99–006 

112TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 1st Session 112–64 

TO AMEND THE PUBLIC HEALTH SERVICE ACT TO CONVERT FUNDING 

FOR GRADUATE MEDICAL EDUCATION IN QUALIFIED TEACHING 

HEALTH CENTERS FROM DIRECT APPROPRIATIONS TO AN AUTHORIZATION OF APPROPRIATIONS 

APRIL 27, 2011.—Committed to the Committee of the Whole House on the State of 

the Union and ordered to be printed 

Mr. UPTON, from the Committee on Energy and Commerce, 

submitted the following 

R E P O R T 

together with 

DISSENTING VIEWS 

[To accompany H.R. 1216] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Energy and Commerce, to whom was referred 

the bill (H.R. 1216) to amend the Public Health Service Act to convert funding for graduate medical education in qualified teaching 

health centers from direct appropriations to an authorization of appropriations, having considered the same, report favorably thereon 

without amendment and recommend that the bill do pass. 

CONTENTS 

Page 

Purpose and Summary ............................................................................................ 2 

Background and Need for Legislation .................................................................... 2 

Hearings ................................................................................................................... 2 

Committee Consideration ........................................................................................ 2 

Committee Votes ...................................................................................................... 3 

Committee Oversight Findings ............................................................................... 6 

Statement of General Performance Goals and Objectives .................................... 6 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 6 

Earmark ................................................................................................................... 6 

Committee Cost Estimate ....................................................................................... 6 

Congressional Budget Office Estimate ................................................................... 6 

Federal Mandates Statement ................................................................................. 8 

Advisory Committee Statement .............................................................................. 9 

Applicability to Legislative Branch ........................................................................ 9 

Section-by-Section Analysis of the Legislation ...................................................... 9 

Changes in Existing Law Made by the Bill, as Reported ..................................... 9 

Dissenting Views ..................................................................................................... 11 


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PURPOSE AND SUMMARY

H.R. 1216, a bill to amend the Public Health Service Act to convert funding for graduate medical education in qualified teaching 

health centers from direct appropriations to an authorization of appropriations was introduced on March 29, 2011, by Representative 

Brett Guthrie (R–KY), and referred to the Committee on Energy 

and Commerce. 

The purpose of H.R. 1216 is to reduce federal spending, deficits, 

and debt by repealing mandatory programs with limited Congressional oversight and ensure that Congress prioritize the programs 

it funds by utilizing the traditional appropriations process. 

BACKGROUND AND NEED FOR LEGISLATION

The Patient Protection and Affordable Care Act contained numerous provisions that contained mandatory spending for public 

health programs that have been traditionally discretionary in nature. In contrast the health care bill that passed the House, H.R. 

3962, contained a division dedicated to public health and workforce 

issues but programs under that division did not contain mandatory 

appropriations but rather were authorizations subject to future appropriations. 

The federal government is now borrowing 42 cents of every dollar 

it spends. The current projected deficit for this fiscal year is $1.6 

trillion while national debt has exceeded $14 trillion. Many that 

support H.R. 1216 also support the concept of providing graduate 

medical education training in health centers. However, these funds 

should first be authorized then separately appropriated. It is this 

system that allows Congress to prioritize spending on those programs that most deserve funding while ensuring that we control 

spending to reduce the budget deficit. We can no longer afford to 

fund new programs without eliminating other spending. Congress 

can set fiscal priorities by subsequently providing funding through 

the appropriations process after weighing the relative value of different programs. 

HEARINGS

The Committee on Energy and Commerce held a hearing on draft 

legislation that became H.R. 1216 on March 9, 2011. The following 

witnesses testified at the hearing: 

• The Honorable Ernest J. Istook, The Heritage Foundation 

• Dr. John Goodman, President and CEO, National Center 

for Policy Analysis 

• The Honorable Joseph F. Vitale, New Jersey State Senate 

COMMITTEE CONSIDERATION

H.R. 1216 was introduced by Mr. Brett Guthrie on March 29, 

2011, and was referred to the Committee on Energy and Commerce. 

On March 31, 2011, the Subcommittee on Health met in open 

markup session to consider H.R. 1216. Subsequently, the Subcommittee ordered H.R. 1216 favorably reported by a recorded vote 

of 14–11. 


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On April 5, 2011, the Energy and Commerce Committee met in 

open markup session to consider H.R. 1216. Subsequently, the 

Committee ordered H.R. 1216 favorably reported by a vote of 21– 

14. 

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list the record votes on the motion 

to report legislation and amendments thereto. 


