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Statement on FY 2001 Appropriations for the Department of Health and Human Services

I am Ralph Muller, President, CEO and Trustee of the University of Chicago Hospitals and Health System. I am also Chairman of the Association of American Medical Colleges, which represents the nation's 125 accredited medical schools, some 400 major teaching hospitals and health systems, 91 professional and scientific societies representing 87,000 faculty members, and the nation's medical students and residents. I am pleased to have this opportunity to comment on several of the research and health programs under the Subcommittee's jurisdiction. The AAMC thanks the Chairman and the members of the Subcommittee for their steadfast support of these programs. Although the AAMC is strongly supportive of all the Public Health Service agencies that make up the public health continuum, our testimony today will focus on five programs that play critical roles in assisting medical schools and teaching hospitals to fulfill their multiple missions of education, research, and patient care: the National Institutes of Health, health professions education funding, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the National Health Service Corps.

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 of this subcommittee and the Congress to the NIH has enabled discoveries and knowledge in the fundamental and applied biological and biomedical sciences that have fueled advances in medicine and 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 of the biotechnology, pharmaceutical, and medical device industries and continues to provide the basis for their sustained success.

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 sustain its commitment to medical research. The AAMC supports the FY 2001 recommendation of the Ad Hoc Group for Medical Research Funding, which advocates for an increase of $2.7 billion (15 percent) as the third installment in the effort to double the NIH budget by FY 2003.

Within the NIH budget, the AAMC believes there are four major areas of concern: peer-reviewed basic science, clinical research, research infrastructure, and research training. Peer-reviewed, investigator-initiated basic research is the heart of NIH research and is primarily supported through research project grants (RPGs). These inquiries into the fundamental cellular, molecular, and genetic events of life are essential if we are to make real progress toward understanding and conquering disease. Additional funding is needed to sustain and enhance basic research activities, including increasing support for current researchers and promoting opportunities for new investigators and in those areas of biomedical science that have historically been under funded.

The application of fundamental research to clinical problems such as the detection, diagnosis, treatment, and prevention of disease is the ultimate mission of the NIH. Clinical research not only is the pathway for application of basic research findings, but it often provides important insights and leads to identify further basic research opportunities. The interactions between basic and clinical research are truly bi-directional and synergistic. Recent increases in the NIH's overall budget have allowed the agency to increase its efforts in the areas of clinical research, and in particular, to support early translational research on new molecular entities and new therapeutic strategies of great promise, but which is still too uncertain to attract significant investment from industry. The AAMC supports additional funding for the continued expansion of 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, especially to enable them to mentor new investigators; expansion of the existing clinical research loan repayment program to the extramural community, and support for the clinical research infrastructure.

Anecdotal evidence suggest that changes in the health care delivery systems and other financial factors pose a serious threat to the clinical research infrastructure on America's academic health centers. The AAMC supports three mechanisms for enhancing the research infrastructure and expanding scientific opportunity. First, the association advocates for increased funding for the general clinical research centers (GCRCs). The GCRC program - which funds approximately 77 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. GCRCs have been chronically underfunded at approximately 75 percent of the recommended levels. Second, the AAMC strongly supports the shared instrumentation grant program which provides grants for expensive equipment such as high-resolution mass spectrometers, high-throughput protein and nucleic acid sequencers, and functional imaging devices that can only be justified on a shared-use basis. Finally, the AAMC is concerned that the cap on extramural salaries continues to hinder the NIH's ability to recruit and retain high-quality scientific investigators. Although we are grateful for the increase approved in the FY 2000 appropriations process, the AAMC continues to believe that increasing the salary cap to a level equivalent to the Senior Biomedical Research Service (SBRS) would provide further incentive for investigators, and particularly physicians, to engage in clinical research. By furthering the development of new clinical research technologies and providing shared resources, NIH enhances the productivity of the federal-academic research partnership and promotes the efficient use of scarce federal dollars.

The institutional research infrastructure at medical schools, teaching hospitals, and other research institutions are the resources that enable NIH-supported research to thrive. Medical schools and teaching hospitals 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 (e.g., gene chip technologies), 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). Therefore, the AAMC urges the subcommittee to pay particular attention to the needs, and the full agenda, of NCRR, which we believe has been chronically underfunded for nearly a decade.

Research training is the fourth 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. For example, the volume of data being generated by the Human Genome Project, as well as the increasing power and sophistication of computing assets on the researcher's lab bench, have created an urgent need, both in academic and industrial settings, for talented individuals well-trained in biology, computational technologies, bioinformatics, and mathematics to realize the promise offered by modern interdisciplinary research.

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 2000 and for its continued support of increased funding for these programs. The AAMC joins over 40 national organizations of the Health Professions and Nursing Education Coalition (HPNEC) to support a FY 2001 appropriation of at least $335 million for health professions programs, excluding the funding for children's hospitals graduate medical education.

