June 4, 1971
Page 18079
HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE AMENDMENTS OF 1971
AMENDMENT NO. 141
(Ordered to be printed and referred to the Committee on Labor and Public Welfare.)
Mr. EAGLETON. Mr. President, I am pleased to join with the distinguished junior Senator from Maine (Mr. MUSKIE) in offering an amendment to S. 934, a bill to amend title VII of the Public Health Service Act to expand and improve our Nation's resources for the training of physicians, dentists, optometrists, pharmacists, podiatrists, veterinarians, and professional public health personnel, and for other purposes.
Improvement of the Nation's health care system has become a dominant objective of this Congress and, in view of the magnitude of the problems involved, I daresay it will remain a major objective for years to come. Access to adequate health care is now accepted as a fundamental human right. Yet, despite great progress, achieved mainly in the last 50 years, the Nation is still beset with enormous health problems – reflected in high levels of premature death, infant mortality, and prevalence of disease and disability.
The consequences of these conditions has been an unprecedented focus of interest on proposed Federal legislation that would work fundamental changes in the existing structure through which health services are delievered. Congress is now considering a number of bills to establish a national system of comprehensive health care. More proposals embodying some variation or another on this theme will undoubtedly be forthcoming. Not only Members of Congress, but also long established organizations in the field of health care are vying with one another to advance their particular remedy.
It is far too early to predict what will emerge from this legislative ferment, but it almost certainly portends some substantial alterations in our health care system. We have all heard the conclusions of very responsible and very respectable medical authorities that America is experiencing a crisis in health care. By definition, a crisis is a turning point – things are either going to improve or they will deteriorate. It is a point at which change is inevitable.
It is equally certain that the most ingenious plan, the most elaborate mechanism, the most refined blueprint will be of little value without an adequate supply of trained health manpower to implement it. There will be no significant improvement – indeed, deterioration is the more likely prospect – if we fail to increase the numbers, and rectify the maldistribution, of health personnel in the United States.
This lack of manpower is felt in all of the health professions. The shortage of doctors and dentists is not the greatest in absolute numbers – it is estimated that we need something in the neighborhood of 150,000 more nurses as compared to about 50,000 doctors and 20,000 dentists – but it is the shortage most acutely felt because of the central role that physicians and dentists play in meeting health needs.
It is clear that a substantial and growing number of the Nation's medical and dental schools are in desperate financial straits. Many of them are engaged in a year-to-year battle to avoid being pushed into bankruptcy.
A number of schools, particularly the private schools, have literally begun to feed off themselves.
Some have begun to exploit their endowments in order to meet on-going operating costs. Others have been forced to seek short-term loans at high interest rates in order to remain solvent.
Clearly, these actions represent a slow sacrifice of the integrity of the institution. They can be sustained for only a brief period of time before the onset of deep financial crisis.
The success achieved under tine present Health Professions Educational Assistance Act – despite its limited scope and even more limited appropriations, as compared with authorizations – demonstrates the significant contributions which the Federal Government can make in preserving existing schools and expanding the Nation's capacity for training in the health professions.
It has had a major impact on the education of physicians. In 1963, at the time of the passage of the HPEA Act, there were 87 U.S. medical schools with 8,772 entering students annually, a total enrollment of 32,001 M..D. candidates, and 7,335 total graduates. In 1970-71, 8 years later, the Nation has 102 medical schools admitting students – an increase of 15, with 12 more schools in development – first-year classes totaling 11,660 – an increase of 2,588 – a total M.D. student body of 40,333 – an increase of 8,332 – and a graduating class estimated to be 8,996 – an increase of 1,661.
The other health professions covered by the HEPA program – dentistry, optometry, pharmacy, podiatry, veterinary medicine, and public health – have also received financial assistance and have increased their training capacity and output.
The expiration of the Health Professions Education Assistance Act at the end of the current fiscal year offers an opportunity to improve and expand it to meet the needs of the seventies. In my judgment the Kennedy bill is well designed to accomplish that end. It reflects the thoughtful concern that the junior Senator from Massachusetts (Mr. KENNEDY) has long displayed for the health care needs of Americans.
The amendments that we propose today in no way detract from the basic strengths of the Kennedy health manpower bill. Rather, they are designed to build upon the structure of that bill to create an even more comprehensive program for educating the health professionals that are now in such short supply.
There are three major areas covered by our amendment:
First. Under section 722 (b) of the present act, the full amount of a grant awarded for the construction of teaching facilities for the health professions must be obligated from funds appropriated for the year in which the grant is awarded. This requirement has proved wholly impractical.
