning 
patients away again, but we will be opening our doors again.
    Senator Merkley. You are completely closed down right now?
    Ms. Nichols. Other than those groups that I mentioned.
    Senator Merkley. He means opening the door to new people?
    Ms. Nichols. Oh, I am sorry. Yes. Yes, we are not closed 
down. We accept those patient populations that I described. 
Other than that, we are referring them elsewhere.
    Mr. Evans. I would like to offer an example, if I may, 
Senator?
    Senator Merkley. Please.
    Mr. Evans. Health care centers also provide a unique 
opportunity for physician-dentist interaction. Take, for 
example, a diabetic patient, we know that there are 
associations between periodontal diseases and diabetes, for 
example. That diabetes exacerbates periodontal diseases, and 
periodontal disease, in turn exacerbates diabetes in terms of 
glycemic control. And that's understandable, as I said 
previously, the jaw bone is connected to the toe bone. If you 
think about it forming an infection anywhere in the body, that 
will, in fact, exacerbate the effects of diabetes.
    Health centers have the option of working with their 
diabetic patients in terms of that referral and the results of 
that referral, and that interaction is better control of 
diabetic conditions, and consequently it is not only 
lifesaving, it's morbidity saving as well, and cost saving, as 
a further example. That interaction is also an important one, I 
think, at the community health centers.
    Senator Sanders. If I could just pick up on a point that 
Congressman Clyburn raised and Dr. Evans raised a moment ago, 
and that is getting primary health care to young people in 
schools, school-based health.
    I will tell you a personal experience. We started a dental 
clinic in a low-income school in the city of Burlington, which 
is now treating kids all over the city and has been hugely 
successful. We have one in Bennington. We are expanding one in 
the northern part of our State as well.
    Does bringing health care and dental care to the kids at 
school, so they do not miss the days that you were talking 
about--stay home because of dental problems--is that something 
that is worth exploring?
    Ms. Davis, do you want to address that?
    Ms. Davis. Yes. As I spoke about it earlier, school-based 
clinics, when I was on the PTA at the high school in Marion. 
One of the things that we're experiencing now is that, after we 
met with the local hospital, we found that they are getting a 
high number of teenaged pregnant students that go to the 
hospital that are now almost in their fifth trimester, where 
they've had no prenatal care. When we were in the high school 
there, we educated the young girls and we talked about it. 
Congressman Clyburn spoke about the vision care, we had all 
means of expertise to come in with us.
    Senator Sanders. This was an opportunity for a physician or 
a medical person to come in and talk to young women about 
sexuality and so forth.
    Ms. Davis. Yes, and as a PTA person, we had the parents to 
come in and they witnessed how the numbers dwindled as to the 
success of the school-based clinic.
    Senator Sanders. Excellent. Let's wait on that one.
    Ms. Nichols.
    Ms. Nichols. We actually just opened a school-based clinic 
on April 6. We did that in conjunction with our local hospital, 
Intermountain Health Care, who funded it because they 
recognized that so many children were coming to the emergency 
department for nonemergent needs. So we don't yet have a lot of 
experience, but we are working closely with the school case 
managers and counselors. Whenever a child misses school, we 
will be on the phone with them scheduling an appointment and we 
hope to have excellent outcomes.
    Senator Sanders. John, you have a relationship with Cabot 
High School, don't you?
    Dr. Matthew. Yes, we have a school-based clinic and have 
for about 16 or 18 years in Cabot for the school kids, but also 
for anybody in the community that wants to come. So that puts 
us out about 15 miles further into the hills.
    I also want to point out that we are going to be the base 
for a dental van, it's called the Care Mobile, that will go 
around to other FQHC areas in our State to take care of kids 
and teens who don't have dental care. In one of our rural 
towns, about an hour from us, there are 1,200 kids with a 
Medicaid card, good for all the dental care they need through 
the age of 21 in Vermont, and no dentist to see them. So we are 
going to be, quarterly, back in town, for about a month each 
time.
    Senator Sanders. Any additional thoughts on school-based 
clinics?
    Senator Merkley.
    Senator Merkley. I wanted to take the conversation to a 
different area.
    Dr. Mullan, I believe you mentioned that we have enough 
physicians, it's the challenge of re-deploying them. Did I hear 
that correctly?
    Dr. Mullan. Yes.
