The Role of Our Safety Net Providers and the Uninsured

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Testimony on the Role of Our Safety Net Providers and the Uninsured by Claude Earl Fox, M.D., M.P.H.
Administrator, Health Resources and Services Administration
U.S. Department of Health and Human Services

Before the Senate Committee on Health, Education, Labor, and Pensions, Subcommittee on Public Health
March 23, 2000

Mr. Chairman, and Members of the Subcommittee: I am Dr. Claude Earl Fox, Administrator of the Health Resources and Services Administration (HRSA), and I am very pleased to appear before you today to discuss an important issue for this country: access to critical primary health care services for uninsured and medically underserved individuals. HRSA's mission is to improve the health of those Americans who are too poor, too sick, or too isolated to access essential health care services, and there are multiple access barriers including cost, capacity and distribution, or fragmentation. We are the "Access Agency." We decrease these barriers through building primary care delivery systems in places where they are sorely lacking - rural communities, public housing complexes, and urban areas where private health care systems are scarce or nonexistent. Through expanding primary care capacity, we are also decreasing disparities in health status experienced by the poor and the underinsured. We are honored to be entrusted with such an important mission and justifiably proud of what we have achieved. But we are also concerned that despite our best efforts, economic, social, and environmental events have created a greater need for the kinds of programs that HRSA supports. Today there are more than 44 million Americans with no health insurance (and that number is growing), and 43 million Americans lack access to a primary care provider. In his Fiscal Year 2001 Budget, the President unveiled a 10-year, $110 billion initiative designed to dramatically improve the affordability of and access to health insurance. The proposal would expand coverage to at least five million uninsured Americans and expand access to millions more. It addresses the nation's multi-faceted coverage challenges by building on and complementing current private and public programs. Specifically, the initiative would (1) provide a new affordable health insurance option for families; (2) accelerate the enrollment of uninsured children eligible for Medicaid and SCHIP; (3) expand health insurance options for Americans facing unique barriers to coverage; and (4) strengthen programs that provide health care directly to the uninsured. Today I want to discuss three unique and essential safety net programs that serve to reduce the barriers and increase access for this Nation's uninsured and underserved population by strengthening and expanding that safety net: the new Community Access Program (CAP), National Health Service Corps, and the Consolidated Health Centers.

Community Access Program (Health Care Access for Uninsured Workers)

I would like to start with the exciting new Community Access Program. It will help us to further assist communities in developing innovative ways to develop integrated delivery networks for the uninsured with a focus on eliminating fragmentation, improving efficiencies in the health care delivery system, and leveraging private sector involvement, where appropriate. This initiative is truly about catalyzing collaboration. At the community level, CAP seeks to build partnerships among health care providers to better integrate services for the uninsured. The grant program would assist safety net providers in developing community-wide infrastructure to assure adequate access to a broad range of health services, thereby allowing these systems to provide more and better care. At the national level, the Department is collaborating with the Robert Wood Johnson Foundation and the Kellogg Foundation to ensure that CAP builds their existing efforts to strengthen the safety net.

In the fiscal year 2000 appropriation for the Department, Congress made available $25 million for a Community Access Program to assist communities and their safety net providers in developing integrated health care delivery systems that serve the uninsured and underinsured and building the infrastructure necessary to manage efficient and effective health systems. Potential grantees are public or private entities that demonstrate a commitment to, and have experience, with provision of care to uninsured people. Applicants should represent community-wide coalitions that are building networks of providers that will provide care to the community's uninsured and underinsured populations regardless of ability to pay. These networks are comprehensive and include prevention, and primary and secondary care. We encourage incorporation of mental health and substance abuse services. The funds can be used to streamline eligibility determination, enrollment, case management and referral, tracking systems, and filling unique gaps in service needs all for the purposes of improved health outcomes for uninsured and underserved people.

The response to the grant announcement in the Federal Register on February 4, 2000 has been overwhelming. We have requests for almost 1,900 application kits. Approximately 1, 000 persons attended pre-application technical assistance workshops recently completed in 6 cities across the country. We witnessed partnerships materializing before our eyes at the technical assistance workshops as providers realized how they could join forces to work together more effectively. The level of interest and commitment evidenced to date suggests that communities across the country are eager to work together to develop better ways to improve access to care for the uninsured and are greatly in need of Federal assistance to kick start their efforts. This year we anticipate awarding approximately 20 grants of up to $1 million each. These grants will serve to demonstrate innovative or creative methods to integrate health care systems.