Construction projects of the kind funded under this program are not built in 1 year, nor even 2 or 3 years.
Since the construction program began in 1965, grants totaling $791,287,000 for such projects have been obligated but the amount spent has been only $310,583,000 – just 40 percent of the total.
The construction portion of our amendment would permit the secretary to obligate only a portion of the total amount of a grant in the year in which the grant is awarded. From an excess of caution, we have provided that one-half of the grant amount shall be obligated in the first year if the project is estimated to require 2 years to complete and the balance in the next year. If the project requires 3 or more years, one-third of the grant amount must be reserved in the initial year and one-third in each of the two succeeding fiscal years. Funds for projects which may be completed within 1 year must be fully reserved at the time of the award, as under the present law.
The immediate effect of this amendment will be to break up the enormous backlog of projects that have been approved but not funded. There are 79 such projects for the construction of teaching facilities for the health professions with a total cost in excess of $1 billion and a Federal share of $614 million. The sponsors of 19 of these projects, with a total cost of $409 million, and a Federal share of $245 million, have their local matching funds in hand and are ready to begin construction as soon as Federal funds are available.
Given the present level of appropriations, it would require 5 years before all of these projects could be begun under the present law. The procedures which our amendment would implement would permit all of the approved projects for which local matching funds are in hand to begin within the next year and the remaining projects to get underway within the next 3 years, once local matching funds are assured.
I consider this proposal to be a major contribution to the present health manpower bill. The release of construction funds will have a major impact in allowing us to train thousands of additional physicians, dentists and other health professionals in the coming decade. If we do not start immediately in expanding these schools, we will never overcome existing shortages and cannot hope to meet increased demands in the future. It makes no sense to have appropriated funds lie idle, awaiting the continuation of construction projects, when our Nation desperately needs more skilled health personnel. Our proposal requires no increased expenditures – it simply provides a more efficient mechanisms for using the money we have. And it permits us to begin now on the construction of teaching facilities that we must have to educate tomorrow's doctors, dentists, and other health personnel.
Second. Another major provision of the amendment recognizes that the training of doctors and dentists does not end after 4 years. For almost all graduates, a period of postgraduate training is regarded as essential before they enter into practice.
The Carnegie Commission, in its excellent report on medical and dental education, has recommended that Congress assist in the cost of postgraduate education along with assistance for undergraduates in the health professions. Our amendment authorizes $140 million for this purpose for the next 5 years.
We have structured the program to attempt to overcome present problems of functional maldistribution. We know that more doctors are needed in areas of primary health care, yet the system now operates to persuade more and more medical graduates away from these areas and into narrow specialties. The program we would establish provides teaching institutions with $3,000 for each resident physician or dentist training in primary health care – such as family practice – or other shortage areas, and $1,500 for each resident training in other specialties.
Training programs operated by medical, dental and osteopathic schools would be eligible. Hospitals that are not affiliated with any accredited teaching institution would also be eligible if their training programs are approved by the Secretary under criteria to be prescribed by him.
We believe that this provision would have two major effects. First, it would provide financial relief for teaching institutions in conducting their costly postgraduate programs. Second, it would encourage these institutions to direct their training toward the areas of greatest need.
Third. This amendment also establishes a program to overcome the present geographical maldristibution of health personnel.
Witnesses before the Senate Health Subcommittee have repeatedly emphasized the problems that result from the concentration of many physicians and dentists in a relatively few affluent areas, while large rural sections and inner city populations experience a severe shortage of health care.
Our proposal would provide incentives to physicians, dentists, and other health professionals to practice in these shortage areas or to serve in the newly created National Health Service Corps, which has as its prime purpose serving such areas. Individuals who have received direct Federal loans, or private loans guaranteed by the Federal Government, for the payment of their educational costs, may have 50 percent of their loan obligations forgiven in return for 2 years services in such areas. Practitioners who agree to extend their service for an additional 2 years would have the entire loan forgiven, up to a maximum of $15,000.
Finally, Mr. President, we call for a report by the Secretary of Health, Education, and Welfare on several critical areas relating to the effects of increased Federal financial assistance for schools of the health professions. We are interested in knowing whether the schools are maintaining and increasing their own efforts, and whether they have sought to stabilize ever-rising tuition charges so that students may reap some of the benefits of Federal aid. Further, we believe that it is most important to determine what steps teaching institutions are taking to reform curriculums that are sometimes outmoded and overlong. The Carnegie Commission and other advisory groups have made valuable recommendations on these subjects and we believe that the Congress should be informed as to whether the schools are seeking to implement them.
