[House Report 112-64]
[From the U.S. Government Publishing Office]


112th Congress  }                                           {    Report
  1st Session   }        HOUSE OF REPRESENTATIVES           {    112-64
=======================================================================
 
TO AMEND THE PUBLIC HEALTH SERVICE ACT TO CONVERT FUNDING FOR GRADUATE 
  MEDICAL EDUCATION IN QUALIFIED TEACHING HEALTH CENTERS FROM DIRECT 
          APPROPRIATIONS TO AN AUTHORIZATION OF APPROPRIATIONS 

                                _______
                                

 April 27, 2011.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

  Mr. Upton, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                             together with

                            DISSENTING VIEWS

                        [To accompany H.R. 1216]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 1216) to amend the Public Health Service Act to 
convert funding for graduate medical education in qualified 
teaching health centers from direct appropriations to an 
authorization of appropriations, having considered the same, 
report favorably thereon without amendment and recommend that 
the bill do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     2
Committee Consideration..........................................     2
Committee Votes..................................................     3
Committee Oversight Findings.....................................     6
Statement of General Performance Goals and Objectives............     6
New Budget Authority, Entitlement Authority, and Tax Expenditures     6
Earmark..........................................................     6
Committee Cost Estimate..........................................     6
Congressional Budget Office Estimate.............................     6
Federal Mandates Statement.......................................     8
Advisory Committee Statement.....................................     9
Applicability to Legislative Branch..............................     9
Section-by-Section Analysis of the Legislation...................     9
Changes in Existing Law Made by the Bill, as Reported............     9
Dissenting Views.................................................    11

                          Purpose and Summary

    H.R. 1216, a bill to amend the Public Health Service Act to 
convert funding for graduate medical education in qualified 
teaching health centers from direct appropriations to an 
authorization of appropriations was introduced on March 29, 
2011, by Representative Brett Guthrie (R-KY), and referred to 
the Committee on Energy and Commerce.
    The purpose of H.R. 1216 is to reduce federal spending, 
deficits, and debt by repealing mandatory programs with limited 
Congressional oversight and ensure that Congress prioritize the 
programs it funds by utilizing the traditional appropriations 
process.

                  Background and Need for Legislation

    The Patient Protection and Affordable Care Act contained 
numerous provisions that contained mandatory spending for 
public health programs that have been traditionally 
discretionary in nature. In contrast the health care bill that 
passed the House, H.R. 3962, contained a division dedicated to 
public health and workforce issues but programs under that 
division did not contain mandatory appropriations but rather 
were authorizations subject to future appropriations.
    The federal government is now borrowing 42 cents of every 
dollar it spends. The current projected deficit for this fiscal 
year is $1.6 trillion while national debt has exceeded $14 
trillion. Many that support H.R. 1216 also support the concept 
of providing graduate medical education training in health 
centers. However, these funds should first be authorized then 
separately appropriated. It is this system that allows Congress 
to prioritize spending on those programs that most deserve 
funding while ensuring that we control spending to reduce the 
budget deficit. We can no longer afford to fund new programs 
without eliminating other spending. Congress can set fiscal 
priorities by subsequently providing funding through the 
appropriations process after weighing the relative value of 
different programs.

                                Hearings

    The Committee on Energy and Commerce held a hearing on 
draft legislation that became H.R. 1216 on March 9, 2011. The 
following witnesses testified at the hearing:
           The Honorable Ernest J. Istook, The Heritage 
        Foundation
           Dr. John Goodman, President and CEO, 
        National Center for Policy Analysis
           The Honorable Joseph F. Vitale, New Jersey 
        State Senate

                        Committee Consideration

    H.R. 1216 was introduced by Mr. Brett Guthrie on March 29, 
2011, and was referred to the Committee on Energy and Commerce.
    On March 31, 2011, the Subcommittee on Health met in open 
markup session to consider H.R. 1216. Subsequently, the 
Subcommittee ordered H.R. 1216 favorably reported by a recorded 
vote of 14-11.
    On April 5, 2011, the Energy and Commerce Committee met in 
open markup session to consider H.R. 1216. Subsequently, the 
Committee ordered H.R. 1216 favorably reported by a vote of 21-
14.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report legislation and amendments thereto.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      Committee Oversight Findings

    Pursuant to clause 3(c)(1) of rule XIII of the Rules of the 
House of Representatives, the oversight findings and 
recommendations of the Committee are reflected in the 
descriptive portions of this report, including the finding that 
reigning in mandatory spending is necessary to avoid a debt 
crisis.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the performance goals and 
objectives of the Committee are reflected in the descriptive 
portions of this report, including the goal that reigning in 
mandatory spending is necessary to avoid a debt crisis.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee finds that H.R. 
1216 would result in no new or increased budget authority, 
entitlement authority, or tax expenditures or revenues.