The geographic, economic, and cultural barriers within the country's health care delivery system need to be addressed to achieve access to health care for all Americans. To begin to eliminate these problems, health care professionals must be recruited, trained, and retained to serve in medically underserved communities. The Title VII and VIII health professions training programs are designed to do this by funding the education and training of an expanded and diverse supply of primary health care providers and public health professionals. One half of students trained in primary care under these programs practice in underserved areas. These programs are also the sole source of federal funding for establishing and maintaining academic departments, predoctoral programs and faculty development in family medicine. Additionally, many individuals in these areas rely on the primary and preventive health services provided for by 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 AAMC is deeply concerned with the Administration's FY 2001 budget request for the health professions programs. While we applaud the increase proposed for the Centers of Excellence and the Health Careers Opportunity programs, the budget request for the remainder of the health professions programs is seriously compromised. The Administration's budget request eliminates the primary care, dentistry and geriatric programs, and reduces funding for public health training. These cuts would result in the closing of programs that train many students and health professionals who practice in underserved areas.

We are pleased with the Administration's proposed increase for the Centers of Excellence and Health Care Opportunities program within the Diversity Training cluster; an increase is necessary to effectively recruit and retain qualified minority medical students. 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. These programs, plus the Scholarships for Disadvantaged Students and the Loans for Disadvantaged Students, are more crucial than ever, given the increasing difficulty many of our medical schools are having in recruiting students from racial and ethnic groups that are underrepresented in medicine. The AAMC hopes the Subcommittee recognizes the importance of maintaining critical support for these programs, which are designed to diversify the health professions workforce.

The AAMC also recommends restoring funding 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. Given America's burgeoning older population and the retirement of the first wave of health professionals trained in geriatrics, support for geriatric training must keep pace with the rising demand for these specialized services.

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 successful, well-crafted federal-state and public-private partnerships.

Agency for Healthcare Research and Quality Complementing the medical research conducted at NIH, the newly renamed and reauthorized Agency for Healthcare Research and Quality (AHRQ) sponsors health services research designed to improve the quality of health care, decrease health care costs, and provide access to essential health care services by translating research into measurable improvements in the health care system.

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 AHRQ recommendation, which calls for a FY 2001 funding level of $300 million for AHRQ.

As the lead federal agency to improve health care quality, AHRQ'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, AHRQ'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, AHRQ 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, AHRQ supports studies to evaluate the effectiveness of treatment strategies for many of the country's most prevalent and costly diseases.

In recognition of the immediate need for closer examination of medical errors and how to prevent them, the AAMC strongly supports the $20 million increase the Administration has proposed for the agency for this purpose. Through funding for the Centers for Education and Research in Therapeutics (CERTs), the agency has already begun to examine the uses and risks of drugs and drug combinations, an area where many costly errors occur. Additionally, the agency has proposed a new broad research initiative for FY 2001, which includes sponsorship of research on why errors occur, development of tools to prevent errors, and collaboration with public- and private-sector partners to translate these advances into improved patient safety. Also proposed is a Center for Patient Safety to be housed within the agency that would set national goals for patient safety and act as a clearinghouse for best health care practices. The Administration is requesting another $5 million to examine how to use technology to prevent medical errors. The AAMC feels the agency is well positioned to take the lead on improving the quality of health care through the reduction of errors.

While the AAMC is pleased with the Administration's requested increase for the agency, we continue to be troubled that all of this funding is derived from inter-agency transfers, rather than direct appropriations, which could set an unfortunate precedent. The AAMC urges the Subcommittee to provide the majority of the agency's funding through direct appropriations.

Centers for Disease Control and Prevention As the nation's lead prevention agency, the Centers for Disease Control and Prevention (CDC) is responsible for promoting health and quality of life by preventing and controlling disease, injury and disability. CDC works with States, local public health agencies and partners across the Nation to monitor health, detect and investigate disease outbreaks, conduct research to enhance prevention, develop and implement sound health policies, foster healthy environments and provide needed leadership and training in public health. The CDC is an important part of the public health continuum and the AAMC's member institutions play a significant role in the support of CDC's extramural programs, activities and research. Therefore, the Association supports increased funding for the CDC to address America's current and new public health challenges.

National Health Service Corps Located in the Health Resources and Services Administration's Bureau of Primary Health Care, the National Health Service Corps (NHSC) remains the most effective mechanism through which the federal government can intervene to redress the present and future inadequacies of health services delivery and inequities in health status and disease burden. The primary mission of the NHSC is to assist underserved communities to develop, recruit, and retain community-responsive, culturally competent, primary care clinicians dedicated to practicing in health professional shortage areas. Open to doctors, dentists, 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 funding at $117 million for the combined field ($38 million) and recruitment ($79 million) NHSC budget, the same amount as the current fiscal year. The AAMC supports increased funding for the NHSC for additional scholarships and loan repayment contracts which would allow for increased access to health care in medically underserved areas by developing new delivery sites and a larger number of clinicians providing care.

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 medical 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.