Senate Report 110-274 - HEALTH CARE SAFETY NET ACT OF 2007

[Senate Report 110-274]
[From the U.S. Government Publishing Office]

Calendar No. 548
110th Congress Report
SENATE
2d Session 110-274

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HEALTH CARE SAFETY NET ACT OF 2007

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March 12, 2008.--Ordered to be printed

_______

Mr. Kennedy, from the Committee on Health, Education, Labor, and
Pensions, submitted the following

R E P O R T

[To accompany S. 901]

The Committee on Health, Education, Labor, and Pensions, to
which was referred the bill (S. 901) to amend the Public Health
Service Act to provide additional authorizations of
appropriations for the health centers program under section 330
of such Act, having considered the same, reports favorably
thereon with an amendment in the nature of a substitute and an
amendment to the title and recommends that the bill (as
amended) do pass.

CONTENTS

Page
I. Purpose and need for legislation.................................1
II. Summary.........................................................14
III. History of legislation and votes in committee...................14
IV. Explanation of bill and committee views.........................15
V. Cost estimate...................................................21
VI. Regulatory impact statement.....................................23
VII. Application of law to the legislative branch....................23
VIII.Section-by-section analysis.....................................23

IX. Changes in existing law.........................................25

I. Purpose and Need for Legislation

The Health Care Safety Net Act of 2007 reauthorizes and
strengthens three programs which together provide a safety net
that helps millions of Americans each year access needed health
care services. In doing so, the committee is acting to
maintain, improve, and increase its support for these programs,
which enable safety net providers located in rural and urban
areas throughout this country to offer health care services to
millions of underserved and uninsured people. The programs
included in this act are:
The Health Centers program, established under
Title III, Section 330 of the Public Health Service Act;
supports the provision of health care and related services to
the medically underserved--meaning those individuals living in
rural or urban communities that are federally-designated as
medically underserved, or whose populations are members of a
federally-designated medically underserved population.
The National Health Service Corps, authorized
under Title III, Sections 331 through 338L of the Public Health
Service Act; assists in the delivery of health services in
health professional shortage areas by providing access to
scholarships and loan repayments to eligible clinicians.
Rural Health Programs, located in Title III,
Sections 330A, 330I, 330J, and 330K of the Public Health
Service Act; assist with the provision of coordinated care in
rural areas. These programs include the Rural Health Care
Services Outreach, Rural Health Network Development, Small
Health Care Provider Quality Improvement, Telehealth Network,
Telehealth Resource Centers, Rural Emergency Medical Service
Training and Equipment Assistance, and Mental Health Service
Delivered Via Telehealth.

THE HEALTH CENTERS PROGRAM

Introduction

The Committee has a long history of supporting the work of
safety net providers in urban and rural areas who dedicate
their efforts to providing care for those individuals who would
otherwise not have access to a regular source of health care.
At a time when 47 million Americans are without health
insurance and over 56 million lack adequate access to a primary
care physician due to an actual physician shortage in their
communities, existing safety net providers continue to grapple
with increasing demands for care from the uninsured and
underinsured populations in this country. Thousands of
communities across the country today continue to experience
shortages of accessible, cost-effective, preventive and primary
health care services especially for individuals who are unable
to pay for such care.

History of Health Centers Program

In response to the large number of individuals living in
medically underserved areas, as well as the growing number of
special populations lacking access to preventive and primary
health care services, in 1965, Congress created the Health
Centers program, formally authorizing it in 1975. For more than
40 years, the Health Centers program has effectively and
efficiently assured access to cost-effective, high quality,
preventive and primary care services, thereby improving the
health status of the Nation's underserved and vulnerable
populations. This program was designed to empower communities
to address local health access challenges and to improve the
health status of their underserved and vulnerable populations.
Health centers do this by building community-based primary care
capacity and by offering case management, home visitation,
outreach, and other enabling services to increase utilization
by vulnerable populations and improve the effectiveness of the
preventive and primary care they offer. Health centers serve as
a prototype for effective public-private partnerships,
demonstrating their ability to meet pressing local health needs
while being held accountable for meeting national performance
standards. The care provided at health centers contributes to
success of the program in reducing avoidable hospitalizations,
lowering emergency room use, and lessening the need for
specialty care, thus saving billions for taxpayers and
society.\1\
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\1\National Association of Community Health Centers and The Robert
Graham Center. Access Denied: A Look at America's Medically
Disenfranchised. March 2007. www.nachc.com/research-data.cfm. NACHC and
Association of Community Affiliated Plans, The Impact of Health Centers
and Community-Affiliated Health Plans on Emergency Department Use,
April 2007. www.nachc.com/research-data.cfm. National Association of
Community Health Centers, The Robert Graham Center, and Capital Link.
Access Granted: The Primary Care Payoff. August 2007. www.nachc.com/
research-reports.cfm.
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Core requirements of the Health Centers Program

The Health Centers program's core elements found in Section
330 of the Public Health Service Act, as established by
Congress, and last reauthorized in 2002 as part of the Health
Care Safety Net Amendments Act, Public Law (P.L.) 107-251
stipulate that each Federally-supported health center must:
1. Be located in, and serve, a community that is
federally-designated as ``medically underserved,'' thus
ensuring the proper targeting of Federal resources to
areas of greatest need;
2. Make its services available to all residents of
the community, without regard for ability (or
inability) to pay for such services, and make those
services affordable by discounting the health center's
charges in accordance with family income for otherwise
uncompensated care provided to low-income families;
3. Provide comprehensive primary health care
services, including preventive care (such as regular
check-ups and pap smears), care for acute and chronic
illnesses and injuries, services to improve both the
accessibility of care (such as transportation and
translation services) and the effectiveness of care
(such as health/nutrition education), and patient case
management;
4. Be governed by a board of directors, a majority of
whose members are active, registered patients of the
health center, thus ensuring that the center is
responsive to the health care needs of the community it
serves.
Health centers must also meet strict operational, clinical
and financial standards, as well as reporting and performance
requirements.

Types of health centers

During the 1996 reauthorization of the Health Centers
program (Health Centers Consolidation Act of 1996, P.L. 104-
299), the committee consolidated four separately targeted
health center authorities under a single authority, while
maintaining distinct resources to serve vulnerable
subpopulations of migrant and seasonal farm workers and their
families, homeless individuals, and residents of public
housing. The program currently serves over 17 million medically
underserved people in more than 6,300 service delivery sites in
every State and territory.\2\
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\2\NACHC, 2008 based on Bureau of Primary Health Care, HRSA, DHHS,
2006 Uniform Data System (UDS). It includes patients of federally-
funded health centers, non-federally funded health centers (health
center ``look-alikes''), and expected patient growth for 2007-2008.
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1. Community Health Centers--Community Health Centers were
first funded by Congress in the mid-1960s as neighborhood
health centers. By the early 1970s, approximately 100
neighborhood health centers had been established under the
Economic Opportunity Act. These centers were designed to
provide accessible, personal health services to low-income
families. Community and consumer participation in the
organization and ongoing governance of the centers remain
central elements of the program. Each center is required to
have a governing board, a majority of whose members are
comprised of consumers of the center's services.
With the phase-out of the Office of Economic Opportunity in
the early 1970s, the centers supported under this authority
were transferred to the Public Health Service Act. While
services were directed to the poor and near poor, the centers
also provided access to a broader population who could pay all
or part of the cost of their health care. The Community Health
Center program, as authorized under Section 330 of the Public
Health Service Act, was established in 1975 by Public Law
(P.L.) 94-63.
2. Migrant Health Center--The Migrant Health Center program
was established by Congress in 1962 under the Migrant Health
Act, P.L. 87-692, and was reauthorized in 1975 by P.L. 94-63.
Migrant Health Centers were created to provide a broad array of
medical and support services to farmworkers and their families.
In addition to primary and preventive health care, many of
these centers provide transportation, translation, outreach,
dental, pharmacy, and environmental health services. In 2002,
P.L. 107-251 clarified the eligibility of certain farmworkers
to receive health center services at section 330-funded health
centers. The 2002 reauthorization also called for the
Department of Health and Human Services to conduct a study of
the barriers to enrollment in and the possible solutions to the
challenges faced by farmworkers under Medicaid and the State
Children's Health Insurance Program. In 2006, a network of 140
migrant health centers provided services to over 800,000
migrant and seasonal farmworkers and their families in more
than 1,052 delivery sites.\3\
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\3\NACHC, 2008 based on Bureau of Primary Health Care, HRSA, DHHS,
2006 Uniform Data System (UDS).
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3. Health Care for the Homeless--The Health Care for the
Homeless program was established by Congress to provide
comprehensive, high quality, case-managed, preventive and
primary health care services, including substance abuse
services and mental health referrals, for homeless individuals
at locations accessible to them. With the enactment of P.L.
107-251, Congress clarified the eligibility of homeless youth
and formerly homeless persons to receive section 330-funded
services during the first 12 months following their transition
to permanent housing, in order to ensure that the program
remained appropriately targeted to the most vulnerable
populations.
The Health Care for the Homeless program has played (and
continues to play) a pivotal role in stimulating local
collaboration and coordination of health and social services. A
total of 184 organizations, including community health centers,
public health departments, and other community-based health
service providers, currently provide care to approximately
828,000 sick and underserved homeless people annually.
4. Health Services for Residents of Public Housing--The
Health Services for Residents of Public Housing program was
established by Congress under the Disadvantaged Minority Health
Improvement Act of 1990. This legislation focused on the
disparity in health status of minority populations and placed
emphasis on the development of comprehensive delivery models
that address the special health problems which affect families
residing in public housing complexes--especially targeting
pregnant women and children. Services are provided at public
housing complexes or at sites either adjacent to or immediately
accessible to these complexes. In 2006, 37 organizations
received funding under the program, and provided comprehensive,
high quality, case-managed, family-based preventive and primary
health care services to approximately 70,000 public housing
residents.

