Contents

• Introduction
• Organization of This Report
• Overview of Title VII
• Detailed Description of Title VII Programs and Activities
• Part A: Student Loans (§§701-728)
• Subpart I—Insured Health Education Assistance Loans to Graduate Students (§§701-720)
• Subpart II—Federally-Supported Student Loan Funds (§§721-728 and §735)
• Part B: Health Professions Training for Diversity (§§736-741)
• Centers of Excellence (COE) (§736)
• Scholarships for Disadvantaged Students (§737)
• Loan Repayments and Fellowships Regarding Faculty Positions (§738)
• Educational Assistance in the Health Professions Regarding Individuals from Disadvantaged Backgrounds (§739)
• Authorization of Appropriations (§740)
• Grants for Health Professions Education (§741)
• Part C: Training in Family Medicine, General Internal Medicine, General Pediatrics, Physician Assistants, General Dentistry, and Pediatric Dentistry (§§747-749B)
• Subpart I: Medical Training Generally (§§747-749A)
• Primary Care Training and Enhancement (§747)
• Training Opportunities for Direct Care Workers (§747A)
• Training in General, Pediatric, and Public Health Dentistry (§748)
• Advisory Committee on Training in Primary Care Medicine and Dentistry (§749)
• Teaching Health Centers Development Grants (§749A)
• Subpart II: Training in Underserved Communities (§749B)
• Rural Physician Training Grants (§749B)
• Part D: Interdisciplinary, Community-Based Linkages (§§750-759)
• General Provisions (§750)
• Area Health Education Centers (§751)
• Continuing Educational Support for Health Professionals Serving in Underserved Communities (§752)
• Education and Training Relating to Geriatrics (§753)
• Quentin N. Burdick Program for Rural Interdisciplinary Training (§754)
• Allied Health and Other Disciplines (§755)
• Mental and Behavioral Health Education and Training Grants (§756)
• Advisory Committee on Interdisciplinary, Community-Based Linkages (§757)
• Interdisciplinary Training and Education on Domestic Violence and Other Types of Violence and Abuse (§758)
• Program for Education and Training in Pain Care (§759)
• Part E: Health Professions and Public Health Workforce (§§761-768)
• Subpart 1: Health Professions Workforce Information and Analysis (§§761-763)
• Health Professions Workforce Information and Analysis (§761)
• Advisory Council on Graduate Medical Education (§762)
• Pediatric Rheumatology (§763)
• Subpart 2: Public Health Workforce (§§765-770)
• General Provisions (§765)
• Public Health Training Centers (§766)
• Public Health Traineeships (§767)
• Preventive Medicine and Public Health Training Grant Program (§768)
• Health Administration Traineeships and Special Projects (§769)
• Authorization of Appropriations (§770)
• Subpart 3: Recruitment and Retention Programs (§§775-778)
• Investment in Tomorrow's Pediatric Health Care Workforce (§775)
• Public Health Workforce Loan Repayment Program (§776)
• Training for Mid-Career Public and Allied Health Professionals (§777)
• Fellowship Training in Applied Public Health Epidemiology, Public Health Laboratory Science, Public Health Informatics, and Expansion of the Epidemic Intelligence Service (§778)
• Part F: General Provisions (§§791-799B)
• Preferences and Required Information in Certain Programs (§791)
• Health Professions Data (§792)
• Prohibition Against Discrimination on Basis of Sex (§794)
• Application (§796)
• Use of Funds (§797)
• Matching Requirement (§798)
• Generally Applicable Provisions (§799)
• Technical Assistance (§799A)
• Definitions (§799B)

Summary

Title VII of the Public Health Service Act (PHSA) supports health professions education and training through grants to and contractual agreements with institutions, and direct assistance to individuals. Institutions may receive Title VII support for such activities as residency programs at medical and dental schools, recruitment and retention initiatives in community-based educational settings, and health workforce data collection and analysis within state health departments. Individuals typically receive direct assistance through scholarships, loans, loan repayments, or fellowships. Title VII authorizes several advisory groups to make recommendations to the Secretary of Health and Human Services and Congress on various health workforce programs and Title VII functions. The Health Resources and Services Administration (HRSA), within the Department of Health and Human Services (HHS), oversees programs authorized in Title VII.

The health care workforce—the backbone of the health care delivery system—includes physicians, nurses, dentists, therapists, and others who deliver health services to individuals in physicians' offices, health centers, clinics, and other community-based health care settings. In 2010, Congress reauthorized Title VII health workforce programs and activities in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). The ACA also added several new authorities that aim to build and sustain the health care workforce alongside other provisions for health reform, including health insurance expansion.

The 113^th Congress has held hearings and introduced legislation to address the adequacy of the health care workforce. Health policy experts anticipate that ACA provisions for health insurance expansion could lead to an increased demand for health service utilization, and they expect that this increased demand for services could prompt increased demand for health providers, including physicians and nurses. Other factors causing concern about the adequacy of the health workforce include uneven provider distribution, attrition and retirement, and demands of the aging population. Legislative interest or action may focus on the impact of Title VII programs on education and training in the health professions.

This report describes and summarizes Title VII programs. It describes federal support for institutions and individuals in efforts to expand and sustain the pipeline for health professions education and training. Appendix A summarizes ACA initiatives for health workforce provisions related to Title VII.

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Health Workforce Programs in Title VII of the Public Health Service Act

Introduction

The Public Health Service Act (PHSA)¹ establishes authority for a wide range of activities that directly or indirectly affect the health of the U.S. population.² In Title VII, Health Professions Education,³ the PHSA supports an education and training pipeline for professionals and pre-professionals to work in the medical, dental, public health, and allied health professions. Title VII provides support to both institutions and individuals. It supports institutions to expand the capacity to build and sustain the health workforce through training programs, mainly through grant awards and contractual agreements. For example, institutions may receive Title VII grants to implement residency programs at medical and dental schools; recruitment and retention initiatives in community-based educational settings; and health workforce data collection activities within state health departments. It supports individuals by providing them with direct assistance to support academic preparation in the health professions through scholarships, loans, loan repayments, and fellowships.

