United States Government Accountability Office

GAO Report to Congressional Requesters

HEALTH 

PROFESSIONS 

EDUCATION 

PROGRAMS 

Action Still Needed to 

Measure Impact 

February 2006 

 

GAO-06-55 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 2006

HEALTH PROFESSIONS EDUCATION 

PROGRAMS 

Highlights of GAO-06-55, a report to Action Still Needed to Measure Impact 

congressional requesters 

For fiscal years 1999 through 2005, 

the Health Resources and Services 

Administration (HRSA), an agency 

within the Department of Health 

and Human Services (HHS), spent

about $2.7 billion to fund the more 

than 40 health professions 

education programs authorized 

under title VII and title VIII of the 

Public Health Service Act. These 

programs include those providing 

grants to institutions, direct 

assistance to students, and funding

for health workforce analyses. Title 

VII includes programs related to

the education of providers, such as

primary care physicians. Title VIII

includes programs related to

nursing education. Most of these 

programs were last reauthorized in 

1998. GAO reviewed changes in

funding and in the number of these 

programs since 1998, HRSA’s goals 

and assessment of the programs,

and HRSA’s national health

professions workforce projections. 

GAO reviewed relevant laws and 

agency documents and data, and 

interviewed HRSA officials and

representatives of health

professions education associations.

What GAO Recommends

GAO recommends that HRSA 

develop a strategy and time frames

to regularly update and publish 

national health professions 

workforce projections. HRSA 

agreed with GAO’s conclusion that 

updated workforce supply and

demand projections are vital for 

informed decision making about 

health professions programs. 

Funding for title VII and title VIII programs increased from about

$300 million in fiscal year 1999 to more than $450 million in fiscal year 

2005, and the overall number of these programs also increased since 

reauthorization in 1998. From fiscal years 1999 through 2005, funding for 

title VII programs rose by about one-fourth, while that for title VIII programs 

more than doubled. The overall numbers of title VII and title VIII programs 

administered by HRSA increased from 46 in fiscal year 1998 to 50 in fiscal

year 2004. The number of title VII programs remained the same, while the 

number of title VIII programs increased.

HRSA has published performance goals for title VII and title VIII health 

professions education programs but cannot fully assess the programs’ 

effectiveness because the goals do not apply to all the health professions 

education programs, and the data for tracking progress are problematic.

Recognizing the need for a better means of measuring the results of title VII 

and title VIII programs, HRSA is developing new performance goals and 

measures for them. The effectiveness of these efforts will depend upon the 

agency’s ability to collect complete and timely data to assess progress 

toward these new goals. 

HRSA has published few recent national workforce projections. In the past 

decade, the agency has published national supply and demand projections 

for the nurse and pharmacist workforces but no national projections for the 

physician and dentist workforces. Yet regular reassessment of future health 

workforce supply and demand is key to setting policies as the nation’s health

care needs change. 

Funding for Title VII and Title VIII Programs, Fiscal Years 1999–2005 

www.gao.gov/cgi-bin/getrpt?GAO-06-55.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie G. 

Aronovitz at (312) 220-7600 or 

aronovitzl@gao.gov. 
Contents 

Letter 1

Results in Brief 4

Background 5

Funding for and Overall Number of Title VII and Title VIII Health 

Professions Education Programs Increased 9 

HRSA’s Goals Do Not Apply to All Title VII and Title VIII Programs, 

and Data Are Problematic, but Agency Is Developing 

Alternatives 15

HRSA Has Published Few National Workforce Projections in 

Recent Years 20 

Conclusions 25

Recommendation for Executive Action 26 

Agency Comments 26 

Appendix I Examples of Additional Sources of Federal Funding 

for Health Professions Education 28 

Appendix II Title VII and Title VIII Clusters and Programs, 

Fiscal Year 2004 30 

Appendix III Additional Performance Goals and Targets for 

Health Professions and Nursing Education Programs 32 

Appendix IV Comments from the Health Resources and Services 

Administration 34 

Appendix V GAO Contact and Staff Acknowledgments 41 

Related GAO Products 42 

Page i GAO-06-55 Health Professions Education Programs
Tables 

Table 1: Title VII and Title VIII Programs in Existence Before, and 

Organized into Clusters After, 1998 Reauthorization 6 

Table 2: Performance Goals and Targets for the Health Professions 

and Nursing Education and Training Programs Funded 

under Title VII and Title VIII 17 

Table 3: HRSA’s Most Recent Reports Containing National 

Workforce Supply and Demand Projections for Physicians, 

Dentists, Nurses, and Pharmacists 22 

Table 4: Examples of Federal Funding Sources, besides Title VII 

and Title VIII Programs, for Postsecondary Education and 

Training Specifically Targeted for Health Professions 28 

Table 5: Examples of Federal Funding Sources for General 

Postsecondary Education and Training Including, but Not 

Exclusive to, Health Professions 29 

Figures 

Figure 1: Funding for Title VII and Title VIII Health Professions 

Education Programs, Fiscal Years 1999–2005 10 

Figure 2: Funding for Title VII Health Professions Education 

Programs, Fiscal Years 1999–2005 11 

Figure 3: Title VII Funding for New and Competitive Continuation 

Grants and for Noncompetitive Continuations, Fiscal 

Years 1999–2004 14 

Figure 4: Title VIII Funding for New and Competitive Continuation 

Grants and for Noncompetitive Continuations, Fiscal 

Years 1999–2004 15 

Page ii GAO-06-55 Health Professions Education Programs
Abbreviations 

AMA American Medical Association 

CMS Centers for Medicare & Medicaid Services 

COGME Council on Graduate Medical Education 

GPRA Government Performance and Results Act 

HHS Department of Health and Human Services 

HRSA Health Resources and Services Administration 

NELRP Nursing Education Loan Repayment Program 

OMB Office of Management and Budget 

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Page iii GAO-06-55 Health Professions Education Programs
United States Government Accountability Office

Washington, DC 20548 

February 28, 2006 

The Honorable Michael B. Enzi 

Chairman 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Judd Gregg 

United States Senate 

An appropriate supply, mix, and distribution of health professionals—

today and in the future—is vital to ensuring that all Americans have 

adequate access to health care. For fiscal years 1999 through 2005, the 

Health Resources and Services Administration (HRSA), an agency within 

the Department of Health and Human Services (HHS), spent about 

$2.7 billion to fund health professions education programs authorized 

under title VII and title VIII of the Public Health Service Act. Administered

by HRSA, the many title VII and title VIII programs include those providing 

grants to institutions training health professionals; direct assistance to 

students in the form of scholarships, loans, or repayment of educational 

loans; and funding for health workforce analyses. Title VII programs 

include those related to the education of providers, such as primary care 

physicians, physician assistants, general dentists, pediatric dentists, and 

allied health practitioners;

1

 programs related to education of the public 

health workforce; and programs related to the analysis of health 

workforce issues, such as estimates of supply and demand. Title VIII 

programs include those related to basic and advanced nursing education 

programs, which are designed to increase nursing workforce diversity, 

promote career advancement, and improve retention. Most of the health

professions education programs were last reauthorized in 1998.2

 1

Allied health practitioners include, for example, audiologists, dental hygienists, clinical 

laboratory technicians, occupational therapists, physical therapists, medical imaging 

technologists, and speech pathologists. 

2

Most title VII and title VIII programs were last reauthorized by the Health Professions 

Education Partnership Act of 1998, Pub. L. No. 105-392, 112 Stat. 3524. Some nursing 

programs were authorized or reauthorized by the Nurse Reinvestment Act of 2002, Pub. L.

No. 107-205, 116 Stat. 811. 

Page 1 GAO-06-55 Health Professions Education Programs
For more than a decade, our reviews of title VII and title VIII programs 

have raised questions about HRSA’s ability to assess the programs’ 

effectiveness.3

 For example, before the 1998 reauthorization, we noted that 

the programs’ effectiveness would remain difficult to measure as long as 

the health professions education programs were authorized to support a 

broad range of health care objectives.4

 For fiscal years 2002 through 2005, 

HRSA’s budget justifications have questioned the need for continued 

federal support of many of these health professions education programs, 

and a review by the Office of Management and Budget (OMB) for the fiscal

year 2004 budget questioned their effectiveness.5

In preparation for congressional consideration of the next reauthorization 

of title VII and title VIII programs, you asked us to review the programs, 

including changes after the 1998 reauthorization. In this report, we provide 

information on (1) changes in funding and in the number of title VII and 

title VIII health professions education programs since the 1998 

reauthorization; (2) HRSA’s stated goals for the programs and the agency’s

efforts to measure progress toward meeting them; and (3) national health

professions workforce projections developed by HRSA. 

To conduct our work, we analyzed pertinent agency documents and 

interviewed HRSA officials. We also analyzed data from HRSA’s grants 

management system, reviewed relevant laws, and interviewed 

representatives of the Health Professions and Nursing Education Coalition 

and the Federation of Associations of Schools of the Health Professions. 

We examined funding for title VII and title VIII programs for fiscal years 

1999 through 2005.6

 To analyze the number of title VII and title VIII 

programs HRSA administered, we counted (1) programs that awarded 

funds competitively through grants or cooperative agreements7

 and that 

 3

See “Related GAO Products” at the end of this report. 

