[House Report 110-872]
[From the U.S. Government Publishing Office]
110th Congress Report
HOUSE OF REPRESENTATIVES
2d Session 110-872
======================================================================
PHYSICIAN WORKFORCE ENHANCEMENT ACT OF 2008
_______
September 23, 2008.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
_______
Mr. Dingell, from the Committee on Energy and Commerce, submitted the
following
R E P O R T
[To accompany H.R. 2583]
[Including cost estimate of the Congressional Budget Office]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 2583) to amend title VII of the Public Health
Service Act to establish a loan program for eligible hospitals
to establish residency training programs, having considered the
same, report favorably thereon with an amendment and recommend
that the bill as amended do pass.
CONTENTS
Page
Amendment........................................................ 1
Purpose and Summary.............................................. 3
Background and Need for Legislation.............................. 3
Hearings......................................................... 4
Committee Consideration.......................................... 4
Committee Votes.................................................. 4
Committee Oversight Findings..................................... 4
Statement of General Performance Goals and Objectives............ 4
New Budget Authority, Entitlement Authority, and Tax Expenditures 4
Earmarks and Tax and Tariff Benefits............................. 5
Committee Cost Estimate.......................................... 5
Congressional Budget Office Estimate............................. 5
Federal Mandates Statement....................................... 6
Advisory Committee Statement..................................... 6
Constitutional Authority Statement............................... 6
Applicability to Legislative Branch.............................. 7
Section-by-Section Analysis of the Legislation................... 7
Changes in Existing Law Made by the Bill, as Reported............ 7
Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Physician Workforce Enhancement Act of
2008''.
SEC. 2. HOSPITAL RESIDENCY LOAN PROGRAM.
Subpart 2 of part E of title VII of the Public Health Service Act is
amended by adding at the end the following new section:
``SEC. 771. HOSPITAL RESIDENCY LOAN PROGRAM.
``(a) Establishment.--Not later than October 1, 2010, the Secretary,
acting through the Administrator of the Health Resources and Services
Administration, shall establish a hospital residency loan program that
provides loans to eligible hospitals to establish a residency training
program.
``(b) Application.--No loan may be provided under this section to an
eligible hospital except pursuant to an application that is submitted
and approved in a time, manner, and form specified by the Administrator
of the Health Resources and Services Administration. A loan under this
section shall be on such terms and conditions and meet such
requirements as the Administrator determines appropriate, in accordance
with the provisions of this section.
``(c) Eligibility; Preference for Rural Areas.--
``(1) Eligible hospital defined.--For purposes of this
section, an `eligible hospital' means, with respect to a loan
under this section, a public or non-profit hospital that, as of
the date of the submission of an application under subsection
(b), meets, to the satisfaction of the Administrator of the
Health Resources and Services Administration, each of the
following criteria:
``(A) The hospital does not operate a residency
training program and has not previously operated such a
program.
``(B) The hospital has secured initial accreditation
by the American Council for Graduate Medical Education
or the American Osteopathic Association.
``(C) The hospital provides assurances to the
satisfaction of the Administrator of the Health
Resources and Services Administration that such loan
shall be used, consistent with subsection (d), only for
the purposes of establishing and conducting an
allopathic or osteopathic physician residency training
program in at least one of the following, or a
combination of the following:
``(i) Family medicine.
``(ii) Internal medicine.
``(iii) Obstetrics or gynecology.
``(iv) Behavioral or Mental health.
``(v) Pediatrics.
``(D) The hospital enters into an agreement with the
Administrator that certifies the hospital will provide
for the repayment of the loan in accordance with
subsection (e).
``(2) Preference for rural areas.--In making loans under this
section, the Administrator of the Health Resources and Services
Administration shall create guidelines that give preference to
rural areas (as such term is defined in section 1886(d)(2)(D)
of the Social Security Act).
``(d) Permissible Uses of Loan Funds.--A loan provided under this
section shall be used, with respect to a residency training program,
only for costs directly attributable to the residency training program,
except as otherwise provided by the Administrator of the Health
Resources and Services Administration.
``(e) Repayment of Loans.--
``(1) Repayment plans.--For purposes of subsection (c)(1)(D),
a repayment plan for an eligible hospital is in accordance with
this subsection if it provides for the repayment of the loan
amount in installments, in accordance with a schedule that is
agreed to by the Administrator of the Health Resources and
Services Administration and the hospital and that is in
accordance with paragraphs (2), (3), and (4).