                                Earmark

    In compliance with clause 9(e), 9(f), and 9(g) of rule XXI, 
the Committee finds that H.R. 1216 contains no earmarks, 
limited tax benefits, or limited tariff benefits.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
section 402 of the Congressional Budget Act of 1974.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
provided by the Congressional Budget Office pursuant to section 
402 of the Congressional Budget Act of 1974:

H.R. 1216--A bill to amend the Public Health Service Act to convert 
        funding for graduate medical education in qualified teaching 
        health centers from direct appropriations to an authorization 
        of appropriations

    Summary: H.R. 1216 would rescind any unobligated funds that 
were appropriated by the Patient Protection and Affordable Care 
Act (PPACA) for health centers to expand or establish programs 
that provide training to medical residents. The bill also would 
amend the Public Health Service Act to make funding for future 
payments to those centers subject to annual discretionary 
appropriations, and it would authorize the appropriation of $46 
million a year for fiscal years 2012 through 2015 for such 
payments.
    CBO estimates that enacting the legislation would decrease 
direct spending by about $195 million over the 2011-2016 period 
and by $220 million over the 2011-2021 period. Pay-as-you-go 
procedures apply because enacting the legislation would affect 
direct spending.
    Assuming appropriation of the specified amounts, CBO 
estimates that the discretionary spending to implement H.R. 
1216 would total $184 million over the 2011-2016 period.
    The bill contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the federal government: The estimated 
budgetary impact of H.R. 1216 is shown in the following table. 
The costs of this legislation fall within budget functions 550 
(health) and 570 (Medicare).


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                By fiscal year, in millions of dollars--
                                               ---------------------------------------------------------------------------------------------------------
                                                  2011    2012    2013    2014    2015    2016    2017   2018   2019   2020   2021  2011-2016  2011-2021
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               CHANGES IN DIRECT SPENDING

Estimated Budget Authority....................     -190       0       0       0       0      -5     -5     -5     -5     -5     -5      -195       -220
Estimated Outlays.............................        0       0     -40     -50     -50     -55     -5     -5     -5     -5     -5      -195       -220

                                                      CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Authorization Level...........................        0      46      46      46      46       0      0      0      0      0      0       184        184
Estimated Outlays.............................        0      37      46      46      46       9      0      0      0      0      0       184        184
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Basis of estimate: For this estimate, CBO assumes that the 
legislation will be enacted by the end of fiscal year 2011.\1\ 
H.R. 1216 would prevent the Secretary of Health and Human 
Services from obligating any unobligated funds appropriated by 
PPACA to health centers to expand or establish programs that 
provide training to medical residents. By rescinding those 
appropriated funds, H.R. 1216 would reduce direct spending by 
$195 million over the 2011-2016 period and by $220 million over 
the 2011-2021 period, CBO estimates.
---------------------------------------------------------------------------
    \1\If the bill was enacted sooner, or if the pace of obligations 
was slower than anticipated, some additional unobligated balances may 
remain at the time of enactment. In that case, the budget authority of 
the grant program would be reduced by the amount of those unobligated 
balances, resulting in a corresponding decrease in direct spending.
---------------------------------------------------------------------------
    In addition, CBO estimates that implementing H.R. 1216 
would incur discretionary costs of $184 million over the 2012-
2021 period, assuming appropriation of the specified amounts.

Rescission of unobligated funds

    Under current law, the Secretary is authorized to make 
payments totalling about $230 million over the 2011-2015 period 
to health centers to expand or establish programs that provide 
training to medical residents. CBO expects that funding will 
enable additional health centers to qualify for payments from 
Medicare for costs incurred for operating an approved training 
program for medical residents. CBO estimates those additional 
Medicare payments under current law will total about $30 
million over the 2012-2021 period.
    Enacting H.R. 1216 would rescind any unobligated funds 
appropriated by PPACA to qualifying health centers to train 
medical residents. Assuming enactment near the end of fiscal 
year 2011, CBO estimates that about $40 million will have been 
obligated, and that $190 million would be rescinded by the 
bill. CBO expects that the Secretary of Health and Human 
Services will obligate funds for 2012 near the end of fiscal 
year 2011 and therefore estimates no change in outlays until 
2013. CBO also expects that the reduction in funding for 
training programs would result in fewer programs qualifying for 
additional Medicare payments. CBO estimates that, as a result, 
Medicare spending for graduate medical education programs would 
be reduced by about $30 million over the 2012-2021 period. In 
total, therefore, CBO estimates that enacting H.R. 1216 would 
reduce direct spending by $220 million over the 2011-2021 
period.