Mr. President, I am convinced that health manpower is the key element for the immediate future in improving the delivery of health services to all Americans. We need more well trained health
professionals and we need incentives that will lead to the rational distribution of their services.
These are the purposes of the amendment we offer today, Mr. President. I urge its favorable consideration by the Senate.
Mr. President, I send to the desk the amendment as offered by me and the Senator from Maine (Mr. MUSKIE). I ask unanimous consent that the amendment be printed at the conclusion of the remarks of the Senator from Maine, and I ask unanimous consent that, following the printing of the amendment itself, an explanatory document likewise be printed, to follow both my remarks and the remarks of the Senator from Maine.
The ACTING PRESIDENT pro tempore. Without objection, it is so ordered. (See exhibits 1 and 2.)
The ACTING PRESIDENT pro tempore. Under the previous order, the Senator from Maine (Mr. MUSKIE) is now recognized for not to exceed 15 minutes.
Mr. MUSKIE. Mr. President, I am delighted to join with the Senator from Missouri (Mr. EAGLETON) in sponsoring the amendment which he has so well described in his remarks this morning. It is an amendment to the health manpower legislation that is about to be considered by the Health Subcommittee of the Committee on Labor and Public Welfare.
This amendment, which contains four separate provisions, will add substantially to this legislation by providing an immediate release of funds for medical school construction, premedical training and an increase in the number of doctors trained to treat the normal medical needs of American families.
The distinguished Senator from Missouri has described the amendment. I should like to speak briefly as to the health care crisis in America, which has only recently emerged into the public consciousness.
We have begun to realize that our health care system does not do an adequate job of keeping Americans healthy. The health crisis affects every American. For those who are very poor, health care is unavailable because of cost. For those who live in our inner cities or in our rural areas, health services are too far away. For the average American family, health care is a problem because costs are rising at alarming rates; routine health care drains our pocketbooks, and serious health care can mean economic catastrophe to a family.
These are some of the stark facts: Between 1966 and 1980, the number of workers who cannot work due to illness will climb from 18 million to 21 million. That 75,000 newborn babies die in the United States each year.
The number of general practitioners has declined 35 percent since 1957 – and foreign physicians now constitute more than 25 percent of our Nation's doctors.
That 150 counties across the country have absolutely no health professionals of any kind. In most central cities, the situation is as bad – or just a little better. In the Kenwood section of Chicago, for example, there are only two physicians for 46,000 people.
The cost of medical care has skyrocketed to over $60 billion annually. At the same time, the health insurance industry has used its actuarial studies to exclude segment after segment of our society from access to medical protection. The poor are abandoned to uneven and often inhuman public health services. And the average family is caught squarely in the middle – too well off to qualify for government help – too pressured to help themselves with comprehensive insurance.
In the end, millions of Americans go without adequate medical care. They cannot afford it. They are afraid it will break them. Or they cannot find a doctor. Some of them die. Others are left destitute. And most of them fall victim to needless pain and needless suffering. Who are they? They are our parents – our children – our friends and our fellow citizens.
As chairman of the Health Care Subcommittee of the Senate Committee on Aging, I held hearings in California during May to see what kind of health care our older citizens are receiving under the medicare and medicaid programs. The hearing clearly demonstrated that because of rising costs and because of poorly designed systems, literally tens of thousands of older Americans receive poor health care or no health care at all. Part of this is due to cutbacks in medicare and medicaid that put even the most basic health care beyond the reach of our elderly citizens, part of this is a result of rigid and shortsighted regulations of the medicare and medicaid programs.
But the hearing made clear that even if the regulations were changed and finances made available, we still would not be able to have decent health care for our older Americans because we do not have the institutions that can deliver it. In minority communities, there are not enough doctors nor clinics. There are not the kind of people who can communicate with the community and earn their sense of trust. There are no means for getting older people to the doctors or, even better, the doctors to the older people.
To remedy this health crisis, we need a medical bill of rights for all Americans. The first medical right of all Americans is care within their means. Admission to a hospital or a doctor's office should depend on the state of an individual's health, not the size of his wallet. And we cannot depend upon reform by half-way measures and half-hearted compromise. A right to medical care which would leave the burden of cost on the poor and the near poor would mock its own purpose. The only sure security is federally funded universal health insurance. That is our best hope for the future – and a priority goal in 1971.