4

GAO, Health Professions Education: Clarifying the Role of Title VII and VIII Programs

Could Improve Accountability, GAO/T-HEHS-97-117 (Washington, D.C.: Apr. 25, 1997). 

5

Office of Management and Budget, Program Assessment Rating Tool,

http://www.whitehouse.gov/omb/budget/fy2006/pma/hhs.pdf, downloaded Aug. 9, 2005. The

most recent OMB assessment of the health professions programs took place for the fiscal 

year 2004 budget. 

6

We excluding funding for one title VII program—Health Education Assistance Loans—

because the program was not authorized to guarantee new loans to student borrowers

during that period.

7

Referred to as “grants” in this report. 

Page 2 GAO-06-55 Health Professions Education Programs
announced funding availability separately or had a separate selection 

panel8

 and (2) programs providing direct assistance, such as student loans

to individuals, regardless of whether the loan program was using current 

appropriations.9

For information on HRSA’s stated goals and measures of performance in 

meeting these goals and on the agency’s plans for the future, we reviewed 

HRSA’s annual performance plans, budget justifications, and strategic 

planning documents, and we attended HRSA’s Bureau of Health 

Professions’ first all-grantee conference in June 2005. Regarding the 

workforce supply and demand projections HRSA developed, we focused 

on the most recent projected estimates of national supply and demand for 

physicians, dentists, nurses, and pharmacists.10 We also reviewed physician

workforce reports published by the Council on Graduate Medical 

Education (COGME),11 which based its physician workforce projections on 

HRSA-developed methodologies. We assessed the reliability of grants and 

other funding data used in our review by discussing with agency officials 

validation and internal controls for HRSA grants data and comparing the 

aggregate data with similar aggregate data from other sources. We 

determined that the funding data were sufficiently reliable for our 

purposes. Although we identified problems with the reliability of other 

agency data, such as those used to measure program performance, we 

included them for illustrative purposes. We conducted our work in 

 8

We used the separate selection panel criterion only for programs funded in fiscal year 

2004. 

9

We excluded advisory groups authorized under title VII or title VIII from our counts of

programs. 

10In addition to the national workforce projections discussed in this report, HRSA and its

six regional centers issue reports—such as state health workforce profiles for each state, 

the District of Columbia, Puerto Rico, and the Virgin Islands—containing information about

the supply; demand; distribution; education; and use of physicians, nurses, dentists, and 20

other health professionals. The scope of our review was limited to HRSA’s estimates of 

national supply and demand. 

11COGME, established under title VII, is required to make recommendations to the

Secretary of HHS and Congress on several issues, including the supply and distribution of 

physicians in the United States; current and future shortages or excesses of physicians in 

medical and surgical specialties and subspecialties and appropriate federal policies with 

respect to such supply, distribution, shortages, or excesses; and deficiencies in and needs 

for improvement in databases concerning the supply and distribution of physicians in the 

United States. Public Health Service Act § 762 (codified at 42 U.S.C. § 294o). The views 

expressed in COGME’s reports are solely those of the council and do not necessarily 

represent the views of HRSA or the U.S. government. 

Page 3 GAO-06-55 Health Professions Education Programs
accordance with generally accepted government auditing standards from 

June 2004 through January 2006. 

After reauthorization in 1998, overall funding for title VII and title VIII 

programs increased from about $300 million in fiscal year 1999 to more 

than $450 million in fiscal year 2005, and the overall number of these 

programs also increased. From fiscal years 1999 through 2005, funding for

title VII programs rose by about one-fourth, while that for title VIII 

programs more than doubled. The overall number of title VII and title VIII

programs administered by HRSA increased from 46 in fiscal year 1998 to 

50 in fiscal year 2004; this overall increase was due to an increase in the

number of title VIII programs. 

Results in Brief 

HRSA has published performance goals for the title VII and title VIII health

professions education programs, but these goals do not apply to all the 

health professions education programs, and the data for tracking progress 

are problematic. These performance goals, prepared as part of HHS’s 

annual reporting under the Government Performance and Results Act 

(GPRA) process,12 are spelled out in HRSA’s fiscal year 2006 budget 

justification. In measuring progress toward meeting these goals, the 

agency relies on data we and others have found to be problematic. For 

example, although one performance goal is to increase the proportion of 

health professionals supported by title VII and title VIII programs who 

enter practice in underserved areas, HRSA does not have complete data 

that track the practice locations of these health professionals. Recognizing 

the need for a better means of measuring the results of title VII and title 

VIII programs, HRSA has since 2002 been developing a new strategic plan 

for the health professions education programs, which includes program 

goals and information on how the agency proposes to measure 

performance. 

Although HRSA is responsible for providing health professions workforce 

information to policymakers, HRSA has in the past decade published 

national supply and demand projections for the nurse and pharmacist 

workforces but no national projections for the physician and dentist 

workforces. According to HRSA officials, the agency is preparing a report 

 12The Government Performance and Results Act of 1993 requires executive agencies to 

develop agencywide performance goals and indicators and to report progress annually. 

Pub. L. No. 103–62, § 4, 107 Stat. 285, 286.

Page 4 GAO-06-55 Health Professions Education Programs
to Congress that will provide information about the health workforce for 

30 health professions, including national supply and demand projections 

for physicians, pharmacists, and nurses. Estimating future health 

workforce supply and demand on a regular basis is important because 

estimates need to be revised periodically to reflect changes in the health

care environment. In 2005, an HHS advisory council strongly

recommended that the nation develop systems to track physician 

workforce supply, demand, and distribution and undertake a 

comprehensive reassessment within the following 4 years to guide future 

decisions on medical education capacity. 

We are recommending that HRSA develop a strategy and time frames to 

regularly update and publish national health professions workforce 

projections. In commenting on a draft of this report, HRSA agreed with 

our conclusion that updated workforce supply and demand projections are 

vital for informed decision making about health professions programs. 

In response to a shortage of health care providers, Congress amended title 

VII of the Public Health Service Act in 196313 and established title VIII in 

1964.

14 These titles have been amended over time and now authorize 

funding for a variety of programs with diverse objectives. As noted in the 

Senate report accompanying the 1998 reauthorization legislation, by the

mid-1970s, two specific areas of need had emerged: overall shortages in 

rural and inner-city communities and an imbalance in the supply of 

primary care providers as compared with specialists. Subsequent revisions 

to title VII focused on encouraging health care workers to practice in 

underserved areas, increasing the number of primary care providers, 

increasing enrollment of minority and disadvantaged students, and 

developing faculty. Revisions to title VIII focused on training advanced 

practice nurses; enrolling disadvantaged students; strengthening basic 

nurse education and practice; and, most recently, fostering nurse retention 

by promoting career development and improving patient care delivery 

systems. 

Background 

 13Health Professions Educational Assistance Act of 1963, Pub. L. No. 88-128, 77 Stat. 164. 

See S. Rep. No. 88-485, at 3 (1963). 

14Nurse Training Act of 1964, Pub. L. No. 88-581, 78 Stat. 1035. See S. Rep. No. 88-1378, at 3 

(1964). 

Page 5 GAO-06-55 Health Professions Education Programs
The 1998 reauthorization resulted in the grouping of the more than 

40 programs in existence at the time into seven clusters. The Senate report 

accompanying the reauthorization legislation stated that “the bureaucracy

required to administer the existing programs should be simplified and 

reduced” and also stated the purpose for each cluster (see table 1).15

According to the Senate report, one purpose of five of the seven clusters 

was to provide administrative flexibility and simplification. The report also

stated that one objective of the reauthorization was to allow for “better 

targeting of limited resources to address national health workforce 

training and distribution deficits.” 

Table 1: Title VII and Title VIII Programs in Existence Before, and Organized into Clusters After, 1998 Reauthorization 

Programs in place before 1998 reauthorizationaCluster namebCluster purposec

Title VII 

Health Education Assistance Loans 

Health Professions Student Loans 

Loans for Disadvantaged Students 

Primary Care Loans 

Student Loans Continue (1) loan programs that do not 

require federal appropriations or 

guarantee the availability of loans for 

health professions students and (2) a 

loan program for the disadvantagedd

Centers of Excellence 

Exceptional Financial Need Scholarships 

Faculty Loan Repayment Program 

Financial Assistance for Disadvantaged Health 

 Professions Students 

Health Careers Opportunity Program 

Minority Faculty Fellowship Program 

Cooperative Agreements for Partnerships for Health 

 Professions Education 

Scholarships for Disadvantaged Students Program 

Health Professions Training 

for Diversity 

Provide for the training of minority and 

disadvantaged health professionals to 

improve health care access in

underserved areas and to improve 

representation in the health professionsd

Departments of Family Medicine 

Faculty Development in Family Medicine 

Faculty Development in General Internal Medicine and 

 General Pediatrics 

Graduate Training in Family Medicine 

Physician Assistants Training

Pre-doctoral Training in Family Medicine 

Residencies and Advanced Education in the Practice of 

 General Dentistry 

Residency Training in General Internal Medicine and 

 General Pediatrics 

Training in Family Medicine, 

General Internal Medicine, 

General Pediatrics, Physician 

Assistants, General Dentistry,

and Pediatric Dentistry 

Provide for the training of family

physicians, general internists, general 

pediatricians, physician assistants, 

general dentists, and pediatric dentists 

to improve access to and quality of 

health care in underserved areas and to 

assure outside input regarding primary 

care training programsd

 15Senate Report No. 105-220 at 13 and 19 (1998) (accompanied legislation that became 

Health Professions Education Partnership Act of 1998, Pub. L. No. 105-392, 112 Stat. 3524). 