    Senator Merkley. I wanted to turn to the issue of 
recruiting providers, and I understand that the loan repayment 
program and scholarship program, under NHSC, there are 
currently a large number of vacancies for certified nurse 
midwives, 62, nearly 1,000 vacancies for nurse practitioners, 
64 vacancies for psychiatric nurse specialists. Are these 
vacancies a result of a lack of funding for scholarships or 
lack of applicants because we are under supplied?
    Dr. Mullan. I did take the opportunity, as I mentioned, to 
do some homework yesterday, talking to people in the program, 
and they told me the following: in the last round of 
scholarship and loan repayment awards, there were roughly 1,000 
applicants--this is across disciplines--for scholarships and 
they were able to award 100. And in loan repayment, there were 
about 2,800 applications, they were able to award about 800. 
There is an eagerness, and this is an environment which many 
students know that there is relatively little chance they are 
going to get an award. If there was a sense that there are 
awards available, one suspects that the application numbers 
would go way up.
    Senator Merkley. In exchange for the loan repayment and the 
scholarships, there is a service commitment. Could you describe 
or elaborate on those types of commitment?
    Dr. Mullan. On the scholarship, the law has been since the 
beginning, it is a year for a year, with a minimum of 2 years. 
You incur a year of obligation for every year of award. So 
typically, if it's a 2-year award, you serve for 2 years, 
although the evidence is that the majority of people placed by 
the scholarship or loan repayment stay in the community longer, 
sometimes for careers, and other times work at other health 
centers or other underserved areas. So it's been quite positive 
in terms of the movement of people from areas that are higher 
density to ones that are lower density in general.
    Senator Merkley. So this is a program we should really look 
at trying to fund at higher levels?
    Dr. Mullan. It would be, I think, critical both to the 
success of the community health movement, and Dan could speak 
to this better, but even at the current level, there are very 
substantial vacancies in health centers for physicians, 
dentists, nurses, and others, and at the expanded levels, 
unless we have an instrument that will move personnel along 
with building health centers, you are going to have great 
buildings that are empty.
    Senator Merkley. Thank you.
    Senator Sanders. Well, Senator Merkley, I mentioned, as I 
said earlier, in the stimulus package, we tripled funding for 
the National Health Service Corps and the legislation that we 
are discussing this morning we would increase it by 10 times.
    Yes, Ms. Nichols.
    Ms. Nichols. I know there is discussion of changing the 
deadline dates of the National Health Service Corps. At this 
point you can apply once a year, and that certainly has been a 
barrier for us because those medical providers don't always 
look for jobs just once a year.
    Senator Sanders. That has changed. The reason for that is 
they didn't have enough money to accommodate the applicants, 
but right now I believe they will be around every 2 months. It 
will be a rolling period. So I think you are going to be able 
to apply at any time. Because now, they have the money to begin 
to provide the debt forgiveness and the scholarships.
    Mr. Evans. May I suggest that recruitment and the promotion 
of those opportunities be very, very early because, per the 
example you provided earlier, Senator, late in the educational 
career is really too late. It has to be done day one, and it 
should be done minus day one.
    Senator Sanders. Absolutely. We're thinking of trying to 
get the information out to college students who are thinking of 
going to medical school or dental school.
    Yes, Dr. Mullan.
    Dr. Mullan. One other affiliated point. There are numerous 
studies in medicine and in some of the other health professions 
that show that students enter with high levels of idealism and 
we beat it out of them.
    [Laughter]
    Senator Sanders. What a process.
    Dr. Mullan. This goes in medicine, through medical school 
and in through residency. I mean the low point of cynicism is 
probably residency years and then it goes along wounded, and 
late in the career you see the optimism and the positive 
attitude that come up a little bit. That is a little bit of a 
phenomena and careers and mortgages and all that, but a lot of 
it is what we do, in the absence of opportunities to express 
positive careers.
    We see right now across the health professions an explosion 
of interest in global health. People are sort of scratching 
their heads, what is it? The globe has always been out there. 
The illnesses have always been out there. The missionary spirit 
has always been out there. I think that for a variety of 
reasons, the seriousness of the HIV world, and what we see in 
images coming back, it is picking of off the idealism.
    But one of the reasons is, frankly, students don't see the 
opportunities here. And what this double set of up-funding 
promises is building, once again, a sense of, ``I can do this 
in America.'' We have an unfinished mission and doing primary 
care community health can make a huge difference. I don't need 
to go to Botswana. I can do it in northern Vermont, etc. It's a 
little bit of smarmi pictures, but I think it's very real.