Senator KENNEDY is leading the battle for this legislation, and I support his efforts in every way. National health insurance will mean that all Americans, no matter what their means, no matter what their needs, can afford quality health care. When this legislation is passed, it will be a landmark in the history of social justice in our Nation.
The second medical right of all Americans is care within their reach. For even if we guaranteed the payment of health costs, millions of our citizens could not find sufficient medical services. The system is not only inequitable – it is also undermanned and inefficient. It is on the verge of collapse. The Nation must now respond with Federal financial incentives that will insure real reform.
So health insurance alone is not enough. We need enough doctors and related medical personnel to treat those who will be able to afford decent health care under national health insurance. And we must provide the institutions to bring that health care to every American. We will need special health clinics and out-reach efforts for our inner cities. In rural areas, different systems for health care delivery must be developed. For the aged, we must create home health care teams that can move doctors to the elderly, when the elderly cannot move to the doctors. And we must devise the techniques to insure that every family in America can and will utilize health care facilities for its children.
Finally, the third medical right is health care on a regular basis so that everyone can receive the benefits of preventive medicine. We must provide enough health education, supervision, and periodic checkups – so that health problems are caught in the beginning, when they can be cured, rather than in the end, when it is too late for cure. Not only is this health care maintenance approach vastly more economical than our system today, but it is also the only humane way to provide for health care treatment.
These tasks will require great changes. They will require great imagination. They will require great resources. But they must be done, if we are to guarantee to every American a healthy life. I plan to contribute to this effort by offering various proposals to increase our health manpower and to create new institutions for health care delivery.
Today, Senator EAGLETON and I are introducing a measure that would allow us to overcome some of these health manpower problems. I intend to propose others as time goes on.
First, we need more doctors and more medical personnel. By 1980 our estimated shortage of doctors will be 26,000; of dentists, 56,000; of nurses, 210,000; and of allied health manpower, 432,000. We simply do not have enough people being trained today to provide the health care for America tomorrow. In fact, we are losing ground, because the increase in the number of medical personnel has not kept up with the increase in our population.
Second, we must reorient our medical training so that doctors are trained in those types of medical practice where we have critical manpower shortages. The largest such category is the "primary care" area. This includes the practice of family medicine – a new kind of general practitioner – internal medicine, pediatrics, obstetrics, and gynecology. An estimated 90 percent of the health care needs of Americans can be handled by these doctors. It is only the unusual case, on a statistical basis, that requires the medical specialist. Yet, only one-third of medical students are now being trained in these areas. It does not make sense to train only one-third of our new medical personnel to take responsibility for about 90 percent of our health care needs.
Third, as I mentioned above, we must directly focus on the problem of training medical personnel to work in our inner cities and rural areas.
Fourth, we must take immediate steps to train ancillary medical personnel. These physicians' assistants and nurses should be trained to assume the routine tasks of examination and medical practice so that doctors will be free to spend more of their time to use their special skills. If we do not use our doctors more efficiently, we will never be able to provide decent health care for everyone.
Fifth, we must begin to introduce into our medical schools more training for interdisciplinary care and the health team approach. The physician and the supporting personnel must be prepared to work together effectively on a single health problem so that we can break down the fractured, disjointed approach to the health care of particular individuals that too often prevails today.
Finally, we must increase the number of minority and disadvantaged group members into medical training at all levels. Without these people we will never be able to fully serve the communities from which they come. Only they can establish the trust and communication with medical consumers which will introduce health care into many of our communities.
The legislation now being considered in the Senate Health Subcommittee begins to remedy many of these problems. I support this legislation. Today, the distinguished Senator from Missouri (Mr. EAGLETON) and I offer an amendment containing four proposals that our staffs have drafted jointly, and that we both feel will substantially improve the bill now under consideration by the Health Subcommittee. I hope the subcommittee will adapt these proposals to make its manpower bill even better.
Mr. President, may I say, in tribute to the Senator from Missouri, that without his leadership and his great assistance and that of his staff, we would not be in a position this morning to present this legislation. I am delighted and proud to join him in this effort.
EXHIBIT 1
AMENDMENT No. 141
On page 4, line 1, redesignate Sec. 104 as Sec. 105 and insert before such Sec. 105 the following:
"Sec. 104. (a) Section 722(b) of the Public Health Service Act is amended–
" (1) by striking out '(b) Upon approval of' nd inserting in lieu thereof '(b) (1) Except as otherwise provided in paragraph (2), upon award of a grant under'; and
"(2) by adding at the end thereof the following new paragraph:
."(2) (A) Upon award of a grant, during the fiscal year ending June 30, 1972, or during either of the next two fiscal years, under any application for such grant pursuant to this part, the Secretary shall enter into an agreement for the full amount of such grant and shall estimate the period which will be required for completion of construction of the project with respect to which such grant is awarded.