Many Title VII programs and activities were reauthorized in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).⁴ The ACA also created the National Health Care Workforce Commission for federal health workforce planning, and State Health Care Workforce Development Grants.⁵ The ACA also made sweeping changes to health care financing and delivery by restructuring the private health insurance market⁶ and setting minimum standards for health insurance coverage.⁷

Beginning in 2014, the ACA mandates that most U.S. citizens obtain health insurance or pay a penalty. Health policy experts expect this mandate combined with additional changes will increase health insurance coverage to be accompanied by a likely increased demand for health services and health care providers.⁸

Title VII represents one among several federal efforts to support the development of the health workforce. These authorities, enacted in various statutes, are established to achieve different purposes and consequently receive different levels of support. For example, in FY2012, the Medicare Graduate Medical Education (GME) payments contribute approximately $8.9 billion annually to residents' salaries, teaching compensation, and other direct costs.⁹ The Medicare direct GME program is the largest source of federal support for health workforce development, followed by the Medicaid GME payments (both state and federal), which were $1.1 billion in FY2011.¹⁰ Medicare and Medicaid GME payments support education and training mainly for physicians. By comparison, Title VII programs contributed approximately $266 million in FY2012 (the President's FY2014 request is for approximately $212 million) to education and training activities for physicians, physician assistants, dentists, therapists, and other health professionals.¹¹ The text box below highlights other examples of federal support to develop or sustain the health workforce.

Organization of This Report

This report describes programs and activities authorized in Title VII of the PHSA. It is divided into two major sections. The first section summarizes the intents and purposes of Title VII, as well as eligibility requirements for institutions interested in applying for Title VII grants, contracts, and agreements, and for individuals applying for direct assistance. The second part of the report provides details on each section within the title, including statutory requirements and preferences. References to "the Secretary" mean the Secretary of Health and Human Services (HHS) unless otherwise specified. Appendix A summarizes two ACA provisions that are Title VII-related.

Overview of Title VII

Title VII consists of six parts that authorize grants, contracts, and agreements to institutions, or direct assistance to individuals. Grants and contracts to institutions support education and training activities for individuals in the medical, dental, public health, and allied health workforce, and support health workforce data collection and analysis. Direct assistance to individuals provides scholarships, loans, and loan repayments to those pursuing health professions education and training. Also, this title authorizes health workforce advisory groups and councils to monitor and assess related programs and activities.

Part A specifies requirements for agreements between the Secretary of HHS and eligible institutions that establish and operate federally-supported school loan funds. School loan funds are created to support students pursuing a full-time course of study in health professions schools. In providing for school loan funds, Part A establishes preferences for primary care medical students and individuals from disadvantaged backgrounds. Part B authorizes programs to increase the diversity of the health workforce. Part C authorizes grants to establish capacity-building programs in primary care medicine and dentistry, and it establishes an advisory committee to report on those activities. Part D authorizes programs to support recruitment and retention activities; community-based interdisciplinary groups; and capacity building within geriatrics and the allied health professions; and authorizes an advisory committee on interdisciplinary collaboration. Part E establishes the National Center for Health Workforce Analysis and authorizes the Council on Graduate Medical Education. It authorizes grants and contracts to institutions to support health workforce data collection, reporting, and analysis. Also, Part E authorizes programs and funds to support education and training in the public health professions. Part F specifies requirements that Title VII participants must adhere to, including preferences, prohibitions against sex discrimination, permissible use of funds, and matching fund requirements.

Various entities are eligible to receive Title VII grants and contracts. Those entities include health professions schools, academic health centers, states, local governments, and other public or private nonprofit and for-profit groups. They must meet general eligibility requirements and, in some cases, specific requirements to qualify for a grant or contract. An example of a general eligibility requirement is that an institution must be accredited by an association that is recognized by the Secretary. An example of a specific eligibility requirement is that a program must collaborate with the Secretary to develop curricula and research and demonstration projects developed under another title.

Individuals who are employed or studying in the health professions may be eligible for Title VII support, either directly or indirectly. Undergraduate or graduate students, medical residents, and professional school faculty are examples of individuals who may be eligible to participate in a program that receives institutional support. Also, individuals may qualify to receive direct assistance in the form of scholarships, loans, or loan repayments if they are studying or have studied in an eligible Title VII profession. Some Title VII programs establish preferences for certain individuals, such as those belonging to an underrepresented minority group.

Table 1 summarizes Title VII by part. Parts are presented in the order that they appear in the PHSA.

Detailed Description of Title VII Programs and Activities

Title VII authorizes a broad range of programs and activities to develop and sustain the education and training pipeline for the health care workforce. The next section of this report describes each part of Title VII, Part A through Part F.

Part A: Student Loans (§§701-728)

Part A consists of two subparts. Subpart I establishes the Health Education Assistance Loan (HEAL) program, which from 1978 to 1998 provided federally insured loans to health professions students to pay for their education costs. Subpart II authorizes requirements for school-administered student loan funds, which provide direct assistance to health professions students to pay for their education costs. Each subpart establishes requirements for the borrowing and lending process. The text box below briefly explains selected terms and concepts related to that process.

