Statement on FY 2002 Appropriations for
the Department of Health and Human Services
Presented by: Terrance Cooper, Ph.D.
Presented to: Subcommittee on Labor, Health and Human Services,
Education and Related Agencies of the Committee on Appropriations, United
States House of Representatives
Date: March 20, 2001
I am Terrance Cooper, Ph.D., Professor of Microbiology and Immunology at
the University of Tennessee, Health Science Center, College of Medicine,
and Chair of the Association of American Medical Colleges (AAMC) Council
of Academic Societies. The AAMC 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. My testimony will address five programs
that play critical roles in assisting medical schools and teaching hospitals
to fulfill their missions of education, research, and patient care: the
National Institutes of Health, health professions education funding through
the Bureau of Health Professions, the Agency for Healthcare Research and
Quality, the Centers for Disease Control and Prevention, and the National
Health Service Corps. The AAMC thanks the Subcommittee for its steadfast
support of these programs.
National Institutes of Health - As a result of the long-standing bipartisan
commitment of this subcommittee and the Congress to the NIH, we have entered
an exciting new era in medicine. A proliferation of discoveries in the fundamental
and applied biological and biomedical sciences, including genomics, is expanding
our understanding of the biological basis of disease and stimulating novel
strategies for disease prevention, diagnosis, treatment, and cures. 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. 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.
If we are to sustain this momentum and translate the promise of science
into the reality of better health, this nation must maintain its commitment
to medical research. The AAMC supports the FY 2002 recommendation of the
Ad Hoc Group for Medical Research Funding, which advocates an increase of
$3.4 billion as the fourth 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 resources,
and research training. Peer-reviewed, investigator-initiated basic research
is the heart of NIH research. 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 the results of basic research to the detection, diagnosis,
treatment, and prevention of disease is the ultimate goal of medical research.
Clinical research not only is the pathway for applying basic research findings,
but it often provides important insights and leads to identify further basic
research opportunities. Recent increases in the NIH's overall budget have
allowed the agency 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; and funding the recent expansion of the
clinical research loan repayment program to the extramural community.
Anecdotal evidence suggests that changes in health care delivery systems
and other financial factors pose a serious threat to the research infrastructure
of America's medical schools and teaching hospitals, particularly for clinical
research. To enhance the research infrastructure, the AAMC supports an additional
$500 million for the NIH's National Center for Research Resources (NCRR).
NCRR provides numerous and varied resources critical to a productive and
cost-effective research environment, which can be grouped into four categories:
resources for clinical investigations; instrumentation and emerging technologies;
animal and other research models; and research infrastructure.
NCRR Resources for Clinical Research - The AAMC strongly supports the General
Clinical Research Centers (GCRC) program, which funds 79 such clinical research
centers at university-based hospitals throughout the country. The GCRCs
are indispensable because they offer centralized and highly specialized
resources for patient-centered research aimed at understanding disease processes
and discovering better therapies and cures for a host of conditions. This
collection of highly specialized staff and resources provides a supportive
environment for patients and enormously facilitates progress in research
on tomorrow's life-saving therapies and cures.
NCRR Instrumentation and Emerging Technologies - The Shared Instrumentation
Grant (SIG) program helps researchers meet critical instrumentation needs
by assisting institutions and investigators to acquire commercially available,
sophisticated instrumentation that would be prohibitively expensive to support
on a single grant application (awarding between $100,000 and $500,000 for
the purchase of such equipment). These grants maximize the utility of federal
research funds by allowing a number of scientists with similar large instrumentation
needs to share such equipment, and promote interactions among scientists,
frequently across scientific disciplines, thereby catalyzing mutually rewarding
new research collaborations.
The current SIG program is often far too limited in assisting the purchase
of state-of-the-art instrumentation. The new generation of high field nuclear
magnetic resonance (NMR) instruments (900 Megahertz to 1 Gigahertz) can
greatly extend the capabilities of biomedical researchers, but cost more
than $5 million and require specialized facilities and support. Other research
equipment, such as top-of-the-line mass spectrometers or confocal microscopes,
also cost in excess of $1 million. A growing number of investigators would
benefit from access to such high-end instrumentation. To meet this demand
in a cost-effective way, a shared instrumentation program providing awards
of more than $1 million is greatly needed and should be a priority of the
NCRR.
NCRR Animal and Other Research Models - The NCRR supports the development
of unique and highly specialized animal resources, including specialized
laboratory animal colonies, cell lines, genetic stock, or other collections,
and may include species from microorganisms to invertebrates to nonhuman
primates. NCRR also sponsors seven Regional Primate Research Centers and
other primate resources to provide specialized facilities for more than
1,400 scientists who work with nonhuman primates as the most effective animal
model in studies of reproductive medicine, geriatrics, hypertension, AIDS,
vaccine development and other human health and disease problems.
