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Statement on FY 1999 Appropriations for the Department of Health and Human Services

I am Robert Kelley, Associate Vice Chancellor for Research and Executive Associate Dean for the Graduate College at the University of Illinois, Chicago. I also am the Chairman of the Association of American Medical Colleges¹, which represents the nation's 125 accredited medical schools, some 400 major teaching hospitals, 86 professional and scientific societies representing 87,000 faculty members, and the nation's medical students and residents. The Association is pleased to have this opportunity to comment on several of the research and health programs under the Subcommittee's jurisdiction. The AAMC wishes to thank the Chairman and the members of the Subcommittee for their steadfast support of these programs.

National Institutes of Health -- The Federal Government, through the National Institutes of Health (NIH), plays a unique and vital role in the support of this nation's biomedical and behavioral research efforts. The NIH is the world's pre-eminent medical research enterprise. The long-standing bipartisan commitment to the NIH by this Subcommittee continues to yield the profusion of fundamental and applied biological and biomedical knowledge that fuels the advances in the practice of medicine that have distinguished the United States globally. NIH-supported research continues to make enormous contributions to improving the health and quality of life for all Americans. Mr. Chairman, we would like to thank you for your leadership on behalf of the NIH.

In addition, NIH-sponsored research has made significant economic contributions, both locally and nationally. Research conducted and supported by the NIH played a major role in the development, and continues to provide the basis for much of the sustained success, of the biotechnology, pharmaceutical, and medical device industries.

Still, America faces serious health problems and new threats constantly appear. Congressional support of biomedical and behavioral research has produced a wealth of scientific opportunities to answer these challenges. If we are to sustain this momentum and translate the promise of science into the reality of better health, this nation must redouble its commitment to medical research.

For FY 1999, the AAMC supports the recommendation of the Ad Hoc Group for Medical Research Funding, which calls for a 15 percent increase in the NH budget as the first step toward the goal of doubling NIH funding over the next five years.

This sustained growth in the NIH budget is needed not just to continue the research of today. The way we do science is changing at a breathtaking pace, as exemplified by the Human Genome Project and the efforts to apply the wealth of information it provides. We must invest in the new technologies, the new personnel, and the new research infrastructure necessary to take full advantage of this new science.

Within the NIH budget, the AAMC believes there are four major areas of concern. First is peer-reviewed, investigator-initiated basic research, supported primarily through research project grants. Basic research is the heart of the NIH. Without these inquiries into the fundamental cellular, molecular, and genetic events of life, real progress toward understanding and conquering disease is unlikely. Additional funding is needed to sustain and enhance basic research activities, including increasing support for current researchers as well as promoting opportunities for new investigators and in those areas of biomedical science that have been under-funded.

Support for clinical research is the second area of concern. The application to clinical problems of knowledge gained through fundamental research into the diagnosis, treatment, and prevention of disease is the ultimate mission of the NIH. Clinical research not only advances the application of basic research findings, but often provides important leads to identify further basic research opportunities. The interactions between basic and clinical research are truly bidirectional and synergistic. Additional funding is needed to expand clinical research and clinical research training opportunities, including rigorous targeted post-doctoral training, developmental support for new and junior investigators, career support for established clinical investigators, and support for the clinical research infrastructure, including increased funding for general clinical research centers (GCRCs).

The GCRC program -- which now funds about 70 clinical research centers at university-based hospitals throughout the country -- supports inpatient and outpatient research facilities, special laboratories, trained research support staff, and other resources crucial to state of-the art, patient-oriented research. The network of GCRCs also provides an effective locus for training and career development in clinical research.

Research training is the third area of concern. The goal here is not necessarily to produce more scientists, but to reinvigorate research training, including increasing pre- and post-doctoral research training stipends, which are widely perceived as inadequate, and developing expanded medical research opportunities for minority and disadvantaged students.

The fourth area of concern is the institutional research infrastructure: the resources at the medical schools, teaching hospitals, and other research institutions, that enable NIH-supported research to thrive. Medical schools are a major partner in this nation's medical research effort, receiving more that 50 percent of the extramural funds awarded annually by the NIH. Additional funds are needed to enhance the institutional research capacity, including renovating outdated facilities, creating new approaches to the support of animal facilities, providing state-of-the-art instrumentation and other research equipment, continuing to develop more powerful and faster informational and computer technology, and substantially increasing funding for the research-support programs under the NIH's National Center for Research Resources (NCRR).