Subpart I—Insured Health Education Assistance Loans to Graduate Students (§§701-720)

Subpart I establishes the Health Education Assistance Loans (HEAL) program. From 1978 through 1998, the HEAL program insured loans to health professions students. It enabled students in medicine, dentistry, osteopathy, veterinary medicine, optometry, and podiatry to borrow amounts up to $80,000 over the course of study. Students enrolled in health professions programs, including pharmacy and chiropractic medicine, were allowed to borrow up to $50,000 over a course of study.¹²

Refinancing of HEAL program loans continued through FY2004. Currently, congressionally appropriated funds support the administration of outstanding loans. According to HRSA, the HEAL program maintains oversight for an outstanding loan portfolio valued at $609 million some of which may not be fully repaid until 2037.¹³

Subpart II—Federally-Supported Student Loan Funds (§§721-728 and §735)¹⁴

Subpart II establishes requirements for health professions institutions that operate Title VII student loan funds.

Section 721 authorizes the Secretary to enter into agreements with health professions schools to establish and operate student loan funds. A student loan fund must provide for deposit into the fund of federal capital contributions, and other collections and earnings such as interest payments. The federal capital contribution must be used to establish a direct account that provides loans to students. Student borrowers replenish the loan fund when they repay loans with interest.

Section 722 specifies provisions for administering the federally supported loan programs. It provides terms and conditions for the loan, including maximum loan amounts, repayment, interest rates, collections, and prohibitions. Maximum loan amounts for a school year may not exceed the cost of attendance (which includes tuition and other reasonable educational and living expenses). An exception is that third- and fourth-year medical school students may borrow additional loan amounts that are needed to pay off additional qualified loan balances related to medical school attendance.

Borrowers may repay loans in equal or graduated periodic installments over a payment period that is between 10 and 25 years. Liability to repay the unpaid loan balances and accrued interest is cancelled if the borrower dies, or if the borrower has become permanently and totally disabled. Loans must bear an interest rate of 5% per year on the unpaid balance of the loan, and computed only for periods for which the loan is repayable. Loans are not transferable to another school except if the borrower transfers to another school participating in a Title VII loan program.

The Secretary is authorized to collect any student loan that is in default. Collected amounts must be deposited into the school's student loan fund. Civil actions regarding student loans must be referred to the Attorney General. The period for which the Secretary may file a suit, or take other action to collect loan repayment, is exempt from statutory limits.

Section 723 requires a medical student who is a borrower to complete a residency training program in primary health care within four years after graduating from the health professions school. The borrower must practice in primary health care for 10 years (including a primary care residency) or through the date on which the loan is fully repaid. However, some students may be exempt from these requirements, depending on the date of their first loan, or the type of the federal capital contribution supporting the loan. If borrowers fail to comply with these obligations, an interest rate of 2% per year above the base interest rate must be applied to their loan.¹⁵ There are two conditions under which the Secretary may waive a student's obligation: (1) the student terminates before graduation from the school, whether voluntarily or involuntarily, and (2) the individual does not, after such termination, resume attendance at the school or begin attendance at any other school of medicine or osteopathic medicine.

Section 724 specifies requirements for loan funds for students from disadvantaged backgrounds.¹⁶ Participating schools must be carrying out recruitment and retention programs for students from disadvantaged backgrounds, and for minority faculty. The Secretary is required to define the term "disadvantaged," and to give special consideration to health professions schools that have enrollments of underrepresented minorities above the national average for health professions schools. ¹⁷

A health professions school that receives a federal capital contribution for disadvantaged students must agree to (1) ensure instruction on minority health issues in its curricula; (2) establish a mentor program for assisting disadvantaged students, including minority students, to complete health professions degrees; (3) enter into arrangements with one or more health clinics to provide students with experience in serving disadvantaged populations; and (4) enter into arrangements with educational institutions to carry out programs to prepare disadvantaged students, including minority students, to enter the health professions. Health professions schools must carry out the above activities no later than one year after the date on which the first federal capital contribution is made to the school, and continue those activities throughout the period that the student loan fund is operational. Schools that enter into agreements to establish student loan funds are required to provide that any federal capital contribution will be used to make loans to individuals from disadvantaged backgrounds, and to cover collection costs and interest on the loan.

Part B: Health Professions Training for Diversity (§§736-741)

Part B establishes grant support for health workforce "pipeline" programs, including interventions that target underrepresented minorities and individuals from socioeconomically disadvantaged backgrounds. Part B authorizes programs for (1) Centers of Excellence (COE); (2) scholarships for disadvantaged students; (3) loan repayments and fellowships for faculty positions; (4) educational assistance in the health professions for individuals from disadvantaged backgrounds; and (5) grants to institutions to support individuals who are entering the health professions pipeline.

Centers of Excellence (COE) (§736)

This section specifies conditions for designating a COE, and it defines grant requirements. In general, the Secretary is required to make grants to, and enter into contracts with, health professions schools to establish or support programs of excellence in health professions education for underrepresented minority individuals.

To be designated as a COE, health professions schools must generally meet the following conditions. A COE must (1) have a significant number of underrepresented minority individuals enrolled or accepted for enrollment in the school; (2) be effective in assisting underrepresented minority students at the school to complete the program for the health professions degree; (3) be effective in recruiting underrepresented minority individuals to enroll in and graduate from the school; and (4) make significant recruitment efforts to increase the number of underrepresented minority individuals serving in faculty or administrative positions at the school.¹⁸ The law provides exceptions for some COEs.¹⁹ A school may be designated as a Center of Excellence in Under-Represented Minority Health Professions Education;²⁰ a Hispanic Center of Excellence in Health Professions Education; or a Native American Center of Excellence in Health Professions Education.

Health professions schools that are COEs are required to fulfill a broad range of requirements, including (1) develop large competitive applicant pools through linkages with community-based entities and establish an education pipeline for health professions careers; (2) establish, strengthen, or expand programs to enhance the academic performance of underrepresented minority students attending the school; and (3) improve the capacity of the school to train, recruit, and retain underrepresented minority faculty.²¹ Additional requirements may apply depending on the type of COE designation.

