[Congressional Record Volume 143, Number 82 (Thursday, June 12, 1997)]
[Senate]
[Pages S5605-S5608]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRAHAM (for himself, Mr. McCain, Mr. Smith of Oregon, Mr. 
        Wyden, Mr. Bumpers, Mr. Thomas, Mr. Hutchinson, Mr. Bond, Mr. 
        Gregg, Mr. Reid, Mr. Ford, Mr. Robb, Mr. Inouye, Mr. Santorum, 
        Mr. Breaux, Mr. Hollings, Mr. Glenn, and Mr. Durbin):
  S. 892. A bill to amend title VII of the Public Health Service Act to 
revise and extend the area health education center program; to the 
Committee on Labor and Human Resources.


         the area health education center program extension act

  Mr. GRAHAM. Mr. President, I rise today to introduce legislation in 
conjunction with Senator McCain and 16 of our colleagues to reauthorize 
the Area Health Education Center Program under title VII of the Public 
Health Service Act.
  Unfortunately, the law of supply and demand does not always operate 
to the benefit of rural Americans or the working poor in the health 
care marketplace. Whether individuals live three counties away from the 
nearest full-service clinic or just across town, often their access to 
primary and preventive care is limited.
  While recent attention has focused on controlling run-away health 
care costs, the problem is not only one of cost, but also one of 
allocation. We need to allocate both our abundant supply of health 
professionals and the highly concentrated resources of our world class 
academic health centers to individuals who are underserved in the 
health care marketplace.
  Since its inception in 1973, one of the most effective means of 
redistributing and reallocating manpower has been the Federal and 
State-funded Area Health Education Centers Program [AHEC]. AHEC's serve 
as bridges between medical schools and our Nation's underserved rural 
and inner-city communities, recruiting and training primary care 
providers and health professionals, and providing continuing education 
to existing providers. Nine years ago, the AHEC Program was expanded to 
include the Health Education Training Centers Program [HETC], which are 
designed to address the persistent unmet health care needs of 
population groups such as migrants, minorities, and others.
  As Governor of Florida, I became aware of the accomplishments of 
AHEC's in addressing the maldistribution of health professionals in 
underserved areas of other southern States

[[Page S5606]]

such as North Carolina and helped catalyze the initial interest for the 
development of AHEC's in my State. Since then, I have been pleased to 
see AHEC's and more recently HETC's grow and flourish throughout 
Florida and throughout the country.
  Based at each of the State's medical schools, Florida's four AHEC 
programs now cover all 67 counties in the State. The programs and their 
10 affiliated centers conduct activities that address regional and 
State priorities in areas such as public and school health, recruitment 
of health professionals to medically underserved communities, and 
special health needs of migrant and immigrant populations.
  With more than 44 AHEC programs operating in 42 States, we are 
finally approaching the full evolution of AHEC into a national system 
with an infrastructure through which to reach those communities and 
populations in greatest need of basic health services. In 1994, 80 of 
142 allopathic and osteopathic medical schools were involved with AHEC 
and HETC programs nationally, and 13 percent of the Nation's total 
medical school enrollment obtained community-based training through the 
program.
  AHEC's effectiveness lies in this unique ability to combine the 
resources of academic health centers with those of medically 
underserved communities and in such a way that enhances the primary 
care training while increasing access to care. This role continues to 
increase in importance as States struggle to adjust to changes in 
medical reimbursements, limitations on welfare, and cutbacks in social 
services.