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COMMITTEE OVERSIGHT FINDINGS

Pursuant to clause 3(c)(1) of rule XIII of the Rules of the House 

of Representatives, the oversight findings and recommendations of 

the Committee are reflected in the descriptive portions of this report, including the finding that reigning in mandatory spending is 

necessary to avoid a debt crisis. 

STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

In accordance with clause 3(c)(4) of rule XIII of the Rules of the 

House of Representatives, the performance goals and objectives of 

the Committee are reflected in the descriptive portions of this report, including the goal that reigning in mandatory spending is 

necessary to avoid a debt crisis. 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

In compliance with clause 3(c)(2) of rule XIII of the Rules of the 

House of Representatives, the Committee finds that H.R. 1216 

would result in no new or increased budget authority, entitlement 

authority, or tax expenditures or revenues. 

EARMARK

In compliance with clause 9(e), 9(f), and 9(g) of rule XXI, the 

Committee finds that H.R. 1216 contains no earmarks, limited tax 

benefits, or limited tariff benefits. 

COMMITTEE COST ESTIMATE

The Committee adopts as its own the cost estimate prepared by 

the Director of the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974. 

CONGRESSIONAL BUDGET OFFICE ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 

of Representatives, the following is the cost estimate provided by 

the Congressional Budget Office pursuant to section 402 of the 

Congressional Budget Act of 1974: 

H.R. 1216—A bill to amend the Public Health Service Act to convert 

funding for graduate medical education in qualified teaching 

health centers from direct appropriations to an authorization of 

appropriations 

Summary: H.R. 1216 would rescind any unobligated funds that 

were appropriated by the Patient Protection and Affordable Care 

Act (PPACA) for health centers to expand or establish programs 

that provide training to medical residents. The bill also would 

amend the Public Health Service Act to make funding for future 

payments to those centers subject to annual discretionary appropriations, and it would authorize the appropriation of $46 million 

a year for fiscal years 2012 through 2015 for such payments. 

CBO estimates that enacting the legislation would decrease direct spending by about $195 million over the 2011–2016 period and 

by $220 million over the 2011–2021 period. Pay-as-you-go proceVerDate Mar 15 2010 06:29 Apr 29, 2011 Jkt 099006 PO 00000 Frm 00006 Fmt 6659 Sfmt 6602 E:\HR\OC\HR064.XXX HR064

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1 If the bill was enacted sooner, or if the pace of obligations was slower than anticipated, some 

additional unobligated balances may remain at the time of enactment. In that case, the budget 

authority of the grant program would be reduced by the amount of those unobligated balances, 

resulting in a corresponding decrease in direct spending. 

dures apply because enacting the legislation would affect direct 

spending. 

Assuming appropriation of the specified amounts, CBO estimates 

that the discretionary spending to implement H.R. 1216 would 

total $184 million over the 2011–2016 period. 

The bill contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). 

Estimated cost to the federal government: The estimated budgetary impact of H.R. 1216 is shown in the following table. The costs 

of this legislation fall within budget functions 550 (health) and 570 

(Medicare). 

By fiscal year, in millions of dollars— 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2011– 

2016 

2011– 

2021 

CHANGES IN DIRECT SPENDING 

Estimated Budget Authority ....................... ¥190 0 0 0 0 ¥5 ¥5 ¥5 ¥5 ¥5 ¥5 ¥195 ¥220 

Estimated Outlays ........ 0 0 ¥40 ¥50 ¥50 ¥55 ¥5 ¥5 ¥5 ¥5 ¥5 ¥195 ¥220 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Authorization Level ....... 0 46 46 46 46 0 0 0 0 0 0 184 184 

Estimated Outlays ........ 0 37 46 46 46 9 0 0 0 0 0 184 184 

Basis of estimate: For this estimate, CBO assumes that the legislation will be enacted by the end of fiscal year 2011.1 H.R. 1216 

would prevent the Secretary of Health and Human Services from 

obligating any unobligated funds appropriated by PPACA to health 

centers to expand or establish programs that provide training to 

medical residents. By rescinding those appropriated funds, H.R. 

1216 would reduce direct spending by $195 million over the 2011– 

2016 period and by $220 million over the 2011–2021 period, CBO 

estimates. 

In addition, CBO estimates that implementing H.R. 1216 would 

incur discretionary costs of $184 million over the 2012–2021 period, 

assuming appropriation of the specified amounts. 