The Senate report is the only congressional report accompanying Pub. L. No. 105-392. 

Page 6 GAO-06-55 Health Professions Education Programs
Programs in place before 1998 reauthorizationa

Cluster namebCluster purposec

Title VII 

Allied Health Project Grants 

Basic/Core Area Health Education Centers

Chiropractic Demonstration Project Grants 

Geriatric Education Centers

Geriatric Fellowships 

Health Education and Training Centers 

Podiatric Primary Care Residency Training 

Grants for Interdisciplinary Training for Health Care for 

 Rural Areas

State-Supported Model Area Health Education Centers 

Interdisciplinary, CommunityBased LinkagesProvide support for (1) training centers 

remote from health professions schools 

to improve and maintain the distribution 

of health providers in underserved 

areas, (2) geriatric education and 

geriatric faculty fellowships, and 

(3) interdisciplinary training projectsd

Center for Health Workforce Health Professions Workforce 

Information and Analysis 

Provide for (1) the development of 

information on the health professions 

workforce and the analysis of 

workforce-related issues, (2) the 

development of necessary information 

for decision making regarding future 

directions in health professions and 

nursing programs, and (3) continued 

analysis of issues affecting graduate 

medical education 

Cooperative Agreement to Support Innovative Projects 

 Relating to Public Health Education and Servicese 

Dental Public Health Specialty Training Grants 

Health Administration Traineeships and Special Projects 

Residency Training in Preventive Medicine 

Public Health Special Project Grants 

Public Health Traineeships to Schools of Public Health 

 and Other Public and Nonprofit Private Institutions 

Public Health Workforce Provide for an increase in the number of 

individuals in the public health 

workforce and enhance the quality of 

this workforce 

Title VIII

Advanced Nurse Education 

Nurse Anesthetist Program: Program Grants

Nurse Anesthetist Program: Fellowships 

Nurse Anesthetist Program: Traineeships 

Nurse Practitioner/Nurse Midwifery 

Nursing Education Loan Repayment Program

Nursing Education Opportunities for Individuals from 

 Disadvantaged Backgrounds

Nursing Special Projects 

Nursing Student Loansf

Professional Nurse Traineeships 

Nursing Workforce 

Development 

Provide for the training of basic and 

advanced-degree nurses to improve 

access to and quality of health care in 

underserved medical and public health 

areasd

Source: GAO analysis.

a

Include (1) programs that awarded funds competitively through grants or cooperative agreements

and that announced funding availability separately and (2) programs providing direct assistance, such

as student loans to individuals, regardless of whether the loan program was using current 

appropriations. Table does not include two advisory groups, COGME and the National Advisory 

Council on Nurse Education and Practice, operating in fiscal year 1998. Names for grant and 

cooperative agreement programs reflect those used in the Federal Register or other program 

announcements.

Page 7 GAO-06-55 Health Professions Education Programs
b

Cluster names reflect headings of parts and subparts of title VII and of title VIII of the Public Health 

Service Act, as amended by Pub. L. No. 105-392, and in some cases differ slightly from those in 

Senate Report No. 105-220. 

c

Cluster purposes as provided in Senate Report No. 105-220. 

d

Another purpose for this cluster, cited in Senate Report No. 105-220, was to provide administrative 

flexibility and simplification. 

e

This program includes a cooperative agreement with the Association of Schools of Public Health 

(ASPH) to provide information to, and coordinate with, the schools of public health that inquire about 

grant funding opportunities under this program. HRSA has discretion to determine whether projects

are funded. 

f

Senate Report No. 105-220 included the Nursing Student Loans program in the student loans cluster.

Because this program is authorized under title VIII, however, we included it in the nursing workforce 

development cluster. 

The programs within each cluster are tied to similar purposes. For 

example, one cluster—Health Professions Training for Diversity—includes 

programs targeting minorities or disadvantaged individuals. Another 

cluster—Health Professions Workforce Information and Analysis—

includes work conducted by and for HRSA on health workforce issues, 

including HRSA’s National Center for Health Workforce Analysis, which 

received less than $1 million per year in fiscal years 1999 through 2005.16

Title VII also authorizes COGME, which provides advice and 

recommendations to the Secretary of HHS and Congress on the supply and 

distribution of physicians in the United States and other issues.17

According to COGME’s charter, “the Council periodically shall prepare 

and transmit a report, to the Secretary and to the Committee on Health, 

Education, Labor and Pensions (formerly the Committee on Labor and 

Human Resources) of the Senate, and the Committee on Commerce 

(formerly the Committee on Energy and Commerce) of the House of 

 16The national center also supports work by six regional centers, which conduct crossdisciplinary assessments of the health workforce, focusing on issues at the state and

regional levels. In addition, the national center facilitates research projects contracted and 

funded by programs within other clusters; for example, the national center facilitates 

nursing workforce research. The congressional conference agreement for the Department 

of Health and Human Services’ appropriation for fiscal year 2006 did not include funding

for the Health Professions Workforce Information and Analysis cluster. H.R. Conf. Rep. No. 

109-337 at 135 (2005). 

17Three advisory groups besides COGME have received contract and staff support from

HRSA and have produced a series of reports on workforce issues. These groups, authorized

by title VII or title VIII of the Public Health Service Act, are the National Advisory Council 

on Nurse Education and Practice; the Advisory Committee on Training in Primary Care 

Medicine and Dentistry; and the Advisory Committee on Interdisciplinary, CommunityBased Linkages. 

Page 8 GAO-06-55 Health Professions Education Programs
Representatives” with respect to supply and distribution of physicians in 

the United States and other issues. 

For fiscal years 2002 through 2005, HRSA’s budget justifications proposed 

reducing overall funding for the health professions education programs—

reducing or eliminating funding for most of the title VII clusters while 

requesting increased funding for the title VIII nursing cluster. The agency’s 

budget justification for fiscal year 2005 cited a number of reasons for 

reducing or eliminating federal funding for many title VII programs.18

These reasons included the availability of alternative sources of funding, 

such as larger federal programs and state, local, and private programs. For 

example, when discussing the reason for not requesting funds for geriatric 

education and training under title VII, HRSA’s fiscal year 2005 budget 

justification stated that recipients of geriatric education grants can secure

support from other sources, including other federal sources. As part of the 

Medicare program, HHS’s Centers for Medicare & Medicaid Services 

(CMS) makes payments for graduate medical education totaling billions of 

dollars each year—nearly $8 billion in fiscal year 2004.

19 The Department 

of Veterans Affairs and the Department of Labor administer additional 

programs that support health professions education. (See app. I for 

information on other federal sources of funding for health professions 

education.) 

After the 1998 reauthorization, overall funding for title VII and title VIII 

programs generally increased, as did the total number of programs. From 

fiscal years 1999 through 2005, overall funding for these programs rose by 

48 percent, from about $304 million to slightly more than $450 million. The 

overall number of title VII and title VIII programs administered by HRSA 

also increased, from 46 programs before reauthorization to 50 programs in 

fiscal year 2004, because of an increase in the number of title VIII 

programs. The allocation of funding for these programs is affected by

factors such as statutory formulas and commitments of future funding to 

grant recipients. 

Funding for and 

Overall Number of 

Title VII and Title VIII 

Health Professions 

Education Programs 

Increased 

 18Department of Health and Human Services, Health Resources and Services

Administration, Fiscal Year 2005 Justification of Estimates for Appropriations

Committees, vol. I, Budget (Washington, D.C.: n.d.). 

19Medicare’s graduate medical education payments are made to teaching hospitals for both

direct and indirect graduate medical education costs on the basis of factors such as the 

number of physicians being trained, Medicare’s share of patient days in the hospital, and 

the hospital’s ratio of residents to beds. 

Page 9 GAO-06-55 Health Professions Education Programs
Over the period from fiscal years 1999 through 2005, funding for both title 

VII and title VIII programs increased (see fig. 1). Title VII funding 

increased from about $236 million to about $300 million, or 27 percent,

and title VIII funding increased from about $68 million to about 

$151 million, or 122 percent. 

Figure 1: Funding for Title VII and Title VIII Health Professions Education Programs, 

Fiscal Years 1999–2005 

1999 2000 2001 2002 2003 2004

Title VII

Title VIII

Fiscal year

Dollars in millions

Source: GAO analysis of HRSA data.

0

50

100

150

200

250

300

350

400

450

500

2005

Note: Graph excludes student loan programs. The Health Education Assistance Loans program was 

not authorized to guarantee new loans to student borrowers during this period. The remaining loan 

programs have received no new federal funds since fiscal year 1998. 