``(2) Commencement of repayment.--Repayment by an eligible
hospital of a loan under this section shall commence not later
than the date that is 18 months after the date on which the
loan amount is disbursed to such hospital.
``(3) Repayment period.--A loan made under this section shall
be fully repaid not later than the date that is 24 months after
the date on which the repayment is required to commence.
``(4) Loan payable in full if residency training program
canceled.--In the case that an eligible hospital borrows a loan
under this section, with respect to a residency training
program, and terminates such program before the date on which
such loan has been fully repaid in accordance with a plan under
paragraph (1), such loan shall be payable by the hospital not
later than 45 days after the date of such termination.
``(f) No Interest Charged.--The Administrator of the Health Resources
and Services Administration may not charge or collect interest on any
loan made under this section.
``(g) Limitation on Total Amount of Loan.--The cumulative annual
dollar amount of a loan made to an eligible hospital under this section
may not exceed $250,000.
``(h) Penalties.--The Administrator of the Health Resources and
Services Administration shall establish penalties to which an eligible
hospital receiving a loan under this section would be subject if such
hospital is in violation of any of the criteria described in subsection
(c)(1). Such penalties shall include the charge or collection of
interest, at a rate to be determined by the Administrator of the Health
Resources and Services Administration. Except as otherwise provided,
penalties collected under this subsection shall be paid to the
Administrator of the Health Resources and Services Administration and
shall, subject to appropriation Acts, be available until expended for
the purpose of enforcing the provisions of this section.
``(i) Reports.--Not later than January 1, 2012, and annually
thereafter (before January 2, 2014), the Administrator of the Health
Resources and Services Administration shall submit to Congress a report
on the efficacy of the program under this section in increasing the
number of residents practicing in each medical specialty described in
subsection (c)(1)(C) during such year and the extent to which the
program resulted in an increase in the number of available
practitioners in each of such medical specialties that serve medically
underserved populations.
``(j) Funding.--
``(1) Authorization of appropriations.--For the purpose of
providing amounts for loans under this section, there are
authorized to be appropriated such sums as may be necessary to
provide--
``(A) $8,000,000 in loans for fiscal year 2010;
``(B) $8,400,000 in loans for fiscal year 2011;
``(C) $8,820,000 in loans for fiscal year 2012;
``(D) $9,261,000 in loans for fiscal year 2013; and
``(E) $9,724,050 in loans for fiscal year 2014.
``(2) Availability.--Amounts appropriated under paragraph (1)
shall remain available until expended.
``(k) Termination of Program.--No loan may be made under this section
after December 31, 2013.''.
Purpose and Summary
The purpose of H.R. 2583, the Physician Workforce
Enhancement Act of 2008, is to establish a loan program for
eligible hospitals to establish residency training programs in
allopathic and osteopathic medicine, with a preference for
hospitals located in rural areas.
Background and Need for Legislation
Recent trends in the physician workforce demonstrate that
the growth in the physician workforce is not keeping pace with
general population growth. Certain areas of practice, including
primary care and pediatrics, are expected to have more critical
shortages in the future. In 2006, the American College of
Physicians released a report entitled ``The Impending Collapse
of Primary Care Medicine and Its Implications for the State of
the Nation's Health Care.'' According to that report, as the
demand has grown for primary care due to growth in the number
of people with chronic diseases and long-term care needs of an
aging population, there has been a decline in the number of
medical students and training opportunities for primary care.
This problem will only be further exacerbated by the decline of
the physician workforce in years to come.
Residency training programs are an integral way to attract
physicians, particularly in hard-to-serve areas such as rural
areas. In the 16th report of the Council of Graduate Medical
Education, entitled, ``Physician Workforce Policy Guidelines
for the United States, 2000-2020,'' the Council recommended
that the number of physicians entering residency training each
year should be increased to 27,000 by 2015 to meet projected
demand of medical services. The Council recommends a
multifaceted approach to achieve this increase, and one
important part of that plan is to facilitate a modest increase
in medical education and training capacity over the next
decade.