Expansion of Health Centers Program

In 2000, Congress launched a historic plan--the Resolution
to Expand Access to Community Health Centers (REACH)
Initiative--which pledged to double access to community health
centers in medically underserved areas over 5 years. With this
initiative came an unprecedented $150 million increase in
Federal funding for health centers, and the Health Centers
program entered into a period of unparalleled growth. In 2001,
the Bush administration joined this historic initiative,
pledging to continue to expand the capacity of health centers
to provide care.\4\
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\4\Administration FY 2001 Budget Overview.
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Wide bipartisan support in Congress has supported these
goals and has ensured the necessary funding increases to expand
the program, while supporting the infrastructure of existing
centers. At the start of the President's Expansion Initiative
in 2001, 10 million patients were served by the Health Centers
Program. By 2006, new and expanded access points created access
to care for more than 16 million people who were served at
6,000 service delivery sites in every State and territory.
Additionally, support from the President and Congress have
allowed several existing health centers to expand the services
they offer beyond primary medical and preventive care. Service
expansions have assisted health centers in providing mental
health, dental, pharmaceutical and optometric services.

Success of the Health Centers Program

Since the reauthorization in 2002, the Health Centers
program has continued to develop and implement a significant
number of highly successful, innovative, preventive, and
primary health care delivery approaches in our Nation's most
needy inner cities and rural areas.
Health centers are effective in increasing access to health
care services in needy communities. In 2006, more than 16
million patients were served at health centers--representing a
32.7 percent increase over the 11.3 million persons served in
2002. Of those 16 million patients, over 6 million patients or
40 percent of all health center patients were uninsured--a 34
percent increase over the 4.4 million uninsured individuals
served by centers in 2002. Further, in 2006, 23.3 percent of
those uninsured individuals were children. Three million health
center patients are enrollees in managed care systems. Health
centers serve 1 in 7 uninsured persons, 1 in 9 Medicaid
beneficiaries, and 1 in 4 low-income individuals in the United
States today.\5\
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\5\NACHC, 2008 based on Bureau of Primary Health Care, HRSA, DHHS,
2006 Uniform Data System (UDS).
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Furthermore, health centers are effective at improving
health outcomes, increasing access to preventive services,
improving the management of chronic diseases, mitigating health
disparities, and reducing avoidable hospitalizations.\6\ The
rates of infants born at low birth weights are lower at health
centers than nationally, even though health center patients are
more at risk. Women of low socio-economic status seeking care
at health centers experience lower rates of low birth weight
compared to all low-social economic status mothers (7.5 percent
vs. 8.2 percent).\7\ This trend holds for each racial/ethnic
group, which is particularly noteworthy for African-American
women who are especially at higher risk for adverse pregnancy
outcomes. Given that two-thirds of health center patients
belong to a minority group with an increased risk for low birth
weight infants, this particular statistic demonstrates the
competent care that health centers provide.
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\6\Starfield B and Shi L. ``The Medical Home, Access to Care, and
Insurance: A Review of Evidence.'' May 2004 Pediatrics 113(5):1493-8.
Hadley J and Cunningham P. ``Availability of Safety Net Providers and
Access to Care of Uninsured Persons.'' October 2004 Health Services
Research 39(5):1527-1546. O'Malley AS, et al. ``Health Center Trends,
1994-2001: What Do They Portend for the Federal Growth Initiative?''
March/April 2005 Health Affairs 24(2):465-472. Shi L. Regan J, Politzer
RM, Luo J. ``Community Health Centers and Racial/Ethnic Disparities in
Healthy Life.'' 2001 International Journal of Health Services
31(3):567-582. Forrest CB and Whelan EM ``Primary care safety-net
delivery sites in the United States: A comparison of community health
centers, hospital outpatient departments, and physicians' offices.''
2000 JAMA 284(16):2077-2083. O'Malley et al, 2005.
\7\Shi, L. Steven, G.D., Wulu, J.T., Politzer, R. M., & Xu, J.
America's health centers: Reducing Racial and Ethnic Disparities in
Perinatal Care and Birth Outcomes. 2004. Health Services Research, 39
(6, Part 1), 1881-1901.
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According to a 2002 Health Resources and Services
Administration (HRSA) Community Health Center User survey,
women who receive their care at health centers are more likely
to receive a pap test than if they were to receive care
elsewhere. This increased access to necessary preventive health
services also is evident for women who are Hispanic and
African-American. Furthermore, health centers have been shown
to effectively mitigate health disparities. According to a
report by the George Washington University, as health centers
serve more of a State's low-income population, key State level
disparities in communities of color decline.
Health centers provide care to millions of Americans
suffering from chronic diseases. In 2006, Health Centers
treated more than 927,000 patients with diabetes, 237,500
patients with heart disease, almost 1,461,000 patients with
high blood pressure, and nearly 461,000 patients with
asthma.\8\ In fact, fully one quarter of all health center
patient visits are related to a chronic illness.
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\8\NACHC, 2008 based on Bureau of Primary Health Care, HRSA, DHHS,
2006 Uniform Data System (UDS).
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Studies comparing health center patients and non-health
center patients demonstrate that health centers provide
services at a lower cost per ambulatory visit, while lowering
the rate of hospital inpatient days, and lower total costs of
care (including decreased inpatient care costs).\9\ Recently,
the Health Centers program was recognized by the Office of
Management and Budget as one of the most effective and
efficiently run programs in the Department of Health and Human
Services.
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\9\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.
Garg A, Probst JC, Sease T, Samuels ME. ``Potentially Preventable
Care: Ambulatory Care-Sensitive Pediatric Hospitalizations in South
Carolina in 1998.'' September 2003 Southern Medical Journal 96(9):850-
8. Epstein AJ. ``The Role of Public Clinics in Preventable
Hospitalizations among Vulnerable Populations.'' 2001 Health Services
Research 32(2):405-420.
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. Stuart ME,
et al. Improving Medicaid Pediatric Care. Spring 1995 Journal of Public
Health Management Practice 1(2):31-38.
Starfield B, et al. Costs vs. Quality in Different Types of Primary
Care Settings, 28 December 1994 Journal of the American Medical
Association 272(24):1903-1908.
Duggar BC, et al. 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.
Duggar BC, et al. 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, 1994.
Braddock D, et al. Using Medicaid Fee-For-Service Data to Develop
Health Center Policy. Washington Association of Community Health
Centers and Group Health Cooperative of Puget Sound, 1994.
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As testament to health centers' ongoing commitment to the
delivery of high-quality health services, nearly 85 percent of
health centers have participated in one or more of HRSA's
Health Disparities Collaboratives, initiatives which focus on
improving health outcomes for chronic conditions among
medically-vulnerable populations, particularly minorities. The
Collaboratives are designed to enhance the skills of clinical
staff, strengthen the process of care through the development
of extensive patient registries that improve clinicians'
ability to monitor and manage the health of individual
patients, and effectively educate patients on self-management
of their conditions. Health center patients with chronic
disease are enrolled in electronic registries for diabetes,
cardiovascular disease, asthma, depression, prevention, cancer,
and HIV. Eventually, every health center may be participating
in at least one Collaborative.\10\
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\10\Chin MH, et al. ``Improving Diabetes Care in Midwest Community
Health Centers With the Health Disparities Collaborative.'' January
2004 Diabetes Care 27(1):2-8.
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A study of 19 Midwestern health centers participating in
the Diabetes Collaboratives demonstrated improved measures of
diabetes-related health outcomes and quality (e.g., HbA1c
measurement, eye examination referral, foot examination, and
lipid assessment). The authors concluded that in just 1 year,
the model employed by the Collaboratives improved diabetes care
at the health centers.\11\ As a result of the success of the
Collaboratives, the Institute of Medicine (IOM) commended
health centers for providing chronic care management that is
``at least as good as, and in many cases superior to, the
overall health system in terms of better quality and lower
costs,'' and recommended health centers as models for reforming
the delivery of primary health care.\12\ The General
Accountability Office (GAO) has recently recognized the
Collaboratives as a promising Federal program targeting health
disparities that should be expanded.
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\11\Chin MH, et al. ``Improving Diabetes Care in Midwest Community
Health Centers With the Health Disparities Collaborative.'' January
2004 Diabetes Care 27(1):2-8.
\12\Institute of Medicine (IOM). Coverage Matters: Insurance and
Health Care. National Academy of Sciences Press, 2001.
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The committee recognizes that the Health Centers program
has been successful because of the ability of the centers to
offer integrated, high quality, prevention-oriented, case-
managed, and family-focused primary and preventive care
services that result in appropriate and cost-effective use of
ambulatory, specialty, and inpatient services by other
providers. Health centers offer primary care for people of all
life cycles, and a range of health and other social services is
available on-site or through referrals.
This broad range of services includes health promotion,
disease prevention, screening, educational, outreach, and case
management services--services that are often missing from the
traditional delivery of medical care, but which are
particularly needed by high-risk populations with multiple
health problems and facing significant barriers to access to
care. Congress broadened this range of health center services
in P.L. 107-251 by increasing the types of additional health
services for which grant funding may be provided with the
inclusion of behavioral and mental health services, public
health services, and recuperative care services as optional
services that health centers can choose to provide.
Additionally, the 2002 reauthorization revised the definition
of ``environmental health services'' to permit health centers
to offer the detection and alleviation of chemical and
pesticide exposures, the promotion of indoor and outdoor air
quality, and the detection and remediation of lead exposures.
More than 11,887 primary care physicians, nurse
practitioners, physician assistants, and certified nurse
midwives create the core clinical staff of health centers
nationally. Further, health centers are home to 2,626 dentists
and hygienists, as well as 1,559 psychiatrists and other mental
health providers. Health centers also have been assisted
greatly in attracting and retaining quality providers through
the National Health Service Corps. Health centers have also
been actively involved with academic medical centers in
providing community-based training of physicians, nurses, and
other health professionals.
In addition, the Health Center program has enabled
underserved communities to design and develop their own local
solutions to their problems of medical underservice. By
supporting the development and operation of health centers at
the community level, the health centers program has assured
that centers are community-responsive and accessible. Community
members and patients play an active role in centers'
decisionmaking and planning. By working with local communities
and State organizations to plan, develop, and determine
priorities for the allocation of resources, the Health Center
program has successfully funded new and expanded programs and
services in those communities that are most in need. Community
Health Centers attract private-pay and privately insured
individuals and families, in addition to individuals who are
uninsured or covered by Medicaid.
Several studies over the years have reported favorably on
the quality and cost-effectiveness of the care offered by
health centers. These studies cite evidence of health centers'
clinical quality and patient satisfaction measures which
compared favorably to national standards.\13\ Studies
demonstrate that patients in underserved areas served by health
centers had 5.8 fewer hospitalizations per 1,000 people over 3
years than those in areas not served by health centers.
According to the National Association of Community Health
Centers, medical expenses for health center patients are 41
percent lower compared to patients seen elsewhere. As a result,
they save the health care system between $9.9 and $17.6 billion
a year.\14\
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\13\Shin P, Markus A, and Rosenbaum S. Measuring Health Centers
against Standard Indicators of High Quality Performance: Early Results
from a Multi-Site Demonstration Project. Interim Report. Prepared for
the United Health Foundation, August 2006. www.gwumc.edu/sphhs/
healthpolicy/chsrp/downloads/
United_Health_Foundation_report_082106.pdf.
\14\NACHC, 2008 ``Access Granted: The Primary Care Payoff''.
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Continued need for health centers