Page 10 GAO-06-55 Health Professions Education Programs
Among title VII’s five program clusters—those other than the cluster for 

student loans20—the proportion of funding allocated to each cluster 

changed little from fiscal year 1999 through 2005. Throughout this period, 

one of the clusters—Health Professions Training for Diversity—received 

the largest share (around 39 percent annually) of title VII funding (see fig. 

2). 

Figure 2: Funding for Title VII Health Professions Education Programs, Fiscal Years 1999–2005 

Source: GAO analysis of HRSA data. 

Health Professions Training for Diversity

Training in Family Medicine, General Internal Medicine, General Pediatrics,

Interdisciplinary, Community-Based Linkages

Health Professions Workforce Information and Analysis

Public Health Workforce

Physician Assistants, General Dentistry, and Pediatric Dentistry

1999 2000 2001 2002 2003 2004

Fiscal year

Dollars in millions

2005

450

500

400

350

300

250

200

150

100

50

0

Title VII 

Title VIII 

Note: Graph excludes student loan programs. The Health Education Assistance Loans program was 

not authorized to guarantee new loans to student borrowers during this period. The remaining loan 

programs have received no new federal funds since fiscal year 1998. 

 20We excluded the student loan cluster from this analysis. The Health Education Assistance 

Loans program was not authorized to guarantee new loans to student borrowers during this

period. The remaining loan programs have received no new federal funds since fiscal year 

1998, although HRSA continues to administer them. 

Page 11 GAO-06-55 Health Professions Education Programs
Although the Senate report accompanying the 1998 reauthorization 

legislation indicated that one of the purposes of five of the seven clusters 

was to provide administrative flexibility and simplification, the 1998 

reauthorization may not have had this effect. The overall number of title 

VII and title VIII programs administered by HRSA increased. The number 

of title VII programs HRSA administered (36) was the same in fiscal year 

1998 before reauthorization as in fiscal year 2004. Over the same period, 

the number of title VIII programs HRSA administered increased from 10 to

14.21 (App. II lists programs that HRSA administered in 2004.22) Regarding 

flexibility, several factors—including provisions of the Public Health 

Service Act that specify how some program funds must be allocated and 

commitments of future funding to grant recipients—affect how HRSA 

allocates available funds among and within the health professions 

programs. 

• Statutory formulas for allocating funding: The Public Health Service Act, 

as amended by the 1998 reauthorization, specifies how funds are to be 

allocated among the institutions and individuals that apply for and receive 

certain health professions education program grant awards. For example, 

the act authorizes funding for grants within the cluster for training in 

family medicine, general internal medicine, general pediatrics, physician 

assistants, general dentistry, and pediatric dentistry by allocating it among 

programs within various disciplines according to a specified formula.23

 21The Nurse Reinvestment Act of 2002 authorized additional title VIII programs. Pub. L. No. 

107-205, §§ 103, 201, 202, 116 Stat. 811, 813, 815, 816 (2002). 

22We used HRSA’s database to identify the title VII and title VIII grant programs that 

received funding in fiscal year 2004. Fiscal year 2004 was the most recent year for which 

data were available at the time of our analysis. We also contacted HRSA officials to obtain 

information on other title VII and title VIII programs, such as scholarship programs, that

HRSA administered in those years. We counted (1) programs that awarded funds

competitively through grants or cooperative agreements and that announced funding

availability separately or had a separate selection panel and (2) programs providing direct 

assistance, such as student loans to individuals, regardless of whether the loan program

received any new appropriations. 

23The act specifies that, of the $78.3 million authorized to be appropriated for fiscal year 

1998, not less than $49.3 million be made available to programs of family medicine, of 

which not less than $8.6 million be made available for family medicine academic 

administrative units, not less than $17.7 million be made available to programs of general 

internal medicine and general pediatrics, not less than $6.8 million be made available to 

programs related to physician assistants, and not less than $4.5 million be made available 

to programs of general or pediatric dentistry. If the amounts appropriated in subsequent

fiscal years are less than the amount authorized to be appropriated for 1998, the act directs 

the secretary to reduce the amounts made available to the programs on a proportional 

basis. See Public Health Service Act, § 747, as amended (codifed at 42 U.S.C. § 293k). 

Page 12 GAO-06-55 Health Professions Education Programs
Another example is the formula for allocating grant funding among 

recipients of one of the programs—Centers of Excellence—within the 

Health Professions Training for Diversity cluster. This program assists 

schools in supporting health professions education for underrepresented 

minorities. The Public Health Service Act specifies formulas for allocating

funding among (1) centers of excellence at certain historically black

colleges and universities, (2) Hispanic centers of excellence, (3) Native 

American centers of excellence, and (4) centers of excellence at other 

institutions.24

• Commitments of future funding to noncompetitive continuations of 

existing grants: There are three types of health professions education 

grant awards: (1) new grants, which are awarded to institutions that do 

not have a current grant under a given program for a particular purpose; 

(2) noncompetitive continuations of existing grants, which provide 

funding for the second and subsequent years of projects approved for 

several years, such as for the second and third years of a 3-year project 

period; and (3) competitive continuations, which are awarded 

competitively to current grantees that have applied for additional funding 

for subsequent years. According to a HRSA official responsible for grants

management, annual appropriations are applied to noncompetitive 

continuations of existing grants first; the remaining grant program funds 

are available for new and competitive continuation grant awards. In fiscal 

year 2004, for example, the share of funds committed to noncompetitive 

continuations amounted to about 75 percent of title VII grant funding, 

leaving about 25 percent for new and competitive continuation grants 

(see fig. 3). From fiscal years 1999 through 2004, the proportion of the 

funds available for new and competitive continuation grants ranged from a 

high of about 41 percent in fiscal year 1999 to a low of about 25 percent in 

fiscal year 2004. 

 24See Public Health Service Act, § 736, as amended (codified at 42 U.S.C. § 293). 

Page 13 GAO-06-55 Health Professions Education Programs
Figure 3: Title VII Funding for New and Competitive Continuation Grants and for

Noncompetitive Continuations, Fiscal Years 1999–2004

The share of title VIII grant funding awarded to noncompetitive 

continuations was smaller (approximately 48 percent) in fiscal year 2004

than that of title VII, leaving about 52 percent of title VIII funds available 

for new and competitive continuation grants (see fig. 4). From fiscal years 

1999 through 2004, the proportion of the title VIII grant funds available for

new and competitive continuation grants ranged from a high of about 

59 percent to a low of about 52 percent. 

1999 2000 2001 2002 2003 2004

Noncompetitive continuation awards

Competitive awards (new and competitive continuation grants)

Fiscal year

Dollars in millions

Source: GAO analysis of HRSA data.

0

50

100

150

200

250 $244

$183 $188

$221

$240

$225

Page 14 GAO-06-55 Health Professions Education Programs
Figure 4: Title VIII Funding for New and Competitive Continuation Grants and for 

Noncompetitive Continuations, Fiscal Years 1999–2004

HRSA has stated goals but they are not comprehensive, and data for 

tracking progress toward meeting them are problematic. Recognizing 

these shortcomings, HRSA is developing new performance goals and 

measures. The effectiveness of these efforts will depend on the agency’s 

ability to collect complete and timely data that it can use to assess its 

success in meeting these new goals. 

1999 2000 2001 2002 2003 2004

Noncompetitive continuation awards

Competitive awards (new and competitive continuation grants)

Fiscal year

Dollars in millions

Source: GAO analysis of HRSA data.

0

20

40

60

80

100

120

$62 $60

$72

$77

$83

$105

HRSA’s Goals Do Not 

Apply to All Title VII 

and Title VIII 

Programs, and Data 

Are Problematic, but 

Agency Is Developing 

Alternatives 

Page 15 GAO-06-55 Health Professions Education Programs
Although HRSA has published program goals and performance measures 

for the health professions and nursing education and training programs, 

these goals are not comprehensive, in that they cannot be used to assess 

the performance of all title VII and title VIII programs. Set forth in the 

budget justification for fiscal year 2006 (see table 2 and app. III), the 

current goals and performance measures were prepared as part of HHS’s 

annual reporting under the GPRA process.25 For example, one published 

performance goal is to increase the proportion of health professionals 

completing title VII– and title VIII–supported health professions education 

programs who are underrepresented minorities or from disadvantaged 

backgrounds. The budget justification also lists a long-term target for this 

goal of 50 percent by the year 2010 and targets for a number of interim 

years, such as 43 percent by 2005 and 44 percent by 2006. HRSA officials 

stated that the agency’s published goals and measures cover only a subset 

of title VII and title VIII programs; they do not, for example, apply directly 

to programs designed to develop curriculums or to recruit and retain 

faculty. 

HRSA’s Goals Are Not 

Comprehensive, and Data 

to Assess Performance Are 

Problematic 

 25Department of Health and Human Services, Health Resources and Services

Administration, Fiscal Year 2006 Justification of Estimates for Appropriations

Committees (Washington, D.C.: n.d.). In addition to the broad performance goals for health 

professions and nursing education and training programs shown in table 2, the budget 

justification also lists goals and performance measures for specific programs, such as

Health Education Assistance Loans, Health Professions Workforce Information and 

Analysis, and the Nursing Education Loan Repayment and Nursing Scholarship Programs 

(see app. III). 

