Maupin, John E. DDS, MBA; Riley, Wayne J. MD, MPH, MBA
The 110th Congress is mired in a battle to pass its appropriations bills for FY2009, including a bill that provides funding for health professions training—the Labor-Health and Human Services-Education (L-HHS) Appropriations bill. The Health Resources and Services Administration's (HRSA) health professions training programs, or “Title VII programs,” are currently being funded far below their historic funding level as a result of funding cuts to the L-HHS bill in FY2006. The diversity cluster of the Title VII programs has fared disproportionately poorly and has sustained the most dramatic cuts. And now, the 2009 budget proposal recommends the total elimination of all funding for the Title VII health professions training programs, including Health Professions Training for Diversity Programs.
From our vantage points as the presidents of two of the nation's private, historically black academic health centers—Meharry Medical College in Nashville, Tennessee, and Morehouse School of Medicine in Atlanta, Georgia—there is deep concern over the administration's FY2009 budget's proposed funding elimination. These programs support institutions that have demonstrated the greatest commitment to and success in training minorities for health professions careers. Meharry and Morehouse are private institutions, with very public missions—to diversify the health professions and to serve the underserved of all races and ethnicities. Thus, our institutions are unique among the nation's array of academic health centers (AHCs).
And, from our vantage points as AHC presidents, we can personally attest to the fact that Title VII programs have changed the lives of many aspiring health care professionals, their patients, and the communities they serve. A worthy example of the quality and impact of these programs is that of coauthor Wayne Riley, whose transformation from student body president at Morehouse School of Medicine to president and CEO of Meharry Medical College was witnessed by coauthor John Maupin as Morehouse School of Medicine's then-executive vice president. The most telling impact of the Title VII programs is Dr. Riley's personal testimony that the Faculty Loan Repayment Program allowed him the chance to focus on a career of medical education. Though Dr. Riley does fulfill the purpose of the Title VII programs by still seeing patients in Nashville, he has been able to avoid the lure of more lucrative private practice to pay off his medical school loans to fulfill his life's mission of medical education. Without that program, Dr. Riley would not have advanced as thoroughly, nor would he be Dr. Maupin's successor as leader of Meharry today.
Both of us know there are many more Wayne Rileys in the pipeline of the Title VII programs. Just this past May, our two institutions collectively graduated approximately 250 new physicians, dentists, biomedical scientists, and public health professionals, many of whom are African American, Hispanic, and others who have special sensitivity for caring for the underserved. They are now in the health professions workforce in graduate medical education training programs, advanced dental education programs, postdoctoral fellowships, and other key positions across this nation. Title VII programs are critical to our continued ability to send these talented young men and women to communities where they are needed most. Sadly, there are many others who are not afforded entrance into the pipeline because of insufficient funding. We have the power to change this through continued and improved Title VII funding.
However, the FY2009 budget contained no funding for the Title VII health professions training programs, and it included no funding for the Health Professions Training for Diversity Programs. Without these important programs, most of our historically black health professions schools will be unable to sustain their valuable and unique roles in helping to enhance the diversity of America's health professions workforce. In 1987, President Ronald Reagan and the U.S. Congress acknowledged their understanding and appreciation of the unique economic circumstances and valuable contributions of Meharry Medical College School of Medicine, Meharry Medical College School of Dentistry, Xavier University College of Pharmacy, and the Tuskegee University School of Veterinary Medicine by amending Part F of Title VII of the Public Health Service Act through the passage of Public Law No. 100-97, the “Excellence in Minority Health Education and Care Act,” creating HRSA's Centers of Excellence (COE) program. Subsequent to this landmark legislation, Morehouse School of Medicine was authorized by Congress to participate in the program because its mission is similar to those mentioned above—to recruit and train minorities and other students as physicians, biomedical scientists, and public health professionals committed to the primary health care needs of the underserved.
Health professions schools, minority or otherwise, pursue four distinct yet interrelated missions: education, patient care, research, and service. Each mission or enterprise is also supported by separate economic circumstances and funding streams. The cross-subsidization of the educational mission from patient-care revenues has declined dramatically during the past decade. For institutions whose training programs are mostly limited to public hospital affiliations, like Meharry and Morehouse School of Medicine, such cross-subsidization is nonexistent, in large part because of the extraordinary volume of uninsured and underinsured patients.
Although Medicare and Medicaid graduate medical education funding supports the training of residents, such funds do not support the direct expenses of medical or dental student education. Contrary to what some federal officials may believe, revenues from research activities and other grants cannot provide funding for the educational activities supported by Title VII health professions training program grants. More than ever, public and private AHCs with similar missions are dependent on support from specially targeted programs such as Title VII and Title III (Higher Education Act).
This environment presents an especially daunting challenge for private, historically black health professions schools, given the unique mission, legacy of undercapitalization, and modest annual revenue sources. Our institutions have always operated with a relatively low tuition revenue base in comparison with nonminority health professions schools. This is reflective of the financial circumstances of the students they tend to attract. The majority of our students primarily come from modest or disadvantaged socioeconomic backgrounds and are often first-generation college graduates. Therefore, it is nearly impossible for historically black health professions schools to raise tuition (and thereby increase student debt) in order to improve financial viability.
Our institutions have subsisted over the years with modest levels of annual gifts and endowment income, reflective of small endowments (1/10 the national average) and a slim donor constituency. Many of our graduates practice in underserved areas and work in federally qualified community health centers and public health department clinics across this nation. Our institutions (and the hospitals we serve) are unable to attract the huge philanthropic gifts and the high level of alumni giving that many other schools take for granted.