While the Health Centers Program has made historic gains in
providing increased access to and availability of health care
services in medically-underserved communities and populations,
major challenges still persist. Lack of access to affordable
and readily available primary and preventive care remains a
pervasive problem throughout the United States. Millions of
Americans experience financial barriers to getting care. Today,
47 million Americans are uninsured, and that number continues
to rise. At the same time that Americans are becoming uninsured
in larger numbers, the amount of charity care that physicians
provide has been decreasing. According to the Center for
Studying Health Systems Change, the percentage of physicians
providing any free or reduced cost care decreased from 76.3
percent in 1996 to 68.2 percent in 2004. Additionally, other
Americans experience barriers to care due to geography or
system capacity. Currently, over 62 million people live in
places designated as Health Professions Shortage Areas,\15\ and
56 million Americans are considered ``medically
disenfranchised'' because they live in areas with insufficient
numbers of primary care physicians.\16\ Other Americans face
transportation, cultural or language barriers to care, and
racial, and ethnic, and geographic disparities in access to and
quality of care continue.
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\15\HRSA, data as of September 30, 2007.
\16\National Association of Community Health Centers and The Robert
Graham Center. Access Denied: A Look at America's Medically
Disenfranchised. March 2007. www.nachc.com/research-data.cfm.
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Despite the success of the President's expansion program,
only 6 million uninsured people are reached by health centers,
accounting for only 13 percent of the Nation's uninsured. Fewer
than half of all approvable applications for new or expanded
health center sites received funding from 2002-2006,
demonstrating a demand for continued expansion. Many
underserved communities continue to lack adequate resources to
submit a competitive application, and in some cases to even
coordinate and complete the current application. For these
reasons, the committee authorized significant funding increases
for this important program.

Health Centers Programs in a changing health care environment

Health centers have done an excellent job of adapting to
the changing health care environment. In 1996, the committee
permitted the use of grant funds to support the establishment
of managed care networks and plans. Health centers across the
country have taken steps to form networks with other local
providers and develop the financial, legal, and business acumen
necessary to function effectively in managed care. Almost
three-fourths of all health centers are participating in
managed care as subcontracting providers to managed care
plans--serving 3 million managed care enrollees.
As the market continues to change, health centers are
joining with each other and with other local providers to form
integrated service delivery networks to coordinate and improve
their purchasing power and/or to better organize the continuum
of care, especially for uninsured populations. Through
networks, health centers are able to leverage their talents and
resources to improve health outcomes, cut administrative costs,
reduce health disparities, and employ health information
technology and electronic medical records. These networks
include practice management networks designed to improve
quality through shared expertise (such as centralized
pharmaceutical or laboratory services, clinical outcomes
management, or joint management/administrative services); to
lower costs through shared services (such as unified financial
or management information systems, or joint purchasing of
services or supplies); to improve access and availability of
health care services provided by the health centers
participating in the network; and/or to improve the health
status of communities by establishing community-based programs
such as vaccine and wellness initiatives.
Today, nearly 200 health centers are involved in
approximately 20 local and regional operational networks across
a majority of States, each designed to lower costs and improve
care. In the 2002 Health Care Safety Net Amendments, Congress
authorized the use of up to 2 percent of Section 330
appropriations for the funding of health center networks.
Since the last reauthorization of the Health Centers
program, Health Information Technology (HIT) has emerged as a
valuable resource for all health care providers. In order to
better coordinate care and improve patient outcomes and
quality, health care providers and medical institutions
throughout the health system have adopted HIT and Electronic
Medical Records (EMR). Use of HIT and EMR reduces medical
errors, allows for greater coordination of care, improves the
quality of care delivered, and saves money at the individual
and systemic level. While a majority of health centers (60
percent) plan on implementing an Electronic Health Records
(EHR) system in the near future, currently 13 percent of health
centers have a fully operational EHR system. Lack of capital
resources is overwhelmingly named as the biggest obstacle to
adoption. By integrating health information technology into
operations, health centers will connect more effectively with
the entire health care system, and can continue to lead the way
toward an improved system of care.