Authorized grant funds

    The bill would authorize the appropriation of $46 million 
for fiscal year 2012 and $184 million over the 2012-2016 period 
for qualifying health centers to expand or establish programs 
that provide training to medical residents. Based on historical 
patterns of spending for similar activities, CBO estimates that 
implementing H.R. 1216 would cost $37 million in 2012 and $184 
million over the 2012-2016 period, assuming appropriation of 
the specified amounts.
    Pay-as-you-go considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The changes in outlays that are subject to those pay-
as-you-go procedures are shown in the following table. Enacting 
H.R. 1216 would have no impact on federal revenues.

         CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 1216, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON APRIL 5, 2011
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                 By fiscal year, in millions of dollars--
                                                --------------------------------------------------------------------------------------------------------
                                                  2011    2012    2013    2014    2015    2016    2017   2018   2019   2020   2021  2011-2016  2011-2021
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                             NET DECREASE (-) IN THE DEFICIT

Statutory Pay-As-You-Go Impact.................       0       0     -40     -50     -50     -55     -5     -5     -5     -5     -5      -195       -220
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Intergovernmental and private-sector impact: H.R. 1216 
contains no intergovernmental or private-sector mandates as 
defined in UMRA. By reclassifying funding for teaching health 
centers, the bill would probably decrease the amount of funds 
that state and local governments receive to implement programs 
that provide graduate medical education.
    Estimate prepared by: Federal Costs: Stephanie Cameron and 
Lisa Ramirez-Branum; Impact on State, Local, and Tribal 
Governments: Lisa Ramirez-Branum; Impact on the Private Sector: 
Jimmy Jin.
    Estimate approved by: Holly Harvey, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Converting Funding for Graduate Medical Education Funding in 
        qualified teaching Health Centers from direct appropriations to 
        an authorization of appropriations

    The legislation would amend Section 340H of the Public 
Health Service Act to convert the direct appropriations for 
graduate medical education grants for teaching health centers 
to an authorization of appropriations for these activities. The 
legislation would rescind the unobligated balances from the 
amounts already provided.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (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

           *       *       *       *       *       *       *



TITLE III--GENERAL POWERS AND DUTIES OF PUBLIC HEALTH SERVICE

           *       *       *       *       *       *       *



Part D--Primary Health Care

           *       *       *       *       *       *       *



Subpart XI--Support of Graduate Medical Education in Qualified Teaching 
                             Health Centers

SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS THAT OPERATE 
                    GRADUATE MEDICAL EDUCATION PROGRAMS.

  (a) * * *
  (b) Amount of Payments.--
          (1) * * *
          (2) Capped amount.--
                  (A) In general.--The total of the payments 
                made to qualified teaching health centers under 
                paragraph (1)(A) or paragraph (1)(B) in a 
                fiscal year shall not exceed the amount of 
                funds appropriated [under subsection (g)] 
                pursuant to subsection (g) for such payments 
                for that fiscal year.

           *       *       *       *       *       *       *

  (d) Amount of Payment for Indirect Medical Education.--
          (1) * * *
          (2) Factors.--In determining the amount under 
        paragraph (1), the Secretary shall--
                  (A) * * *
                  (B) based on this evaluation, assure that the 
                aggregate of the payments for indirect expenses 
                under this section and the payments for direct 
                graduate medical education as determined under 
                subsection (c) in a fiscal year do not exceed 
                the amount appropriated for such expenses as 
                determined [in subsection (g)] pursuant to 
                subsection (g).

           *       *       *       *       *       *       *

  [(g) Funding.--To carry out this section, there are 
appropriated such sums as may be necessary, not to exceed 
$230,000,000, for the period of fiscal years 2011 through 
2015.]
  (g) Authorization of Appropriations.--To carry out this 
section, there are authorized to be appropriated $46,000,000 
for each of fiscal years 2012 through 2015.