Moreover, our institutions have not benefited significantly from research activity, and its related technology transfer revenues, because of the relatively small faculties and their heavy teaching and patient-care responsibilities. In addition, our institutions are challenged by their inability to secure the capital needed to support the infrastructure required for a large, highly competitive research environment.
Fortunately, in recent years, great strides have been made to strengthen historically black health professions schools. Private institutions, such as the Kresge Foundation, have provided resources to strengthen their fundraising expertise and capacity. The research infrastructure and capacity of these institutions have been significantly enhanced by initiatives sponsored by the National Center for Research Resources and the National Center on Minority Health and Health Disparities (NCMHD) within the National Institutes of Health (NIH). Partnerships with local government agencies—such as Meharry's partnership with Nashville Metropolitan General Hospital and Vanderbilt University Medical School, and Morehouse's collaboration with Emory University Medical School—and recent advances in both institutions' relationship with the Veterans Administration medical facilities have helped to mitigate some of the clinical training and patient-care challenges these institutions have traditionally faced. Yet, the limits under which historically black health professions schools operate have only partially been mitigated by these advances.
These conditions were echoed in the 1987 Excellence in Minority Health Education and Care Act report by the Committee on Labor and Human Resources: the original four private, historically black health professions schools (the original four minority centers of excellence), which many consider as national resources, deserve appropriate federal support in recognition of the contributions they make by training large numbers of African Americans and other minorities in the health professions. The committee report also acknowledged that the economic challenges faced by these institutions as a consequence of their unique mission, modest resources, and composition of their student, patient, and donor constituency placed them in chronic financial jeopardy unless federal support was provided. The proposed elimination of such funding would further dismantle the cornerstone of this nation's efforts to improve the geographic distribution, quality, and racial and ethnic diversity of the health care workforce.
Without annual support from Title VII health professions training programs, the affected institutions would face severe financial challenges to maintaining their academic programs. Immediately, there would be insufficient funds for faculty salary support, necessitating a major reduction, thus significantly compromising the quality of existing programs and jeopardizing accreditation. Ultimately, approval of the administration's budget as recommended would have a disproportionate crippling impact on Meharry Medical College, Morehouse School of Medicine, and similar institutions, eventually leading to the possibility of mission change or closure of some programs. This is especially true given today's challenging AHC environment, which portends continuing deterioration of clinical margins, reductions in Medicaid and Medicare funding and a growing number of uninsured and underinsured, increasing competition for biomedical research funding, tremendous clinical service capital demands and system gaps in research capitalization, and increased emphasis on the use of biomedical informatics to drive health care quality and scientific discovery. Although the above-described environment is difficult for all academic health centers, it is particularly challenging for an institution with a generalist training, community-centered mission focus.
Furthermore, the elimination of these programs would curtail the contributions these institutions make toward ensuring the availability and placement of culturally sensitive health care providers and public health practitioners for service in federally qualified community health centers, public health departments, and private practice settings in medically underserved communities.
Specifically, the continued underfunding of the Health Professions Training for Diversity Programs (the Minority Centers of Excellence, Health Careers Opportunity, Scholarships for Disadvantaged Students, and Faculty Loan Repayment programs) would severely hinder the viability of core academic and academic support activities of Meharry Medical College's Schools of Medicine and Dentistry and Morehouse School of Medicine along with other vulnerable historically black institutions which have made significant contributions to minority health professionals' education.
There is also an indirect negative consequence to the elimination of these programs, in particular the COE program. The eligibility criteria for the endowment grant program of the NCMHD of NIH requires that the applicant institution is designated as a Minority Center of Excellence grantee by HRSA. Without designation as COEs, our institutions would not qualify for the NCMHD Research Endowment Program, NIH's investment initiative that promotes minority health and health disparities research and capacity building at eligible academic institutions by investing in the education and training of underrepresented minorities and socioeconomically disadvantaged individuals through the endowment funding.
In addition to the adverse consequences for minority institutions, there are, of course, negative outcomes for AHCs, broadly speaking. Many nonminority academic institutions across the nation are involved in and contributing to the biomedical research and health disparities research fields in ways they never did before because of the Title VII health professions training programs. When fully funded, Title VII programs focused on health disparities populations were housed at majority institutions such as the University of Pennsylvania, Stanford University, the Medical College of Georgia, the University of Michigan, and others. The venture into Title VII by these majority institutions has exposed students nationwide to the pipeline of health care opportunities and has provided a venue for majority institutions to build relationships with traditional minority serving institutions.
Unfortunately, the proposed elimination of funding for Title VII health professions training programs destroys the delicate economic balance of the four missions of education, patient care, research, and service, thereby negating the substantial investments and notable progress made during the past decade.
When the 111th Congress convenes in early January, the appropriations bill for the U.S. Department of Health and Human Services may still be under consideration, and it will provide funding for the remainder of the fiscal year. Negotiations on the final funding levels for health professions programs are starting to take place now. For all of the reasons we have outlined in this commentary, we urge the current and incoming administration and Congress to provide restored funding to $300 million for HRSA's health professions training programs, in particular the Health Professions Training for Diversity Programs. This is a societal and governmental imperative, given the well-documented disparities in access to and outcomes of medical and health care among minority and other socioeconomic populations. It is simply the right thing to do.