Grant periods may not exceed five years. Payments are subject to annual approval by the Secretary and the available appropriations. Funds are allocated to the various types of COEs according to a formula, which is based on whether the amount appropriated for a given fiscal year is (1) less than $24 million, (2) more than $24 million but less than $30 million, (3) more than $30 million but less than $40 million, or (4) more than $40 million. Health professions schools that receive a COE grant must maintain non-federal spending at the same levels expended before receiving the COE grant. An appropriation of $50 million is authorized for each of FY2010 through FY2015, and such sums as may be necessary (SSAN) for each subsequent fiscal year.

Scholarships for Disadvantaged Students (§737)

This section authorizes the Secretary to make grants to eligible entities to award scholarships to eligible students. An eligible entity is a school of medicine, osteopathic medicine, dentistry, nursing,²² pharmacy, podiatric medicine, optometry, veterinary medicine, public health, chiropractic, or allied health; a school offering a graduate program in behavioral and mental health practice; or, an entity providing programs to train physician assistants. Also, an eligible entity must carry out a recruitment and retention program for students from disadvantaged backgrounds, including those who are members of racial and ethnic minority groups. An eligible student (1) is from a disadvantaged background, (2) has a financial need for a scholarship, and (3) is enrolled (or accepted for enrollment) at an eligible health professions or nursing school as a full-time student in a program leading to a degree in a health profession or nursing.

The Secretary is prohibited from making a grant to an eligible entity unless it agrees that it will give scholarship preference to students who face severe financial hardship and to recipients of certain previous scholarships.²³ The Secretary must establish priority for grant amounts based on the proportions of graduating students going into primary care, underrepresented minority students, and graduates working in medically underserved communities.²⁴ (See Section 740, which authorizes funds for this section.)

Loan Repayments and Fellowships Regarding Faculty Positions (§738)

This section requires the Secretary to establish a loan repayment program for individuals who agree to serve as members of the faculty at eligible health professions schools. Individuals must have a contract with an eligible health professions school where the individual agrees to serve as a faculty member or fellow for two or more years. In return for each year of service, the federal government pays up to $30,000 of the principal and interest of the individual's educational loans.

Eligible individuals must be from disadvantaged backgrounds and have a degree in medicine, osteopathic medicine, dentistry, nursing, or other health profession. Alternatively, they may be in an approved graduate program or they may be enrolled full-time in an eligible health professions school and be in the final year of study in a degree program. Eligible health professions schools are schools of medicine, nursing, osteopathic medicine, dentistry, pharmacy, allied health, podiatric medicine, optometry, veterinary medicine, or public health; schools offering physician assistant education programs; and schools offering graduate programs in behavioral and mental health.

The employing institution must make payments of the principal and interest amount equal to the amount provided by the HHS Secretary for each year that the faculty member serves. In addition, the payments that the school makes on behalf of the individual must be in addition to the pay that the individual would otherwise receive for serving as a faculty member. However, the Secretary may waive these requirements if the requirement will impose an undue financial hardship on the school involved. Selected requirements for the National Health Service Corps program, such as obligated service requirements, apply to the loan repayment features of this program.²⁵

This section also authorizes the Secretary to make grants to and enter into contracts with eligible institutions to assist them in increasing the number of underrepresented minority faculty members. To be eligible to receive institutional grants for the faculty fellowships program, health professions schools must demonstrate the ability to identify, recruit, and select underrepresented minority individuals who have the potential for teaching, administration, or research at a health professions institution. In addition, they must provide individuals with the skills needed to secure a tenured faculty position at the institution, must provide services designed to assist individuals in preparing for an academic career, and must provide health services to rural or medically underserved populations. Further, an institution must assure the Secretary that it will (1) make matching funds available for the fellowship, directly through cash donations; (2) provide institutional support for the fellow for the second and third years at a level that is equal to the total amount of funds that the institution provided prior to receiving the award; (3) place the fellow on the school faculty; and (4) provide the fellow with advanced preparation and special skills that are needed to teach and practice. Each fellowship must include a stipend and an allowance.²⁶ (See Section 740, which authorizes funds for this section.)

Educational Assistance in the Health Professions Regarding Individuals from Disadvantaged Backgrounds²⁷ (§739)

This section authorizes grants and contracts to assist eligible entities to support health professions training for individuals from disadvantaged backgrounds. Eligible entities are schools of medicine, osteopathic medicine, public health, dentistry, veterinary medicine, optometry, pharmacy, allied health, chiropractic medicine, and podiatric medicine. In addition, eligible entities include programs to train physician assistants; public and nonprofit private schools that offer graduate programs in behavioral and mental health; and other public or private nonprofit health or educational entities. Grant support is intended to assist institutions with meeting the cost of a variety of activities, which include (1) identifying, recruiting, and selecting individuals from disadvantaged backgrounds for education and training in a health profession; (2) facilitating the entry of selected individuals into a health professions school; and (3) providing counseling, mentoring, or other services designed to assist selected individuals to complete successfully their education at a health professions school.

The Secretary must give preference to projects that involve a comprehensive partnership approach that will result in a competitive pool of individuals from disadvantaged backgrounds who want to enter the health professions. The Secretary also is required to ensure that services and activities are adequately allocated among various racial and ethnic populations who are economically disadvantaged. The Secretary may require that an entity provide non-federal matching funds to ensure institutional commitment to the funded project. (See Section 740, which authorizes funds for this section.)

Authorization of Appropriations (§740)

• For Section 737, Scholarships for Disadvantaged Students,²⁸ this section authorizes $51 million for FY2010 and SSAN for each of FY2011 through FY2014.
• For Section 738, Loan Repayments and Fellowships Regarding Faculty, this section authorizes $5 million for each of FY2010 through FY2014.
• For Section 739(a)(1), Educational Assistance in the Health Professions Regarding Individuals from Disadvantaged Backgrounds (grants),²⁹ this section authorizes $60 million for FY2010 and SSAN for each of FY2011 through 2014.