           *       *       *       *       *       *       *


  Subpart [XI] XII--Community-Based Collaborative Care Network Program

SEC. [340H.] 340I. COMMUNITY-BASED COLLABORATIVE CARE NETWORK PROGRAM.

  (a) * * *

           *       *       *       *       *       *       *


                           DISSENTING VIEWS 

    We, the undersigned members of the Committee on Energy and 
Commerce, oppose the passage of H.R. 1216, a bill to convert 
funding for graduate medical education in qualified teaching 
health centers from direct appropriations to an authorization 
of appropriations. Accordingly, we submit the following 
comments to express our concerns about this extremely short-
sighted and deeply divisive legislation.

                      Introduction and Background

    Enacted in 2010, the Patient Protection and Affordable Care 
Act (ACA)\1\ expands access to health care for some 32 million 
Americans and improves health benefits for millions more who 
are already insured.\2\
---------------------------------------------------------------------------
    \1\The ACA is comprised of two public laws, P.L. 111-148 and P.L. 
111-152.
    \2\Letter from Douglas W. Elmendorf, Director, CBO to Speaker Nancy 
Pelosi (Mar. 20, 2010) (on line at http://www.cbo.gov/ftpdocs/113xx/
doc11379/AmendReconProp.pdf).
---------------------------------------------------------------------------
    But as valuable as it is, health insurance cannot do 
everything necessary to make our nation healthy. Even if the 
ACA makes it possible for virtually everyone to be insured, 
there will still be a major role for its public health 
provisions. Moreover, there will be an ongoing need for funding 
for these public health activities.
    ``Public health'' includes many different things:
     It is working with groups and whole communities to 
improve health, often more effectively than could be done 
between a provider and a patient. Fluoridation of water for a 
town is, for instance, vastly better than simply filling every 
citizen's cavities. Exercise programs to prevent obesity are 
better than having to treat diabetes among people who become 
obese.
     It is tailoring health insurance and health care 
to prevent and diagnose disease early rather than simply 
treating it in its later stages. Immunizations are always 
better than outbreaks. Screening for hypertension is better 
than simply waiting for strokes.
     It is providing for safety-net services where the 
insurance market alone fails to do so. Community health 
centers, HIV-service providers, and family planning clinics 
provide care to people who might not otherwise be able to find 
a provider. Health professions education programs can add to 
the primary care workforce when the market might produce only 
specialists. (Such programs will be even more necessary once 
the insurance expansion provisions of the ACA are implemented.)
     And, least glamorous but crucial, it is the 
infrastructure of daily disease control and health promotion. 
Closing down unsanitary restaurants is better than treating 
food poisoning. Compiling and studying epidemic trends can 
prevent major waves of disease.
    The case might be made clearer by analogy: No community 
would be well-served if all its homeowners had fire insurance 
but there were no fire departments, firefighters, fire 
hydrants, smoke detectors, or indoor sprinklers. That very 
well-insured town would still burn to the ground. Insurance is 
necessary, but it is nowhere near sufficient.
    The ACA addresses both approaches, with insurance and with 
public health. This required going beyond the investments in 
the law to provide health insurance to also include provisions 
to make significant public health commitments.
    It would be insufficient simply to authorize future 
appropriations for these activities while providing mandatory 
spending for coverage initiatives. While the Committees on 
Appropriations of both the House and the Senate have shown 
ongoing and great leadership in these public health programs, 
their budget allocations have been too tight to allow 
significant new initiatives of these sorts. Consequently, the 
ACA provides as firm a funding and organizational base for 
these services as possible--mandatory spending--because they 
are essential in making insurance efficient and productive and 
in making the nation healthier.
    Among the programs designated for mandatory spending in the 
ACA is the teaching health center (THC) program.\3\ Its purpose 
is to support the training of individuals who will practice in 
family medicine, internal medicine, pediatrics, internal 
medicine-pediatrics, obstetrics and gynecology, psychiatry, 
general dentistry, pediatric dentistry, or geriatrics--primary 
care disciplines where our nation is experiencing significant 
physician shortages. Training takes place in community-based 
settings such as community health centers where these health 
professionals are especially in need.
---------------------------------------------------------------------------
    \3\ACA Section 5508(c).
---------------------------------------------------------------------------
    The THC program is administered by the Health Resources and 
Services Administration (HRSA) of the Department of Health and 
Human Services (HHS). For FY 2011 through FY 2015, $230 million 
in mandatory funding is provided for the program. H.R. 1216 
seeks to convert this mandatory funding stream into a program 
of discretionary spending, subjecting the THC program to the 
annual and unpredictable appropriations process.

