[Congressional Record Volume 149, Number 167 (Tuesday, November 18, 2003)]
[Senate]
[Pages S15067-S15068]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. ENZI (for himself, Mr. Bingaman, Mr. Thomas, and Mr. 
        Craig):
  S. 1883. A bill to amend the Public Health Service Act to provide 
greater access for residents of frontier areas to the healthcare 
services provided by community health centers; to the Committee on 
Health, Education, Labor, and Pensions.
  Mr. ENZI. Mr. President, I rise today to introduce legislation that 
would increase the likelihood that citizens who live on the American 
frontier and in other sparsely populated areas will have access to 
affordable healthcare in their communities.
  Since my election to the Senate in 1996, one of my goals has been to 
educate folks in Washington about what life is like in the West.
  Obviously there are rural areas along the East and West Coasts and in 
the Midwest. But people who live in these places are always surprised 
when they travel for the first time to places like my home State of 
Wyoming. They are amazed at just how rural Wyoming is.
  Well, Wyoming is more than rural. Most Wyomingites live in the 
remaining stretches of the American frontier. Now, that's not to say 
that there aren't plenty of sparsely populated areas elsewhere, even in 
coastal States. There are many places outside the West that share the 
characteristics of the frontier. But almost all of Wyoming is sparsely 
populated. In fact, more people live in the 68 square miles of the 
District of Columbia than live in the 98,000 square miles of Wyoming.
  People who live on the frontier and other sparsely populated areas 
face some unique challenges, and one of those challenges is access to 
affordable healthcare. People who live in frontier areas are more 
likely to lack health insurance than other rural and urban citizens. 
Also, frontier areas generally do not have population centers that can 
support the full range of healthcare services available in most urban 
and some rural areas.
  One of the proven ways of improving healthcare in medically 
underserved areas is through the establishment of federally qualified 
community health centers, or CHCs. Community health centers are not-
for-profit providers of health care to the working poor, the uninsured, 
and other vulnerable populations. These safety-net providers served ten 
million people across America in 2001.
  Community health centers deliver preventive and primary care to 
patients regardless of their ability to pay. Almost half of the 
patients treated at community health centers have no insurance coverage 
at all. Community health centers set their charges according to income, 
and they do not collect any fees from their poorest clients.
  President Bush has proposed major increases in funding for the 
establishment and expansion of community health centers, and Congress 
has begun to provide that funding. Senators across the political 
spectrum agree that community health centers play an important role in 
providing health services to the uninsured and underinsured in many 
medically underserved areas. We all agree that we ought to encourage 
the development of more sites where those in need but without means can 
get proper care.
  Unfortunately, many frontier areas do not have community health 
centers. Wyoming, for example, only has one CHC, located in Casper. 
That center just opened a satellite clinic in Riverton, a town of 9,300 
people almost 125 miles away, so now we have two sites.
  The Federal Government keeps statistics on the degree of ``health 
center penetration into the unserved.'' In other words, we keep track 
of what percentage of those who need access to affordable healthcare 
can get adequate service through community health centers.
  In Wyoming, only 7.9 percent of the unserved had reasonable access to 
community health center services, based on 2001 data. Lest you think 
this is just a Wyoming problem, Mr. President, let me share some 
percentages from other states: Alabama: 15.9 percent; Georgia: 8.9 
percent; Indiana: 10.1 percent; Kansas: 10.4 percent; Louisiana: 4.3 
percent; Maryland: 15.8 percent; Nebraska: 5.3 percent; Nevada: 7.8 
percent; North Carolina: 11.1 percent; Oklahoma: 7.8 percent; Texas: 
9.0 percent; and Virginia: 12.2 percent.
  Why are these access figures so low? It's not because communities 
aren't interested in helping their less fortunate neighbors. It's 
because many communities on the frontier and in other sparsely 
populated areas can't even apply for community health center funding.
  Why can't they apply? Well, believe it or not, the Federal Government 
doesn't consider many isolated communities to be located in ``medically 
underserved areas.'' And a community has to be designated as being a 
``medically underserved area'' before one can even apply for CHC 
funding.
  The barrier for frontier communities lies in the index that the 
Federal Government uses to determine ``medical underservice.'' That 
index looks at four factors: the percentage of people over 65 years of 
age, and the ratio of primary-care physicians per 1,000 people.
  Using these four factors, the agency has calculated that only four 
Wyoming's 23 counties qualify to be ``medically underserved areas.'' I 
find this interesting, since Wyoming ranks 46th out of the 50 State in 
terms of physician-to-population ratio.

