Training Tomorrow's Doctors, For Now

July 12, 2005

Growing up in a moderate income area near San Diego, Arnold Cuenca had an interest in and aptitude for science in high school. But as he contemplated potential careers, he, like most of his peers, was encouraged to enter the military or take a job right out of high school -- paths most of his peers chose. His mom was a nurse, though, and that got him thinking about being a doctor.

"Other than my mom, I had nothing to encourage me to become a health professional -- I didn't know what medicine was," says Cuenca.

After high school, Cuenca went to the University of California at San Diego, where he majored in cell biology and biochemistry, and then to Western University of Health Sciences, where he became an osteopathic physician. Now, in addition to being a family medicine resident at a clinic in Chula Vista, Calif., he volunteers at the San Diego Border Area Health Education Center, which among other things encourages middle and high school students in the heavily Hispanic and economically struggling region to pursue careers in medicine and health.

"The children we work with have an opportunity to really know what it's like to work in medicine, to see patients, work in clinics," says Cuenca. "Programs like this give them exposure they won't receive anywhere else, and encourage them to come back and give service to their community, which is what I'm doing now."

Health education centers like the one on the San Diego-Mexico border are dotted throughout the country. They receive much of their funds from the U.S. Department of Health and Human Services' Health Resources and Services Administration, through a series of federal programs aimed at increasing and diversifying the pool of health care providers, directing them to high-need urban and rural areas, and preparing them to work in underserved fields like primary care and interdisciplinary, high demand ones such as geriatrics and allied health. 

The programs are now on the chopping block, as the government seeks to rein in burgeoning federal spending and to find budget savings to pay for competing priorities, such as tax cuts and the war in Iraq. Following a recommendation by the Bush administration, the House of Representatives approved a 2006 spending bill last month that would eliminate about $250 million of the $300 million that the government is spending this year on the health professions programs.

As Senate committees prepare this week to consider their chamber's measure to finance the Health and Human Services Department and other agencies, supporters of the programs hope lawmakers will consider just how much the programs help not only the current and future health workers they train, but, in turn, the patients they treat.

"Elimination of these programs will threaten access to health care in our neediest communities by placing further stress on the national shortage of health professionals," Jordan J. Cohen, president of the Association of American Medical Colleges, wrote last month to Sen. Bill Frist (R-Tenn.), the Senate majority leader and a physician, and his 99 colleagues in the Senate.

'Low Priority Programs'?

The health professions programs are facing elimination not so much because anyone on Capitol Hill views them as objectionable as because the Bush administration and the Republicans who control Congress are trying to find billions of dollars in budget cuts to pay for competing priorities like the war in Iraq and, as Democratic critics see it, "tax cuts for millionaires." 

On Monday, the House Appropriations Committee issued a news release that listed 99 "low priority" programs that face elimination "in a reflection of the austere budget climate." Ten of the programs were in HRSA's Bureau of Health Professions, including the Minority Health Careers Opportunity Program ($36 million) and $89 million for Primary Care Medicine and Dentistry. In 2004, the minority health-careers program gave grants to institutions as disparate as Bergen Community College, Morgan State University and Marquette University. In the Bush administration's budget proposal in February, the White House rated the health professions programs as "ineffective," according to its Program Assessment Rating Tool.

Compared to the tens of billions of dollars that flow into medical schools and research institutions via the grant programs at the National Institutes of Health, the $300 million that the government spends each year on the HRSA's health professions programs, known as "Title VII programs," are practically a pittance. But their small size means that, unlike those biomedical research programs, they tend not to top the priority lists of lobbyists, medical school deans, or other campus officials, which, supporters of the program acknowledge, partially explains why it's easy to characterize them as "low priority."

"Medical school deans get most of their money from the NIH, and believe me, they're on top of that," says John Blossom, professor of clinical family and community medicine at the University of California at San Francisco and director of California's statewide Area Health Education Center program. "The dollar amounts from the HRSA program are not as big, and they end up in silos with the department chairs, and so advocacy is harder."

But talk to the people who run these programs about their impact, and it is clear that the money makes a difference. Most of the programs team up medical schools and other campus health schools with local hospitals, nonprofit groups and government agencies in their communities, and the federal money tends to draw in state and private funds as well, often in support of goals that don't tend to top other priority lists. HRSA, for example, provided nearly $32 million in 2005 in grants for geriatric education centers, which train doctors and other health care workers to work with the elderly. 

"Geriatrics is an unfortunate example of market failure," says Elyse Perweiler, associate director of the New Jersey Geriatric Education Center, which is affiliated with the University of Medicine and Dentistry of New Jersey, and president of the National Association of Geriatric Education Centers. "People just don't go into the field, because it's not a big money maker and it's not glamorous."

That's an increasingly big problem as the number of elderly Americans balloons, so centers like Perweiler's find themselves increasingly stretched to the limits. "They don't get nearly enough money to deliver all the things we're expected to deliver," she says. "We're one of the best bargains around; we train so many and do so much with so little."

One of the challenges for the HRSA programs is proving it, given the broad array of services they provide and the difficulty in "attributing improvements in patient care to the training people receive" in the programs. "When legislators turn around and say, 'What impact have you had?, we know we do some good, and it can be implied or imputed, but it's hard to prove it in quantifiable ways."

Programs like Perweiler's have begun providing the government with statistics on the number of patients who are treated by the health care workers who have been trained through HRSA's health professions programs. Those who received training through the country's 47 geriatric centers in 2004, Perweiler says, had nearly 2.5 million "face to face patient encounters" that year. "That's reaching a huge number of people," she adds.

Advocates for the various health professions programs are looking to the Senate to rescue them, and there are some hopeful signs, including a letter signed by 44 senators urging continued funding for the health professions programs. But they recognize that scores of other programs and their supporters are looking for similar salvation, and that the climb is an uphill one.

Blossom, who oversees the California health education centers, prefers not to think what would happen if the federal money disappears from programs like the one that helps Arnold Cuenca try to persuade and encourage today's middle and high-schoolers to follow in his footsteps.

"Pulling that money out of it certainly threatens its existence," Blossom says. "Would it go away? I don't know. But you certainly wouldn't start any new ones."

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