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Statement on FY 2000 Appropriations for the Department of Health and Human Services 

The Association of American Medical Colleges, which represents the nation's 125 accredited medical schools, some 400 major teaching hospitals and health systems, 86 professional and scientific societies representing 87,000 faculty members, and the nation's medical students and residents, 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 preeminent medical research enterprise. The long-standing bipartisan commitment to the NIH by this Subcommittee has enabled discovery and knowledge in the fundamental and applied biological and biomedical sciences that fuel the advances in medicine that have distinguished the United States globally. NIH-supported research continues to improve the health and quality of life for all Americans in dramatic ways. In addition, NIH-sponsored research has had a significant economic impact, 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 their 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 2000, the AAMC supports the recommendation of the Ad Hoc Group for Medical Research Funding, which calls for a 15 percent increase in the NIH budget as the second step toward doubling it by 2003. 

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 bi-directional 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 under funded for nearly a decade.

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. 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 endangering this base of support. 

As a first step toward addressing the many unmet needs caused by these increasing fiscal constraints, the AAMC strongly urges the Subcommittee to include funding in FY 2000 for the NIH to support the establishment of a Research Innovation Opportunity (RIO) grant program. This program would provide flexible funds to strengthen and stabilize the institutional base for all NIH-supported research programs. It also would support biomedical research needs not funded by other programs. The program would allow NIH-grantee institutions to exercise prompt on-site judgment regarding emphasis, specific direction, and content of research 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. The program would enhance the institution's ability to encourage young investigators, explore new and unorthodox research ideas and techniques, respond promptly to opportunities that develop in the course of active research programs, and acquire essential equipment and other shared resources.

Both the House and Senate Labor-HHS-Education Appropriations Subcommittees recognized the need for such a program in the reports accompanying their respective FY 1998 appropriations bills when they requested that NIH explore the feasibility of establishing a mechanism to provide flexible research support to institutions (see attached committee report language). This support would cover direct costs only and would be rigorously peer-reviewed at the institutional level and administered with full accountability. Institutions would exercise individual judgment about how to best support and enhance their research portfolios. As a means to ensuring accountability and appropriate use of funds, institutions receiving RIO awards should be required to establish committees of NIH-supported faculty who would review proposed uses of these funds for merit and priority. The institution would be obligated to report to its faculty and the NIH on the use of all monies under this award. NIH would provide a retrospective review of each institution's effectiveness in the use of the funds. 

The AAMC strongly urges that Congress work with the NIH to support this nation's medical schools and teaching hospitals by establishing a Research Innovation Opportunity Grant program. The AAMC proposes that an amount equal to 2% of the NIH's total research project grant budget be devoted for the RIO program. In FY 1999, this would have equaled $117 million.

National Health Service Corps Funding -- Located in the Health Resources and Services Administration's Bureau of Primary Health Care, the National Health Service Corps assists underserved communities by developing, recruiting, and retaining community-responsive, culturally competent, primary care clinicians dedicated to practicing in health professional shortage areas. Open to doctors, nurse-midwives, nurse practitioners, and physician assistants practicing in primary care, the NHSC administers four major programs. 

• The NHSC Scholarship program provides students with funding for tuition, fees, other reasonable education expenses, and a monthly stipend in return for a minimum two-year commitment to serve in a designated area. 
• The Loan Repayment program offers fully-trained primary care providers up to $25,000 per year for the first two years of service in a designated area. 
• The State Loan Repayment program provides grants allowing states to provide dollar-for-dollar matching assistance to eligible students. 
• The Community Scholarship program is a federal, state, and local partnership to provide grants to community organizations located in designated health professional shortage areas. The communities then use these funds to provide scholarships to local health professions students.

The NHSC estimates that between 43 and 46 million people live in medically underserved areas and are served by only 11,000 primary care clinicians, approximately 2,300 from the NHSC, where 25,000 are needed. Because many medically underserved areas lack health systems and other valuable resources, they are unable to recruit and retain primary care providers. With additional funding, the NHSC will be able to move more money into pre-placement activities and bring the areas of greatest need up to a level where they can recruit and retain health care professionals.

The NHSC's activities are divided into two budgetary categories, field and recruitment. The field portion of the budget is used for mentoring activities such as building partnerships with health professions schools to make them more sensitive to NHSC students, providing money to state primary care associations, linking students to service delivery sites early in their careers, and working with communities to develop sites for service. The recruitment piece of the budget funds the scholarship and loan repayment programs. The Administration's budget provides flat funding at $115 million for the combined field ($37 million) and recruitment ($78 million) NHSC budget. This is the same amount the NHSC was appropriated in FYs 1998 and 1999. The AAMC recommends an appropriation of $133 million (15 percent increase) for FY 2000. An appropriation of this amount would allow the NHSC to increase access to health care in medically underserved areas by developing new delivery sites and increasing the number of clinicians providing care through additional scholarships and loan repayment contracts.

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 1999. The AAMC joins the nearly 40 national organizations of the Health Professions and Nursing Education Coalition (HPNEC) in urging the Subcommittee to continue its support for these programs by providing a FY 2000 appropriation of at least $316 million. 

The geographic and specialty maldistribution of physicians in the United States continue to be significant issues facing the Congress, medical educators, and the nation. The Title VII and VIII health professions training programs are 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.

We are deeply concerned with the Administration's FY 2000 budget, which proposes elimination of the primary care programs and public health and preventive medicine programs and a 30 percent cut in community-based programs. Any reduction in health professions education funding will further complicate the arduous task of providing quality medical care to minority and underserved communities. 

Title VII 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.

The AAMC also 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.

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 loan and scholarship programs that assist needy and disadvantaged medical students in covering the costs of their education. These programs are 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 $316 million for FY 2000 to maintain and improve medical care access to the most needy communities. 

Agency for Health Care Policy and Research -- Complementing 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 a rapidly changing market. In addition, the agency has made a major commitment to the advancement of evidence based medicine.

As the lead federal agency to improve health care quality, AHCPR's overall mission is to support research and disseminate 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 funds 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. 

The AAMC firmly believes 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 Friends of AHCPR recommendation which calls for a FY 2000 funding level of $225 million for AHCPR.

The AAMC is pleased with the Administration's budget request of $206 million for the Agency representing a $35 million or 21% increase over FY 1999. However, we are troubled that the majority of this funding is derived from inter-agency transfers, rather than direct appropriations. The agency would receive only $27 million in direct appropriations, down from $100 million in FY 1999, while transfers would increase to $179 million, up from $71 million in FY 1999. The AAMC urges the Subcommittee to provide the majority of the agency's funding through direct appropriations.

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