"'(B) If the Secretary estimates that construction of any such project will be completed in the fiscal year in which the grant with respect to such project is awarded, he shall in the fiscal year in which such grant is awarded, reserve (from any appropriation available for grants under this part for such fiscal year) an amount equal to 100 per centum of such grant.
"‘(C) If the Secretary estimates that construction of any such project will be completed in the fiscal year following the fiscal year in which the grant with respect to such project is awarded, he shall–
"'(i) in the fiscal year in which such grant is awarded, reserve (from funds appropriated for grants under this part for such fiscal year) an amount equal to 50 per centum of such grant; and
"'(ii) in the fiscal year following the fiscal year in which such grant is awarded reserve (from funds appropriated for grants under this part for such fiscal year) an amount equal to so much of such grant as has not been reserved under clause (i).
"'(D) If the Secretary estimates that construction of any such project will not be completed until after the fiscal year following the fiscal year in which the grant with respect to such project is awarded, he shall–
"‘(1) in the fiscal year in which such grant is awarded, reserve (from funds appropriated for grants under this part for such fiscal year) an amount equal to 33⅓ per centum of such grant;
"'(ii) in the fiscal year following the fiscal year in which such grant is awarded, reserve (from funds appropriated for grants under this part for such fiscal year) an amount equal to 50 per centum of so much of such grant as has not been reserved under clause (i), and
'(iii) in the second fiscal year following the fiscal year in which such grant is awarded, reserve (from funds appropriated for grants under this part for such fiscal year) an amount equal to so much of such grant as has not been reserved under clauses (i) and (ii).
"'(E) The Secretary, in reserving amounts for grants under this section from funds appropriated therefor for any fiscal year, shall first reserve amounts for grants with respect to which amounts have (in accordance with the preceding provisions of this subsection) been reserved from funds appropriated therefor in a preceding fiscal year.,"
On page 5, lines 20 through 24, and page 6, lines 1 and 2, strike out subsection (c) and insert in lieu thereof the following:
"(c) Section 741 (f) of such Act is amended to read as follows:
"'(f) In the case of any individual"'(1) Who has received a degree of doctor of medicine, doctor of osteopathy, doctor of dentistry or an equivalent degree, doctor of veterinary medicine or an equivalent degree, doctor of optometry or an equivalent degree, bachelor of science in pharmacy or an equivalent degree, or doctor of podiatry or an equivalent degree;
"'(2) who obtained, (A) one or more loans from a loan fund established under this part, or (B) any other educational loan authorized by Title IV-B of the Higher Education Act (20 U.S.C. 1071 et seq.) for his costs at a school of medicine, osteopathy, dentistry, veterinary medicine, optometry, pharmacy, or podiatry for tuition, fees, books, supplies, and other related education expenses included under regulations of the Secretary; and
"'(3) who enters into an agreement with the Secretary–
"'(A) to practice his profession for a period of at least two years in an area in a State determined .by the Secretary, after consultation with the appropriate State health authority, to have a shortage of and need for persons trained in his profession, or
"' (B) to engage in the practice of his profession as a member of the National Health Service Corps for a period of at least two years: Provided, That such practice as a member of the National Health Service Corps is not in lieu of service as a member of the Armed Forces of the United States; the Secretary shall pay whichever is the least, $7,500 or up to 50 per centum of the outstanding principal and interest on the total of such loans upon completion by that individual of the practice specified in such agreement: Provided, That if such individual shall extend his agreement for an additional period of at least two years, the Secretary shall pay whichever is the least, a cumulative sum of $15,000 or up to 100 per centum of the outstanding principal and interest on the total of such loans upon completion by the individual of the practice specified in such agreement as extended. The Secretary shall, on or before the due date thereof, in amounts not to exceed the maximum limits provided in this section, pay any loan or loan installment which may fall due within the two-year period (or four-year .period) with respect to which the borrower has entered into an agreement (or an extension thereof) with the Secretary pursuant to paragraph (3), upon the declaration of such borrower, at such times and in such manner as the Secretary may prescribe (and supported by such other evidence as the Secretary may reasonably require), that the borrower is then engaged as described by paragraph (3), and that he will continue to be so engaged for the period required (in the absence of this sentence) to entitle him to have made the payments provided by this subsection for such period. A borrower who fails to fulfill an agreement (or an extension thereof) with the Secretary entered into pursuant to paragraph (3) shall be liable to reimburse the Secretary for any payments made pursuant to the preceding sentence in consideration of such agreement or for any additional payments made pursuant to the preceding sentence in consideration of the extension of such agreement.' "