    Senator Sanders. One of the absurdities of the current 
situation appropriately related to what you said, Dr. Mullan, 
in terms of nursing. You talked about globalization. Do you 
know where we get many of our nurses from right now? We get 
them from the Philippines. So we are depleting struggling Third 
World systems, taking their professionals into our country, 
because we are not producing the doctors, the dentists, the 
nurses that we need. So it's a reverse globalization, if you 
like.
    Mr. Hawkins. Senator, I also wanted to add, especially in 
light of your point about what you heard from the students at 
Dartmouth, and Senator Harkin's point about the question of how 
do we re-elevate the value and the position of primary care 
within our health care system? You talked about the 2,000 or 
4,000 clinicians in the Corps today, but really if you think 
about it in terms of medical school and residency fits, it's 
not just one-quarter of one percent, but it might be less than 
2 percent of residents across the country are actually on loan 
repayment or scholarship.
    But if you can grow the National Health Service Corps to 
the size, Senator, that your bill portends, a much higher 
proportion of--now they are going into medical schools. They 
are going to go into medical schools and offer loan repayment 
to those who didn't take scholarships before they begin their 
residency, to pick them up in their third or fourth year of 
medical school. What you will see is a much greater proportion 
of medical students going into primary care as a residency and 
career choice, and as you do that, Senator Harkin, yes, we've 
got to improve the payment for primary care because it is well 
below what it should be, just to be appropriate, but it won't 
be a king's ransom that has to be paid. You will have more 
folks coming out of the training pipeline, ready to go into 
primary care. Several years ago we partnered with an 
osteopathic medical school to create the first community health 
center-focused dental school in America, in Arizona, that is 
now pumping out over 60 dentists every year, the vast majority 
going into practice at a health center in oral health.
    Two years after that, we partnered with the same school to 
create one of the most recent osteopathic medical schools in 
America, with more than 100 students who spend 3 of their 4 
years of medical education in a community health care center-
based setting. Although it hasn't graduated its first class, 
and as a result its students didn't qualify for help from the 
National Health Service Corps, it will next year. And more than 
100 medical students every year will be coming out, going into 
residency and we believe the vast preponderance, going into 
practice in community health centers.
    This is what we need to do, target the support that is 
going to be provided as the National Health Service Corps does, 
on two things: primary care; service in underserved 
communities. Those are the two great needs.
    Senator Sanders. Dr. Matthew.
    Dr. Matthew. Senator, I make the point that we have got to 
get at medical students very early on. Our doctors are all on 
the faculty of the University of Vermont and I'm on the faculty 
of Dartmouth. We get first-year students out for a thing called 
``Doctoring in Vermont.'' They are obliged to come about six 
times and then three times towards the end of the year. Some of 
them come every week. We really try to track them and make them 
feel welcome and include them in our medical staff, so to 
speak. We also teach third and fourth year students, usually 
for about 3\1/2\ weeks at a time, but I think that's a bit late 
in the game. I think we need them early on so they get oriented 
to this and know that there can be excellent practice in the 
periphery. It's not all public health. It's having the 
individual physician to be, recognize that can be good work, 
done well, and that you don't have to be in an academic 
institution to do that.
    Senator Sanders. I think we are going to wind down, Senator 
Harkin, do you have any last thoughts you want to share?
    Senator Harkin. I want to thank everyone here. As we are 
working on this health care reform we need your best 
suggestions on how we structure this to accomplish the ends 
that we've all talked about and that Senator Sanders has taken 
the lead on. We don't want to miss this boat. This ship is 
moving and we want to get onboard. We want to make sure that we 
restructure it properly.
    Senator Sanders. Let me just concur with Senator Harkin and 
say this, I think because of the work that all of you have 
done, and many thousands more around this country, there is a 
growing understanding and we are seeing it manifested in the 
funding levels here in Congress, that we need nothing less than 
a revolution in primary health care. That it's absurd that 60 
million Americans have no health care home, that even more lack 
a dentist, that there is so much unnecessary human suffering 
because of the crisis of primary health care, and then to add 
insult to injury, we are wasting hundreds of billions of 
dollars because we are not keeping people healthy, and giving 
them access to primary health care. So I think we are beginning 
to change the paradigm and as Senator Harkin indicated, we need 
your continued help and support to move the ball forward. I 
think this has been a productive hearing.
    Senator Harkin, thank you very much for all of your 
contributions, and all of the members of the panel, thank you 
so much for being here.
    Thank you.
    [Whereupon, at 11:31 a.m., the hearing was adjourned.]

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