One important source of funding for residency training
programs is Medicare. The Medicare program, however, caps the
number of residents and fellows eligible for Medicare
reimbursement. This can narrow the number of resources
available to some smaller hospitals that have the need for
residents that will later serve the community as physicians.
That cap was implemented at a time when it appeared that the
physician workforce would enjoy surpluses for some time and
that the use of managed health care services would reduce the
demand for medical services. Both trends have significantly
reversed in recent years, precipitating the need for a new
strategy to improve the health and vitality of the U.S.
physician workforce.
Hearings
No hearings were held in connection with H.R. 2583.
Committee Consideration
On Wednesday, September 17, 2008, the full Committee met in
open markup session and ordered H.R. 2583 favorably reported to
the House, amended, by a voice vote.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report legislation and amendments thereto. No
record votes were taken on amendments or in connection with
ordering H.R. 2583 reported to the House. A motion by Mr.
Dingell to order H.R. 2583 favorably reported to the House,
amended, was agreed to by a voice vote.
Committee Oversight Findings
Regarding clause 3(c)(1) of rule XIII of the Rules of the
House of Representatives, the oversight findings of the
Committee regarding H.R. 2583 are reflected in this report.
Statement of General Performance Goals and Objectives
The objective of H.R. 2583 is to expand and improve the
distribution of the physician workforce by creating new
opportunities for residency training programs, particularly in
rural areas.
New Budget Authority, Entitlement Authority, and Tax Expenditures
Regarding compliance with clause 3(c)(2) of rule XIII of
the Rules of the House of Representatives, the Committee finds
that H.R. 2583 would result in no new or increased budget
authority, entitlement authority, or tax expenditures or
revenues.
Earmarks and Tax and Tariff Benefits
Regarding compliance with clause 9 of rule XXI of the Rules
of the House of Representatives, H.R. 2583 does not contain any
congressional earmarks, limited tax benefits, or limited tariff
benefits as defined in clause 9(d), 9(e), or 9(f) of rule XXI.
Committee Cost Estimate
The Committee adopts as its own the cost estimate on H.R.
2583 prepared by the Director of the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974.
Congressional Budget Office Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate on
H.R. 2583 provided by the Congressional Budget Office pursuant
to section 402 of the Congressional Budget Act of 1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, September 23, 2008.
Hon. John D. Dingell,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 2583, the
Physician Workforce Enhancement Act of 2008.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Kirstin
Nelson.
Sincerely,
Peter A. Fontaine
(For Peter R. Orszag, Director).
Enclosure.
H.R. 2583--Physician Workforce Enhancement Act of 2008
H.R. 2583, the Physician Workforce Enhancement Act of 2008,
would allow eligible hospitals to receive a no-interest loan to
establish a residency training program. Eligible hospitals are
public or nonprofit hospitals that are not currently operating
and have not previously operated a residency training program.
Loans to individual hospitals could not exceed $250,000
annually. Loans could only be for costs directly related to
certain residency programs in one of (or a combination of) the
following areas: family medicine, internal medicine, obstetrics
and gynecology, behavioral or mental health, and pediatrics.
Assuming appropriation of the necessary amounts, CBO
estimates that implementing the bill would cost an additional
$1 million in 2010 and $4 million over the 2010-2013 period.
Enacting H.R. 2583 would not affect direct spending or
revenues.
H.R. 2583 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act. Public
hospitals in rural areas that establish residency training
programs would benefit from loans authorized in the bill.
Under H.R. 2583, hospitals would be required to enter into
an agreement with the Administrator of the Health Resources and
Services Administration (HRSA) to repay the loan in
installments beginning 18 months after the loan is disbursed.
H.R. 2583 would require that loans be repaid no later than 24
months after the loan repayment begins. Under the bill, if a
hospital receives a loan and then terminates the residency
training program before repaying the loan, the hospital would
have 45 days to repay the loan after terminating the residency
program. In making loans to eligible hospitals, the HRSA
Administrator would be required to establish guidelines that
give preference to hospitals in rural areas.
Lastly, H.R. 2583 would establish the loan program no later
than October 1, 2010. No loans could be made under this program
after December 31, 2013.