The NCRR provides state-of-the-art instrumentation, advanced technologies, essential animal and non-animal models and resources, and comprehensive support for clinical research. In addition, NCRR programs emphasize shared resources, which promote the efficient use of scarce Federal research dollars. These programs encourage interactions among scientists, which stimulate interdisciplinary efforts. By furthering the development of new research technologies and providing shared resources, the NCRR enhances the productivity of the Federal-academic research partnership. Therefore, the AAMC urges the Subcommittee to pay particular attention to the needs of the National Center for Research Resources, which we believe has been chronically underfunded for nearly a decade.

There is growing concern about the ability of medical schools and teaching hospitals to provide an environment in which research can flourish. The transformation of the health care system to a market-driven, price-competitive structure poses a significant threat to the fiscal stability of medical schools and teaching hospitals and their ability to maintain an environment for research and innovation. To address many of the unmet needs caused by these increasing fiscal constraints, the AAMC strongly urges the Congress to provide funding for a program of flexible but accountable institutional support, such as the Biomedical Research Support Grant (BRSG) program. The BRSG program evolved from legislation, enacted in 1960, to provide flexible funds to strengthen and stabilize NIH-supported research programs. A review of the funding history of the BRSG program during the 1980s suggests an appropriate level of support would equal somewhere between at least one and two percent of the NIH's research grant budget. For FY 1999, this would be at least $100 million to $200 million.

The fundamental rationale for the BRSG Program -- that effective health research requires a strong institutional base of support -- is even more important in the current unstable environment than it was in 1960. The financial structure of medical schools and teaching hospitals is heavily dependent on clinical revenues and other forms of contributed support made possible by payments for patient care services. There is a growing, pervasive sense that changes in the health care marketplace are eroding this base of support.

A flexible institutional support program would fund biomedical research needs not served by other programs. The program should allow NIH-grantee institutions to exercise on-site judgment regarding emphasis, specific direction, and content of activities supported, thus enabling the institutions to respond quickly and effectively to emerging opportunities and unpredictable requirements, to enhance creativity, to encourage innovation, to provide for pilot studies, and to improve research resources, both physical and human. Such a program would provide flexible but accountable biomedical research support to fund new investigators, explore new and unorthodox research ideas and techniques, respond promptly to opportunities that develop in the course of active research programs, and provide expensive but essential central shared resources.

The AAMC recognizes the difficulty in achieving a 15 percent increase within the appropriations framework under the current discretionary spending caps and urges Congress to consider carefully the various proposals before it to identify new resources that could be used to support this increase.

Biomedical and behavioral research supported and conducted by the NIH is the first step in a continuum of public health activities including health professions education, health services research, disease and injury prevention, and targeted health care services to special at risk populations. These public health activities are critical to ensuring that the enormous benefits of medical research can reach all of the American people. At the same time, advancements in medical research rely more than ever before on advancements in others areas of science, including chemistry, physics, mathematics, and engineering. The AAMC supports the concept of increasing the NIH budget in the context of an across-the-board investment in all science, and has endorsed the Unified Statement on Research: "Decade of Investment," which articulates the goal of doubling the non-military science budget over the next ten years.

Health Professions Education and Training -- The AAMC thanks the Subcommittee for increasing funding for Titles VII and VIII of the Public Health Service Act in FY 1998. The AAMC joins the more than 40 national organizations of the Health Professions and Nursing Education Coalition (HPNEC), representing a variety of schools, programs, and individuals dedicated to educating professional health personnel. We urge the Subcommittee to continue its support for these programs by providing a FY 1999 appropriation of at least $306 million.

The geographic and speciality maldistribution of physicians in the United States continue to be significant issues facing the Congress, medical educators, and the nation. The National Health Service Corps (NHSC) and the health professions training programs under Titles VII and VIII of the Public Health Service Act were designed to meet the nation's needs for an expanded supply of primary health care providers and public health professionals. Funding for these programs provides opportunity and access for health care professionals to train and provide primary and preventive care to people in medically underserved communities. Many individuals in underserved areas rely on the services provided for in these programs as their only means of medical care. Over the past 20 years, these programs have not received funding in the amounts necessary to enable them to meet the critical needs they were created to address.

The NHSC was established to assist in the recruitment of primary care health professionals for service in federally designated health professionals shortage areas. In FY 1998, the NHSC received an appropriation of $115.4 million. This is a significant reduction from the $125.1 million the NHSC received in FY 1995. Through the Scholarship and Loan Repayment programs the NHSC continues to play an important role in addressing the geographic imbalance of primary care physician distribution. The AAMC supports the NHSC and urges the Subcommittee to increase its funding.

Any reduction in health professions education funding will further complicate the arduous task of providing quality medical care to minority and underserved communities. The AAMC recommends continued support for geriatric education centers and geriatric training programs for physicians and other health professionals. These centers were created to provide physicians and other health professionals with the skills necessary to care for the growing number of elderly Americans. Support for geriatric training must keep pace with the rising demand for specialized services necessary to care for an aging population.