On page 6, line 3, redesignate subsection (d) as subsection (e), and, on page 6, insert between lines 2 and 3 the following new subsection:
"(d) Notwithstanding the amendment made by subsection (c) to Section 741(f), any individual who obtained one or more loans from a loan fund established under Part C of title VII of the Public Health Service Act and who on such date was engaged in a practice for which cancellation of all or part of such loans (including accrued interest) was authorized under such section (as so in effect), such section (as so in effect) shall continue to apply to such individual for purposes of providing such loan cancellation until he terminates such practice: Provided, That nothing in this paragraph shall be construed to prevent any individual from entering into an agreement for loan cancellation under section 741(f) of the Public Health Service Act (as amended by subsection (c) of this section) except that any individual who has previously had some portion of his loans from a loan fund established under such Part C cancelled shall have the total of such cancelled loans subtracted from the sum of $15,000 before a determination is made under subsection (c) as to the extent of the loans which may be cancelled under an agreement with the Secretary for a period of two years or an extension thereof for two additional years."
On page 11, strike out lines 18 through 20 and insert in lieu thereof the following: "Sec. 304. Section 773 of the Public Health Service Act is amended to read as follows–
"'RESIDENT POSTGRADUATE TRAINING PROGRAMS
"'SEC. 773. (a) There are hereby authorized to be appropriated $15,000,000 for the fiscal year ending June 30, 1973, $30,000,000 for the fiscal year ending June 30, 1974, $45,000,000 for the fiscal year ending June 30, 1975, $50,000,000 for the fiscal year ending June 30, 1976, for the Secretary to make grants to–
" '(1) public or private non-profit schools of medicine, osteopathy or dentistry which are accredited as provided in section 721 (b) (1) (B), and
"'(2) public or private non-profit hospitals, not affiliated with an accredited school of medicine, osteopathy, or dentistry, which conduct training programs approved by the Secretary as provided in section 774, for the support of the educational costs of approved resident postgraduate training programs in the practice of medicine or dentistry.
"'(b) The Secretary shall make an annual grant under subsection (a) to each such school or hospital equal to the product of the number of physicians or dentists in full time resident postgraduate training programs in clinical facilities with which such school has a written agreement of affiliation, or in non-affiliated hospitals which conduct training programs approved by the Secretary under section 774, multiplied by–
" ' (1) $3,000 in the case of physicians and dentists who are enrolled in approved resident postgraduate training programs in the area of primary health care or any other shortage area designated by the Secretary pursuant to section 774 (c) ;
"'(2) $1,500 in the case of physicians and dentists who are enrolled in all other approved resident postgraduate training programs.
"'(c) In determining the amount of the grant under subsection (b) the Secretary shall count only
"'(1) the number of first-year physicians and dentists in full-time resident postgraduate training programs for the fiscal year ending June 30, 1973;
"'(2) the number of first- and second-year physicians and dentists in full-time resident postgraduate training programs for the fiscal year ending June 30, 1974;
"'(3) the number of first-, second-, and third-year physicians and dentists in full time resident postgraduate training programs for the fiscal years ending June 30, 1975, and June 30, 1976;
No physician or dentist shall be counted for more than three years for the purpose of calculating grants under this Section.
"SEC. 305. Section 774 of the Public Health Service Act is amended to read as follows:
"'APPLICATIONS FOR RESIDENT POSTGRADUATE TRAINING GRANTS
"'SEC. 774(a). The Secretary may from time to time set dates (not earlier than the fiscal year preceding the year for which a grant is sought) by which applications for grants under section 773 for any fiscal year must be filed.