The Administration is requesting $125 million in funding for the Community Access Program in fiscal year 2001. Fiscal year 2000 funded communities may be eligible for available fiscal year 2001 funding to support further infrastructure development and filling service gaps. In addition, fiscal year 2001 funding would support integrated health service networks.

The Administration is aggressively pursuing legislative authority to ensure that the Community Access Program becomes a core element of the health care safety net. Our legislative proposal gives communities flexibility in developing integrated care systems that build off traditional safety net providers and encourage innovation without supplanting funding for existing federal programs that provide services to low-income populations. We urge passage of our forthcoming legislative proposal.

National Health Service Corps

HRSA, through the National Health Service Corps, has collaborated with communities for 25 years and has served as a critical piece of the health care safety net by assisting frontier, rural, and inner cities to recruit clinicians to meet their needs. Despite the fact that there is an oversupply of physicians in this country, there is also severe maldistribution. Therefore, there is still a need for the National Health Service Corps to address the problems of capacity. According to the Council on Graduate Medical Education (COGME), physicians are not being trained in the right specialties; physicians are not working in the right places; and physicians are not serving the populations with the greatest disparities in access and health status. Further, the racial and ethnic diversity of the Nation's health care workforce does not reflect that of our population that is in most need of its services. HRSA remains committed to addressing health disparities and the lack of access. Maldistribution is a barrier to both access to care and to the elimination of health disparities that the National Health Service Corps is uniquely positioned to address.

Today, National Health Service Corps clinicians serve in every State, the District of Columbia, Puerto Rico, and the Pacific Basin. These clinicians include 533 scholars, 1,306 loan repayors, and, through the National Health Service Corps' partnership with 33 States, 508 State loan repayors. Historically, 60 percent of the National Health Service Corps clinicians serve in rural areas, reflecting the National Health Service Corps' ability to respond to the critical access needs of these communities. In this fiscal year, the National Health Service Corps anticipates that approximately 400 scholars will be available for service, and nearly 800 additional scholars will be in the path for future service. The composition of the National Health Service Corps' Field Strength is an expression of its interdisciplinary approach to health care: 13.5 percent physician assistants, 3 percent certified nurse midwives, approximately 12 percent nurse practitioners, over 12 percent dentists and dental hygienists, 8 percent mental and behavioral health clinicians, and approximately 50 percent physicians.

We believe the National Health Service Corps is working, and I would like to take a moment to review the successes of the National Health Service Corps:

Over 22,000 clinicians have provided needed services since 1972 - - spending all or part of their careers serving where others choose not to go;
Approximately 97 percent of clinicians fulfill their commitments;
Approximately 60 percent of the National Health Service Corps alumni continue to serve the underserved four years after completion of their service obligation;
National Health Service Corps clinicians are selected to best match the characteristics of the communities they serve;
National Health Service Corps clinicians include significantly higher percentages of underrepresented minorities than the Nation's workforce, and over 30 percent of its awards went to minorities;
The National Health Service Corps targets areas with high disparities in access and health status;
National Health Service Corps interdisciplinary teams assist in meeting the primary care needs of the Nation; and
National Health Service Corps clinicians must provide services to all, regardless of an individual's ability to pay.

We believe the need for a National Health Service Corps is clear, and we can go farther:

Maldistribution continues;
Community demand is three times the supply;
800 physicians leave health professional shortage areas annually;
Currently, the National Health Service Corps' 2,500 clinicians addresses 12.5 percent of the overall need (16.4 percent of primary care need, 6 percent of oral health need, and 6 percent of mental health need);
20,402 clinicians could be used in communities (12,303 primary care, 5,179 oral, and 2,920 in mental and behavioral health).

For the above reasons, we strongly urge that you reauthorize the National Health Service Corps for a five-year period before this Congress adjourns. Flexibility is key to our ability to react to a rapidly changing health care marketplace and environment. For example, a demonstration authority would allow the National Health Service Corps clinicians to serve the community on a less-than-full-time basis. Also, the flexibility to award scholarships consistent with community demand for clinicians is a change that could be considered. The current legislative requirement which sets aside scholarship funding for specific disciplines regardless of community need for their services. Finally, we are very aware that to be truly effective in addressing the needs of the community, a primary care health delivery system must be integrated with a dependable referral network. Over its history, the National Health Service Corps has effectively contributed to the strengthening and expansion of the health care safety net. We believe the National Health Service Corps stands ready to increase access to primary care services by exercising flexibility in being community responsive: by leveraging resources with communities as they prepare to attract and retain clinicians. The Program, and its clinicians, will have a significant impact on the Nation's health B both now and in the future.