The extraordinary advancements of the Human Genome Project and other research,
has dramatically increased the need for and the costs of animal research. "Functional
genomics" requires that individual genes and sets of genes be studied
in complex physiological systems through the use of transgenic mice and
other specialized models. Veterinarian investigators are of paramount importance
to this research to correctly identify and understand the pathological changes
induced by experimentation. They are also needed to discover new and more
effective means to safeguard the welfare of these valuable animals. To address
the critical need for training and career development of young veterinarians
and other researchers, the NCRR has instituted special emphasis research
career awards in pathology and comparative medicine to assist veterinarians
motivated toward research careers. NCRR has also established midcareer investigator
awards for veterinarians in mouse pathobiology, and is considering establishment
of centers of clinical excellence in veterinary medicine.
NCRR Research Facilities - The Research Facilities Improvement Program
provides grants to improve or construct research facilities, including animal
facilities, at institutions funded by the Public Health Service. Congress
passed legislation last year that authorizes up to $250 million annually
for the construction of "21st Century" laboratories. This funding,
allocated by merit review, would address perennially documented shortfalls
in research space and physical plant. Federal funding is also beneficial
in leveraging private philanthropy, state and municipal bond issues, and
debt financing.
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 providing increased funding for Titles VII and VIII of the Public Health
Service Act in FY 2001. The AAMC joins the Health Professions and Nursing
Education Coalition (HPNEC) to support a FY 2002 appropriation of at least
$440 million for health professions programs. These programs work to improve
the quality, geographic distribution, and ethnic diversity of the public
health and health care workforce, particularly in underserved areas. This
recommendation does not include funding for the children's hospitals graduate
medical education program.
The AAMC is disappointed with the President's proposal to reduce funding
for these programs, which help meet the health care delivery needs of the
over 2,800 Health Professions Shortage Areas in this country, at times serving
as the only source of health care in many rural and disadvantaged communities.
These programs provide an essential and stable infrastructure for the training
and education of health professionals, with a needed emphasis on primary
care and preventive medicine across the life-span, from pediatrics to geriatrics.
The Bureau of Health Professions, which administers the Title VII and VIII
programs, has identified several priorities to ensure that all health care
providers are prepared to meet the challenges of health care in the 21st
century:
Geriatrics - Increased longevity brings the need for all health care professionals
to understand the aging process, the presentation of diseases and disabilities
in old age, and age-appropriate treatment and supportive services, including
rehabilitation, acute care, and long-term care. Geriatrics training is supported
through three programs: Geriatric Education Centers (GECs), which form a
national network that educates health care professionals; postdoctoral geriatric
training programs for a variety of health care providers; and Geriatric
Academic Career Awards, designed to increase the number of geriatrics faculty
at medical schools.
Genetics - This field of medicine promises to revolutionize health care.
The Bureau has launched a number of initiatives to expand the level of genetics
education, including a "Genetics in Primary Care" faculty development
program and an expert panel on genetics and nursing. Also being funded is
research on the genetics workforce that will assess the practices and professional
activities of genetics specialists and establish a system to monitor demands
for genetics services.
Diversity - As underrepresented minorities make up 25 percent of the population
but less than 10 percent of health care providers, it is important to encourage
promising students from all racial and ethnic backgrounds to pursue health
professions careers. These students are more likely to return to their communities
and provide care to underserved areas experiencing shortages of physicians
and other health care providers. The programs supported by Title VII and
VIII graduate three to five times more minorities than other education and
training programs.
Title VII also provides grants for the creation and operation of area health
education centers (AHECs) and health education training centers (HETCs),
which provide clinical training opportunities for medical students and residents
in predominately rural settings and border regions by extending the resources
of academic health centers to the communities. These linkages 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 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 2002 funding
level of $400 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 $50 million in
FY 2002 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 issued the first three in a series
of six request for applications under the new patient safety and medical
errors research program, 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 AAMC believes the agency
is perfectly positioned to take the lead on improving the quality of health
care through the reduction of errors.
While research in many areas at the agency has flourished in recent years,
the number of investigator-initiated grants has remained constant, leaving
important health services research unfunded. Congress recognized this need
and included language in the FY 2001 conference report that AHRQ should
support more of these types of grants. AAMC supports the Friends of AHRQ
recommendation for an additional $60 million to fund 350 new investigator-initiated
grants at an average cost of $125,000 per grant.
While AAMC is pleased with the increased support for the agency, in recent
years much of its funding has been derived from inter-agency transfers,
rather than direct appropriations. 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 the recommendation of the CDC Coalition, which
calls for an FY 2002 appropriation of at least $5.0 billion to sustain a
network of successful programs in illness and injury prevention and health
promotion and to move cutting-edge health programs from idea to implementation.
National Health Service Corps - The National Health Service Corps (NHSC)
is 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 the NHSC Scholarship program,
which 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, and the Loan Repayment program,
which offers fully-trained primary care providers up to $25,000 per year
for the first two years of service in a designated area.
Currently, the NHSC meets approximately 12% of the health care needs for
the 47 million Americans who live in health professional shortage areas.
The AAMC supports an appropriation of at least $169 million for the NHSC
for additional scholarships and loan repayment contracts which would allow
for increased access to health care in 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.
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