This section also required the Secretary to submit a report to Congress on the efforts taken to address the need of a representative mix of individuals from historically minority health professions schools, or other institutions.³⁰

Grants for Health Professions Education (§741)

The Secretary is authorized to award grants, contracts, or cooperative agreements to eligible entities to develop, evaluate, and disseminate research, demonstration projects, and model curricula on cultural competency, prevention, reducing health disparities, and other public health issues. Eligible entities are health professions schools, academic health centers, state or local governments, other appropriate public or private nonprofit entities, or (as deemed appropriate by the Secretary) for-profit entities.

In making grants, the Secretary is required to collaborate with entities, including health professions schools, health professional societies, licensing and accreditation entities, and experts in minority health and cultural competency. In addition, the Secretary is required to coordinate model projects developed under this section with those developed under Section 807.³¹ Model curricula developed under this section must be disseminated through the Internet Clearinghouse established under Section 270³² and by other means as the Secretary requires. The Secretary is required to evaluate the adoption and implementation of cultural competency, prevention, public health, and training curricula for working with individuals with a disability; and to facilitate efforts to include competency measures in quality measurement systems.³³ This section authorizes SSAN to be appropriated for each of FY2010 through FY2015.

Part C: Training in Family Medicine, General Internal Medicine, General Pediatrics, Physician Assistants, General Dentistry, and Pediatric Dentistry (§§747-749B)

Part C consists of two subparts. In general, Subpart I authorizes grants to increase access to education and training opportunities for primary care professionals who specialize in primary care medicine (which includes the specialties of family medicine, general internal medicine, and general pediatrics) and dentistry (which includes general, pediatric, and public health specialties). Specifically, it authorizes support to (1) develop capacity-building programs in primary care medicine; (2) provide new training opportunities for direct care workers who are employed in long-term care settings; (3) develop dental training programs in the fields of general dentistry, pediatric dentistry, or public health dentistry; and (4) establish or expand primary care residency training programs at teaching health centers. Finally, Subpart I establishes the Advisory Committee on Training in Primary Care Medicine and Dentistry. Subpart II authorizes a single grant program, which assists institutions in recruiting students who are most likely to practice medicine in underserved rural communities.

Subpart I: Medical Training Generally (§§747-749A)

Primary Care Training and Enhancement (§747)

Section 747(a) authorizes the Secretary to make grants to, and contracts with, eligible entities to support or develop primary care training programs. Eligible entities are accredited public or nonprofit private hospitals, schools of medicine or osteopathic medicine, academically affiliated training programs for physician assistants, or public or private nonprofit entities as the Secretary may determine. Funds are to be used for various activities, including to (1) plan, develop, operate, or participate in an accredited professional training program, including an accredited residency or internship program in the field of family medicine, general internal medicine, or general pediatrics for medical students, interns, residents, or practicing physicians; (2) plan, develop and operate a program for the training of physicians who plan to teach in family medicine, general internal medicine, or general pediatrics training programs; and (3) plan, develop and operate a program for the training of physicians teaching in community-based settings. The award period for a grant or contract is five years.

Section 747(b) authorizes grants for primary care capacity-building. The Secretary may award grants or contracts to medical schools (allopathic or osteopathic) to establish, maintain, or improve academic units or programs for clinical teaching and research in primary medical care (which includes family medicine, general internal medicine, or general pediatrics). In addition, this section authorizes support for programs that integrate academic administrative units in primary medical fields for the purpose of enhancing interdisciplinary recruitment, training, and faculty development.

This section establishes award preference for applicants who agree to use the award to (1) establish academic units, or (2) substantially expand such units or projects. Also, this section establishes priority for projects that propose to carry out a variety of specified activities in primary care.

The section authorizes an appropriation of $125 million for FY2010 and SSAN for each of FY2011 through FY2014, and requires that 15% of the amount appropriated in each fiscal year be allocated to physician assistant training programs that prepare students to practice in primary care. For purposes of carrying out programs that integrate academic administrative units in the various primary care specialties,³⁴ the section authorizes an appropriation of $750,000 for each of FY2010 through FY2014.

Training Opportunities for Direct Care Workers (§747A)

This section requires the Secretary to award grants to eligible entities to provide new training opportunities for direct care workers who are employed in long-term care settings such as nursing homes, assisted living facilities, skilled nursing facilities, community-based settings, and other settings as determined appropriate by the Secretary. An eligible entity is an institution of higher education that (1) is accredited by a nationally recognized accrediting agency or association, and (2) has established a public-private educational partnership with a nursing home or skilled nursing facility, agency, or entity that provides home- and community-based services to individuals with disabilities, or other long-term care provider.

An institution must use the grant to assist eligible individuals to offset the cost of tuition and required fees for enrolling in academic programs supported by the award. An eligible individual must be enrolled in courses provided by the institution and maintain satisfactory academic progress. As a condition of receiving assistance, an individual must agree to work in the field of geriatrics, disability services, long-term services, or chronic care management for a minimum of two years. This section authorizes an appropriation of $10 million for the period of fiscal years 2011 through 2013.

Training in General, Pediatric, and Public Health Dentistry (§748)

This section authorizes programs to support and develop education and training programs in general, pediatric, and public health dentistry. Section 748(a)(1) authorizes the Secretary to award grants and contracts to eligible entities. An eligible entity is a school of dentistry, public or nonprofit private hospital, or a public or private nonprofit entity. Also eligible are entities with programs in dental or dental hygiene schools; or residency or advanced education programs in the practice of general, pediatric, or public health dentistry. Eligible entities also may partner with schools of public health to educate dental students, residents, and dental hygiene students. Authorized activities and functions include programs for student financial assistance, traineeships, faculty development, and pre- and post-doctoral training.

Section 748(a)(2) authorizes the Secretary to award grants or contracts to a general, pediatric, or public health dentistry program to establish or operate a faculty loan repayment program. Individuals must agree to serve as full-time faculty members in exchange for participation in the loan repayment program, which pays the principal and interest on their outstanding student loans.