Page 16 GAO-06-55 Health Professions Education Programs
Table 2: Performance Goals and Targets for the Health Professions and Nursing

Education and Training Programs Funded under Title VII and Title VIII 

GPRA performance goals

Long-term and 

interim targets 

Available data

for yeara

Increase the proportion of health 

professionals graduating from or 

completing title VII– and title VIII–

supported health professions education 

programs who are underrepresented 

minorities or from disadvantaged 

backgrounds 

50% in 2010: 

44% in 2006b

43% in 2005b

40% in 2004b

42% for 2001 

(baseline)c

Increase the proportion of persons in the 

United States who have a specific 

source of ongoing care

96% in 2010 87% in 1998 

(baseline)

88% in 2003 

(estimate)

Increase the proportion of health 

professionals trained in programs 

supported by titles VII and VIII who are 

serving in medically underserved 

communities 

40% in 2010: Average, 19% 

for 1999–2001 

(baseline)d

Increase the proportion of trainees in

programs supported by titles VII and VIII 

who are training in medically 

underserved communities 

54% in 2006b

53% in 2005b

30% in 2004b

Average, 52% 

for 1999–2001 

(baseline)d

Increase the proportion of health 

professionals in programs supported by 

titles VII and VIII programs who enter 

practice in underserved areas

21% in 2006b

20% in 2005b

30% in 2004b

Average, 19% 

for 1999–2001 

(baseline)d

Source: Department of Health and Human Services, Health Resources and Services Administration, Fiscal Year 2006 Justification of 

Estimates for Appropriations Committees (Washington, D.C.: n.d.).

Note: All years are fiscal years. 

a

According to HRSA officials, HRSA has historically counted graduating students as belonging to the 

year in which their institution began receiving funding under a specific grant, not to the year in which 

the students graduated. For example, according to HRSA officials, data listed in the table as the 

baseline for 2001 pertain to grants awarded in 2001, although the data were collected in 2003. 

b

The target for fiscal year 2004 was set before baseline data were available. Fiscal year 2005 and 

2006 targets were adjusted to reflect the baseline.

c

The baseline estimate is a partial one based on data submissions for fiscal year 2001. 

d

Grantees in programs not designed to increase health professionals in underserved areas are not 

required to submit these data. HRSA’s fiscal year 2006 budget justification indicates that the Bureau

of Health Professions within HRSA intends to propose an alternative measure after work on a new 

strategic plan has been completed. 

Page 17 GAO-06-55 Health Professions Education Programs
According to HRSA officials, a number of HRSA’s previous performance 

goals were deleted, and others added, in response to an OMB assessment 

of title VII and title VIII programs for the fiscal year 2004 budget. In its 

review, OMB noted a lack of consensus among various parties regarding 

the purpose of the health professions programs, stating, “The 

Administration has tended to focus on diversity and distribution [of health

professionals]. Congressional committees often focus on the program as a 

means of helping rural areas. Advocates also emphasize the financial 

vulnerability of funded institutions.” Further, OMB found little evidence 

that HRSA used performance data to adjust program priorities, to allocate 

resources, or to take other management actions.

In reporting on progress toward meeting its published goals, HRSA relies 

in part on grantees’ self-reported data, which HRSA acknowledges are 

problematic. The agency requires grantees to submit an annual progress 

report on accomplishments and movement toward achieving the 

objectives described in the original grant agreement.26 For example, some 

title VII and title VIII grantee institutions are required to determine the 

proportion of their graduates who go on to practice in certain areas, such 

as medically underserved communities. HRSA officials stated, however, 

that obtaining data on where graduates go after leaving training programs 

is not easy. For example, according to the officials, grantees rely on their 

graduates to voluntarily provide practice location information, and some 

do not do so. HRSA officials also said that some grantees do not provide 

information because of concerns related to state privacy laws. 

Problems with HRSA’s data to measure progress toward meeting its stated 

goals are longstanding. For example, in 1997, we reported that data 

provided to HRSA by grantees about graduates placed in medically 

underserved communities were not necessarily complete or comparable 

among schools, and the agency had not established a way to validate the 

data provided.27 Five years later, these problems remained. In 2002, an 

evaluation of grantees’ data collection processes prepared for HRSA found 

that 56 percent of grantees collected and submitted data on the number of 

their graduates who were employed in medically underserved

 26To collect these data, HRSA developed its comprehensive performance management 

system and uniform progress report. 

27GAO/T-HEHS-97-117. 

Page 18 GAO-06-55 Health Professions Education Programs
communities in fiscal year 2000.28 Although almost all the grantees that 

were not collecting these data reported that they planned to do so in the 

future, a few reported that they had no plans to do so because they lacked 

the staff, their students were not yet employed, or their program was too

new. Of grantees able to report the information, 36 percent relied in part 

on their former students to “self-report” whether they were employed in a 

medically underserved community. The 2002 evaluation also reported that 

grantees had difficulties understanding or interpreting the definition of 

“medically underserved community” and recommended that HRSA clarify 

the term in its instructions to grantees. As a result, HRSA could not be sure 

that the self-reported data followed consistent criteria, making the results 

unreliable. 

Since fall 2002, HRSA has been developing a new strategic plan that 

includes goals for title VII and title VIII programs and a description of how 

the agency proposes to measure performance. The HRSA official 

overseeing this effort noted that reviews by both GAO and OMB made it 

clear that HRSA needed to come up with an effective means of measuring 

the results of title VII and title VIII programs and communicating these 

results to the public. According to HRSA, implementing the new strategic 

plan will enable the agency to “ better . . . capture the accomplishments of

title VII’s and title VIII’s diverse portfolio of programs.” HRSA released a 

draft of its new strategic plan and its proposed performance measures 

during a June 2005 all-grantee conference attended by title VII and title VIII 

grant recipients. According to officials in HRSA’s Bureau of Health 

Professions, a primary purpose of the conference was to introduce the

draft of the newly revised strategic plan and proposed performance 

measures to grantees and receive feedback as to whether the proposed 

revised measures were practicable. The plan contained 118 proposed 

program measures (specific performance measures for each title VII and 

title VIII program); 17 proposed core measures (performance measures 

common to a number of health professions programs with similar goals); 

and 14 national measures (national indicators sensitive to access to 

HRSA Is Developing New 

Goals and Performance 

Measures 

 28Mia Cahill et al., Evaluation of Data Collection Processes Used by the Bureau of Health

Professions’ Grantees to Determine the Number of Graduates and Program Completers

Practicing in Medically Underserved Communities, final report prepared for HRSA 

(Princeton, N.J.: Mathematica Policy Research, Mar. 31, 2002). 

Page 19 GAO-06-55 Health Professions Education Programs
primary care, such as the immunization rate among children 19–35 months 

old or mammography rates among women 40 years old or older29). 

Once HRSA has finalized the updated goals and performance measures, 

identifying and obtaining the necessary data will be key. The quality, 

completeness, and timeliness of the data used to calculate baseline values,

as well as to measure actual performance and track the progress the 

programs are making in meeting their goals, will be critical. Without 

comprehensive goals, performance measures, and data, the agency will be 

unable to target federal resources to the most effective programs. 

As of October 2005, a performance measurement working group in HRSA 

had begun to catalog the data needed to implement the proposed 

performance measures; to reconcile these needs with the data HRSA 

currently collects from its grantees; and, according to the group’s lead 

official, to recommend improvements to the agency’s grantee data 

collection and monitoring system. HRSA officials said that their schedule 

called for finalizing and testing the new measures, developing forms for 

collecting the data, and updating the data collection and monitoring 

system by October 2006.30 According to agency officials, the new approach 

would improve the quality, timeliness, and relevance of the agency’s 

performance data. 

One of HRSA’s tasks is to supply information to policymakers on a broad

range of health workforce issues, including forecasts of supply and 

demand for physicians, dentists, nurses, and pharmacists. The agency has, 

however, published few recent national health professions workforce 

projections. For example, its projections for the physician and dentist 

workforces are more than a decade old. Yet regular reassessment of health 

workforce supply and demand is key to setting policies as health care 

needs change. 

HRSA Has Published 

Few National 

Workforce 

Projections in Recent 

Years

 29HRSA officials acknowledged that such proposed national indicators are driven by a 

number of factors other than funding support from title VII and title VIII programs. 

30HRSA officials noted that the agency must seek approval from OMB for any change in 

reporting requirements for grantees, and that they expected to submit their plans to OMB 

by spring 2006. 

Page 20 GAO-06-55 Health Professions Education Programs
HRSA’s fiscal year 2006 budget justification states that a goal of the Health

Professions Workforce Information and Analysis cluster is to “provide 

health workforce information and analyses to national, state, and local

policymakers and researchers on a broad range of issues, such as 

shortages of registered nurses, shortages of pharmacists, and the 

distribution of health care workers in underserved areas.”31 Although 

HRSA maintains a variety of indicators and statistics on the health care 

workforce, in the past decade the agency has published no national supply 

and demand projections for the physician or dentist workforces.32 The 

most recent HRSA national nursing workforce projections were published 

in 2002, and the latest HRSA report containing national pharmacist 

workforce projections was published in 2000. The agency’s most recent 

national physician and dentist workforce projections were published in 

1991. Table 3 summarizes HRSA’s latest publications containing national

workforce projections for physicians, dentists, nurses, and pharmacists. 