    Teaching Health Centers Address National Primary Care Workforce 
                                Shortage

    With or without health reform, there is little disagreement 
among experts that our nation faces a dire need for more 
primary care providers. According to a recent article in the 
Journal of the American Medical Association on this issue, only 
two percent of all medical students plan a career in general 
internal medicine.\4\ This will hardly meet the needs 
identified by health professionals. The American Academy of 
Family Physicians, for example, estimated in 2006 that an 
additional 39,000 family physicians are needed by 2020.\5\ The 
American Association of Medical Colleges estimates that an 
additional 45,000 primary care physicians will be required by 
2020.\6\ And the Council on Graduate Medical Education (COGME) 
stated just six months ago that ``there is a shortage of 
primary care physicians in this country and that shortage is 
likely to worsen''; and it has recommended that the percent of 
the workforce that is primary care should increase from 32% to 
40%.\7\
---------------------------------------------------------------------------
    \4\Hauer KE, Durning SJ, Kernan WN, Factors Associated with Medical 
Students' Career Choices Regarding Internal Medicine, Journal of the 
American Medical Association 2008; 300(10):1154-1164.
    \5\American Academy of Family Physicians, Workforce Reform (online 
at http://www.aafp.org/online/en/home/policy/policies/w/
workforce.html).
    \6\American Association of Medical Colleges, Physician Shortage to 
Worsen Without Increases in Residency Training (online at https://
www.aamc.org/download/150584/data/physician_ 
shortages_to_worsen_without_increases_in_residency_tr.pdf).
    \7\Council on Graduate Medical Education, Twentieth Report: 
Advancing Primary Care (Dec. 2010) (online at http://cogme.gov/
20thReport/cogme20threport.pdf).
---------------------------------------------------------------------------
    Members of Congress on both sides of the aisle agree that 
we are at a crisis point in addressing this issue.\8\ 
Republicans in particular have been adamant about the need to 
increase our primary care workforce.\9\ Indeed, they have 
repeatedly made this point in their effort to tear down the 
ACA, arguing that it makes no sense to expand access to health 
insurance coverage at a time when we lack an adequate number of 
primary care physicians to provide services.\10\
---------------------------------------------------------------------------
    \8\See, e.g., the comments of Rep. Guthrie made during the full 
Committee mark up of H.R. 1216: ``And I agree, and I think everyone 
here agrees and I appreciate the bipartisan work that has been done 
before on the need for more primary care physicians in our health 
system, the need for more healthcare providers in our health system.'' 
(House Committee on Energy and Commerce, Business Meeting to Mark Up 
H.R. 1213 et al., 112th Cong., pp. 283-284 (Apr. 5, 2011) (transcript 
of the proceeding).
    \9\See, e.g., comments by Rep. Pitts during the mark up of H.R. 
1217, a bill to repeal the Prevention and Public Health Fund: ``There 
is no doubt that we are facing a provider shortage, especially in 
primary care nursing. . . . I would suggest that if you wanted more 
funding to go toward training more doctors and nurses, the healthcare 
law should have contained a section explicitly authorizing that 
funding.'' (House Committee on Energy and Commerce, Business Meeting to 
Mark Up HR. 1213 et al., 112th Cong., pp. 241-242 (Apr. 5, 2011) 
(transcript of the proceeding).
    \10\See, e.g., the February 2009 press release of Rep. Burgess in 
which he states: ``What's the point of all the stress we've been going 
through in Congress to reform the healthcare system if there won't be 
enough doctors to go around by the time we're done? If we're going to 
pour our efforts into bettering American healthcare, we need to cover 
all the bases, instead of doing spot-treatments.'' (Burgess: It's Time 
to Do Something about the Looming Doctor Shortage (online at http://
burgess.house.gov/News/DocumentSingle.aspx?DocumentID=110634)).
---------------------------------------------------------------------------
    The THC program is designed specifically to help address 
this concern.
    Because most graduate medical education (GME) is currently 
conducted in hospitals, many experts have recommended new 
channels to train residents in the outpatient setting. The 
Medicare Payment Advisory Commission (Medpac), for example, has 
recently suggested that such training include ``increase[ed] 
experience in nonhospital settings.''\11\ COGME has also 
recommended that our nation ``increase training in ambulatory, 
community, and medically underserved sites by . . . promoting 
educational collaborations between academic programs and 
Federally Qualified Health Centers (FQHCs), rural health 
clinics, and the National Health Service Corps'', including new 
methods of funding GME.\12\
---------------------------------------------------------------------------
    \11\Medpac, Report to the Congress: Aligning. Incentives in 
Medicare (June 2010) (online at www.medpac.gov/documents/
Jun10_EntireReport.pdf).
    \12\Council on Graduate Medical Education, Twentieth Report: 
Advancing Primary Care (Dec. 2010) (online at http://cogme.gov/
20thReport/cogme20threport.pdf).
---------------------------------------------------------------------------
    The THC program takes these recommendations to heart. Under 
the program, physician training takes place in community-based 
settings such as federally qualified FQHCs and community health 
centers. According to HRSA, although the program is not limited 
to FQHCs, ``evidence has shown that resident physicians who 
train in FQHC settings are nearly three times as likely to 
practice in underserved settings after graduation. They are 3.4 
times as likely to work in a [health clinic], when compared to 
residents who did not train in health clinics].''\13\ This is 
precisely where the need for such physicians is the greatest. 
Indeed, according to HRSA, it would take another 16,643 primary 
care physicians simply to meet the needs of the 65 million 
people currently living in health professional shortage 
areas.\14\
---------------------------------------------------------------------------
    \13\HRSA, Bureau of Health Professions, Division of Medicine and 
Dentistry. Teaching Health Center Graduate Medical Education (THCGME) 
Program, Announcement Number: HRSA-11-149 (Nov. 29, 2010) (online at 
http://www.im.org/PolicyAndAdvocacy/PolicyIssues/Education/Funding/
Documents/THC%20guidance.pdf).
    \14\HRSA, Shortage Designation: HPSAs, MUAs & MUPs (updated May 28, 
2010) (online at http://bhpr.hrsa.gov/shortage/).
---------------------------------------------------------------------------