Rescission of unobligated funds 

Under current law, the Secretary is authorized to make payments totalling about $230 million over the 2011–2015 period to 

health centers to expand or establish programs that provide training to medical residents. CBO expects that funding will enable additional health centers to qualify for payments from Medicare for 

costs incurred for operating an approved training program for medical residents. CBO estimates those additional Medicare payments 

under current law will total about $30 million over the 2012–2021 

period. 

Enacting H.R. 1216 would rescind any unobligated funds appropriated by PPACA to qualifying health centers to train medical 

residents. Assuming enactment near the end of fiscal year 2011, 

CBO estimates that about $40 million will have been obligated, 


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and that $190 million would be rescinded by the bill. CBO expects 

that the Secretary of Health and Human Services will obligate 

funds for 2012 near the end of fiscal year 2011 and therefore estimates no change in outlays until 2013. CBO also expects that the 

reduction in funding for training programs would result in fewer 

programs qualifying for additional Medicare payments. CBO estimates that, as a result, Medicare spending for graduate medical 

education programs would be reduced by about $30 million over the 

2012–2021 period. In total, therefore, CBO estimates that enacting 

H.R. 1216 would reduce direct spending by $220 million over the 

2011–2021 period. 

Authorized grant funds 

The bill would authorize the appropriation of $46 million for fis- cal year 2012 and $184 million over the 2012–2016 period for qualifying health centers to expand or establish programs that provide 

training to medical residents. Based on historical patterns of 

spending for similar activities, CBO estimates that implementing 

H.R. 1216 would cost $37 million in 2012 and $184 million over the 

2012–2016 period, assuming appropriation of the specified 

amounts. 

Pay-as-you-go considerations: The Statutory Pay-As-You-Go Act 

of 2010 establishes budget reporting and enforcement procedures 

for legislation affecting direct spending or revenues. The changes 

in outlays that are subject to those pay-as-you-go procedures are 

shown in the following table. Enacting H.R. 1216 would have no 

impact on federal revenues. 

CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 1216, AS ORDERED REPORTED BY THE 

HOUSE COMMITTEE ON ENERGY AND COMMERCE ON APRIL 5, 2011 

By fiscal year, in millions of dollars— 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2011– 

2016 

2011– 

2021 

NET DECREASE (¥) IN THE DEFICIT 

Statutory Pay-As-You-Go 

Impact ........................ 0 0 ¥40 ¥50 ¥50 ¥55 ¥5 ¥5 ¥5 ¥5 ¥5 ¥195 ¥220 

Intergovernmental and private-sector impact: H.R. 1216 contains 

no intergovernmental or private-sector mandates as defined in 

UMRA. By reclassifying funding for teaching health centers, the 

bill would probably decrease the amount of funds that state and 

local governments receive to implement programs that provide 

graduate medical education. 

Estimate prepared by: Federal Costs: Stephanie Cameron and 

Lisa Ramirez-Branum; Impact on State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: Jimmy 

Jin. 

Estimate approved by: Holly Harvey, Deputy Assistant Director 

for Budget Analysis. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates prepared by the Director of the Congressional Budget Office 

pursuant to section 423 of the Unfunded Mandates Reform Act. 


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ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act were created by this legislation. 

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that the legislation does not relate to the 

terms and conditions of employment or access to public services or 

accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Converting Funding for Graduate Medical Education 

Funding in qualified teaching Health Centers from direct appropriations to an authorization of appropriations 

The legislation would amend Section 340H of the Public Health 

Service Act to convert the direct appropriations for graduate medical education grants for teaching health centers to an authorization of appropriations for these activities. The legislation would rescind the unobligated balances from the amounts already provided. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

existing law in which no change is proposed is shown in roman): 

PUBLIC HEALTH SERVICE ACT 

* * * * * * * 

TITLE III—GENERAL POWERS AND DUTIES OF PUBLIC 

HEALTH SERVICE 

* * * * * * * 

PART D—PRIMARY HEALTH CARE

* * * * * * * 

Subpart XI—Support of Graduate Medical 

Education in Qualified Teaching Health Centers 

SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS 

THAT OPERATE GRADUATE MEDICAL EDUCATION PROGRAMS. 

(a) * * * 

(b) AMOUNT OF PAYMENTS.— 

(1) * * * 

(2) CAPPED AMOUNT.— 

(A) IN GENERAL.—The total of the payments made to 

qualified teaching health centers under paragraph (1)(A) 

or paragraph (1)(B) in a fiscal year shall not exceed the 

amount of funds appropriated øunder subsection (g)¿ purVerDate Mar 15 2010 06:29 Apr 29, 2011 Jkt 099006 PO 00000 Frm 00009 Fmt 6659 Sfmt 6602 E:\HR\OC\HR064.XXX HR064

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suant to subsection (g) for such payments for that fiscal 

year. 