HRSA Has Not Regularly 

Published National Health 

Professions Workforce 

Projections 

 31Other goals include federal-state collaborative efforts directed at assessing the adequacy 

of the current and future heath care workforce from federal, state, and local perspectives 

and developing strategies for improving the diversity and distribution of the health 

workforce. See Department of Health and Human Services, Health Resources and Services

Administration, Fiscal Year 2006 Justification of Estimates for Appropriations

Committees. 

32In addition to national workforce projections and other reports issued by HRSA and its 

six regional centers, HRSA supports a database, the Area Resource File, containing 

statistics on health professions, health training programs, health facilities, measures of 

resource scarcity, and health status. This information is derived from existing data sources, 

such as the National Center for Health Statistics and American Hospital Association. 

Page 21 GAO-06-55 Health Professions Education Programs
Table 3: HRSA’s Most Recent Reports Containing National Workforce Supply and Demand Projections for Physicians, 

Dentists, Nurses, and Pharmacists 

Health

profession

Latest workforce projections 

published by HRSA Discussion of models and data used to make projections

Physicians Health Personnel in the United States: 

Eighth Report to Congress (1991) 

HRSA developed physician supply and demand models. HRSA’s 

current supply model uses data from sources such as the American 

Medical Association (AMA) Physician Masterfilea

 to project national 

estimates of physician supply by 36 medical specialties through the 

year 2020. HRSA’s current physician demand model uses Census 

Bureau population projections, plus data from sources such as the 

National Ambulatory Medical Care Surveyb

 and the Nationwide 

Inpatient Sample,c

 to project demand for physicians in 18 medical

specialties to the year 2020. 

Dentists Health Personnel in the United States: 

Eighth Report to Congress (1991) 

According to HRSA officials, the supply and demand models for 

dentists are out of date, and HRSA plans to update them. HRSA has 

a cooperative agreement with the American Dental Association to 

develop dentist supply and demand estimates. 

Nurses Projected Supply, Demand, and Shortages 

of Registered Nurses: 2002–2020 (2002) 

HRSA collects data on the nurse workforce through its National 

Sample Survey of Registered Nurses, which is conducted every 

4 years, and generally publishes nurse workforce projections after 

the most recent survey. The agency’s nursing supply model projects 

the state-level registered nurse supply through 2020. The nursing 

demand model projects state-level demand for registered nurses, 

licensed practical nurses, and nursing and home health aides 

through 2020 in a number of employment settings, such as hospitals, 

nursing facilities, and doctors’ offices. As of December 2005, the 

nursing supply and demand models were being updated to 

incorporate data from the most recently completed National Sample 

Survey of Registered Nurses (2004).d

Pharmacists The Pharmacist Workforce: A Study of the 

Supply and Demand for Pharmacists (2000)

HRSA created a pharmacist supply model to generate estimates of 

pharmacist numbers in the United States through 2020. But because 

the pharmacy profession lacks a comprehensive database like the 

physician database maintained by AMA, the pharmacist model uses 

a base-year count of active pharmacists from a 1992 pharmacist 

census. The model then projects the number of practicing 

pharmacists into the future by adding, each year, the projected 

number of new entrants and subtracting, each year, the projected 

number of pharmacists who will die or retire. For the pharmacist 

projection published in 2000, HRSA did not develop a pharmacist 

demand model per se but instead described issues affecting the 

demand for pharmacists, such as the number of retail prescriptions 

dispensed and the growth in demand for pharmacists in hospitals. 

According to HRSA officials, as of 2005, the agency had begun 

updating the pharmacist supply model. 

Source: HRSA. 

Note: Table lists most recent reports as of October 2005. In addition, the agency published a report 

containing preliminary forecasts, developed using the agency’s physician and nursing demand 

models, of the impact of changing demographics on the demand for physicians, nurses, and other 

health professions. See Department of Health and Human Services, Health Resources and Services 

Administration, Changing Demographics: Implications for Physicians, Nurses, and Other Health 

Workers (Rockville, Md.: 2003). 

Page 22 GAO-06-55 Health Professions Education Programs
a

The AMA Physician Masterfile is a computer database of physicians that includes current and 

historical data on physicians, including AMA members and nonmembers and graduates of foreign 

medical schools who reside in the United States and who have met the educational and credentialing 

requirements necessary for recognition as physicians. 

b

Administered by the Centers for Disease Control and Prevention’s National Center for Health 

Statistics, the National Ambulatory Medical Care Survey is a nationwide survey based on a sample of

visits to nonfederally employed office-based physicians who are engaged primarily in direct patient 

care. The survey was conducted annually from 1973 to 1981, in 1985, and annually since 1989. 

c

The Nationwide Inpatient Sample, part of the Healthcare Cost and Utilization Project sponsored by 

the Agency for Healthcare Research and Quality, is a database of hospital inpatient stays. It contains 

data on about 7 million hospital stays taken from a sample of about 1,000 U.S. community hospitals.

d

The seventh National Sample Survey of Registered Nurses was conducted in 2000, and the results 

were published on February 22, 2002. The eighth National Sample Survey of Registered Nurses was 

conducted in 2004; as of December 2005, HRSA had posted preliminary results on its Web site but 

had not published any updated national nursing supply or demand projections. The survey collects 

information on the number of registered nurses; their educational background and specialty areas; 

their employment status, including type of employment setting, position level, and salaries; their 

geographic distribution; and their personal characteristics, including gender, racial or ethnic 

background, age, and family status. 

Although HRSA has not published national projections for the physician

workforce in the past decade, agency officials noted that individual HRSA

staff members have contributed articles to journals,33 and COGME, which 

advises the Secretary of HHS and congressional committees, used HRSA’s 

models to develop physician workforce projections through 2020 for 

COGME’s January 2005 report.34 HRSA officials said they have not 

contributed to any similar national projections for the dentist workforce in 

the past decade. 

From the 1970s through the early 1990s, HRSA periodically provided 

health professions workforce information by producing a series of 

legislatively mandated reports to Congress on the supply and distribution 

of health personnel, including recommendations for improving health care 

in the nation. Some but not all of these reports included original national

workforce supply and demand projections. For example, the eighth report, 

dated 1991, did include such projections, but the ninth report did not. The 

 33See, for example, Jack M. Colwill and James M. Cultice, “The Future Supply of Family 

Physicians: Implications for Rural America,” Health Affairs, vol. 22, no. 1 (2003), and 

Robert M. Politzer et al., “Matching Physician Supply and Requirements: Testing Policy 

Recommendations,” Inquiry, vol. 33: 181–194 (1996). 

34Council on Graduate Medical Education, Department of Health and Human Services, 

Health Resources and Services Administration, Physician Workforce: Policy Guidelines 

for the United States, 2000–2020 (Rockville, Md.: January 2005). The views expressed in 

COGME’s report are solely those of the council and do not necessarily represent the views

of HRSA or the U.S. government. 

Page 23 GAO-06-55 Health Professions Education Programs
mandated reporting requirement was eliminated by the Federal Reports 

Elimination and Sunset Act of 1995, which took effect in December 1999;

the last of HRSA’s reports, however, was issued 4 years earlier, in 1995.35

According to a HRSA official involved in reporting on workforce issues, 

the agency began work on a tenth report to Congress in 1995 after 

releasing the ninth report, but because of passage of the Federal Reports 

Elimination and Sunset Act, the report effort was given few resources. 

HRSA officials said that the tenth report would provide information about 

the health workforce for 30 key health professions, including national 

supply and demand projections for physicians, pharmacists, and nurses. 

Information on dentists would be more limited. While HRSA has not 

planned to include supply or demand projections for other health 

professions, such as dental hygienists, dental assistants, and physical or 

occupational therapists, agency officials said they planned to report on 

issues and trends relevant to those health professions. As of October 2005,

HRSA officials said they were revising major sections of the tenth report. 

According to the officials, the agency had no specific plans to publish 

reports like the tenth report in the future, but the National Center for 

Health Workforce Analysis did plan to continue publishing analyses of 

selected health professions, including profiles of the health workforce 

within a state at a given time.36

Regular Reassessment of 

Health Workforce 

Predictions Is Critical 

Because of a Changing 

Health Care Environment 

Estimating future health workforce supply and demand on a regular basis 

is important because estimates need to be updated as circumstances 

change. For example, estimates prepared in the 1980s and early 1990s led 

to concern about an impending surplus of physicians overall but a 

shortage of physicians trained in primary care. This anticipated shortage 

of primary care physicians resulted in part from an assumption that the 

nation would need fewer specialty physicians because of an increase in 

 35The Public Health Service Act required that HRSA report to Congress in 1993 and every 2 

years thereafter; see §792, codified at 42 U.S.C. §295k. After submitting the ninth report to

Congress in 1995, HRSA did not submit additional biennial reports before the requirement

was eliminated in 1999 by the Federal Reports Elimination and Sunset Act of 1995. Pub. L. 