               Implementation of Teaching Health Centers

    In January 2011, HHS Secretary Sebelius announced the first 
round of grants for 11 teaching health centers to train 50 
additional residents, and distributed $1.9 million for the last 
three months of this fiscal year. The grants are designed to 
support a center for five years, in part because it takes 
several years to complete residency training. The first groups 
of awards were made to teaching centers in California, Idaho, 
Illinois, Maine, Massachusetts, Montana, New York, 
Pennsylvania, Texas, Washington, and West Virginia.\15\
---------------------------------------------------------------------------
    \15\HHS, HHS Announces New Teaching Health Centers Graduate Medical 
Education Program (Jan. 25, 2011) (online at: http://www.hrsa.gov/
about/news/pressreleases/110125teaching healthcenters.html).
---------------------------------------------------------------------------
    The THC program is only a part of a broader effort under 
the ACA to bolster the primary care workforce.\16\ This package 
of programs already appears to be having an impact even beyond 
the direct number of new primary care residents trained. Data 
from this year's National Resident Matching Program indicate 
that U.S. medical students are choosing careers in primary care 
in greater numbers. Approximately 99% of internal medicine 
residency slots were filled this year, and some 94% of family 
medicine residency slots were also filled--the highest fill 
rate ever for family medicine.\17\ The ACA has received much 
credit for these improvements. According to the executive 
director for the National Residency Matching Program, ``[t]he 
Obama administration has been trying to funnel money into 
primary care graduate medical education and we think that in 
this year's match we were seeing the results of that.''\18\
---------------------------------------------------------------------------
    \16\See, e.g., ACA Section 3502 (relating to community health 
teams); Section 5101 (relating to the National Health Care Workforce 
Commission); Section 5102 (relating to state health care workforce 
development); Section 5103 (relating to the National Center for Health 
Workforce Analysis); Section 5204 (relating to public health 
workforce); Section 5207 and Section 10503(b)(2) (relating to the 
National Health Service Corps); Section 5301 (relating to primary care 
training); Section 5402 (health workforce diversity); Section 5403(a) 
(relating to Area Health Education Centers); Section 5405 (relating to 
primary care); and Section 10501(I) (relating to rural physician 
training). Numerous payment and delivery system reforms also will serve 
to enhance the primary care workforce. (See, e.g., ACA Section 5501 
(relating to Medicare bonus payments for primary care providers.)
    \17\National Residency Matching Program, Advance Data Tables: 2011 
Main Residency Match (Mar. 17, 2011) (online at http://www.nrmp.org/
data/2011Adv%20Data%20Tbl.pdf).
    \18\Internal Medicine News, Interest in Primary Care Builds in 
Resident Match (Mar. 17, 2011) (online at http://
www.internalmedicinenews.com/index.php?id=495&cHash=071010&tx_ 
ttnews[tt_news1=53175).
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                           Mandatory Spending