H.R. 2583 would authorize the appropriation of such sums as
may be necessary to provide $8 million in loans for 2010 and
$34 million in loans over the 2009-2013 period. Under the
Federal Credit Reform Act of 1990, the cost of a loan program
is measured as the net present value of cash flows over the
life of the loan. Hospitals would begin to repay the loan 18
months after disbursement and would repay the entire loan
amount within 24 months after repayments begin. CBO estimates
that the subsidy cost for the no-interest loans would total
about $1 million per year over the 2010-2013 period.
The estimated cost of H.R. 2583 is shown in the following
table. The costs of this legislation fall within budget
function 550 (health).
------------------------------------------------------------------------
By fiscal year, in millions of
dollars--
---------------------------------------
2009 2010 2011 2012 2013
------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Authorization Level............. 0 1 1 1 1
Estimated Outlays............... 0 1 1 1 1
------------------------------------------------------------------------
The CBO staff contact for this estimate is Kirstin Nelson.
This estimate was approved by Keith J. Fontenot, Deputy
Assistant Director for Health and Human Resources, Budget
Analysis Division.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 2583 prepared by the Director of the
Congressional Budget Office pursuant to section 423 of the
Unfunded Mandates Reform Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
2583.
Constitutional Authority Statement
Pursuant to clause 3(d)(1) of rule XIII of the Rules of the
House of Representatives, the Committee finds that the
Constitutional authority for H.R. 2583 is provided in the
provisions of Article I, section 8, clause 1, that relate to
expending funds to provide for the general welfare of the
United States.
Applicability to Legislative Branch
The Committee finds that H.R. 2583 does not relate to the
terms and conditions of employment or access to public services
or accommodations within the meaning of section 102(b)(3) of
the Congressional Accountability Act of 1995.
Section-by-Section Analysis of the Legislation
Section 1. Short title
Section 1 establishes the short title as the Physician
Workforce Enhancement Act of 2008.
Section 2. Hospital residency loan program
Section 2 establishes the date of establishment for the
program as October 1, 2010; clarifies that an eligible hospital
means a public or non-profit hospital; establishes the list of
eligible professions as family medicine, internal medicine,
obstetrics or gynecology, behavioral or mental health,
pediatrics, or a combination of such professions; extends the
preference for loans to be given to rural areas, as defined by
section 1886(d)(2)(D) of the Social Security Act; makes clear
that permissible uses of loan funds are only meant to cover
direct costs that are determined by the Administrator of the
Health Resources and Services Administration to be necessary to
run the residency training program; establishes the date to
commence repayment as 18 months and the repayment period as 24
months; sets the limitation on the total amount of the loan, so
that no annual dollar amount may exceed $250,000; establishes a
penalties provision so that the Secretary may collect interest,
together with any other penalties, on defaulted loans (thereby
making the restriction in subsection (f) subject to the
authority to collect interest); and establishes the
authorization of appropriations ($8 million for fiscal year
(FY) 2009, $8.4 million for FY 2010, $8.82 million for FY 2011,
$9.261 million for FY 2012; and $9,724,050 for FY 2013); and
terminates the program after December 31, 2013.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
PUBLIC HEALTH SERVICE ACT
* * * * * * *
TITLE VII--HEALTH PROFESSIONS EDUCATION
* * * * * * *
PART E--HEALTH PROFESSIONS AND PUBLIC HEALTH WORKFORCE
* * * * * * *
Subpart 2--Public Health Workforce
* * * * * * *
SEC. 771. HOSPITAL RESIDENCY LOAN PROGRAM.
(a) Establishment.--Not later than October 1, 2010, the
Secretary, acting through the Administrator of the Health
Resources and Services Administration, shall establish a
hospital residency loan program that provides loans to eligible
hospitals to establish a residency training program.
(b) Application.--No loan may be provided under this section
to an eligible hospital except pursuant to an application that
is submitted and approved in a time, manner, and form specified
by the Administrator of the Health Resources and Services
Administration. A loan under this section shall be on such
terms and conditions and meet such requirements as the
Administrator determines appropriate, in accordance with the
provisions of this section.
(c) Eligibility; Preference for Rural Areas.--
(1) Eligible hospital defined.--For purposes of this
section, an ``eligible hospital'' means, with respect
to a loan under this section, a public or non-profit
hospital that, as of the date of the submission of an
application under subsection (b), meets, to the
satisfaction of the Administrator of the Health
Resources and Services Administration, each of the
following criteria:
(A) The hospital does not operate a residency
training program and has not previously
operated such a program.