No. 104-66, §303, 109 Stat. 707, 734. 

36The most recent state profiles compiled 2000 data on levels of employment, projected

growth, and key environmental factors affecting demand for health care. Because these 

profiles did not include national workforce projections, they were outside of the scope of 

our review. See http://bhpr.hrsa.gov/healthworkforce/reports/profiles/, downloaded

September 7, 2005. 

Page 24 GAO-06-55 Health Professions Education Programs
managed care, which makes use of primary care “gatekeepers.” The 

assumption was that the gatekeepers would limit patients’ use of specialist

care. Partly because the assumption about growth in managed care proved 

incorrect, however, the projected shortage of primary care physicians 

failed to materialize.37

COGME’s January 2005 report recognized the uncertainty inherent in any 

effort to forecast the physician workforce many years into the future. 

COGME’s report showed, for example, that physician supply and demand

could shift because changing lifestyles may prompt new physicians to 

work fewer hours than their predecessors, an increase in the nation’s 

wealth could contribute to continued increases in the use of medical 

services, or an increased supply of nurse practitioners and other 

nonphysician clinicians could reduce the demand for physicians. Given 

this uncertainty, as well as the costs to expand medical education and 

training capacity, COGME strongly recommended that the nation develop

systems to track physician workforce supply, demand, and distribution 

and undertake a comprehensive reassessment within the next 4 years to 

guide future decisions on medical education capacity. 

Our work continues to point to the need for better information to assess 

the performance of title VII and title VIII programs. The agency’s current 

published goals and measures are not comprehensive, and the data to

measure performance in meeting them have been problematic. As a result, 

HHS cannot fully inform Congress or the public about the value of title VII 

and title VIII health professions education programs. It remains to be seen 

whether HRSA’s current strategic planning and associated data collection

efforts will remedy these shortcomings. 

Conclusions 

In addition, the ability of HHS and Congress to target federal resources to 

appropriate health professions education programs will remain limited 

without useful information on future health workforce needs. Updated 

workforce supply and demand projections are vital for informed decision 

making about health professions programs. Without relevant goals and 

performance measures, coupled with key data, HHS and Congress will 

 37More recent workforce research has again raised concerns that the nation is likely to face 

a shortage of physicians. For example, in October 2003, AMA noted that several published 

studies have demonstrated that the expected oversupply had not appeared. COGME, in a

January 2005 report, has also acknowledged that the nation may face a physician shortage

by the year 2020. 

Page 25 GAO-06-55 Health Professions Education Programs
lack information that would enable them to target federal funds effectively 

to those health professions education programs most critical to meeting 

the nation’s anticipated need for health professionals. 

We recommend that the Administrator of HRSA develop a strategy and 

establish time frames to more regularly update and publish national 

workforce projections for the health professions. 

In written comments on a draft of this report (see app. IV), HRSA agreed 

with the need for clear, relevant goals and performance measures backed 

by timely and complete data, and it agreed with the importance of updated 

workforce supply and demand projections. HRSA stated that completing 

development of the agency’s new performance goals and measures and 

integrating these new goals and measures into the agency’s data collection 

systems are a top priority. HRSA also agreed with our conclusion that 

updated workforce supply and demand projections are vital for informed 

decision making in the changing health care environment. 

Recommendation for 

Executive Action 

Agency Comments 

The agency commented, however, on the scope of our work. First, HRSA 

commented that the draft report did not include the many objectives 

authorized for funding under title VII and title VIII of the Public Health 

Service Act. Although we reviewed the act’s provisions for background 

purposes, our scope was to examine HRSA’s stated goals for the title VII 

and title VIII programs and the agency’s efforts to measure progress 

toward meeting those goals. According to HRSA officials, the GPRA goals 

in the fiscal year 2006 budget justification were the agency’s published 

goals for the programs at the time of our review. While we were aware of, 

and reported on, the agency’s efforts to develop a new strategic plan and 

associated goals, measures, and data, they were in draft form at the time of

our review, and HRSA had yet to formally adopt or finalize them. Since the 

agency provided technical comments including time frames associated 

with these efforts, we removed a recommendation that the agency 

establish such time frames. 

Second, regarding workforce analyses, the agency commented that our 

draft report did not discuss the considerable body of work produced by

regional workforce centers and advisory committees that receive title VII 

and title VIII funding from HRSA. Because the scope of our review 

regarding workforce issues was limited to the most recent projected 

estimates (completed and published) of national supply and demand for 

physicians, dentists, nurses, and pharmacists, we did not include other 

Page 26 GAO-06-55 Health Professions Education Programs
reports produced or drafted by or for HRSA, its regional workforce 

centers, or its advisory groups. We did, however, acknowledge that 

HRSA’s National Center for Health Workforce Analysis conducts a variety

of activities other than national supply and demand projections. We 

incorporated HRSA’s technical comments as appropriate. 

As agreed with your offices, unless you publicly announce the contents of

this report earlier, we plan no further distribution of it until 30 days after 

its issue date. At that time, we will send copies to the Secretary of HHS, 

the Administrator of HRSA, and appropriate congressional committees. 

We will also provide copies to others upon request. In addition, the report

is available at no charge on the GAO Web site at http://www.gao.gov. 

If you or your staff have any questions regarding this report, please 

contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this report. GAO staff who made major contributions to this 

report are listed in appendix V. 

Leslie G. Aronovitz 

Director, Health Care 

Page 27 GAO-06-55 Health Professions Education Programs
Appendix I: Examples of Additional Sources 

of Federal Funding for Health Professions Appendix I: Examples of Additional Sources Education 

of Federal Funding for Health Professions 

Education 

Table 4: Examples of Federal Funding Sources, besides Title VII and Title VIII Programs, for Postsecondary Education and 

Training Specifically Targeted for Health Professions

Agency Program

2004 funding 

(millions of dollars)

Department of Health and Human Services Centers for Medicare & Medicaid Services: Medicare payments 

for graduate medical educationa

$7,900

Centers for Medicare & Medicaid Services: Medicaid payments 

for graduate medical education b

Health Resources and Services Administration: Children’s 

Hospitals Graduate Medical Education Payment Program $303

Health Resources and Services Administration: National Health 

Service Corps $170

Health Resources and Services Administration: Bioterrorism

Training and Curriculum Development Program $28

Indian Health Service: Loan Repayment Program $12

Department of Defense Defense Health Program: health professions scholarship 

program and education and training $318

Department of Labor Employment and Training Administration: President’s High 

Growth Job Training Initiative (health care) c

Department of Veterans Affairs Veterans Health Administration: education and training 

programs for health professions students and residents $493

Source: GAO.

a

Medicare’s graduate medical education payments are made to teaching hospitals for both direct and 

indirect graduate medical education costs on the basis of factors such as the number of physicians 

being trained, Medicare’s share of patient days in the hospital, and the hospital’s ratio of residents to

beds. 

b

Citing a 50-state survey conducted for the Association of American Medical Colleges, COGME 

reported that Medicaid provided teaching hospitals between $2.5 and $2.7 billion in 2002. See 

Council on Graduate Medical Education, Department of Health and Human Services, Health 

Resources and Services Administration, State and Managed Care Support for Graduate Medical 

Education: Innovations and Implications for Federal Policy (Rockville, Md.: July 2004). 

c

This initiative focuses on 14 targeted sectors, one of which is health care. As part of this initiative, the 

Secretary of Labor announced awards of more than $24 million in grants to counter health care labor 

shortages in 2004. 

Page 28 GAO-06-55 Health Professions Education Programs
Appendix I: Examples of Additional Sources 

of Federal Funding for Health Professions

Education 

Table 5: Examples of Federal Funding Sources for General Postsecondary Education and Training Including, but Not 

Exclusive to, Health Professions

Agency Source

2004 funding

(millions of dollars)

Department of Education Federal student aid programsa$20,544

Department of Health and Human Services National Institutes of Health: NIH Extramural Loan Repayment 

Programs $73

Department of Labor Employment and Training Administration: Job Corpsb$1,537

Source: GAO.

a

Include programs such as the Department’s Federal Family Education Loan Program, Federal Pell 

Grant Program, Federal Perkins Loan Program, Federal Supplemental Educational Opportunity Grant

Program, and Federal Work-Study Program. 

b

As of May 2004, according to an official in the Department of Labor’s Employment and Training 

Administration, 105 Job Corps centers provided training in one or more of 12 different health-related 

training programs. 