* * * * * * * 

(d) AMOUNT OF PAYMENT FOR INDIRECT MEDICAL EDUCATION.— 

(1) * * * 

(2) FACTORS.—In determining the amount under paragraph 

(1), the Secretary shall— 

(A) * * * 

(B) based on this evaluation, assure that the aggregate 

of the payments for indirect expenses under this section 

and the payments for direct graduate medical education as 

determined under subsection (c) in a fiscal year do not exceed the amount appropriated for such expenses as determined øin subsection (g)¿ pursuant to subsection (g). 

* * * * * * * 

ø(g) FUNDING.—To carry out this section, there are appropriated 

such sums as may be necessary, not to exceed $230,000,000, for the 

period of fiscal years 2011 through 2015.¿ 

(g) AUTHORIZATION OF APPROPRIATIONS.—To carry out this section, there are authorized to be appropriated $46,000,000 for each 

of fiscal years 2012 through 2015. 

* * * * * * * 

Subpart øXI¿ XII—Community-Based 

Collaborative Care Network Program 

SEC. ø340H.¿ 340I. COMMUNITY-BASED COLLABORATIVE CARE NETWORK PROGRAM. 

(a) * * * 

* * * * * * * 


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1The ACA is comprised of two public laws, P.L. 111–148 and P.L. 111–152. 

2Letter from Douglas W. Elmendorf, Director, CBO to Speaker Nancy Pelosi (Mar. 20, 2010) 

(on line at http://www.cbo.gov/ftpdocs/113xx/doc11379/AmendReconProp.pdf). 

DISSENTING VIEWS 

We, the undersigned members of the Committee on Energy and 

Commerce, oppose the passage of H.R. 1216, a bill to convert funding for graduate medical education in qualified teaching health centers from direct appropriations to an authorization of appropriations. Accordingly, we submit the following comments to express 

our concerns about this extremely short-sighted and deeply divisive 

legislation. 

INTRODUCTION AND BACKGROUND

Enacted in 2010, the Patient Protection and Affordable Care Act 

(ACA) 1 expands access to health care for some 32 million Americans and improves health benefits for millions more who are already insured.2

But as valuable as it is, health insurance cannot do everything 

necessary to make our nation healthy. Even if the ACA makes it 

possible for virtually everyone to be insured, there will still be a 

major role for its public health provisions. Moreover, there will be 

an ongoing need for funding for these public health activities. 

‘‘Public health’’ includes many different things: 

• It is working with groups and whole communities to improve 

health, often more effectively than could be done between a provider and a patient. Fluoridation of water for a town is, for instance, vastly better than simply filling every citizen’s cavities. Exercise programs to prevent obesity are better than having to treat 

diabetes among people who become obese. 

• It is tailoring health insurance and health care to prevent and 

diagnose disease early rather than simply treating it in its later 

stages. Immunizations are always better than outbreaks. Screening 

for hypertension is better than simply waiting for strokes. 

• It is providing for safety-net services where the insurance market alone fails to do so. Community health centers, HIV-service 

providers, and family planning clinics provide care to people who 

might not otherwise be able to find a provider. Health professions 

education programs can add to the primary care workforce when 

the market might produce only specialists. (Such programs will be 

even more necessary once the insurance expansion provisions of the 

ACA are implemented.) 

• And, least glamorous but crucial, it is the infrastructure of 

daily disease control and health promotion. Closing down unsanitary restaurants is better than treating food poisoning. Compiling 

and studying epidemic trends can prevent major waves of disease. 


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3 ACA Section 5508(c). 

4 Hauer KE, Durning SJ, Kernan WN, Factors Associated with Medical Students’ Career 

Choices Regarding Internal Medicine, Journal of the American Medical Association 2008; 

300(10):1154–1164. 5 American Academy of Family Physicians, Workforce Reform (online at http://www.aafp.org/ 

online/en/home/policy/policies/w/workforce.html). 

The case might be made clearer by analogy: No community 

would be well-served if all its homeowners had fire insurance but 

there were no fire departments, firefighters, fire hydrants, smoke 

detectors, or indoor sprinklers. That very well-insured town would 

still burn to the ground. Insurance is necessary, but it is nowhere 

near sufficient. 