  One of the most important contributions AHEC's have made in Florida 
and around the Nation is in the training of health professionals in 
collaboration with local health education institutions, public health 
departments, community health centers, rural hospitals, local school 
systems, and volunteer organizations. As a result AHEC's have generated 
a great deal of academic and community support. During fiscal year 
1994, 32 AHEC programs received $22 million in Federal allocations; 
this was matched by approximately $106 million in State and local 
funds. These programs have had such success in gaining local and State 
funds because State legislators and community leaders have witnessed 
the very real impact and benefits that AHEC's bring to the lives of the 
people in their States and communities.
  Despite promising health care reforms and increased enrollment in 
managed care networks, the number of uninsured and underinsured 
Americans continues to rise. Hundreds of counties throughout the United 
States are still without doctors, and for many low-income families, 
whether they be located in the inner-city or a small, rural community, 
preventive dental care is considered a luxury.
  Because these problems have yet to be resolved, and because AHEC is 
needed as much today as when it was created, Senator McCain and I are 
sponsoring this legislation to reauthorize AHEC, as we did successfully 
in 1992. This reauthorization already enjoys widespread bipartisan 
support--a testament to the pliable nature of this program in meeting 
the needs of diverse communities. In their first 25 years, AHEC's 
around the country have repeatedly shown that the sum total of Federal 
and State dollars that they have been allocated has been money well 
spent. We would like to see this successful program extended for 5 more 
years.
  Thanks to AHEC, the face of health professions education is changing 
into a more community-centered enterprise that places higher priority 
on the everyday needs of all Americans, including those who 
historically have been underserved. While we have already begun to see 
the results of this change, many challenges lie ahead in the ongoing 
effort to ensure access to health care for all Americans. With the 
contribution of AHEC, our communities and academic health centers will 
have the means necessary to work together and meet those challenges.
  Mr. President, I invite my colleagues to join Senator McCain and me 
in supporting the reauthorization of this important program which 
targets health care services to our Nation's most underserved areas. I 
ask unanimous consent that the full text of the bill and letters of 
support from the Association of American Medical Colleges and the 
American Association of Colleges of Osteopathic Medicine be printed in 
the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                 S. 892

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Area Health Education Center 
     Program Extension Act''.

     SEC. 2. AREA HEALTH EDUCATION CENTER PROGRAM.

       Section 746 of the Public Health Service Act (42 U.S.C. 
     293j et seq.) is amended to read as follows:

     ``SEC. 746. AREA HEALTH EDUCATION CENTER PROGRAMS.

       ``(a) Authority for Provision of Financial Assistance.--
       ``(1) Assistance for planning, development, and operation 
     of programs.--
       ``(A) In general.--The Secretary shall award grants to and 
     enter into contracts with schools of medicine and osteopathic 
     medicine and incorporated consortia made up of such schools, 
     or the parent institutions of such schools, for projects for 
     the planning, development and operation of area health 
     education center programs that--
       ``(i) improve the recruitment, distribution, supply, 
     quality and efficiency of personnel providing health services 
     in underserved rural and urban areas and personnel providing 
     health services to populations having demonstrated serious 
     unmet health care needs;
       ``(ii) increase the number of primary care physicians and 
     other primary care providers who provide services in 
     underserved areas through the offering of an educational 
     continuum of health career recruitment through clinical 
     education concerning underserved areas in a comprehensive 
     health workforce strategy;
       ``(iii) carry out recruitment and health career awareness 
     programs to recruit individuals from underserved areas and 
     under-represented populations into the health professions;
       ``(iv) prepare individuals to more effectively provide 
     health services to underserved areas or underserved 
     populations through field placements, preceptorships, the 
     conduct of or support of community-based primary care 
     residency programs, and agreements with community-based 
     organizations such as community health centers, migrant 
     health centers, Indian health centers, public health 
     departments and others;
       ``(v) conduct health professions education and training 
     activities for students and medical residents;
       ``(vi) conduct at least 10 percent of medical student 
     required clinical education at sites remote to the primary 
     teaching facility of the contracting institution; and
       ``(vii) provide information dissemination and educational 
     support to reduce professional isolation, increase retention, 
     enhance the practice environment, and improve health care 
     through the timely dissemination of research findings using 
     relevant resources.
       ``(B) Project terms.--
       ``(i) In general.--Except as provided in clause (ii), the 
     period during which payments may be made under an award under 
     subparagraph (A) may not exceed--

       ``(I) in the case of a project, 12 years or
       ``(II) in the case of a center within a project, 6 years.

       ``(ii) Exception.--The periods described in clause (i) 
     shall not apply to--

       ``(I) projects that have completed the initial period of 
     Federal funding under this section and that desire to compete 
     for model awards under paragraph (2)(A); and
       ``(II) projects that apply for awards under subsection (d) 
     regardless of whether such projects have completed their 
     initial period of Federal funding under this section.