  I have an idea about the source of this contradiction. When I went to 
accounting school, one of the things I learned about was a concept 
called ``statistical validity.'' What I learned was that the 
statistical validity of a sample is a function of sample size: in other 
words, the larger the sample, the more accurate the results associated 
with the sample.
  Well, as you can imagine, sparsely populated states like Wyoming 
offer

[[Page S15068]]

less statistically valid samples than other states. Many of our 
counties score very well on factors like infant mortality. Take Western 
County, for instance. Weston County has a very low infant mortality 
rate--in fact, their rate in 2002 was zero. But there were only 59 
births in Weston County. Now I'm happy to see that statistic, but it 
really hurts Weston County's score on the agency index.
  Even looking at 5 years of data in sparsely populated counties 
doesn't provide a statistically valid sample. From 1994 to 1998, Weston 
County's infant mortality rate was 8.5 per 1000 births, slightly above 
the national average. From 1995 to 1999, Weston County's rate jumped to 
14.7 percent--nearly twice the national average.
  Why did the infant mortality rate jump so dramatically in Weston 
County? The only difference was that in 1999, two of the 60 babies born 
in the county died soon after birth.
  When two deaths have such a dramatic impact on the infant mortality 
rate, it's because the sample size simply isn't large enough to provide 
a valid result. Slight variations in small samples can result in huge 
differences when translated into statistical data. And in my opinion, 
we shouldn't be making decisions based on statistics that aren't valid 
indicators of the healthcare status of a community.
  I am concerned that the Federal definition of ``medically underserved 
areas'' does not recognize the unique nature and needs of people who 
live in the sparsely populated areas of our country. This makes me 
concerned that frontier communities are going to miss out on a great 
opportunity to participate in our national expansion of community 
health centers.
  That's why I'm joining today with my distinguished colleagues 
Senators Bingaman, Thomas, and Craig to introduce the Frontier 
Healthcare Access Act. We believe that people who live on the frontier 
and in other sparsely populated areas ought to have a fair shot at 
competing for federal support as we grow the community health center 
program.
  Our bill would automatically deem ``frontier areas'' to be eligible 
for Federal funding for the development and expansion of community 
health centers.
  The bill would require no new funding--it would simply designate 
frontier communities as special populations eligible for federal CHC 
support. Nor would the bill create a new preference for frontier 
areas--it would simply allow frontier communities into the competition 
for funding. The bill would end the application of a statistical 
formula that doesn't provide a valid assessment of need in sparsely 
populated areas--but it would still require frontier communities to 
compete with other communities to receive federal CHC support.
  The Frontier Healthcare Access Act also would direct the Federal 
Government to create a new definition of ``frontier area.'' The bill 
would require that the new definition go beyond the traditional 
population-density approach to include important factors like distance 
in miles and travel time in minutes to the nearest significant 
healthcare service area or market. This is important, because defining 
frontier solely by population overlooks some important considerations.
  For example, in some large counties, the presence of a city in one 
corner skews population density and overshadows the existence of many 
large frontier areas. Furthermore, a key component to frontier life is 
distance. Even areas with population density as high as 20 people per 
square mile should be considered frontier if the community is located 
far from the closest significant service center or market.
  The National Rural Health Association and the Western Governors 
Association have already endorsed a definition using the factors 
proposed by the Frontier Healthcare Access Act. If the federal 
government adopts a similar definition, it would ensure eligibility for 
community health center development and expansion for about ten million 
citizens who live in more than 800 counties located in 38 states--not 
just the frontier West.
  Mr. President, people in hundreds of cities and towns across the 
country have access to affordable healthcare services through community 
health centers. People who live in sparsely populated areas ought to 
have a fair opportunity to create the same sort of access.
  The Frontier Healthcare Access Act would create this opportunity for 
people who live in isolated communities across our great country. I 
hope that my colleagues will join me in making this opportunity 
possible for our citizens who live in every part of our remaining 
American frontier--whether the buffalo still roam there or not.
  I ask unanimous consent that the text of the bill be printed in the 
Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1883

