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AAMC Reporter: July 2005
A Word from the President:
"Converting Title VII to Monumental Status"
Some of you may be familiar with the "Washington Monument" ploy. It's commonly used by administrations, both Democratic and Republican, in tight budget times. Here's how it works. In an effort to minimize the apparent deficit in a budget submitted to Congress in
a fiscally challenging year, the administration proposes to "zero out" a program that is an obvious favorite of Congress, knowing full well that Congress will restore the money in the final appropriation process. In that way, Congress, rather than the administration, gets the blame for increasing the federal deficit. Imagine a president's budget that proposed no money for maintaining the Washington Monument. Congress would never let such a thing happen. That's where the ploy got its name.
A variant on the Washington Monument ploy is to test the resolve of Congress by zeroing out a program about which the administration is, at best, indifferent. In effect, it dares Congress to find the money for a program that may have only marginal political support.
For each of the past several years, the administration has used this latter approach to challenge Congress's commitment to "Title VII." Title VII of the Public Health Service Act authorizes Congress to fund the health professions programs residing in the Health Resources and Services Administration (HRSA). These programs are widely regarded as essential components of our nation's healthcare safety net. They provide federal support for the education and training of healthcare providers through loans, loan guarantees, and scholarships to students, and through grants and contracts to medical schools, teaching hospitals, and other health professions schools. The objectives served by these programs include increasing minority representation in the health professions, expanding the primary care provider workforce, and supporting community-based training of various health professions in rural and urban underserved areas.
Over the years, bolstered by strong advocacy from our community, Congress has risen to the administration's challenge and has appropriated sufficient funds to sustain the Title VII programs. Last year, programs under the mantle of Title VII received a total of $300 million. Unhappily, this year is shaping up to be a different story. In early June, the House Labor-HHS-Education Appropriations Subcommittee, in an unprecedented move, eliminated federal funding for all Title VII programs except $47.1 million to support Scholarships for Disadvantaged Students (SDS). The full House Appropriations Committee went along with this drastic (84 percent!) reduction in Title VII funding, choosing merely to move $12 million from SDS to the Centers of Excellence (COE) program, leaving $35 million for SDS.
In the short run, our challenge is to persuade the Senate to restore funding for all the Title VII programs and to urge senators to prevail in negotiations with the House when the Labor-HHS-Education appropriations bill reaches the conference committee. Clearly, this is not the time to eliminate the only federal programs aimed at training and deploying healthcare professionals for medically underserved areas and at encouraging and supporting individuals from minority backgrounds to pursue careers in the health professions.
In the long run, our challenge is to formulate a more appealing political rationale for Title VII programs, recognizing that opponents are gaining ground by pointing to the lack of evidence documenting program success. For this reason, several months ago the AAMC appointed a committee chaired by Ron Franks, dean of East Tennessee Medical School, to review the missions and effectiveness of these programs and to develop recommendations for Congress. The urgency for doing so is underscored by the Senate's plan to consider reauthorizing Title VII this fall.
In its deliberations, the AAMC committee agreed that Title VII programs' existing goals remain compelling. As noted, they are: enhancing primary care; providing care to the underserved; and improving diversity of the healthcare workforce. In June, the AAMC Executive Council approved the committee's recommendation that the funding streams for Title VII programs be aligned specifically with these goals. A central theme of the committee's report is to link the training of primary care clinicians to the provision of care to underserved areas. Hence, a key recommendation is that the Title VII reauthorization give preference to primary care applicants who submit joint proposals either with Federally Qualified Health Centers (or their equivalent), with Area Health Education Centers, or with clinics serving at least 40 percent uninsured or Medicaid patients. The committee report also recommends increased funding for existing programs aimed at improving diversity within the health professions (i.e., SDS, COE, Health Careers Opportunity Program, and Faculty Loan Repayment) and calls for a new program to support demonstration projects designed to increase the number of underrepresented minority faculty.
Given the justifiable demand for greater accountability, the committee report goes on to recommend that recipients of Title VII support be required to monitor their program's impact by collecting and analyzing relevant data, and that HRSA be required to develop credible outcomes measures for Title VII programs, in the aggregate. Finally, the AAMC committee recommends that Congress:
- Reauthorize the six Regional Centers for Health Workforce Studies at an annual level of $2 million
- Provide $3 million to establish a new national workforce database to track health professionals who have been educated and trained in Title VII programs
- Establish a new grants program for schools or departments to improve the quality of primary care in selected areas
- Fund Title VII primary care programs at $198 million.
My hope is that our committee's report will not only remind Congress about how critically important Title VII is to maintaining our country's healthcare safety net but will also provide Congress with a blueprint for reshaping and strengthening Title VII to withstand all future Washington Monument ploys.
Jordan J. Cohen, M.D.
AAMC President
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