       ``(2) Assistance for operation of model programs.--
       ``(A) In general.--In the case of any entity described in 
     paragraph (1)(A) that--
       ``(i) has previously received funds under this section;
       ``(ii) is operating an area health education center 
     program; and
       ``(iii) is no longer receiving financial assistance under 
     paragraph (1);

     the Secretary may provide financial assistance to such entity 
     to pay the costs of operating and carrying out the 
     requirements of the program as described in 746(a)(1).
       ``(B) Matching requirement.--With respect to the costs of 
     operating a model program under subparagraph (A), an entity, 
     to be eligible for financial assistance under subparagraph 
     (A), shall make available (directly or through contributions 
     from State, county or municipal governments, or the private 
     sector) recurring non-Federal contributions in cash toward 
     such costs in an amount that is equal to not less than 50 
     percent of such costs.
       ``(C) Limitation.--The aggregate amount of awards provided 
     under subparagraph (A) to entities in a State for a fiscal 
     year may not exceed the lesser of--
       ``(i) $2,000,000; or
       ``(ii) an amount equal to the product of $250,000 and the 
     aggregate number of area health education centers operated in 
     the State by such entities.

[[Page S5607]]

       ``(b) Requirements for Centers.--
       ``(1) General requirement.--Each area health education 
     center that receives funds under this section shall encourage 
     the regionalization of health professions schools through the 
     establishment of partnerships with community-based area 
     health education centers.
       ``(2) Service area.--Each area health education center that 
     receives funds under this section shall specifically 
     designate a geographic area or medically underserved 
     population to be served by the center. Such area or 
     population shall be in a location removed from the main 
     location of the teaching facilities of the schools 
     participating in the program with such center.
       ``(3) Other requirements.--Each area health education 
     center that receives funds under this section shall--
       ``(A) assess the health personnel needs of the area to be 
     served by the center and assist in the planning and 
     development of training programs to meet such needs;
       ``(B) arrange and support rotations for students and 
     residents in family medicine, general internal medicine or 
     general pediatrics, with at least one center in each program 
     being affiliated with or conducting a rotating osteopathic 
     internship or medical residency training program in family 
     medicine, general internal medicine, or general pediatrics in 
     which no fewer than 4 individuals are enrolled in first-year 
     positions;
       ``(C) conduct interdisciplinary training that involves 
     physicians and other health personnel including, where 
     practicable, public health professionals, physician 
     assistants, nurse practitioners, and nurse midwives; and
       ``(D) have an advisory board, at least 75 percent of the 
     members of which shall be individuals, including both health 
     service providers and consumers, from the area served by the 
     center.
       ``(c) Certain Provisions Regarding Funding.--
       ``(1) Allocation to centers.--Not less than 75 percent of 
     the total amount of Federal funds provided to an entity under 
     this section shall be allocated by an area health education 
     center program to the area health education centers. Such 
     entity shall enter into an agreement with each center for 
     purposes of specifying the allocation of such 75 percent of 
     funds.
       ``(2) Operating costs.--With respect to the operating costs 
     of the area health education program of an entity receiving 
     funds under this section, the entity shall make available 
     (directly or through contributions from State, county or 
     municipal governments, or the private sector) non-Federal 
     contributions in cash toward such costs in an amount that is 
     equal to not less than 50 percent of such costs, except that 
     the Secretary may grant a waiver for up to 75 percent of the 
     amount of the required non-Federal match in the first three 
     years in which an entity receives funds under this section.
       ``(d) Health Education and Training Centers.--
       ``(1) Requirements.--A health education training center 
     shall be an entity eligible for funds under this section 
     that--
       ``(A) addresses the persistent and severe unmet health care 
     needs in States along the border between the United States 
     and Mexico and in the State of Florida, and in other urban 
     and rural areas with populations with serious unmet health 
     care needs;
       ``(B) establishes an advisory board comprised of health 
     service providers, educators and consumers from the service 
     area;
       ``(C) conducts training and education programs for health 
     professions students in these areas;
       ``(D) conducts training in health education services, 
     including training to prepare community health workers; and
       ``(E) supports health professionals practicing in the area 
     through educational and other services.
       ``(2) Allocation of funds.--The Secretary shall make 
     available 50 percent of the amounts appropriated for each 
     fiscal year under subsection (e) for the establishment or 
     operation of health education training centers through 
     projects in States along the border between the United States 
     and Mexico and in the State of Florida.
       ``(e) Authorization of Appropriations.--
       ``(1) Area health education center programs.--
       ``(A) In general.--There is authorized to be appropriated 
     to carry out this section, other than subsection (d), 
     $40,000,000 for each of the fiscal years 1998 through 2002.
       ``(B) Required obligation.--Of the amounts appropriated 
     under subparagraph (A) for each fiscal year, the Secretary 
     may obligate for awards under subsection (a)(2)--
       ``(i) not less than 20 percent of such amounts in fiscal 
     year 1998;
       ``(ii) not less than 25 percent of such amounts in fiscal 
     year 1999;
       ``(iii) not less than 30 percent of such amounts in fiscal 
     year 2000;
       ``(iv) not less than 35 percent of such amounts in fiscal 
     year 2001; and
       ``(v) not less than 40 percent of such amounts in fiscal 
     year 2002.
       ``(C) Health education and training centers.--There is 
     authorized to be appropriated to carry out subsection (d), 
     $10,000,000 for each of the fiscal years 1998 through 2002.
       ``(2) Sense of Congress.--It is the sense of the Congress 
     that--
       ``(A) every State have an active area health education 
     center program in effect under this section; and
       ``(B) the ratio of Federal funding for the model program 
     under section 746(a)(2) should increase over time and that 
     Federal funding for other awards under this section shall 
     decrease so that the national program will become entirely 
     comprised of programs that are funded at least 50 percent by 
     State and local partners.''.
                                  ____