Consolidated Health Centers

Another of HRSA's three safety net programs is the Health Centers. Health Centers comprise a consolidation of the Community Health Centers, Migrant Health Centers, Health Care for the Homeless programs, and Health Care for Residents of Public Housing. Collectively, these programs provide case-managed, family-oriented preventive and primary health care services to over 9 million people, including 3.5 million children, who live in medically underserved rural and urban communities. The Health Center program has an extraordinarily successful track record of delivering cost-effective, high quality primary health care to underserved, low income, and minority populations for more than 30 years. The Health Centers comprise 700 community-based organizations with 3,100 sites employing 50,000 full-time employees, representing over 75,000 employed individuals (including 8,000 clinicians), and involving 10,000 community members participating on Health Center boards. The Health Center patient population consists of approximately:

86 percent below 200 percent of poverty;
40 percent uninsured (Health Center uninsured patients have increased at twice the national rate since 1990);
34 percent Medicaid recipients;
65 percent minorities;
40 percent children; and
30 percent women of child-bearing age.

The Health Centers are invaluable safety net providers: essential, effective, and efficient. They are located in low income and minority neighborhoods, underserved rural communities, and in communities with a disproportionate number of at-risk people. The homeless community is particularly in need of health services. Health Care for the Homeless is part of the Consolidated Health Centers program and serves nearly 438,000 homeless patients (75 percent of whom are uninsured) through culturally competent clinicians - - homeless individuals and families who might otherwise have not received care from a safety net provider.

Health Centers have demonstrated their effectiveness by:

improved health outcomes;
increased preventive services
improved management of chronic disease
reduced avoidable hospitalizations; and
high patient satisfaction.

Health Center low birth weights approximate the national average for all infants and are lower than the national average for African American infants. Women served at Health Centers received more up-to-date mammograms than women in the general population (62.2 percent to 44.5 percent). African American and Hispanic with hypertension using Health Centers are three times as likely to report blood pressure under control as a National Health Interview Survey comparison group. Medicaid Health Center patients have significantly lower odds of being hospitalized for an ambulatory care sensitive condition than Medicaid non-Health Center patients (MDS Associates, 1996). Health Center users report high satisfaction levels (94 percent overall satisfaction).

Not only are Health Centers seen by HMOs as effective partners, but studies comparing Health Center patients and non-patients show:

lower cost per ambulatory visit;
lower rate of hospital inpatient days and lower inpatient care costs; and
lower total costs.

Health Centers are the building blocks for the CAP initiative:

support for 44 practice management networks and 13 managed care networks consisting of Health Centers partnering with hospitals, health departments, sub-specialists, and other safety net providers;
21 Health Center-controlled managed care plans involving 125 Health Centers in 12 States;
Health Centers were the impetus for the CAP Access for Uninsured Workers initiative with models in Brooklyn, New York and Marshfield, Wisconsin.

Health Centers also utilize resources totaling approximately $3 billion in cash revenues (Medicaid, Federal, State and local support; other third party reimbursements; and patient fees). Taken together, these resources positively impact economies (local jobs, goods, and services). Health Centers receive $3 for every $1 in Federal grant support: $2 in insurance and patient payments and $1 in State, local, and private grant and contract support. Health Centers serve as catalysts for economic development:

generate jobs;
provide job training opportunities;
utilize local suppliers;
attract complementary businesses (i.e. pharmacies and labs) and;
provide an overall economic multiplier effect on the community's economy.

In collaboration with other safety net providers, HRSA's indispensable Health Centers are truly the access workhorses of increased access for the uninsured, underinsured, and underserved.

Conclusion

In conclusion, we at HRSA are extremely proud of our safety net providers, and in collaboration with our partners who operate the nations's public hospitals, we look forward to working with the Subcommittee in strengthening the safety net. However, our truest source of pride is with our clinicians in the field - - at our Health Centers and National Health Service Corps sites B serving 10.35 million underserved people at 3,800 sites. Their dedication, humility, and steadfast purpose, in serving one in every 6 low income children, one in every 7 low income uninsured individuals, one in every 10 Medicaid recipients, one in every 5 homeless persons, and one in every 5 migrant farmworkers, as well as the courage and humility of their patients, is a lesson to us all, and a clarion call to us to remedy this uninsured crisis with all deliberate speed.

Chairman Frist, Senator Kennedy, and members of the Subcommittee: I would be happy to address any questions you may have.