NATIONAL HEALTH SERVICE CORPS

Introduction

The National Health Service Corps (NHSC), authorized under
Title III of the Public Health Service Act, plays a critical
role in providing care for medically underserved populations by
placing clinicians in urban and rural communities with severe
shortages of health care providers. The NHSC is comprised of
scholarship and loan repayment programs that provide education
assistance to health professions students in return for a
period of obligated service in a shortage area.

Background and need for Program

Nationwide, there is a shortage of primary care providers,
and this problem is exacerbated in rural and certain urban
areas. The availability of primary care physicians has
deteriorated in recent years. In fact, the number of primary
care physicians per capita has changed very little, while the
number of specialists has been rapidly growing--accounting for
more than three-quarters of the growth in per capita physicians
from 1980 to 1999. At the same time, it is estimated that the
demand for primary care providers will increase 38 percent from
2000 to 2020. The lack of primary care physicians is expected
to be compounded by a rapidly rising elderly population. The
number of people ages 65 and older is expected to grow 54
percent between 2000 and 2010, while the number over the age of
85 will grow 43 percent over the same time.\17\ This
combination of factors will lead to a growing shortage of
primary care providers, estimated by the Council on Graduate
Medical Education to be a shortage of at least 90,000 full time
physicians by 2020.\18\ Communities that are already
experiencing shortages are especially likely to be hard hit.
Additionally, low income individuals will bear a significant
burden, because studies suggest that fewer physicians are
willing to treat Medicaid and uninsured patients. Therefore,
investment in the NHSC program, which helps to get providers in
these medically underserved communities, is needed.
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\17\American College of Physicians. The Impending Collapse of
Primary Care Medicine and Its Implications for the State of the
Nation's Health Care. January 30, 2006. http://www.acponline.org/hpp/
statehc06_1.pdf.
\18\Council on Graduate Medical Education (January 2005). Sixteenth
Report: Physician Workforce Policy Guidelines for the United States,
2000-2020. http://www.cogme.gov/16.pdf.
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While NHSC assignees are successful in providing health
care services to nearly 5 million Americans each year, there is
still a great need for investment in the program. This is
demonstrated by the fact that there are more qualified
applicants to the NHSC program than awards available to be
made. In 2006 there were approximately 1,800 applicants to the
program, but only sufficient funding to award approximately 800
awards. Additionally, the number of vacancies posted on the
NHSC Job Opportunity List far exceeds the number of NHSC
awardees. As of October 2007, there were 4,888 vacancies posted
on the Job Opportunity List, with 55 percent (2,704) of these
in health centers.

History and description of program

The National Health Service Corps (NHSC) program was
originally enacted by the Emergency Health Personnel Act of
1970 to respond to the geographic misdistribution of primary
care health professionals. In 1972, Congress created the
Scholarship programs to allow health professions students to
receive support for their educational costs in return for
service in a designated area. In return for each year of
scholarship support they receive, students agree to provide
services for 1 year, with a 2-year minimum service obligation.
In 1987, Congress enacted the NHSC Loan Repayment program,
under which the Federal Government agrees to repay both
governmental and commercial loan obligations incurred by health
professionals for their education in exchange for service in a
designated area. In that same year, Congress established a
State Loan Repayment program. Under this program, if a State
establishes a loan repayment program similar to the NHSC Loan
Repayment program, the Department could fund up to 75 percent
of the total costs through a grant to the State.
In 1990, Congress reauthorized the NHSC, extending the
program for 10 years with the enactment of the National Health
Service Corps Revitalization Amendments of 1990 (P.L. 101-597).
In reauthorizing the NHSC, Congress made several changes to the
program, including a strict prioritization of areas of greatest
shortages for placement of new assignees; requirements to
include individual assignees' characteristics in making
placements; improved incentives for recruitment and retention
of health professionals; increased utilization of nurse
practitioners, physician assistants, and nurse midwives; and
renaming of Health Manpower Shortage Areas (HMSAs) to Health
Professions Shortage Areas (HPSAs). The NHSC was last
reauthorized in 2002, and this authorization expired on
September 30, 2006.
While the NHSC program has proven successful in addressing
health professional shortages in many areas, funding
limitations have restricted the program's ability to meet its
primary goal. After reauthorization of the NHSC in 2002,
funding for the program increased to $171 million in fiscal
year 2003, $169.9 million in fiscal year 2004, and $131.4
million in fiscal year 2005, before returning to the fiscal
year 2001 level of $125 million in fiscal year 2006 and fiscal
year 2007.
According to HRSA, in 2006, 4,109 clinicians were
practicing in underserved areas through the National Health
Service Corps. Of these, 2,051 clinicians worked in grant
supported health centers, while the remaining 2,058 clinicians
worked in ``free standing'' sites which include rural health
centers, public health departments, community mental health
centers, private and group practices, Indian Health Service
sites (tribal and Federal), State and Federal prisons, and
Immigration and Customs Enforcement sites. NHSC funding is
available to a variety of clinicians, including physicians
(including psychiatrists), dentists, dental hygienists, nurse
practitioners, physician assistants, nurse midwives, and mental
and behavioral health professionals. Throughout its history,
NHSC awards have also been made to other types of providers
such as optometrists, chiropractors, and pharmacists. The
committee notes that in many cases, the provision of some
health care services may not have been possible without the
presence of an NHSC assignee. Nevertheless, the committee also
notes that partly due to a lack of adequate funding, the NHSC
has a limited capacity to meet the needs of people living in
primary care, mental, or dental HPSAs.

Relationship between health centers and rural health clinics and the
NHSC

There is synergy between the NHSC program and the community
health centers program and rural health clinics because both
entities frequently utilize NHSC providers to staff their
facilities. However, despite the investment already being made
in placing providers in these entities, there is still a
shortage of providers in these, as well as other settings. In
light of the national shortage of primary care providers, the
committee strongly believes that we must act to reauthorize and
improve the NHSC program to help meet the need for physicians
caring for underserved populations. Our increased investment in
community health centers since 2001 should be matched by
additional authorizations for the NHSC as well.

RURAL HEALTH CARE PROGRAMS

In section 330A(j) of the PHSA, the committee reauthorizes
Rural Health Care Services Outreach, Rural Health Network
Development, and Small Health Care Provider Quality Improvement
Grant Programs. The programs in section 330A(j) specifically
consider the diversity of rural America and have provided rural
communities with flexible mechanisms of receiving Federal funds
for specific health care needs. The five grant programs under
this authority support collaborative models to deliver basic
health care services to the 54 million Americans living in
rural areas.
The Rural Health Care Services Outreach Program supports
projects that demonstrate creative or effective models of
outreach and service delivery in rural communities that lack
essential health care services. The emphasis is on community
involvement in the development and ongoing operation of the
program, requiring the grantee to form a consortium with at
least two additional partners. Through consortia of schools,
churches, emergency medical service providers, local
universities, private practitioners and the like, rural
communities have managed to provide many services including
hospice care, health check-ups for children and prenatal care
to women in remote areas. The population served by the grants
has historically been across the spectrum of care, with a
majority of grants focusing on the non-Medicare population. The
Department of Health and Human Services estimates these funds
have brought care that would not otherwise have been available
to at least 2 million rural citizens across the country. In the
past 3 years, this program has funded many projects, including
a grant to rural New Hampshire enabling implementation of a
chronic disease management program for individuals with
diabetes and congestive heart failure; a grant to rural
Louisiana targeting at-risk and obese preteens; and a program
in rural Kansas providing dental services targeted to children
and pregnant women. The general program line includes support
for grants to the eight States in the Mississippi Delta for
network and rural health infrastructure development, and a
cooperative agreement supporting targeted activities focusing
on frontier extended stay clinics.
The Small Health Care Provider Quality Improvement
provision, a subset of the Rural Health Outreach Grant Program,
was added to this authority when the program was re-authorized
by the Safety Net Amendments of 2002. The programs were
initially funded in 2006. These grants help small health care
providers focus on specific interventions to improve health
care quality in specific chronic disease areas. Fifteen grants
were awarded in fiscal year 2007 with a focus on diabetes, and
there are plans for up to 60 grants in fiscal year 2008
targeting cardiovascular disease. These grant programs provide
an opportunity for grantees to improve quality and enhance
small rural health care providers in delivering care to rural
communities.
The Rural Health Network Development grant program allows
grants to fund the integration of health services provided by
rural communities. This integration helps to overcome the
fragmentation of health care services in rural areas, improves
the coordination of those services, and achieves economies of
scale. The grants focus on integrating clinical, information,
administrative and financial systems across members. This
integration enables rural communities to strengthen the
infrastructure of health delivery.
In authorizing the continuation of these programs, the
committee recognizes the great importance of these flexible
grants in enabling smaller, rural communities to provide health
services to a population of about 3.2 million that is
frequently underserved, have higher rates of poverty and
unemployment, are older, and have a poorer health status.