"'(b) A grant under section 773 may be made only if the application therefor
"'(1) is approved by the Secretary upon his determination that the applicant meets the eligibility conditions set forth in Section 773(a);
"'(2) contains a specific program or programs which such applicant has undertaken to encourage physicians and dentists to enroll in resident postgraduate training programs in the area of primary health care or in other shortage areas to be designated pursuant to subsection (c);
"'(3) contains or is supported by assurances that such applicant will increase the number of postgraduate positions open to resident physicians and dentists in the area of primary health care or in other shortage areas to be designated pursuant to subsection (c) under guidelines to be established by the Secretary pursuant to such subsection;
"'(4) provides for such fiscal control and accounting procedures, and access to the records of the applicant, as the Secretary may require to assure proper disbursement of and accounting for any such grants;
"'(5) contains a statement, in such detail as the Secretary may determine necessary, describing the manner in which any grant made pursuant to section 773 will be applied to meet the educational costs of the resident postgraduate training program, including any payments proposed to be made by the applicant from the proceeds of the grant to any clinical facility which participates in such training program under a written agreement of affiliation with the applicant and which shares in the payment of the educational costs of such program; and
"'(6) contains such additional information as the Secretary may require to make the determinations required of him and such assurances as he may find necessary.
"'(c) The Secretary–
"'(1) shall not approve or disapprove any application for a grant under section 773 except for consultation with the National Advisory Council on Education for Health professions;
"'(2) shall define, in consultation with such Council, those health care fields included within the term ‘primary health care' and shall designate any other health fields in which there is a shortage of qualified physicians and dentists; and
"'(3) shall, on an annual basis, establish guidelines specifying the absolute or percentage increases in the numbers of physicians or dentists receiving full time resident postgraduate training which any applicant receiving a grant under section 773 shall be required to meet as a condition of such a grant.
"'(4) shall define those items of cost included within the term "educational cost", but which shall not include costs relating primarily to patient care;
"'(5) Shall, by regulation, prescribe criteria for the approval of resident postgraduate training programs conducted by public or private non-profit hospitals not affiliated with an accredited school of medicine, osteopathy or dentistry."'
On page 13, following line 16, insert the following new section:
"PART E – REPORT
"SEC. 501. The Secretary shall prepare and submit to the Congress, prior to June 30, 1974, a report on the administration of Title VII of the Public Health Service Act, which shall include analyses of:
"(1) the effects of financial assistance provided to teaching institutions for the health professions under this title with respect to increases or decreases in (A) total expenditures, and (B) non-federal expenditures for the educational costs of such institutions;
"(2) changes in the amounts of tuition charged by teaching institutions receiving financial assistance under this title, in sufficient detail for Congress to determine whether students at such institutions have shared in the benefits of such assistance through the stabilization of tuition charges;
"(3) significant improvements in the curriculums of such institutions receiving financial assistance under this title.
"For the purpose of preparing the report required by this section, the Secretary may require institutions receiving financial assistance under this title to submit such data, in such form, and in accordance with such accounting and reporting procedures, as he shall determine necessary."
EXHIBIT 2
EXPLANATION OF EAGLETON-MUSKIE AMENDMENTS TO S. 934
A bill to amend title VII of the Public Health Service Act to expand and improve our Nation's resources for the training of physicians, dentists, optometrists, pharmacists, podiatrists, veterinarians, and professional public health personnel, and for other purposes.
I. CONSTRUCTION GRANTS
The full amount of any grant awarded under Part B of Title VII of the Public Health Service Act for the construction of teaching facilities for the health professions is now required, by Section 722(b) of such Act, to be obligated out of funds appropriated for the fiscal year in which the grant is awarded, even though the proceeds of the grant are normally expended over a period of several years thereafter, depending on the size of the project and the pace of construction. Since fiscal year 1965, when the program began, $791 million has been obligated, of which about 40% has actually been spent. Largely as a consequence of the Sec. 722(b) restriction on the use of appropriated funds, there is a backlog of 79 approved but unfunded projects, with a total federal share amounting to $614 million. The sponsors of 19 of these projects, with a total federal share of $245 million, have local matching funds in hand (usually 40%, to 50% of the cost of the projects) and are ready to begin construction as soon as federal funds are available. The remaining 60 projects, with a total federal share of $369 million, have been approved subject to the final guarantee of sufficient local matching funds.
To reduce this backlog, Section 722(b) of such Act is amended to provide that, for a limited period, the Secretary of HEW shall obligate a portion of the funds appropriated for the construction of health education teaching facilities on a phased basis. The procedure prescribed by the amendment is as follows:
(1) For a project requiring three or more years to complete, the Secretary shall obligate one-third of the federal share of the cost of the project from funds appropriated for the fiscal year in which the grant is awarded. An additional one-third of the federal share shall be obligated from funds appropriated for each of the two succeeding fiscal years.
(2) For a project to be completed in two years, the Secretary shall obligate one-half of the federal share of the cost of the project from funds appropriated for the fiscal year in which the grant is awarded. The remaining one-half of the federal share shall be obligated from funds appropriated for the succeeding fiscal year.