The ACA addresses both approaches, with insurance and with 

public health. This required going beyond the investments in the 

law to provide health insurance to also include provisions to make 

significant public health commitments. 

It would be insufficient simply to authorize future appropriations 

for these activities while providing mandatory spending for coverage initiatives. While the Committees on Appropriations of both 

the House and the Senate have shown ongoing and great leadership in these public health programs, their budget allocations have 

been too tight to allow significant new initiatives of these sorts. 

Consequently, the ACA provides as firm a funding and organizational base for these services as possible—mandatory spending— 

because they are essential in making insurance efficient and productive and in making the nation healthier. 

Among the programs designated for mandatory spending in the 

ACA is the teaching health center (THC) program.3 Its purpose is 

to support the training of individuals who will practice in family 

medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, or geriatrics—primary care disciplines where our 

nation is experiencing significant physician shortages. Training 

takes place in community-based settings such as community health 

centers where these health professionals are especially in need. 

The THC program is administered by the Health Resources and 

Services Administration (HRSA) of the Department of Health and 

Human Services (HHS). For FY 2011 through FY 2015, $230 million in mandatory funding is provided for the program. H.R. 1216 

seeks to convert this mandatory funding stream into a program of 

discretionary spending, subjecting the THC program to the annual 

and unpredictable appropriations process. 

TEACHING HEALTH CENTERS ADDRESS NATIONAL PRIMARY CARE

WORKFORCE SHORTAGE

With or without health reform, there is little disagreement 

among experts that our nation faces a dire need for more primary 

care providers. According to a recent article in the Journal of the 

American Medical Association on this issue, only two percent of all 

medical students plan a career in general internal medicine.4 This 

will hardly meet the needs identified by health professionals. The 

American Academy of Family Physicians, for example, estimated in 

2006 that an additional 39,000 family physicians are needed by 

2020.5 The American Association of Medical Colleges estimates 


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6 American Association of Medical Colleges, Physician Shortage to Worsen Without Increases 

in Residency Training (online at https://www.aamc.org/download/150584/data/physicianl 

shortagesltolworsenlwithoutlincreaseslinlresidencyltr.pdf). 7 Council on Graduate Medical Education, Twentieth Report: Advancing Primary Care (Dec. 

2010) (online at http://cogme.gov/20thReport/cogme20threport.pdf). 8See, e.g., the comments of Rep. Guthrie made during the full Committee mark up of H.R. 

1216: ‘‘And I agree, and I think everyone here agrees and I appreciate the bipartisan work that 

has been done before on the need for more primary care physicians in our health system, the 

need for more healthcare providers in our health system.’’ (House Committee on Energy and 

Commerce, Business Meeting to Mark Up H.R. 1213 et al., 112th Cong., pp. 283–284 (Apr. 5, 

2011) (transcript of the proceeding). 9See, e.g., comments by Rep. Pitts during the mark up of H.R. 1217, a bill to repeal the Prevention and Public Health Fund: ‘‘There is no doubt that we are facing a provider shortage, especially in primary care nursing. . . . I would suggest that if you wanted more funding to go 

toward training more doctors and nurses, the healthcare law should have contained a section 

explicitly authorizing that funding.’’ (House Committee on Energy and Commerce, Business 

Meeting to Mark Up HR. 1213 et al., 112th Cong., pp. 241–242 (Apr. 5, 2011) (transcript of the 

proceeding). 10See, e.g., the February 2009 press release of Rep. Burgess in which he states: ‘‘What’s the 

point of all the stress we’ve been going through in Congress to reform the healthcare system 

if there won’t be enough doctors to go around by the time we’re done? If we’re going to pour 

our efforts into bettering American healthcare, we need to cover all the bases, instead of doing 

spot-treatments.’’ (Burgess: It’s Time to Do Something about the Looming Doctor Shortage (online at http://burgess.house.gov/News/DocumentSingle.aspx?DocumentID=110634)). 11Medpac, Report to the Congress: Aligning. Incentives in Medicare (June 2010) (online at 

www.medpac.gov/documents/Jun10lEntireReport.pdf). 12 Council on Graduate Medical Education, Twentieth Report: Advancing Primary Care (Dec. 