II. Summary

The purpose of the Health Care Safety Net Act of 2007 is to
amend the Public Health Service Act to provide additional
authorizations of appropriations for fiscal year 2008 through
fiscal year 2012 for Health Centers, the National Health
Service Corps, and Rural Health Programs, to meet the health
care needs of medically underserved populations.

COMMUNITY HEALTH CENTERS

The legislation increases authorization levels for the
health centers program, and also authorizes several studies
including:
1. A school based health center study conducted by the
Comptroller General of the United States.
2. A health care quality study conducted by the Agency for
Healthcare Research and Quality.
3. A study on an integrated health systems model for the
delivery of care to medically underserved population conducted
by the Comptroller General of the United States.

NATIONAL HEALTH SERVICE CORPS

The National Health Service Corps is amended by increasing
the authorization levels for fiscal year 2008 through fiscal
year 2012. Additionally, the bill strikes language that placed
a 6-year time limit on automatic Health Professional Shortage
Area (HPSA) facility designations that were extended to
Federally Qualified Health Centers (FQHCs) and Rural Health
Clinics (RHCs). The NHSC is also amended to provide increased
emphasis on professional development and training for Corps
members.

RURAL HEALTHCARE PROGRAMS

The authorization level for rural health care programs is
increased to $45 million for fiscal years 2008 through 2012.

III. History of Legislation and Votes in Committee

The Community Health Centers, National Health Service
Corps, and rural health programs were last reauthorized in the
107th Congress with the Health Care Safety Net Amendments of
2001 (S. 1533). This bill was passed by the House and Senate,
and became Public Law No. 107-251 on October 26, 2002.
During the 109th Congress, Senator Hatch and 63 cosponsors
introduced, S. 3771, The Health Centers Renewal Act of 2006.
This bill amended the Public Health Service Act to include
increased authorization of appropriations for the Community
Health Centers program. The bill was read twice and referred to
the committee. On September 20, 2006, the committee ordered the
bill to be reported without amendment favorably to the full
Senate. On September 25, 2006, Senator Enzi reported the bill
with an amendment in the nature of a substitute, without
written report. The bill was placed on the Senate Legislative
Calendar under General Orders (Calendar no. 638). No further
action was taken on this bill during the 109th Congress.
The bill was reintroduced in the 110th Congress as S. 901,
the Health Centers Renewal Act of 2007 by Senator Kennedy on
March 15, 2007. The bill, which had 17 original cosponsors, and
68 total cosponsors, amended the Public Health Service Act to
include increased authorization of appropriations for the
Community Health Centers program for fiscal years 2008 through
2012. The bill was combined with S. 941 introduced by Senator
Sanders. On November 14, 2007 the committee considered and
unanimously approved a manager's amendment to S. 901, and the
committee approved the bill, as amended, by voice vote. The
bill was placed on the Senate Legislative Calendar under
General Orders (Calendar no. 548) on December 18, 2007.

IV. Explanation of Bill and Committee Views

The committee recognizes that the health centers, NHSC, and
rural grants programs have made a significant contribution to
the health of medically needy populations. The committee bill
reauthorizes the programs, and increases the authorization
levels for 5 years, beginning in fiscal year 2008.

COMMUNITY HEALTH CENTERS

Explanation of bill

The legislation increases the authorization levels for the
community health centers program as follows:
$2,213,020,000 in fiscal year 2008;
$2,451,394,400 in fiscal year 2009;
$2,757,818,700 in fiscal year 2010;
$3,116,335,131 in fiscal year 2011; and
$3,537,040,374 in fiscal year 2012.
Additionally, the legislation authorizes several studies as
follows:
1. A study on school-based health centers to be conducted
by the Comptroller General of the United States. The study
would determine the impact of Federal funding on the operation
of school-based health centers, costs savings to other
programs, the impact on the Federal budget and the health of
students by providing funds, and the impact of access to health
care from school-based health centers in rural or underserved
areas.
2. A health care quality study to be conducted by HRSA.
HRSA would produce a report that describes the agency's efforts
to expand and accelerate quality improvement activities in
health centers.
3. A study on the integrated health systems model for the
delivery of health care services to medically underserved
populations. The GAO shall conduct a study on integrated health
systems models at not more than 10 sites.
Forty-seven million Americans continue to lack health
insurance and the number of uninsured continues to rise. Many
private, nonprofit safety net providers have a historical
mission of serving the poor and vulnerable and many of these
providers established neighborhood clinics as a way to improve
access to primary and preventive care, and to offer the
uninsured a cost-effective alternative to the hospital
emergency room for their primary care needs. In this study, the
Comptroller General of the United States would be required to
report back to Congress on the role of integrated health care
systems in providing access to primary and preventive care to
the medically underserved, as well as access to specialty and
hospital care. For purposes of this study, an integrated health
system is defined as a private nonprofit health system that has
a demonstrated capacity and commitment to provide a full range
of primary, specialty, and hospital care in both inpatient and
outpatient settings and is organized to provide such care in a
coordinated fashion. The Comptroller General should include in
its report any economies of scale that are beneficial to a
clinic because of its affiliation with a parent provider,
current sources of its funding, patient mix based on income and
insurance status, payer reimbursement rates in comparison to
other providers, the number of patients served by the clinic,
and whether these clinics improve specialty and hospital access
for poor and vulnerable populations.
Such study shall include an assessment of providers in a
wide variety of settings, including inner city, frontier areas,
and a major rural teaching hospital defined as a hospital that
is located in a rural area (as defined in Section 1886(d)(2)(D)
of the Social Security Act) that is engaged in approved
graduate medical education residency programs in medicine,
osteopathy, dentistry, or podiatry, and sponsors accredited
residency and fellowship programs, including active programs in
medicine, surgery, obstetrics/gynecology, pediatrics, family
practice, and psychiatry. One nurse managed health clinic
should also be included and would be defined as an integrated
health system for purposes of this study (the term ``nurse-
managed health clinic'' means nurse-practice arrangement,
managed by advanced practice nurses, that provides care for
underserved and vulnerable populations and is associated with a
school, college or department of nursing and/or an independent
non-profit health or social services agency). Finally, clinics
operated by large non-profit organizations with a historical
commitment to providing primary and preventive care for the
medically underserved should also be included.