                                           Association of American


                                             Medical Colleges,

                                    Washington, DC, June 11, 1997.
     Hon. Bob Graham,
     U.S. Senate, Washington, DC.
       Dear Senator Graham: The Association of American Medical 
     Colleges (AAMC) strongly supports your legislation to 
     reauthorize the Area Health Education Centers (AHEC) and 
     Health Education Training Centers (HETC) programs, which are 
     authorized under Title VII of the Public Health Service Act.
       The Area Health Education Center Program Extension Act will 
     protect the primary objectives of the AHEC and HETC programs, 
     which seek to train physicians and other health professionals 
     to provide primary and preventive medical services to 
     communities that are medically underserved. The flexibility 
     and innovativeness of AHEC programs distinguish them among 
     Title VII programs. Medical schools have led AHEC programs 
     successfully since the inception of the program by Congress. 
     The success of the AHEC program is very much due to the 
     ability of the centers to make the substantial resources of 
     medical schools and their parent institutions available to 
     medically underserved communities. It is essential to these 
     communities that these linkages be preserved.
       In a nation with over 2,000 health professionals shortage 
     areas and a changing health care delivery system, the federal 
     government and health professions community must continue to 
     develop innovative ways to train physicians and other health 
     professionals to address the health care needs of the 
     medically underserved. The goal of the AHEC and HETC programs 
     is to provide the catalyst to develop long-term 
     collaborations between medical schools and the community-
     based health care delivery centers.
       Thank you for your leadership on this issue. We look 
     forward to working with you to sustain this vital partnership 
     between medical schools and the communities they serve.
           Sincerely,
     Jordan J. Cohen, M.D.
                                  ____

         American Association of Colleges of Osteopathic Medicine,
                                   Chevy Chase, MD, June 12, 1997.
     Hon. Bob Graham,
     U.S. Senate, Washington, DC.
       Dear Senator Graham: The American Association of Colleges 
     of Osteopathic Medicine is very pleased to endorse the Area 
     Health Education Centers Program Extension Act. The AHEC 
     program provides clinical training opportunities to health 
     professions students in rural settings by extending the 
     resources of academic health centers in need of health care 
     and education. Through this linkage, AHEC projects form 
     networks of health related institutions to provide 
     educational services to students, faculty, and practitioners, 
     and ultimately improve health care delivery.
       Senator Graham, we applaud your and Senator McCain's 
     leadership in introducing this important legislation. Please 
     contact us if we can be of assistance.
           Sincerely,
                                     Douglas L. Wood, D.O., Ph.D.,
                                                        President.