    The primary objection to the THC program voiced by 
Republicans is that they are opposed to its being funded 
through mandatory spending. Given the program's purpose, its 
track record of accomplishment to date, and concern about the 
nation's primary care workforce, this position comes as a great 
disappointment.
    Congress has long recognized the need for financial 
certainty in supporting medical residency training. In fact, 
since 1965, the vast majority of resident trainees in this 
country have been supported by mandatory funding through 
Medicare's GME program, which provided some $9.5 billion in 
support in 2009 alone. This is because training a single 
resident involves at least a three-year commitment; it takes 
even more time for an institution to build the infrastructure 
necessary to support residency training. Republicans have 
acknowledged the necessity for such ongoing and consistent 
funding support.\19\
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    \19\See, e.g., the comments of Rep. Burgess on this issue made 
during the floor debate on H.R. 1217, a bill to repeal the Prevention 
and Public Health Fund: ``Some of this money is going to go for 
scholarships, but it sets up a big problem. . . . [S]ome of those same 
students could receive a scholarship for one year, only to find that 
the Secretary has bigger and better things to spend it on next year.'' 
(Statement of Rep. Michael Burgess, Congressional Record, H2624 (Apr. 
13, 2011)).
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    The need for this funding continuity is exactly why support 
for the THC program should remain mandatory spending. 
Subjecting the program to the whims of the appropriations 
process would undermine the ability for any institution to 
effectively recruit and train their residents. Applicants for 
THC funding need to know it will be worth the investment to 
create a program to train residents. And resident trainees need 
to know they will be able to complete their training over three 
years. Without the funding to back up these commitments, 
training programs simply can not operate as we have come to 
know them.
    Thus, HRSA has structured the THC program to be 
administered within these kinds of parameters. For example, in 
its program announcement, the agency stated that ``although the 
program period is one year, it is HRSA's intent to fund 
qualified THCs for the entire five year THC GME program period 
pending satisfactory performance of awardees and availability 
of federal funds.''\20\ Any reduction in this funding would be 
crippling for those 11 programs that have already made the 
decision to participate--in consultation with key stakeholders 
such as teaching hospitals and their boards--based on an 
expectation that continued funding would be available. 
Converting the program to discretionary funding will also deter 
other entities from making the business decisions necessary to 
expand residency training (e.g., securing commitments from 
potential partners to agree to train new or additional 
residents, applying for accreditation if not already part of an 
eligible consortia, and hiring new faculty) since funding would 
be subject to the annual appropriations fight.
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    \20\HRSA, Bureau of Health Professions, Division of Medicine and 
Dentistry. Teaching Health Center Graduate Medical Education (THCGME) 
Program, Announcement Number: HRSA-11-149 (Nov. 29, 2010) (online at 
http://www.im.org/PolicyAndAdvocacy/PolicyIssues/Education/Funding/
Documents/THC%20guidance.pdf).
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    In comparing it to the fate of the Children's Hospital 
Graduate Medical Education program,\21\ Republicans actually 
underscore the need for mandatory funding for the THC program. 
Residents currently training under the children's hospital GME 
program are now greatly concerned about their ability to 
continue their training. Ending mandatory spending for the THC 
program simply place residents in that program in the same 
position of insecurity that their pediatric resident colleagues 
now face. Such a step is particularly ill-advised at a time 
when the demand for primary care physicians is--and will 
continue to be--high.
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    \21\The President's FY 2012 budget proposal calls for the 
elimination of mandatory spending for this program. During the 
Committee mark up of H.R. 1216, Republicans argued that the THC program 
should be treated similarly. (See House Committee on Energy and 
Commerce, Business Meeting to Mark Up HR. 1213 et al., 112th Cong., 
comments of Rep. Guthrie (p. 283) and Rep. Gingrey (pp. 305-306) (Apr. 
5, 2011) (transcript of the proceeding).
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    Republicans' opposition to mandatory funding for the THC 
program is especially ironic given their arguments against 
mandatory funding for the school-based health centers (SBHCs) 
construction/renovation program also established in the ACA\22\ 
and in support of H.R. 1214, a bill to repeal mandatory funding 
for school-based health center construction. During the mark up 
of that bill, Republicans argued that they could not support 
the construction/renovation program because, in their view, it 
made no sense to build centers for which there was not adequate 
physician staffing.\23\ While we vigorously and completely 
disagree with the Republican analysis of how the SBHC 
construction/renovation program is designed to operate in terms 
of staffing requirements, we wholeheartedly agree with Rep. 
Burgess's statement during the debate over H.R. 1214: ``If 
increasing annual wellness visits for children age 10 to 17 is 
a priority then increasing the physician workforce should also 
be a priority.''\24\ The THC program is all about just that--
making our workforce in primary care a top priority. We believe 
mandatory spending for the THC program will help ensure that it 
remains that way.
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    \22\ACA Section 4101(a).
    \23\See, e.g., comments made to this effect by Reps. Burgess and 
Blackburn during the full Committee mark up. (House Committee on Energy 
and Commerce, Business Meeting to Mark Up H.R. 1213 et al., 112th 
Cong., (Apr. 5, 2011) (transcript of the proceeding).
     Rep. Burgess: You are funding the bricks and mortar . . . 
and you got no doctor, no nurse.'' (pp. 154-155 of transcript of the 
proceeding)
     Rep. Blackburn: ``. . . you can build all sorts of 
buildings . . . but if there is a shortage, if you do not have enough 
physicians available to deliver the care, individuals . . . do not end 
up with access to that care delivery, and you still have a problem.'' 
(p. 221 of transcript of the proceeding)
    \24\House Committee on Energy and Commerce, Business Meeting to 
Mark Up H.R. 1213 et al., 112th Cong., pp. 180-181 (Apr. 5, 2011) 
(transcript of the proceeding).
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                An Anti-Health Reform Ideological Agenda