Committee views

Importance of health centers' base grant adjustments
Considerable investment in new community health centers
and in expansion of services at existing CHCs has occurred
during the past 5 years with strong leadership by the Executive
and Congressional branches of the government. The committee
supports the addition of new health centers and expansion of
existing ones, and supports consideration of base grant
adjustments for health centers that meet Program Expectation
guidelines. Most CHCs operate on narrow margins, and there are
ongoing requirements to keep up with rising costs for
providers, facilities, technology, and energy in order to
sustain current service levels. Health centers also face
increasing numbers of uninsured and under-insured individuals
as employer-based insurance shrinks. The committee notes that
Congress has routinely allocated annual increased funding for
existing centers to offset the rising cost of health care and
to meet the demands for care for the uninsured populations
served by the centers. The committee encourages HRSA to develop
criteria and allocate funding that will allow health centers to
receive an annual grant adjustment that adequately addresses
rising costs, growing patient populations, and other pressing
concerns as they arise.
Value and importance of expanded technical assistance
The committee believes that the health centers program has
been successful in large part because of attention to
continuous quality improvement to all facets of health center
operations. The committee recognizes the valuable information,
training and technical assistance activities performed by
national, State and regional organizations that represent the
recipients of service grants under the health centers program.
These organizations have provided a full range of tools for
health center staff, including training programs regarding
financial management, clinical practice guidelines, regulatory
and legal requirements, board governance, corporate compliance,
program planning and proposal writing, and strategic business
planning. In order to ensure the sustained and successful
operation and expansion of the health centers program, the
committee expects the collaborative technical assistance
program, and the funding provided in support of it, to be
continued and expanded.
Proportional funding allocation
The committee continues the statutory funding allocation
requirement for the Community Health, Migrant, Homeless, and
Public Housing sub authorities under section 330. The committee
restored this funding allocation requirement in P.L. 107-251,
enacted in 2002. The committee notes that when the four
separate health center programs were consolidated under a
single section 330 authority in 1996, the law included a
requirement for allocating funds appropriated under section 330
for each of the sub authorities in accordance with the
proportion of total funding they each received in Fiscal Year
1996. The committee recognizes that despite the expiration of
this statutory funding allocation requirement in 1998, the
Secretary has continued to adhere to the proportional
allocation methodology in distributing overall health centers
program funding among the four health center programs sub
authorities, thus enabling health center programs to provide
needed services to vulnerable, hard to reach ``special
populations'' such as homeless individuals, residents of public
housing projects, and migrant and seasonal farmworkers. These
programs should be continued and expanded in accordance with
the funding allocation methodology in the statute. The
committee commends the Secretary for continuing to allocate the
same percentage each fiscal year as was allocated the previous
years. The committee encourages HRSA to expand and enhance the
provision of technical assistance to promote high quality
applications for funding to serve special populations as well
as sparsely populated communities.
Importance of health center owned and controlled networks
Health centers currently collaborate with each other and
with other community providers, in many different forms of
networks and partnerships designed to improve operational
quality, efficiency, and effectiveness. These collaborations
include managed care, integrated service, and practice
management networks, which are designed to improve quality of
care through shared expertise (such as shared electronic
medical records systems, centralized pharmaceutical or
laboratory services, clinical outcomes management, and/or joint
management/ administrative services), to lower costs through
shared services (such as unified financial or Management
Information systems, or joint purchasing of services or
supplies), or to improve access and availability of health care
services. Today, nearly 200 health centers are involved in
approximately 20 local and regional operational networks across
a majority of States, each designed to lower costs and improve
care. These networks have played a central role in the
adoption, integration and maintenance of Health Information
Technology (HIT), including Electronic Health Records (EHR) at
and among health centers nationwide. Most of these networks,
once developed, need ongoing operational support to continue
and further enhance their benefits. The committee supports the
continued use of these public-private partnerships to assist
with the provision of health care services, and encourages the
Secretary to continue allocating a portion of an increase in
appropriated funds towards this purpose.
Expanding access through the Health Centers program
The committee supports continued efforts to expand the
Health Centers program into medically underserved communities
and populations with high poverty and no current access to a
health center. The committee commends States that have made
commitments to expanding access to Community Health Centers to
all underserved areas throughout their States, and believes
that these States should be given serious consideration when
expansion opportunities are made available.

NATIONAL HEALTH SERVICE CORPS

The committee recognizes the importance of reauthorizing
the National Health Service Corps program to demonstrate our
commitment to addressing the need to locate providers in
medically underserved areas. The legislation increases the
authorization level for the NHSC program as follows:
$131,500,000 in fiscal year 2008;
$143,335,000 in fiscal year 2009;
$156,235,150 in fiscal year 2010;
$170,296,310 in fiscal year 2011; and
$185,622,980 in fiscal year 2012.

Automatic HPSA designation for community health centers and rural
health clinics

The committee revised the NHSC placement criteria during
the last reauthorization in 2002. The amended statute extended
Automatic HPSA facility status to health centers and rural
health clinics, thus making them eligible for placement of NHSC
personnel, in order to reduce bureaucratic barriers to allow
coordinated use of Federal resources in meeting the health care
needs of areas that lack sufficient providers and services.
That action recognized that the NHSC, health centers, and rural
health clinics programs are intended to address similar goals:
to meet the primary care needs of underserved populations.
The committee is striking language that placed a 6-year
time limit on automatic Health Professional Shortage Area
(HPSA) facility designations that were extended to Federally
Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs). It is the committee's intent that FQHCs and RHCs
automatic HPSA designation continue. The committee notes that
all FQHCs must by law be located in medically underserved areas
as determined by the Secretary, and that both FQHCs and RHCs
must compete with all applicants to obtain NHSC placements.
Therefore, the committee has concluded that the 6-year limit is
unnecessary. The committee also notes concern about the current
HPSA scoring process and its effect on certain medically
underserved communities.

Inclusion of other health care providers

Currently various types of primary care providers are
funded through the NHSC scholarship and loan repayment
programs. The committee recognizes that the intent of the NHSC
program, as stated in statute, is to assure an adequate supply
of primary care providers such as physicians, dentists,
behavioral and mental health professionals, certified nurse
midwives, certified nurse practitioners, and physicians
assistants, and if needed by the Corps, other health
professionals. The committee understands that these other
practitioners provide first contact care for basic health
services that are needed by most or all of the population. For
the purposes of the Act, Section 338B National Health Service
Corps Loan Repayment Program, the term ``other health
professionals'' is intended to include optometrists,
pharmacists, chiropractors, and physical therapists.

Frontier areas

The health care challenges facing rural America are
magnified in the Nation's frontier. Frontier communities often
do not have adequate access to health care providers. Their
populations must travel for an excessive time or across a great
distance to see a doctor, dentist, or counselor. Even when
frontier communities have local access to health care, they are
frequently underserved. Moreover, frontier communities may fail
to be designated as HPSA because the population-to-provider
ratio used can overestimate a frontier population's access to
health care. There are two reasons for this problem. First,
frontier communities are sparsely populated. Low population
communities can exceed the 3000-to-1 threshold with a single
health provider. Second, the population-to-provider ratio
ignores the extra strain that geographic isolation imposes on
health care providers. For example, a frontier area with a
population of 4,000 may be served by only a few healthcare
providers. With the nearest hospital an hour long drive or more
away, these few providers may need to work long hours every day
of the week to provide critical emergency care in addition to
basic health care.
The committee recommends that HRSA consider the challenges
faced by frontier areas in the HPSA scoring process. The
committee also encourages HRSA to consider incorporating other
factors into the HPSA scoring process, such as the travel time
and/or distance frontier residents have to travel to reach the
nearest health care center. Consideration of these factors may
more accurately reflect a frontier community's true access to
health care.

Professional development

The Public Health Service Act is amended in two places to
include an increased emphasis on professional development and
training for Corps members. Section 333 amends the assignment
of Health Professional Shortage Areas to include language
indicating that the entity demonstrate a willingness to support
or facilitate mentorship, professional development, and
training opportunities for Corps members. Section 336,
subsection d is amended to include a section on professional
development and training.
More than 3,000 Health Professional Shortage Areas have
been designated in our country, and approximately 56 million
people live in communities without access to health care. The
National Health Service Corps program was developed to help
assign Federal personnel to these shortage areas. It was later
expanded to provide scholarships to health professionals who
then provided service to underserved communities. Currently,
there are more than 4,000 health care professionals serving
with the National Health Service Corps and providing care to
communities that lack adequate access to primary care. However,
there is still enormous unmet need in the program, with more
sites that request health professionals than there are
enrollees in the program.
Part of this shortage is due to the lack of funding for
the program; part of this shortage is due to changes in the
number of health professionals choosing careers in primary
care. From 1995 to 2005, the number of medical school graduates
entering family medicine training programs dropped by double
digits.\19\ In addition, there are shortages of faculty needed
to train other primary care providers, like nurse
practitioners. As a result, the National Health Service Corps
is facing competition for an increasingly limited pool of
health professionals.
---------------------------------------------------------------------------
\19\Journal of the American Medical Association Sept 7, 2005; Vol
294, No 9.
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While the National Health Service Corps provides
scholarships and loan repayment opportunities, in this
reauthorization, the committee sought to increase the
incentives to help with recruitment and retention of primary
care providers. The reauthorization contains language to expand
the types of professional development opportunities available
to enrollees, including expanding the professional and support
networks among enrollees, and encouraging increased use of
distance learning opportunities. In addition, the
reauthorization requires entities seeking NHSC enrollees to
demonstrate willingness to support professional development and
training opportunities. With this expansion, the committee
believes that NHSC members will have added benefits that may
help to increase recruitment and retention.