(3) For a project to be completed in one year or less, the Secretary shall obligate the full amount of the federal share from funds appropriated for the fiscal year in which the grant is awarded.
(4) The procedure described above shall be followed with respect to all funds appropriated for fiscal year 1972. From funds appropriated for fiscal years 1973 and 1974, the Secretary shall first obligate the amounts necessary to continue or to complete the reservation of funds for grants awarded in prior fiscal years, and shall then obligate the balance (if any) of such appropriations for new grants in the same manner as in fiscal year 1972.
(5) From funds appropriated for fiscal years 1975 and 1976, the Secretary shall first obligate the amounts necessary to continue or to complete the reservation of funds for grants awarded in prior fiscal years, and may then obligate the balance (if any) of such appropriations for new grants. However, to insure that funds will not be obligated beyond the five-year period covered by the bill, any funds far new grants awarded in fiscal years 1975 and 1976 must be fully reserved from funds appropriated for the fiscal year in which the grant is awarded.
No new funds are authorized to effect the procedures described above since they do not necessitate the expenditure of additional funds, but rather permit the more efficient use of funds otherwise authorized.
GRANTS FOR POSTGRADUATE TRAINING PROGRAMS FOR RESIDENT PHYSICIANS AND DENTISTS
Grants are authorized to (A) accredited schools of medicine, osteopathy and dentistry, and (B) public or private non-profit hospitals which are not affiliated with an accredited school and which conduct training programs approved by the Secretary, for payment of the educational costs of approved resident postgraduate training programs in the practice of medicine or dentistry. Grants are to be calculated on the basis of–
$3,000 for each full-time resident being trained in the area of primary health care or in any other shortage area, as defined by the Secretary;
$1,500 for each resident being trained in all other areas.
The program is authorized to begin in FY 1973 to allow time for administrative preparations. In FY 1973, only first-year residents may be counted in calculating grants under this section. One additional class is counted each succeeding fiscal year until FY 1975, when all first-, second-, and third-year residents are counted for this purpose. No credit is received for such grants for residents in training more than three years.
Teaching institutions applying for grants under this section must undertake a program, to be approved by the Secretary, to encourage enrollment in resident training programs in the area of primary health care, or other shortage areas. Applicants must also assure the Secretary that they will increase the number of resident training slots in the area of primary health care, or other shortage areas. The Secretary is required to establish guidelines, on an annual basis, to specify the increased number of training slots necessary to qualify for grants under this section.
New authorizations for this grant program are
FY 1973 – $15,000,000
FY 1974 – $30,000,000
FY 1975 – $45,000,000
FY 1976 – $50,000,000
3. INCENTIVES FOR PRACTICE IN SHORTAGE AREAS
The amendment entitles any individual who has
(1) received a degree in one of the health professions for which student loans are authorized under Part C of Title VII, and
(2) obtained direct federal loans or federally guaranteed loans to finance the cost of his education to have up to 50% or $7500, whichever is less, of the principal and interest of such loans repaid by the Secretary upon completion by that individual of service in the practice of his profession, under an agreement with the Secretary, for a period of at least two years
(1) in an area designated by the Secretary, in consultation with state health authorities, as having a shortage of persons trained in such individual's profession; or
(2) as a member of the National Health Service corps, so long as such service is not in lieu of service in the Armed Forces.
The Secretary is further authorized to pay a cumulative sum of $15,000 or 100% of such loans, whichever is less, for individuals who extend an agreement to practice as specified above for a period of two additional years. The Secretary shall also pay loans or loan installments that become due during a period of practice under an agreement with the Secretary pursuant to this section. A borrower who fails to fulfill an agreement made with the Secretary under this section is liable for reimbursing the Secretary for any payments made on the borrower's behalf.
4. REPORT BY THE SECRETARY
The Secretary of HEW is required to submit a report to Congress, no later than June 30, 1974, on the administration of Title VII of the Public Health Service Act, which covers federal assistance to schools for the health professions. The report must include analyses of:
(1) the effects of the federal financial assistance provided to such schools with respect to increases or decreases in both total expenditures and non-federal expenditures for educational purposes;
(2) any changes in tuition charged by such schools to determine whether increased federal assistance has helped to stem the steady rise in tuition costs, thus permitting students to share in the benefits of such federal assistance and increasing educational opportunities for low income students.
(3) reforms that have made in the schools' curriculums as, for example, shortening the course of study.