2010) (online at http://cogme.gov/20thReport/cogme20threport.pdf). 

that an additional 45,000 primary care physicians will be required 

by 2020.6 And the Council on Graduate Medical Education 

(COGME) stated just six months ago that ‘‘there is a shortage of 

primary care physicians in this country and that shortage is likely 

to worsen’’; and it has recommended that the percent of the workforce that is primary care should increase from 32% to 40%.7

Members of Congress on both sides of the aisle agree that we are 

at a crisis point in addressing this issue.8 Republicans in particular 

have been adamant about the need to increase our primary care 

workforce.9 Indeed, they have repeatedly made this point in their 

effort to tear down the ACA, arguing that it makes no sense to expand access to health insurance coverage at a time when we lack 

an adequate number of primary care physicians to provide services.10

The THC program is designed specifically to help address this 

concern. 

Because most graduate medical education (GME) is currently 

conducted in hospitals, many experts have recommended new channels to train residents in the outpatient setting. The Medicare Payment Advisory Commission (Medpac), for example, has recently 

suggested that such training include ‘‘increase[ed] experience in 

nonhospital settings.’’ 11 COGME has also recommended that our 

nation ‘‘increase training in ambulatory, community, and medically 

underserved sites by . . . promoting educational collaborations between academic programs and Federally Qualified Health Centers 

(FQHCs), rural health clinics, and the National Health Service 

Corps’’, including new methods of funding GME.12

The THC program takes these recommendations to heart. Under 

the program, physician training takes place in community-based 

settings such as federally qualified FQHCs and community health 

centers. According to HRSA, although the program is not limited 

to FQHCs, ‘‘evidence has shown that resident physicians who train 

in FQHC settings are nearly three times as likely to practice in unVerDate Mar 15 2010 06:42 Apr 29, 2011 Jkt 099006 PO 00000 Frm 00013 Fmt 6604 Sfmt 6602 E:\HR\OC\HR064.XXX HR064

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13 HRSA, Bureau of Health Professions, Division of Medicine and Dentistry. Teaching Health 

Center Graduate Medical Education (THCGME) Program, Announcement Number: HRSA–11– 

149 (Nov. 29, 2010) (online at http://www.im.org/PolicyAndAdvocacy/PolicyIssues/Education/ 

Funding/Documents/THC%20guidance.pdf). 14 HRSA, Shortage Designation: HPSAs, MUAs & MUPs (updated May 28, 2010) (online at 

http://bhpr.hrsa.gov/shortage/). 15 HHS, HHS Announces New Teaching Health Centers Graduate Medical Education Program 

(Jan. 25, 2011) (online at: http://www.hrsa.gov/about/news/pressreleases/110125teaching 

healthcenters.html). 16See, e.g., ACA Section 3502 (relating to community health teams); Section 5101 (relating 

to the National Health Care Workforce Commission); Section 5102 (relating to state health care 

workforce development); Section 5103 (relating to the National Center for Health Workforce 

Analysis); Section 5204 (relating to public health workforce); Section 5207 and Section 

10503(b)(2) (relating to the National Health Service Corps); Section 5301 (relating to primary 

care training); Section 5402 (health workforce diversity); Section 5403(a) (relating to Area 

Health Education Centers); Section 5405 (relating to primary care); and Section 10501(I) (relating to rural physician training). Numerous payment and delivery system reforms also will serve 

to enhance the primary care workforce. (See, e.g., ACA Section 5501 (relating to Medicare bonus 

payments for primary care providers.) 17 National Residency Matching Program, Advance Data Tables: 2011 Main Residency Match 

(Mar. 17, 2011) (online at http://www.nrmp.org/data/2011Adv%20Data%20Tbl.pdf). 18 Internal Medicine News, Interest in Primary Care Builds in Resident Match (Mar. 17, 2011) 

(online at http://www.internalmedicinenews.com/index.php?id=495&cHash=071010&txl 

ttnews[ttlnews1=53175). 

derserved settings after graduation. They are 3.4 times as likely to 

work in a [health clinic], when compared to residents who did not 

train in health clinics].’’ 13 This is precisely where the need for such 

physicians is the greatest. Indeed, according to HRSA, it would 

take another 16,643 primary care physicians simply to meet the 

needs of the 65 million people currently living in health professional shortage areas.14

IMPLEMENTATION OF TEACHING HEALTH CENTERS

In January 2011, HHS Secretary Sebelius announced the first 

round of grants for 11 teaching health centers to train 50 additional residents, and distributed $1.9 million for the last three 

months of this fiscal year. The grants are designed to support a 

center for five years, in part because it takes several years to complete residency training. The first groups of awards were made to 

teaching centers in California, Idaho, Illinois, Maine, Massachusetts, Montana, New York, Pennsylvania, Texas, Washington, and 

West Virginia.15

The THC program is only a part of a broader effort under the 

ACA to bolster the primary care workforce.16 This package of programs already appears to be having an impact even beyond the direct number of new primary care residents trained. Data from this 

year’s National Resident Matching Program indicate that U.S. 

medical students are choosing careers in primary care in greater 

numbers. Approximately 99% of internal medicine residency slots 

were filled this year, and some 94% of family medicine residency 

slots were also filled—the highest fill rate ever for family medicine.17 The ACA has received much credit for these improvements. 