V. Cost Estimate

U.S. Congress,
Congressional Budget Office,
Washington, DC, March 11, 2008.
Hon. Edward M. Kennedy, Chairman,
Committee on Health, Education, Labor, and Pensions,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 901, the Health Care
Safety Net Act of 2007.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lara
Robillard.
Sincerely,
Robert A. Sunshine
(For Peter R. Orszag, Director).
Enclosure.

S. 901--Health Care Safety Net Act of 2007

Summary: S. 901 would amend the Public Health Service Act
to authorize programs that provide funding for community health
centers, the National Health Service Corps, and certain rural
health programs administered by the Health Resources and
Services Administration.
The bill would authorize the appropriation of $2.4 billion
for 2008 and $15.1 billion over the 2008-2012 period. However,
$2.2 billion has already been appropriated for those activities
for 2008. Thus, S. 901 would authorize the appropriation of an
additional $0.2 billion for fiscal year 2008 and $12.9 billion
over the 2008-2012 period.
CBO estimates that implementing the bill would cost $94
million in 2008, $1.5 billion in 2009, and $12.5 billion over
the 2008-2013 period, assuming the appropriation of the
authorized amounts. S. 901 would not affect direct spending or
revenues.
S. 901 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would impose no costs on state, local, or tribal
governments.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 901 is shown in the following table. The
costs of this legislation fall within budget function 550
(health).

----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------
2008 2009 2010 2011 2012 2013
----------------------------------------------------------------------------------------------------------------
SPENDING SUBJECT TO APPROPRIATION

Spending Under Current Law:
Community Health Centers:
Budget Authority........................................ 2,022 0 0 0 0 0
Estimated Outlays....................................... 2,035 989 231 0 0 0
National Health Service Corps:
Budget Authority........................................ 123 0 0 0 0 0
Estimated Outlays....................................... 122 62 10 0 0 0
Rural Health Outreach Grants:
Budget Authority........................................ 48 0 0 0 0 0
Estimated Outlays....................................... 47 20 2 0 0 0
Total:
Budget Authority........................................ 2,193 0 0 0 0 0
Estimated Outlays....................................... 2,204 1,071 243 0 0 0
Proposed Changes:
Community Health Centers:
Authorization Level..................................... 191 2,451 2,758 3,116 3,537 0
Estimated Outlays....................................... 90 1,383 2,505 2,883 3,266 1,579
National Health Service Corps:
Authorization Level..................................... 8 143 156 170 186 0
Estimated Outlays....................................... 4 79 144 160 175 83
Rural Health Outreach Grants:
Authorization Level..................................... 0 45 45 45 45 0
Estimated Outlays....................................... 0 24 43 44 44 20
Total Changes:
Authorization Level..................................... 199 2,639 2,959 3,331 3,768 0
Estimated Outlays....................................... 94 1,486 2,692 3,087 3,485 1,682
Estimated Spending Under S. 901:
Community Health Centers:
Authorization Level..................................... 2,213 2,451 2,758 3,116 3,537 0
Estimated Outlays....................................... 2,125 2,372 2,736 2,883 3,266 1,579
National Health Service Corps:
Authorization Level..................................... 131 143 156 170 186 0
Estimated Outlays....................................... 126 141 154 160 175 83
Rural Health Outreach Grants:
Authorization Level..................................... 48 45 45 45 45 0
Estimated Outlays....................................... 47 44 45 44 44 20
Total Spending:
Authorization Level..................................... 2,392 2,639 2,959 3,331 3,768 0
Estimated Outlays....................................... 2,298 2,557 2,935 3,087 3,485 1,682
----------------------------------------------------------------------------------------------------------------
Note: Components may not add to totals because of rounding.

Basis of estimate: S. 901 would authorize three programs
that provide funding for health programs in rural and medically
underserved areas. In total, the bill would authorize the
appropriation of $2.4 billion for 2008 and $15.1 billion over
the 2008-2012 period. The Omnibus Appropriations Act (Public
Law 110-161) appropriated $2.2 billion in 2008 for those
activities. Thus, S. 901 would authorize the appropriation of
an additional $199 million for fiscal year 2008 and $12.9
billion over the 2008-2012 period.
Based on historical patterns of spending for those
programs, and assuming the appropriation of the authorized
amounts, CBO estimates that implementing the bill would cost
$94 million in 2008, $1.5 billion in 2009, and $12.5 billion
over the 2008-2013 period.
Community health centers are community-based and patient-
directed organizations that serve populations with limited
access to primary health care services. S. 901 would authorize
the appropriation of $2.2 billion for 2008 (an increase of $191
million over the current appropriation), and $11.9 billion over
the 2009-2012 period. Assuming the appropriation of the
additional funds for 2008 in the spring, and the appropriation
of the authorized amounts in subsequent years, CBO estimates
that spending for the community health center program from the
funds authorized by this bill would total $90 million in 2008
and $11.7 billion over the 2008-2013 period.
The National Health Service Corps operates loan repayment
and scholarship programs for clinicians who provide primary
care services in medically underserved areas. S. 901 would
authorize the appropriation of $132 million for 2008 (an
increase of $8 million over the current appropriation), and
$655 million over the 2009-2012 period. Assuming the
appropriation of the additional funds for 2008 in the spring,
and the appropriation of the authorized amounts in subsequent
years, CBO estimates that spending for the National Health
Service Corps program from the funds authorized by this bill
would total $4 million in 2008 and $645 million over the 2008-
2013 period.
The rural health care services outreach, network and
quality improvement program provides grants for activities to
increase access to primary health care services in rural areas;
help rural health care providers develop community-based,
integrated systems of care; and improve the quality of health
care for certain chronic diseases. The bill would authorize the
appropriation of $45 million a year for fiscal years 2008
through 2012. The amount authorized for 2008 is less than the
$48 million appropriated for 2008. Therefore, the estimate
assumes that enacting S. 901 would have no effect on funding
for 2008. Assuming the appropriation of the amounts authorized
for fiscal years 2009 through 2012, CBO estimates that spending
for rural health outreach grants from the funds authorized by
this bill would total $175 million over the 2008-2013 period.
Intergovernmental and private-sector impact: S. 901
contains no intergovernmental or private-sector mandates as
defined in UMRA. Funds authorized in the bill would benefit
local governments that participate in community and rural
health programs.
Estimate prepared by: Federal Costs: Lara Robillard; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Patrick Bernhardt.
Estimate approved by: Keith J. Fontenot, Deputy Assistant
Director for Health and Human Resources, Budget Analysis
Division.

VI. Regulatory Impact Statement

The committee has determined that there is no legislative
impact.

VII. Application of Law to the Legislative Branch

The committee has determined that there will be minimal
increases in the regulatory burden imposed by this bill.

VIII. Section-by-Section Analysis

Section 1. Short title

Section 1 provides the short title of the bill, the
``Health Care Safety Net Act of 2007.''

Section 2. Community Health Centers Program of the Public Health
Service Act

Section 2 part (a) amends section 330(r) of the Public
Health Service Act to increase the authorization levels for the
Health Centers Program for Fiscal Year 2008-2012.
Part (b) includes several studies relating to community
health centers.
Subsection 1 includes definitions of the terms ``community
health center'' and ``medically underserved.''
Subsection 2 describes a school based health center study
to be conducted by the Comptroller General of the United
States. No later than 2 years after the enactment of the act,
the GAO shall study the economic costs and benefits of school
based health centers and the impact on the health of students
served by these centers. The study would analyze the impact of
Federal funding on the operation of school based health
centers, any cost savings to other Federal programs derived
from providing services in these centers, the potential impact
on the Federal budget and the health of students, and the
impact on access to health care in rural or underserved areas.
Subsection 3 describes a health care quality study to be
conducted by the Agency for Healthcare Research and Quality
(AHRQ). This study would describe AHRQ's efforts to expand and
accelerate quality improvement activities in community health
centers, including Federal efforts towards improved healthcare
quality, identification of effective models for quality
improvement, and efforts to determine how effective quality
improvement models may be adapted for implementation by CHCs
with varying characteristics such as size, budget, staffing
etc. This section also directs the Administrator of HRSA to
establish a formal mechanism for the ongoing dissemination of
agency initiatives, best practices, and other information that
may assist health care quality improvement efforts.
Subsection 4 describes a study to be conducted by the GAO
on an integrated health systems model for the delivery of
health care services to medically underserved populations. This
study, to be conducted at not more than 10 sites, would examine
health care delivery models sponsored by public or nonprofit
entities that integrate primary, specialty, and acute care and
serve medically underserved populations in rural or urban
areas. The report would evaluate the model's ability to expand
access to primary and preventive services for medically
underserved populations, improve care coordination and health
care outcomes, while also assessing the challenges in providing
care to medically underserved populations, and the advantages
and disadvantages of such health care delivery models compared
to other such models.