  Mr. McCAIN. Mr. President, I am proud to join my colleague Senator 
Bob Graham in sponsoring the reauthorization legislation for the 
national Area Health Education Center Program.
  The Graham-McCain reuthorization legislation represents the consensus 
opinion of the Area Health Education Center community nation-wide. The 
Area Health Education Center Program Extension Act strives to not only 
reauthorize the existing act, but to do so in an innovative manner.
  Currently, 42 States participate in the AHEC program which originated 
in 1976 when Congress recognized the lack of quality health care 
available in our country--especially in our rural and low income urban 
communities. Too many of these cities and towns did not have access to 
primary medical care services. Too many communities were losing their 
bright, educated youth to the larger, economically strong cities and 
medical communities. Our rural and low income communities were faced 
with many disadvantages including shortages of physicians and a lack of 
access to basic health care services.
  In response to the health care problems facing our rural and low 
income urban communities, Congress created the Area Health Education 
Center Program to generate partnerships between medical schools or 
academic health centers and rural areas throughout a State. Through 
these partnerships the AHEC program strives to improve the supply and 
distribution of health care

[[Page S5608]]

professionals while increasing access to quality health care.
  The AHEC programs work to meet the medical needs of undeserved areas 
by creating and implementing innovative methods and educational 
partnerships. Each AHEC program is individually established and created 
on a State-by-State basis and provides health professional student 
training, continuing professional education, student recruitment and 
placement, development of remote site learning resources, and other 
projects designed to influence the quantity and distribution of health 
personnel. Several years ago, this program was expanded to include the 
Health Education Training Center (HETC) program which addresses the 
high impact needs which exist in certain areas--particularly those 
along the Mexican-American border.
  However, despite all the progress and success of the AHEC and HETC 
programs over the last 21 years, the need for recruiting and keeping 
health care professionals still remains a challenge for many of our 
rural and low-income urban communities. This is why Senator Graham and 
I, along with 16 of our colleagues are introducing the Area Health 
Education Center Program Extension Act.
  The Graham-McCain reauthorization of the Area Health Education Center 
Program Extension Act would reauthorize for 5 years the core AHEC 
program and the existing HETC program. This bill would allow the 
Secretary of Health and Human Services to award grants and enter into 
contracts with schools of medicine and osteopathic medicine to develop 
AHEC and HETC programs.
  Under this bill, AHEC and HETC programs are required to continue 
improving the distribution of health professionals in communities with 
serious, unmet health care needs. The programs are also required to 
increase the number of primary care providers in under served areas 
while recruiting individuals from these areas and from populations not 
equally represented into health professions. In addition, the AHEC and 
HETC programs are responsible for conducting training and education 
activities for health care students, including medical residents.
  Initially, funding for AHEC programs is a Federal responsibility. 
However, after the first 6 years of operation the AHEC program must 
obtain 50 percent of their funding from their State, county or 
municipal government or the private sector in order to continue 
receiving matching Federal funding.
  It is important that we continue to support and promote programs like 
AHEC and HETC which have developed and are implementing innovative, 
effective and efficient approaches for making high quality health care 
accessible throughout our Nation, particularly in rural communities, 
border States and low-income urban areas.
  I believe the AHEC and HETC programs are both bright lights with 
regard to the potential for addressing the health provider shortage and 
unmet medical needs in our country. Both the AHEC and HETC programs 
have clearly demonstrated they are fulfilling a very definite need and 
ought to be reauthorized and extended. These programs have tremendous 
potential to continue assisting in effectively addressing the critical 
health problems in our communities. I urge all of my colleagues to 
review this important legislation and consider joining us as a 
cosponsor of this bill.
                                 ______