This section establishes priority in the awarding of training grants to qualified applicants who demonstrate (1) a proposal for collaborative projects between departments of primary care medicine and departments of general, pediatric, or public health dentistry; (2) a record of training the greatest percentage of providers, or significant improvements in the percentage of providers, who enter and remain in qualified fields of dentistry; (3) a record of training individuals who are from a rural or disadvantaged background, or from an underrepresented minority population; (4) formal relationships with federally qualified health centers, rural health clinics, or other authorized entities that conduct training for students, residents, fellows, or faculty; (5) a record of teaching programs that target vulnerable populations such as older adults, homeless individuals, victims of abuse or trauma, individuals with mental health or substance-related disorders, individuals with disabilities, and individuals with HIV/AIDS; (6) educational activities in cultural competency and health literacy; (7) a high rate of placing graduates in practice settings that serve underserved areas or health disparity populations, or a significant increase in the rate of graduate placements in such settings; (8) intentions to establish a special populations oral health care education center or training program for the didactic and clinical dental education for dental professionals who plan to teach oral health care for special populations, including the vulnerable elderly and people with developmental disabilities.

The award period is five years for a grant or contract for dental support or training programs (excluding faculty loan payment programs). An entity that receives an award may carry over funds from one fiscal year to another for up to three years. This section authorizes an appropriation of $30 million for FY2010 and SSAN for each of FY2011 through FY2015.³⁵

Advisory Committee on Training in Primary Care Medicine and Dentistry (§749)

This section requires the Secretary to establish an Advisory Committee on Training in Primary Care Medicine and Dentistry (the Advisory Committee), and it authorizes requirements for the Advisory Committee's composition, duties, terms, meetings, documents, expenses, and compensation.

The duties of the Advisory Committee are to (1) provide advice and recommendations to the Secretary on policy and program development and other matters of significance concerning the activities under Section 747; (2) develop, publish, and implement performance measures for programs under this part; (3) develop and publish guidelines for longitudinal evaluations under this part; and (4) recommend appropriation levels for programs under this part.

The Secretary is required to determine the appropriate number and appoint health professionals who will serve on the Advisory Committee. In appointing members, the Secretary is required to ensure a fair balance of expertise, and that at least 75% of the members of the Advisory Committee are health professionals. In addition, the Secretary must ensure a broad geographic representation of members and a balance between urban and rural members. Members shall be appointed based on their competence, interest, and knowledge of the mission of the profession involved. Officers or employees of the federal government are not allowed to participate on the Advisory Committee.

Teaching Health Centers Development Grants (§749A)

This section authorizes grants to cover the costs of establishing or expanding primary care residency training programs at teaching health centers. Grants may cover costs associated with items including (1) curriculum development; (2) recruitment, training, and retention of residents and faculty; (3) accreditation; (4) faculty salaries during the development phase and (5) technical assistance. This section establishes preference for applicants who have an existing affiliation agreement with an Area Health Education Center (AHEC). A discussion of AHECs appears later in the report under Section 751.

This section defines a "teaching health center" as an entity that is a community-based, ambulatory patient care center; and operates a primary care residency program. It may include (1) a federally qualified health center;³⁶ (2) a community mental health center; (3) a rural health clinic; (4) a health center operated by the Indian Health Service, Indian tribe, or tribal organization, or urban Indian organization;³⁷ and (5) an entity receiving funds under Title X of the PHSA.³⁸ Grants may be awarded for up to three years, and grant amounts must not exceed $500,000.

For the purpose of carrying out this section, the following amounts are authorized to be appropriated: $25 million for FY2010, $50 million for FY2011, $50 million for FY2012, and SSAN for each subsequent fiscal year. No more than $5 million annually may be used for technical assistance grants.

Subpart II: Training in Underserved Communities (§749B)

This subpart consists of one section that authorizes grants to institutions to train physicians to work in rural communities.

Rural Physician Training Grants (§749B)

This section requires the Secretary to establish a grant program to assist eligible entities in recruiting students who are most likely to practice medicine in underserved rural communities. Eligible entities are nationally accredited or Secretary-approved schools of allopathic or osteopathic medicine, or any combination or consortium of such schools.

This section establishes basic requirements for the rural-focused program. The program must enroll a minimum of 10 students per class per year, and must prioritize admission for students who have either lived or served in an underserved rural community for two or more years and express a commitment to practice medicine in such an area. The curriculum must provide didactic coursework and clinical experience particularly applicable to medical practice in underserved rural communities, including clinical rotations in underserved rural communities, or other coursework or clinical experience deemed appropriate by the Secretary. All students must receive assistance in obtaining clinical training experiences in locations with postgraduate residency training opportunities in underserved rural communities, or in local residency training programs that support and train physicians to practice in underserved rural communities. The Secretary is required to define by regulation "underserved rural community."³⁹ The entity that receives the grant must submit an annual report to the Secretary.

This section establishes priority for entities that demonstrate (1) rural community institutional partnerships; (2) a record of successfully training students who practice medicine in underserved rural communities; and (3) a record of having a high percentage of graduates from an existing program, who practice medicine in underserved rural communities. Applicants must submit a long-term plan to track graduate placements.

Awards must supplement, not supplant, any other federal, state, and local funds that an entity would otherwise expend to carry out the activities described in this section. Additionally, an eligible entity must agree to maintain expenditures of non-federal amounts for grant activities at a level that is no less than the level that the entity maintained for the fiscal year before the entity received the grant. This section authorizes an appropriation of $4 million for each of FY2010 through FY2013.