According to the executive director for the National Residency 

Matching Program, ‘‘[t]he Obama administration has been trying to 

funnel money into primary care graduate medical education and we 

think that in this year’s match we were seeing the results of 

that.’’ 18


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19See, e.g., the comments of Rep. Burgess on this issue made during the floor debate on H.R. 

1217, a bill to repeal the Prevention and Public Health Fund: ‘‘Some of this money is going to 

go for scholarships, but it sets up a big problem.... [S]ome of those same students could receive a scholarship for one year, only to find that the Secretary has bigger and better things 

to spend it on next year.’’ (Statement of Rep. Michael Burgess, Congressional Record, H2624 

(Apr. 13, 2011)). 20 HRSA, Bureau of Health Professions, Division of Medicine and Dentistry. Teaching Health 

Center Graduate Medical Education (THCGME) Program, Announcement Number: HRSA–11– 

149 (Nov. 29, 2010) (online at http://www.im.org/PolicyAndAdvocacy/PolicyIssues/Education/ 

Funding/Documents/THC%20guidance.pdf). 

MANDATORY SPENDING

The primary objection to the THC program voiced by Republicans 

is that they are opposed to its being funded through mandatory 

spending. Given the program’s purpose, its track record of accomplishment to date, and concern about the nation’s primary care 

workforce, this position comes as a great disappointment. 

Congress has long recognized the need for financial certainty in 

supporting medical residency training. In fact, since 1965, the vast 

majority of resident trainees in this country have been supported 

by mandatory funding through Medicare’s GME program, which 

provided some $9.5 billion in support in 2009 alone. This is because 

training a single resident involves at least a three-year commitment; it takes even more time for an institution to build the infrastructure necessary to support residency training. Republicans 

have acknowledged the necessity for such ongoing and consistent 

funding support.19

The need for this funding continuity is exactly why support for 

the THC program should remain mandatory spending. Subjecting 

the program to the whims of the appropriations process would undermine the ability for any institution to effectively recruit and 

train their residents. Applicants for THC funding need to know it 

will be worth the investment to create a program to train residents. 

And resident trainees need to know they will be able to complete 

their training over three years. Without the funding to back up 

these commitments, training programs simply can not operate as 

we have come to know them. 

Thus, HRSA has structured the THC program to be administered 

within these kinds of parameters. For example, in its program announcement, the agency stated that ‘‘although the program period 

is one year, it is HRSA’s intent to fund qualified THCs for the entire five year THC GME program period pending satisfactory performance of awardees and availability of federal funds.’’ 20 Any reduction in this funding would be crippling for those 11 programs 

that have already made the decision to participate—in consultation 

with key stakeholders such as teaching hospitals and their 

boards—based on an expectation that continued funding would be 

available. Converting the program to discretionary funding will 

also deter other entities from making the business decisions necessary to expand residency training (e.g., securing commitments 

from potential partners to agree to train new or additional residents, applying for accreditation if not already part of an eligible 

consortia, and hiring new faculty) since funding would be subject 

to the annual appropriations fight. 


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16 

21The President’s FY 2012 budget proposal calls for the elimination of mandatory spending 

for this program. During the Committee mark up of H.R. 1216, Republicans argued that the 

THC program should be treated similarly. (See House Committee on Energy and Commerce, 

Business Meeting to Mark Up HR. 1213 et al., 112th Cong., comments of Rep. Guthrie (p. 283) 

and Rep. Gingrey (pp. 305–306) (Apr. 5, 2011) (transcript of the proceeding). 22 ACA Section 4101(a). 23See, e.g., comments made to this effect by Reps. Burgess and Blackburn during the full 

Committee mark up. (House Committee on Energy and Commerce, Business Meeting to Mark 

Up H.R. 1213 et al., 112th Cong., (Apr. 5, 2011) (transcript of the proceeding). • Rep. Burgess: You are funding the bricks and mortar . . . and you got no doctor, no nurse.’’ 