Page 29 GAO-06-55 Health Professions Education Programs
Appendix II: Title VII and Title VIII Clusters 

and Programs, Fiscal Year 2004 

Cluster nameaPrograms funded in fiscal year 2004b

Title VII 

Student Loans Health Professions Student Loans 

Loans for Disadvantaged Students 

Primary Care Loans 

Health Professions Training for Diversity Centers of Excellence 

Faculty Loan Repayment Program 

Health Careers Adopt a School Demonstration Program 

Health Careers Opportunity Program 

Minority Faculty Fellowship Program 

Scholarships for Disadvantaged Students Program 

Training in Family Medicine, General

Internal Medicine, General Pediatrics, 

Physician Assistants, General Dentistry, 

and Pediatric Dentistry 

Academic Administrative Units in Primary Care

Cooperative Agreement to Plan, Develop, Implement and Operate a Continuing 

 Clinical Education Program in the Pacific Basin 

Faculty Development in Primary Care 

Physician Assistant Training in Primary Care

Predoctoral Training in Primary Care 

Residency Training in General and Pediatric Dentistry 

Residency Training in Primary Care 

Training in Primary Care Medicine and Dentistry 

Interdisciplinary, Community-Based 

Linkages 

Allied Health Projects 

Basic/Core Area Health Education Centers

Chiropractic Demonstration Project Grants 

Geriatric Academic Career Awards 

Geriatric Education Centers

Geriatric Training for Physicians, Dentists, and Behavioral and Mental Health 

 Professionals

Graduate Geropsychology Education Program

Graduate Psychology Education Program 

Health Education and Training Centers 

Model State-Supported Area Health Education Centers 

Podiatric Residency Training in Primary Care

Quentin N. Burdick Program for Rural Interdisciplinary Training 

Health Professions Workforce Information 

and Analysis 

Center for Health Workforce 

Public Health Workforce ASPH [Association of Schools of Public Health] Cooperative Agreementc 

Dental Public Health Residency Training Grants 

Health Administration Traineeships and Special Projects 

Preventive Medicine Residency Program 

Public Health Traineeships 

Public Health Training Centers Grant Program

Appendix II: Title VII and Title VIII Clusters 

and Programs, Fiscal Year 2004 

Page 30 GAO-06-55 Health Professions Education Programs
Appendix II: Title VII and Title VIII Clusters 

and Programs, Fiscal Year 2004 

Cluster nameaPrograms funded in fiscal year 2004b

Title VIII

Nursing Workforce Development Advanced Education Nursing Program 

Advanced Education Nursing Traineeships 

Basic Nurse Education and Practice Grants

Clinical Experience in Federally-Funded Community Health Centers for Nurse 

 Practitioners and/or Nurse-Midwifery Students 

Comprehensive Geriatrics Education Program

Nurse Anesthetist Traineeships

Nurse Education, Practice, and Retention Grant Program: Grants for Career Ladder 

 Programs 

Nurse Education, Practice, and Retention Grant Program: Grants for Enhancing Patient

 Care Delivery System Program 

Nurse Education, Practice, and Retention Grant Program: Grants for Internships and 

 Residency Programs 

Nurse Faculty Loan Program

Nursing Education Loan Repayment Program

Nursing Scholarship Program

Nursing Student Loans 

Nursing Workforce Diversity Grants 

Source: GAO analysis.

a

Cluster names reflect headings of parts and subparts of title VII and of title VIII of the Public Health 

Service Act, as amended by Pub. L. No. 105-392, and in some cases differ slightly from those in 

Senate Report No. 105-220. 

b

Include (1) programs that awarded funds competitively through grants or cooperative agreements

and that announced funding availability separately or had a separate selection panel and 

(2) programs providing direct assistance, such as student loans to individuals, regardless of whether 

the loan program received any new appropriations. Table does not include four advisory groups—

COGME, the National Advisory Council on Nurse Education and Practice, the Advisory Committee on

Training in Primary Care Medicine and Dentistry, and the Advisory Committee on Interdisciplinary, 

Community-Based Linkages—operating in fiscal year 2004. Names for grant and cooperative 

agreement programs reflect those used in the Federal Register or other program announcements. 

c

This program, which allows schools of public health to apply for HRSA funding to support certain 

special projects, includes a cooperative agreement with ASPH to provide information to, and 

coordinate with, the schools of public health that inquire about grant opportunities under this program.

HRSA has sole discretion to determine whether projects are funded. 

Page 31 GAO-06-55 Health Professions Education Programs
Appendix III: Additional Performance Goals

and Targets for Health Professions and Appendix III: Additional Performance Goals Nursing Education Programs

and Targets for Health Professions and 

Nursing Education Programs 

GPRA performance goals

Long-term and 

interim targets Available data for year

Health Education Assistance Loans Program 

Phase out the outstanding loan portfolio, resulting in a reduction in the 

federal liability associated with the Health Education Assistance Loans 

Program 

$1.7 million in 2006 

$1.9 million in 2005 

$2.6 million in 2004 

$2.7 million in 2003 

$3.3 million in 2002 

$3.4 million in 2001 

$3.6 million in 2000 

$2.0 million in 2004

$2.3 million in 2003

$2.7 million in 2002

$3.2 million in 2001

$3.5 million in 2000

Health Professions Workforce Information and Analysis 

Annually produce results of data collection and analysis activities to inform 

the market regarding issues relevant to health professions and nursing 

workforce (number of reports) 

25 reports in 2006 

25 reports in 2005 

23 reports in 2004 

23 reports in 2003 

11 reports in 2002 

10 reports in 2001 

21 reports in 2004

23 reports in 2003

14 reports in 2002

10 reports in 2001

Nursing Education Loan Repayment Program (NELRP) and Scholarship Program 

Increase the number of individuals enrolled in professional nursing education 

programs 

Baseline +

10% in 2010 

Estimated 240,500 

in 2004 (baseline)a

Increase the proportion of nursing scholarship recipients who, within 

4 months of licensure, are working in a facility with a critical shortage of 

nurses 

85% in 2006 

80% in 2005 

75% in 2004 23% in 2004b

Increase the proportion of NELRP participants working in shortage facilities, 

such as disproportionate share hospitals for Medicare and Medicaid, nursing 

homes, public health departments (state and local), and public health clinics 

within these departments 

85% in 2010:c 

90% in 2006c

85% in 2005c

65% in 2004c 100% in 2004

100% in 2003

Increase the proportion of states in which NELRP contract recipients work 93% in 2006 

93% in 2005 

85% in 2004 

65% in 2003 

50% in 2002 

98% in 2004

88% in 2003

82% in 2002

Increase the proportion of NELRP participants who remain employed at a 

critical-shortage facility for at least 1 year beyond termination of their NELRP 

service 

28% in 2010: 

11% in 2006 

11% in 2005 

10% in 2004 40% in 2004d

Reduce the federal investment per year of direct support by increasing the 

proportion of program participants who extend their service contracts and 

commit to work at a critical-shortage facility for an additional year 

45% in 2006 

40% in 2005 

22% in 2004 44% in 2004

18% in 2001 (baseline)

Source: Department of Health and Human Services, Health Resources and Services Administration, Fiscal Year 2006 Justification of 

Estimates for Appropriations Committees (Washington, D.C.: n.d.).

Note: All years are fiscal years. 

a

Number of students in all prelicensure registered nursing programs in the 2002–03 academic year. 

Page 32 GAO-06-55 Health Professions Education Programs
Appendix III: Additional Performance Goals

and Targets for Health Professions and 

Nursing Education Programs

b

The target was based on the assumption that all scholars would complete programs and enter 

service at the same time. According to the Health Resources and Services Administration, 23 percent

of the 2003 scholarship recipients had completed programs in fiscal year 2004 and entered into 

service. 

c

The actual performance greatly exceeded the original targets because a large number of applicants

worked in facilities with the most critical shortages. As a result, the agency increased the targets for 

2005 and 2006. 

d

Preliminary estimate. HRSA’s fiscal year 2006 budget justification indicates that targets will be 

revised once the fiscal year 2004 data are finalized. 

Page 33 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and Appendix IVServices Administration : Comments from the Health 

Resources and Services Administration 

Page 34 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and 

Services Administration 

Page 35 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and 

Services Administration 

Page 36 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and 

Services Administration 

Page 37 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and 

Services Administration 

Page 38 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and 

Services Administration 

Page 39 GAO-06-55 Health Professions Education Programs
Appendix IV: Comments from the Health Resources and 

Services Administration 

Page 40 GAO-06-55 Health Professions Education Programs
Appendix V: GAO Contact and Staff Acknowledgments

Page 41 GAO-06-55 

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact Leslie G. Aronovitz at (312) 220-7600 or aronovitzl@gao.gov 

In addition to the person named above, Kim Yamane, Assistant Director; 

George Bogart; Matt Byer; Ellen W. Chu; and Karlin Richardson made key 

contributions to this report. 

Acknowledgments 

 Health Professions Education Programs
Related GAO Products 

Page 42 GAO-06-55 

Related GAO Products 

Physician Workforce: Physician Supply Increased in Metropolitan and 

Nonmetropolitan Areas but Geographic Disparities Persisted. GAO-04-

124. Washington, D.C.: October 31, 2003. 

Health Care: Adequacy of Pharmacy, Laboratory, and Radiology 

Workforce Supply Difficult to Determine. GAO-02-137R. Washington, D.C.: 

October 10, 2001. 

Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. 

GAO-01-944. Washington, D.C.: July 10, 2001. 

Health Professions Education: Clarifying the Role of Title VII and VIII 

Programs Could Improve Accountability. GAO/T-HEHS-97-117. 

Washington, D.C.: April 25, 1997. 

Health Professions Education: Role of Title VII/VIII Programs in 

Improving Access to Care Is Unclear. GAO/HEHS-94-164. Washington, 

D.C.: July 8, 1994. 

(290382) Health Professions Education Programs
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