Title VII also provides grants for the creation and operation of area health education centers (AHECs) and health education training centers (HETCs). These programs provide clinical training opportunities for medical students and residents in predominately rural settings by extending the resources of academic health centers to communities in need of health care and health education. Through these linkages, AHEC projects, which are extremely successful and eventually become state- or self-supported, form networks of institutions that simultaneously provide health care to underserved populations and educational services to students, faculty, and practitioners. The AAMC urges the Subcommittee to continue its commitment to AHECs and HETCs, which exemplify the synergies possible in well-crafted federal-state and public-private partnerships.

Several Title VII programs assist medical schools with the AAMC's Project 3000 by 2000 initiative that has set a goal of matriculating at least 3,000 underrepresented minority students in medical school by the year 2000, and each year thereafter. Grants made to medical schools under the Health Careers Opportunity Program (HCOP) are used to identify and recruit disadvantaged students, facilitate their entry into medical school, and help them complete their education. The Centers of Excellence program extends grants to health professions schools for the establishment and expansion of programs to enhance the academic performance of minority students. The AAMC hopes the Subcommittee's funding recommendations will recognize the critical support these two programs provide to efforts in recruiting and retaining qualified minority medical students. This support is more crucial than ever before, given the increasing difficulty many of our medical schools are having in recruiting students from racial and ethnic groups in our society that are underrepresented in medicine.

Title VII provides four loan and scholarship programs that assist needy and disadvantaged medical students in covering the costs of their education. These programs are the Exceptional Financial Need scholarship, the Financial Aid for Disadvantaged Health Professions Students scholarship, the Scholarships for Disadvantaged Students, and the Loans for Disadvantaged Students programs. The recipients of these loans and scholarships come from backgrounds that may not allow them to find adequate financing for a medical education. Many of these same students return to communities similar to those from which they came to provide medical care to some of our nation's most needy urban and rural communities.

Funding under Titles VII and VIII must receive an appropriation of at least $306 million for fiscal year 1999 to maintain and improve medical care access to the most needy communities.

Agency for Health Care Policy and Research -- Complementing and building upon the medical research conducted at NIH, the Agency for Health Care Policy and Research (AHCPR) sponsors health services research designed to improve the quality of health care, decrease health care costs and provide access to essential health care services in an rapidly changing market place. It is the major federal program supporting the widely recognized need to strengthen our knowledge of and commitment to evidence based medicine.

The AAMC believes firmly in the value of health services research as this nation continues to strive to provide high-quality, efficient, and cost-effective health care to all of its citizens. The AAMC supports the recommendation of the Friends of AHCPR, which calls for a FY 1999 funding level of $175 million for AHCPR, a lead Federal agency in the effort to improve the quality of this nation's health care system.

AHCPR's overall mission is to generate research and disseminate the resulting information that improves the delivery of health care by identifying evidence based medical practices and procedures. In support of this mission, AHCPR's budget includes a number of research initiatives designed to enhance consumer and clinical decision making, provide improved health care services, and promote efficiency in the organization of public and private systems of health care delivery. To build an evidence base for clinical practice, AHCPR created twelve Evidence Based Practice Centers to review relevant literature about selected topics and publish evidence reports summarizing such information. In an effort to improve medical outcomes, AHCPR supports studies to evaluate the effectiveness of treatment strategies for many of the country's most prevalent and costly diseases.

To provide consumers with science-based information that will assist them in making informed personal health care decisions, AHCPR is sponsoring the Consumer Assessment of Health Plans project to develop report cards that assess health plans and services, thus enabling consumers to compare health plans across a variety of categories.

Finally, as part of an effort to monitor and evaluate health care access and utilization, AHCPR administers the Medical Expenditure Panel Survey (MEPS) which is designed to provide timely information on health care spending and insurance coverage for the whole population and various subgroups.

To assess changes in the health care market place and to effect changes in the delivery of health care, AHCPR works in partnership with public and private sector to identify research priorities, design and conduct studies and disseminate and implement research findings.

In conclusion, the AAMC emphasizes the essential linkage between robust support of medical research and support of health services and public health research to ensure that the benefits of basic and clinical biomedical research will flow to the advantage of all our citizens. We appreciate the continued support the Subcommittee has given these programs and look forward to working with the Subcommittee members and staff to sustain these worthy initiatives.

¹ For fiscal years 1995-97, the AAMC received $2.042 million in Federal funding from the National Institutes of Health and the Health Resources and Services Administration. During this same time period, Dr. Kelley received approximately $275,000 in grant support from the NIH.