    In our view, the Republican opposition to the THC program 
as it is currently structured is without merit. It is difficult 
to see how opposition could be grounded on the merits of 
discretionary spending versus mandatory spending or the need to 
protect Congress's prerogative to fund or not to fund health 
programs. Congress, Republicans and Democrats alike, makes 
those kinds of choices--often difficult choices--all of the 
time.\25\ Moreover, opposition based on the substance of the 
program runs counter to traditional bi-partisan support for 
primary care training.
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    \25\For examples of various federal programs that are supported 
through mandatory spending, see Committee on Energy and Commerce, 
Democratic Staff, The Pitts Proposal to Block Mandatory Funding in the 
Affordable Care Act (Mar. 9, 2011) (online at: http://democrats. 
energycommerce.house.gov/sites/default/files/image_uploads/
Fact%20Sheet_03.09.11.pdf).
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    Instead, it appears that H.R. 1216 is simply another 
component of the Republican effort to disrupt, dismantle, and 
ultimately destroy the ACA--even those programs that have been 
funded and are up and running, and even those that make good 
health policy sense, in or out of the health reform law. What 
they have not been able to achieve whole cloth,\26\ Republicans 
are now attempting to do piece by piece. H.R. 1216 puts the 
Teaching Health Centers Program in the frontline of this 
ongoing assault.
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    \26\Although the House of Representatives has passed legislation to 
repeal the ACA, that legislation will not become law since the Senate 
has defeated the proposal. (H.R. 2 passed the House of Representatives 
in January 2011 (Congressional Record, H322-323 (Jan. 11, 2011)). The 
Senate defeated a similar proposal a month later. (Congressional Record 
S475 (Feb. 2, 2011)).
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    We do not believe this is where the THC program should be. 
Rather, is should remain exactly where it is--at the forefront 
of helping to build our national health workforce to ensure 
that all those in need have access to basic health care 
services.

                                   Henry A. Waxman.
                                   Frank Pallone, Jr.
                                   Doris O. Matsui.
                                   Anna G. Eshoo.
                                   Mike Doyle.
                                   Donna M. Christensen.
                                   Anthony Weiner.
                                   Edolphus Towns.
                                   Charles A. Gonzalez.
                                   Lois Capps.
                                   Eliot L. Engel.
                                    Edward J. Markey.
                                   John D. Dingell.
                                   Jay Inslee.
                                   Diana DeGette.
                                   Jan Schakowsky.
                                   Tammy Baldwin.
                                   Bobby L. Rush.
                                   G.K. Butterfield.
                                   Gene Green.

                                  
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