Part D: Interdisciplinary, Community-Based Linkages⁴⁰ (§§750-759)

Title VII, Part D authorizes grants and contracts to institutions to collaborate on education and training development that will result in health care delivery to underserved and vulnerable populations in non-hospital, community-based health care settings.⁴¹ For example, Area Health Education Centers (Section 751) support institutions in developing collaborative education and training programs for rural populations, geriatrics professionals, mental and behavioral health professionals, and other groups. In addition to providing funds for community-based training, Part D authorizes programs to develop the geriatric, allied health, and mental/behavioral health workforce to serve in community-based settings. Finally, Part D establishes an advisory committee to make recommendations to the Secretary and Congress concerning policy and program development to develop the community-based linkages.

General Provisions (§750)

This section contains requirements for eligible entities to receive grants for interdisciplinary, community-based linkages. Eligible academic institutions must use grants collaboratively with two or more disciplines. Eligible entities must use funds to carry out innovative demonstration projects to meet national goals for interdisciplinary, community-based linkages. Authorized activities include support for, and the development of (1) workforce training programs, (2) faculty development, and (3) other activities that will produce outcomes consistent with the purposes this part.

Area Health Education Centers (§751)

This section establishes two types of grant awards for academic institutions to be used in collaboration with two or more disciplines. Awards must be used to carry out innovative demonstration projects for workforce supplementation. It establishes provisions for grants to Area Health Education Center (AHEC) Programs⁴² and Area Health Education Centers (AHECs),⁴³ which support workforce development and training for medical, public, and allied health professionals in rural areas.

First, the infrastructure development award enables eligible entities to initiate an AHEC program, or to continue a comparable program that is already operating. Eligible entities are schools of medicine or osteopathic medicine, an incorporated consortium of such schools, or the parent institutions of such a school. In a state with no AHEC program, the Secretary may award a grant or contract to a school of nursing.

Second, the point of service maintenance and enhancement award supports an existing AHEC program, to maintain and improve its effectiveness and capabilities, and to make other modifications to the program. Eligible entities include AHEC programs that have AHEC centers that are no longer eligible for infrastructure development grants.

Required activities are the same for each type of award. To receive a grant, an entity must agree to carry out several activities, including but not limited to the following: (1) develop and implement strategies, in coordination with the applicable one-stop delivery system under Section 134(c) of the Workforce Investment Act of 1998,⁴⁴ to recruit individuals from underrepresented minority populations or from disadvantaged or rural backgrounds into the health professions; (2) prepare individuals to more effectively provide health services to underserved areas and health disparity populations through field placements or preceptorships in conjunction with community-based organizations; and (3) propose and implement effective evaluation strategies for program and outcomes measurement. Funds may also be used to support innovative activities such as curriculum development in collaboration with community-based organizations to increase the number of primary care physicians and other primary care providers prepared to serve in underserved areas and health disparity populations.

The Secretary must provide assurances for each type of grant depending on the type of institution and any previous grants that have been awarded under this section. AHEC programs must ensure that they conduct at least 10% of clinical education for medical students in community settings that are removed from the primary teaching facility of the contracting institution for grantees that operate a school of medicine or osteopathic medicine. For a nursing school or its parent institution, which receives an award under this section, the Secretary must ensure that the nursing school conducts at least 10% of clinical education required for nursing students in community settings that are remote from the primary teaching facility of the school; and that the entity maintains an agreement with a medical school to place its medical students in training sites within the local area health education center program.

The Secretary must ensure that AHEC programs include AHEC centers that are public or private organizations whose structure, governance, and operation are independent from the awardee and the parent institution of the awardee, and are not medical schools, or the parent institution or branch of a medical school.

An entity must provide non-federal matching funds or in-kind contributions to receive a grant, totaling at least 50% of total operating costs. At least 25% of the total required non-federal contributions must be made in cash. An entity may apply to the Secretary for a waiver of up to 75% of the matching requirement for each of the first three years the entity is funded through an infrastructure award development grant.

At least 75% of the total funds provided for the two types of AHEC awards must be allocated to participating AHEC centers. To provide needed flexibility to newly funded AHEC programs, the Secretary may waive this requirement for the first two years that a new AHEC program is funded through an infrastructure development award.

Awards must provide at least $250,000 annually per AHEC center. If appropriated amounts to carry out this section are not sufficient to provide this minimum award amount, the Secretary may reduce the per center amount. Generally, infrastructure development awards may not exceed 12 years for an AHEC program, and six years for an AHEC, but exceptions are allowed.

This section authorizes an appropriation of $125 million for each of FY2010 through FY2014. Of the amounts appropriated for a fiscal year, no less than 35% are for infrastructure development awards; no less than 60% are for point of service maintenance and enhancement awards; no more than 1% is to be used for grants and contracts to implement outcomes evaluation for the area health education centers; and no more than 4% is for technical assistance. Appropriated funds may be carried over from one fiscal year to another without obtaining approval from the Secretary. However, funds may not be carried over for more than three years.

Continuing Educational Support for Health Professionals Serving in Underserved Communities (§752)

This section requires the Secretary to make grants to, and enter into contracts with, eligible entities to improve health care, increase health worker retention, increase the representation of minority faculty members, enhance the practice environment, and provide information dissemination and educational support to reduce professional isolation. Eligible entities are defined by reference to Section 799(b); examples include health professions schools, academic health centers, state or local governments, and public or private nonprofit entities participating in health professions and nursing training activities. Eligible entities are required to use grants or contract awards to enhance education through distance learning, continuing educational activities, collaborative conferences, and electronic and distance learning activities. This section gives priority to primary care. This section authorizes $5 million for each of FY2010 through FY2014, and SSAN for each subsequent fiscal year.

Education and Training Relating to Geriatrics (§753)

This section includes subsections that authorize programs for geriatric education centers, geriatric training for physicians and dentists, geriatric faculty training, and other incentives to develop the geriatric health workforce.