(B) The hospital has secured initial
accreditation by the American Council for
Graduate Medical Education or the American
Osteopathic Association.
(C) The hospital provides assurances to the
satisfaction of the Administrator of the Health
Resources and Services Administration that such
loan shall be used, consistent with subsection
(d), only for the purposes of establishing and
conducting an allopathic or osteopathic
physician residency training program in at
least one of the following, or a combination of
the following:
(i) Family medicine.
(ii) Internal medicine.
(iii) Obstetrics or gynecology.
(iv) Behavioral or Mental health.
(v) Pediatrics.
(D) The hospital enters into an agreement
with the Administrator that certifies the
hospital will provide for the repayment of the
loan in accordance with subsection (e).
(2) Preference for rural areas.--In making loans
under this section, the Administrator of the Health
Resources and Services Administration shall create
guidelines that give preference to rural areas (as such
term is defined in section 1886(d)(2)(D) of the Social
Security Act).
(d) Permissible Uses of Loan Funds.--A loan provided under
this section shall be used, with respect to a residency
training program, only for costs directly attributable to the
residency training program, except as otherwise provided by the
Administrator of the Health Resources and Services
Administration.
(e) Repayment of Loans.--
(1) Repayment plans.--For purposes of subsection
(c)(1)(D), a repayment plan for an eligible hospital is
in accordance with this subsection if it provides for
the repayment of the loan amount in installments, in
accordance with a schedule that is agreed to by the
Administrator of the Health Resources and Services
Administration and the hospital and that is in
accordance with paragraphs (2), (3), and (4).
(2) Commencement of repayment.--Repayment by an
eligible hospital of a loan under this section shall
commence not later than the date that is 18 months
after the date on which the loan amount is disbursed to
such hospital.
(3) Repayment period.--A loan made under this section
shall be fully repaid not later than the date that is
24 months after the date on which the repayment is
required to commence.
(4) Loan payable in full if residency training
program canceled.--In the case that an eligible
hospital borrows a loan under this section, with
respect to a residency training program, and terminates
such program before the date on which such loan has
been fully repaid in accordance with a plan under
paragraph (1), such loan shall be payable by the
hospital not later than 45 days after the date of such
termination.
(f) No Interest Charged.--The Administrator of the Health
Resources and Services Administration may not charge or collect
interest on any loan made under this section.
(g) Limitation on Total Amount of Loan.--The cumulative
annual dollar amount of a loan made to an eligible hospital
under this section may not exceed $250,000.
(h) Penalties.--The Administrator of the Health Resources and
Services Administration shall establish penalties to which an
eligible hospital receiving a loan under this section would be
subject if such hospital is in violation of any of the criteria
described in subsection (c)(1). Such penalties shall include
the charge or collection of interest, at a rate to be
determined by the Administrator of the Health Resources and
Services Administration. Except as otherwise provided,
penalties collected under this subsection shall be paid to the
Administrator of the Health Resources and Services
Administration and shall, subject to appropriation Acts, be
available until expended for the purpose of enforcing the
provisions of this section.
(i) Reports.--Not later than January 1, 2012, and annually
thereafter (before January 2, 2014), the Administrator of the
Health Resources and Services Administration shall submit to
Congress a report on the efficacy of the program under this
section in increasing the number of residents practicing in
each medical specialty described in subsection (c)(1)(C) during
such year and the extent to which the program resulted in an
increase in the number of available practitioners in each of
such medical specialties that serve medically underserved
populations.
(j) Funding.--
(1) Authorization of appropriations.--For the purpose
of providing amounts for loans under this section,
there are authorized to be appropriated such sums as
may be necessary to provide--
(A) $8,000,000 in loans for fiscal year 2010;
(B) $8,400,000 in loans for fiscal year 2011;
(C) $8,820,000 in loans for fiscal year 2012;
(D) $9,261,000 in loans for fiscal year 2013;
and
(E) $9,724,050 in loans for fiscal year 2014.
(2) Availability.--Amounts appropriated under
paragraph (1) shall remain available until expended.
(k) Termination of Program.--No loan may be made under this
section after December 31, 2013.
* * * * * * *