       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 ``Frontier Healthcare Access 
     Act of 2003''.

     SEC. 2. FINDINGS AND PURPOSE.

       Congress makes the following findings:
       (1) People who live in frontier areas are medically 
     underserved and face unique challenges in accessing 
     affordable healthcare.
       (2) People who live in frontier areas are more likely to 
     lack health insurance than other rural and urban citizens.
       (3) Frontier areas generally do not have population centers 
     that can support the full range of healthcare services 
     available in most urban and some rural areas.
       (4) Community health centers play an important role in 
     providing health services to many medically underserved areas 
     and populations.
       (5) Many frontier areas do not have community health 
     centers.
       (6) Many frontier areas cannot currently qualify for 
     community health centers because the Federal definition of 
     medically underserved areas or populations does not 
     appropriately or effectively recognize the unique nature and 
     needs of frontier areas and those who live in them.
       (7) Any definition of frontier areas for purposes of 
     eligibility for Federal or State healthcare programs should 
     look beyond simple measures of population density to consider 
     such factors as the distance from and travel time to the 
     nearest significant healthcare service center or market.
       (8) President George W. Bush has made the development of 
     new community health centers a priority of his 
     administration.
       (9) People who live in frontier areas should be included 
     explicitly in this expansion of the community health center 
     program.
       (b) Purpose.--It is the purpose of this Act to provide 
     greater access for residents of frontier areas to the 
     healthcare services provided by community health centers.

     SEC. 3. FRONTIER COMMUNITY HEALTH CENTERS.

       Section 330 of the Public Health Service Act (42 U.S.C. 
     254b) is amended--
       (1) in subsection (a)(1), by striking ``and residents of 
     public housing'' and inserting ``residents of public housing, 
     and residents of frontier areas'';
       (2) by redesignating subsections (j), (n), (o), (p), (q), 
     (r), (s), (q), and (s) as subsections (k), (l), (m), (n), 
     (o), (p), (q), (r), and (s), respectively; and
       (3) by inserting after subsection (i), the following:
       ``(j) Residents of Frontier Areas.--
       ``(1) In general.--The Secretary may award grants for the 
     purposes described in subsections (c), (e), and (f) for the 
     planning and delivery of services to areas identified under 
     paragraph (3)(B).
       ``(2) Supplement not supplant.--A grant awarded under this 
     subsection shall be expended to supplement, and not supplant, 
     the expenditures of the health center and the value of in-
     kind contributions for the delivery of services to the 
     population described in paragraph (1).
       ``(3) Definition.--
       ``(A) In general.--In this subsection, the term `frontier 
     area' means a county or a rational area identified by the 
     Secretary in consultation with appropriate State offices of 
     rural health.
       ``(B) Regulations.--The Secretary shall through regulations 
     develop a definition to identify frontier areas and shall 
     designate residents of such areas as medically underserved 
     for purposes of this section. In developing such definition 
     the Secretary shall consider factors such as population 
     density, distance in miles from the nearest significant 
     healthcare service center or market, and travel time in 
     minutes from the nearest significant healthcare service 
     center or market.''.
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