Lack of Reauthorization Leaves Training Programs Without Adequate Direction or Funds

Congress has failed to reauthorize a number of primary-care related training programs during the past few years, leaving each without a renewed sense of direction or focus and making it much more difficult to obtain adequate funding for the initiatives, according to analysts interviewed by AAFP News Now.

In recent years, Congress has not reauthorized Title VII of the Public Health Service Act or the National Health Service Corps. The primary care training grants outlined in Title VII are designed to strengthen the primary care educational infrastructure at medical schools and residency programs and to encourage residents to pursue careers in locations where they can work with underserved populations. Section 747 of Title VII provides the only federal grants for the training of family physicians. The NHSC, meanwhile, provides financial assistance to medical students who agree to practice primary care in underserved areas after graduation.

Congress last reauthorized Title VII in 1998 for five years, leaving the program unauthorized since 2003. By the same token, Congress has not reauthorized the NHSC since 2002, leaving that program unauthorized since the start of 2007.

"Congress can and does continue to fund these programs and many other programs that are not currently authorized," said Dan Hawkins, policy director for the National Association of Community Health Centers. "As long they have not been repealed by Congress or stricken from the federal law, Congress can continue to fund them."

However, the reauthorization process gives Congress the opportunity to adjust or re-focus programs in key ways to meet emerging needs and trends. Without these periodic adjustments, the programs may continue to operate under outdated or obsolete rules and regulations, failing to adjust to changing circumstances and priorities and stagnating in the process, according to Hawkins and others.

Title VII, for instance, needs to be "more effective in dealing with community needs," but the changes that would enable the program to achieve that goal cannot be made until the program is reauthorized, said Hope Wittenberg, director of government relations for the Academic Family Medicine Advocacy Alliance.

The Bush administration, like previous administrations, has sought to eliminate Title VII funding; in 2004, the administration described the health professions provision of Title VII as ineffective based on a flawed analysis by the Office of Management and Budget, said Wittenberg. Title VII officials could not refute the administration's analysis with their own data because Title VII lacks internal ways of measuring the effectiveness of the program, said Wittenberg. A reauthorized bill could include a research component, giving officials the data they need to counter past and future mischaracterizations of the program.

By not reauthorizing Title VII and the NHSC, Congress is sending a subtle but clear message that these programs are not a priority, according to analysts. And that, in turn, has impeded funding efforts, they say.

"There is a fear that if a program goes unauthorized, it will languish," said Hawkins. "It will not get the attention of Congress, whether it is the appropriations committee or other committees that might relate to it because no one is paying attention."

Without a current authorization, appropriators do not have a clear sense of the true needs of the programs or where they are headed and, thus, are forced to make funding decisions based on their own determinations, leading in turn, to reduced funding levels, Hawkins said.

"This is not like a light switch -- it doesn't just turn off at a particular moment," he said. "It is more like a dimmer switch in that if a program goes years and years without being reauthorized, the light gets dimmer and dimmer."

Congress has provided level funding for Title VII and the NHSC for the past few years, but both programs have experienced dramatic funding decreases since they were last reauthorized. Section 747 of Title VII is now funded at $47.8 million, nearly $46 million less than the program's funding level in 2003. In the meantime, funding for the NHSC fell from $165 million in 2002 to $125 million in 2008.

Congress' inability to reauthorize Title VII and the NHSC does not reflect a lack of support for primary care programs on Capitol Hill, according to analysts. Congress itself has become more polarized in recent years, making the reauthorization process increasingly difficult.

For example, although the nation's community health centers enjoy overwhelming bipartisan support on Capitol Hill and from the Bush White House, Congress has been unable to approve legislation reauthorizing the centers since the last reauthorization in 2001.

In 2006, the House and the Senate both passed reauthorization bills, but they could not reach agreement on a final bill. This year, both chambers again have passed versions of a reauthorization bill, but they have not yet been able to reconcile the differences between the two to send a final version to the president for enactment.

"We appreciate the strong and solid work of the committee leaders and the leaders of the House and Senate on both sides of the aisle to move this legislation forward," said Hawkins. But he expressed frustration with a "legislative process that makes it more difficult to successfully (reauthorize) programs that have broad, bipartisan support."

"It is a cautionary tale of just how difficult the legislative process has become in recent years," Hawkins said.