Section 3. National Health Service Corps

Section 3 part (a) amends section 331 through 338G of the
Public Health Service Act to increase the authorization levels
for the National Health Service Corps program for Fiscal Years
2008-2012.
Part (b) amends section 332(a)(1) of the Public Health
Service Act to strike language that limited the automatic
Health Professions Shortage Area designation for Community
Health Centers and rural health programs to 6 years. The
automatic HPSA designation will continue indefinitely.
Part (c) amends section 333(a)(1)(D)(ii) of the Public
Health Service Act on the assignment of personnel to HPSAs to
include a new requirement that a site seeking a NHSC assignee
must demonstrate a willingness to support mentorship,
professional development, and training opportunities for Corps
members.
Part (d) amends subsection (d) of section 336 of the Public
Health Service Act to include a new section on professional
development and training. This new language requires the
Secretary to assist Corps members in establishing and
maintaining professional relationships and development
opportunities. In providing this assistance, the Secretary
shall focus on establishing relationships with hospitals,
academic medical centers, health professions schools, area
health education centers, health education and training
centers, and border health education and training centers. The
Secretary shall also assist Corps members in obtaining faculty
appointments at health professions schools.

Section 4. Reauthorization of Rural Health Care Programs

Section 4 amends section 330A(j) of the Public Health
Service Act by increasing the authorization level for rural
health care programs to $45 million for fiscal years 2008
through 2012.

IX. Changes in Existing Law

In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, the following provides a print of the
statute or the part or section thereof to be amended or
replaced (existing law proposed to be omitted is enclosed in
black brackets, new matter is printed in italic, existing law
in which no change is proposed is shown in roman):

PUBLIC HEALTH SERVICE ACT

* * * * * * *

SEC. 330. [254B] HEALTH CENTERS.

(a) Definition of Health Center.--
(1) In general.-- * * *

* * * * * * *

(r) Authorization of Appropriations.--
[(1) In general.--For the purpose of carrying out
this section, in addition to the amounts authorized to
be appropriated under subsection (d), there are
authorized to be appropriated $1,340,000,000 for fiscal
year 2002 and such sums as may be necessary for each of
the fiscal years 2003 through 2006.]
(1) In general.--For the purpose of carrying out this
section, in addition to the amounts authorized to be
appropriated under subsection (d), there are authorized
to be appropriated--
(A) $2,213,020,000 for fiscal year 2008;
(B) $2,451,394,400 for fiscal year 2009;
(C) $2,757,818,700 for fiscal year 2010;
(D) $3,116,335,131 for fiscal year 2011; and
(E) $3,537,040,374 for fiscal year 2012.

* * * * * * *

SEC. 330A. [254C] RURAL HEALTH CARE SERVICES OUTREACH, RURAL HEALTH
NETWORK DEVELOPMENT, AND SMALL HEALTH CARE PROVIDER
QUALITY IMPROVEMENT GRANT PROGRAMS.

(a) Purpose.--* * *

* * * * * * *

(j) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section [$40,000,000 for
fiscal year 2002, and such sums as may be necessary for each of
fiscal years 2003 through 2006.] $45,000,000, for each of
fiscal years 2008 through 2012.

* * * * * * *

Sec. 332. [254e] (a)(1) For purposes of this subpart the
term ``health professional shortage area'' means (A) an area in
an urban or rural area (which need not conform to the
geographic boundaries of a political subdivision and which is a
rational area for the delivery of health services) which the
Secretary determines has a health manpower shortage, (B) a
population group which the Secretary determines has such a
shortage, or (C) a public or nonprofit private medical facility
or other public facility which the Secretary determines has
such a shortage. All Federally qualified health centers and
rural health clinics, as defined in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)), that meet the
requirements of section 334 shall be automatically designated
as having such a shortage. [Not earlier than 6 years after such
date of designation, and every 6 years thereafter, each such
center or clinic shall demonstrate that the center or clinic
meets the applicable requirements of the Federal regulations
regarding the definition of a health professional shortage area
for purposes of this section.] The Secretary shall not remove
an area from the areas determined to be health professional
shortage areas under subparagraph (A) of the preceding sentence
until the Secretary has afforded interested persons and groups
in such area an opportunity to provide data and information in
support of the designation as a health professional shortage
area or a population group described in subparagraph (B) of
such sentence or a facility described in subparagraph (C) of
such sentence, and has made a determination on the basis of the
data and information submitted by such persons and groups and
other data and information available to the Secretary.

* * * * * * *

Sec. 333. [254f] (a)(1) * * *
(A) * * *

* * * * * * *

(D) * * *
(I) * * *

* * * * * * *

(IV) the area has made unsuccessful efforts
to secure health manpower for the area; [and]
(V) there is a reasonable prospect of sound
fiscal management, including efficient
collection of fee-for-service, third-party, and
other appropriate funds, by the entity with
respect to Corps members assigned to such
entity[.]; and
(VI) the entity demonstrates willingness to
support or facilitate mentorship, professional
development, and training opportunities for
Corps members.

* * * * * * *

SEC. 336. [254H-1] FACILITATION OF EFFECTIVE PROVISION OF CORPS
SERVICES.

(a) Consideration of Individual Characteristics of Members
in Making Assignments.--* * *

* * * * * * *

[(d) Assistance in Establishing Local Professional
Relationships.--The Secretary shall assist Corps members in
establishing appropriate professional relationships between the
Corps member involved and the health professions community of
the geographic area with respect to which the member is
assigned, including such relationships with hospitals, with
health professions schools, with area health education centers
under section 781, with health education and training centers
under such section, and with border health education and
training centers under such section. Such assistance shall
include assistance in obtaining faculty appointments at health
professions schools.]
(d) Professional Development and Training.--
(1) In general.--The Secretary shall assist Corps
members in establishing and maintaining professional
relationships and development opportunities, including
by--
(A) establishing appropriate professional
relationships between the Corps member involved
and the health professions community of the
geographic area with respect to which the
member is assigned;
(B) establishing professional development,
training, and mentorship linkages between the
Corps member involved and the larger health
professions community, including through
distance learning, direct mentorship, and
development and implementation of training
modules designed to meet the educational needs
of offsite Corps members;
(C) establishing professional networks among
Corps members; or
(D) engaging in other professional
development, mentorship, and training
activities for Corps members, at the discretion
of the Secretary.
(2) Assistance in establishing professional
relationships.--In providing such assistance under
paragraph (1), the Secretary shall focus on
establishing relationships with hospitals, with
academic medical centers and health professions
schools, with area health education centers under
section 751, with health education and training centers
under section 752, and with border health education and
training centers under such section 752. Such
assistance shall include assistance in obtaining
faculty appointments at health professions schools.
(3) Supplement not supplant.--Such efforts under this
subsection shall supplement, not supplant, non-
government efforts by professional health provider
societies to establish and maintain professional
relationships and development opportunities.
Sec. 338. [254k] (a) For the purpose of carrying out this
subpart, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years [2002 through
2006] 2008 through 2012.

* * * * * * *

SEC. 338H. [254Q] AUTHORIZATION OF APPROPRIATIONS.

(a) Authorization of Appropriations.--For the purposes of
carrying out this subpart, there are authorized to be
[appropriated $146,250,000 for fiscal year 2002, and such sums
as may be necessary for each of fiscal years 2003 through
2006.] appropriated--
(1) for fiscal year 2008, $131,500,000;
(2) for fiscal year 2009, $143,335,000;
(3) for fiscal year 2010, $156,235,150;
(4) for fiscal year 2011, $170,296,310; and
(5) for fiscal year 2012, $185,622,980.

* * * * * * *

Amend the title so as to read: A bill to amend the Public
Health Service Act to reauthorize the Community Health Centers
program, the National Health Service Corps, and rural health
care programs.