(pp. 154–155 of transcript of the proceeding) • Rep. Blackburn: ‘‘. . . you can build all sorts of buildings . . . but if there is a shortage, 

if you do not have enough physicians available to deliver the care, individuals . . . do not end 

up with access to that care delivery, and you still have a problem.’’ (p. 221 of transcript of the 

proceeding) 24 House Committee on Energy and Commerce, Business Meeting to Mark Up H.R. 1213 et 

al., 112th Cong., pp. 180–181 (Apr. 5, 2011) (transcript of the proceeding). 25For examples of various federal programs that are supported through mandatory spending, 

see Committee on Energy and Commerce, Democratic Staff, The Pitts Proposal to Block Mandatory Funding in the Affordable Care Act (Mar. 9, 2011) (online at: http://democrats. 

energycommerce.house.gov/sites/default/files/imageluploads/Fact%20Sheetl03.09.11.pdf). 

In comparing it to the fate of the Children’s Hospital Graduate 

Medical Education program,21 Republicans actually underscore the 

need for mandatory funding for the THC program. Residents currently training under the children’s hospital GME program are now 

greatly concerned about their ability to continue their training. 

Ending mandatory spending for the THC program simply place 

residents in that program in the same position of insecurity that 

their pediatric resident colleagues now face. Such a step is particularly ill-advised at a time when the demand for primary care physicians is—and will continue to be—high. 

Republicans’ opposition to mandatory funding for the THC program is especially ironic given their arguments against mandatory 

funding for the school-based health centers (SBHCs) construction/ 

renovation program also established in the ACA 22 and in support 

of H.R. 1214, a bill to repeal mandatory funding for school-based 

health center construction. During the mark up of that bill, Republicans argued that they could not support the construction/renovation program because, in their view, it made no sense to build centers for which there was not adequate physician staffing.23 While 

we vigorously and completely disagree with the Republican analysis of how the SBHC construction/renovation program is designed 

to operate in terms of staffing requirements, we wholeheartedly 

agree with Rep. Burgess’s statement during the debate over H.R. 

1214: ‘‘If increasing annual wellness visits for children age 10 to 17 

is a priority then increasing the physician workforce should also be 

a priority.’’ 24 The THC program is all about just that—making our 

workforce in primary care a top priority. We believe mandatory 

spending for the THC program will help ensure that it remains 

that way. 

AN ANTI-HEALTH REFORM IDEOLOGICAL AGENDA

In our view, the Republican opposition to the THC program as 

it is currently structured is without merit. It is difficult to see how 

opposition could be grounded on the merits of discretionary spending versus mandatory spending or the need to protect Congress’s 

prerogative to fund or not to fund health programs. Congress, Republicans and Democrats alike, makes those kinds of choices—often 

difficult choices—all of the time.25 Moreover, opposition based on 


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26 Although the House of Representatives has passed legislation to repeal the ACA, that legislation will not become law since the Senate has defeated the proposal. (H.R. 2 passed the House 

of Representatives in January 2011 (Congressional Record, H322–323 (Jan. 11, 2011)). The Senate defeated a similar proposal a month later. (Congressional Record S475 (Feb. 2, 2011)). 

the substance of the program runs counter to traditional bi-partisan support for primary care training. 

Instead, it appears that H.R. 1216 is simply another component 

of the Republican effort to disrupt, dismantle, and ultimately destroy the ACA—even those programs that have been funded and 

are up and running, and even those that make good health policy 

sense, in or out of the health reform law. What they have not been 

able to achieve whole cloth,26 Republicans are now attempting to 

do piece by piece. H.R. 1216 puts the Teaching Health Centers Program in the frontline of this ongoing assault. 

We do not believe this is where the THC program should be. 

Rather, is should remain exactly where it is—at the forefront of 

helping to build our national health workforce to ensure that all 

those in need have access to basic health care services. 

HENRY A. WAXMAN. 

FRANK PALLONE, Jr. 

DORIS O. MATSUI. 

ANNA G. ESHOO. 

MIKE DOYLE. 

DONNA M. CHRISTENSEN. 

ANTHONY WEINER. 

EDOLPHUS TOWNS. 

CHARLES A. GONZALEZ. 

LOIS CAPPS. 

ELIOT L. ENGEL. 

EDWARD J. MARKEY. 

JOHN D. DINGELL. 

JAY INSLEE. 

DIANA DEGETTE. 

JAN SCHAKOWSKY. 

TAMMY BALDWIN. 

BOBBY L. RUSH. 

G.K. BUTTERFIELD. 

GENE GREEN. 

Æ 


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