Section 753(a) requires the Secretary to award grants or contracts to various health professions schools and entities⁴⁵ to establish or operate a Geriatric Education Center. A Geriatric Education Center is required to (1) improve the geriatric health professions training through residencies, traineeships, or fellowships; (2) develop and disseminate curricula for geriatric health and medicine; (3) support faculty training and retraining to provide instruction in geriatrics; (4) support continuing education for geriatric professionals; and (5) provide students with clinical training in geriatric settings, including nursing homes and ambulatory care centers.

Section 753(b)⁴⁶ authorizes the Secretary to make grants to, and enter into contracts with, entities to provide support (including residencies, traineeships, and fellowships) for geriatric workforce training projects. Entities must be medical schools, teaching hospitals, and graduate medical education programs. Physicians, dentists, and behavioral and mental health professionals who plan to teach geriatric medicine, geriatric behavioral or mental health, or geriatric dentistry are qualified to study in programs funded under this subsection. Institutional applicants must meet specific training requirements. For example, geriatric training projects must be staffed by qualified physicians, dentists, or behavioral mental health professionals who have experience or training in geriatrics, and programs must provide training in geriatrics and exposure to the physical and mental disabilities of elderly individuals through a variety of service rotations. The program must provide training options consisting of a one-year retraining program in geriatrics for physicians, dentists, or mental and behavioral health professionals, and a two-year fellowship program designed to provide training in clinical geriatrics and geriatrics research.

Subsection 753(c)⁴⁷ requires the Secretary to establish a program for geriatric faculty fellowships for individuals. An eligible individual must (1) be board-certified or board-eligible in internal medicine, family practice, psychiatry, or licensed dentistry, or have completed any required training in a discipline, and be employed in an accredited health professions school that is approved by the Secretary; (2) have completed an approved fellowship program in geriatrics or have completed specialty training in geriatrics, and any additional geriatrics training as required by the Secretary; and (3) have a junior (non-tenured) faculty appointment at an accredited school of medicine, osteopathic medicine, nursing, social work, psychology, dentistry, pharmacy, or other allied health discipline in an accredited health professions school. Eligible individuals must commit to meet service requirements and spend 75% of total time providing training in clinical geriatrics, including training of interdisciplinary teams of health professionals. The amount awarded to physicians must be equal to $50,000, which is the 1998 base amount, plus an adjustment based on the Consumer Price Index. The maximum award term is five years.

Section 753(d) requires the Secretary to award Geriatric Workforce Development grants or contracts to entities that operate a geriatric education center.⁴⁸ A geriatric education center that receives an award is required to use funds to offer short-term intensive courses, or fellowships, which focus on geriatrics, chronic care management, and long-term care. Fellowships must provide supplemental training for faculty members in medical schools and other qualified health professions schools. Fellowships are open to current faculty, credentialed volunteer faculty, and practitioners who have no formal geriatric training. A fellowship program must be located either at the geriatric education center sponsoring it, or at an eligible health professions school.

In addition, this section requires a geriatric education center that receives a fellowship award to apply funds to one of two options: Family Caregiver and Direct Care Provider Training⁴⁹ or Incorporation of Best Practices.⁵⁰ The option for Family Caregiver and Direct Care Provider Training requires the geriatric education center to offer at least two courses each year to family caregivers and direct care providers who support frail elders and individuals with disabilities. The Incorporation of Best Practices option requires a geriatric education center to develop and include material on depression and other mental disorders common among older adults. This section requires awards in the amount of $150,000. Up to 24 geriatric education centers may receive an award. A geriatric education center must assure the Secretary that awards will be used only to supplement, not to supplant, the amount of federal, state, and local funds otherwise expended by the geriatric education center. In addition to any other funding available to carry out this section, this section authorizes $10.8 million for FY2011 through FY2014, to carry out Geriatric Workforce Development (including awards, contracts, fellowship programs, and other required activities).

Section 753(e) requires the Secretary to award grants or contracts, in the form of Geriatric Career Incentive Awards, to foster the interest of individuals entering the field of geriatrics, long-term care, and chronic care management. An advanced practice nurse, clinical social worker, pharmacist, or student of psychology who is pursuing a doctorate or other advanced degree in geriatrics or other qualified health profession is eligible to receive an award. As a condition of receiving an award, an individual is required to teach or practice in the field of geriatrics, long-term care, or chronic care management for a minimum of five years. This section authorizes $10 million for FY2011 through FY2013.

Quentin N. Burdick Program for Rural Interdisciplinary Training (§754)⁵¹

This section authorizes the Secretary to make grants or contracts to help entities to fund interdisciplinary training projects designed to (1) train health care practitioners to provide services in rural areas; (2) demonstrate and evaluate innovative interdisciplinary methods designed to provide access to cost-effective comprehensive health care; (3) deliver health care services to individuals residing in rural areas; (4) enhance the quantity of research on health care issues in rural areas; and (5) increase the recruitment and retention of health care practitioners from rural areas.

Allied Health and Other Disciplines (§755)

This section authorizes the Secretary to award grants or contracts to help entities⁵² fund activities that may (1) assist institutions with meeting the costs of expanding or establishing allied health professions; (2) involve planning and implementing projects in preventive and primary care training for podiatric physicians in approved or provisionally approved residency programs; and (3) carry out demonstration projects for chiropractors and physicians to collaborate on identifying and providing effective treatment for spinal and lower-back conditions. Activities may include projects that expand education and training opportunities for a broad range of health professionals. Examples are projects that provide rapid transition training programs for allied health professionals in health-related sciences; establish community-based allied health training programs that link academic centers to rural clinical settings; and develop curricula in the areas of prevention and health promotion, geriatrics, long-term care, among other allied health fields.

Mental and Behavioral Health Education and Training Grants (§756)

The Secretary is authorized to award grants to eligible higher education institutions to support student recruitment, education, and clinical experiences in mental and behavioral health. An eligible institution must demonstrate that it (1) participates in programs that recognize individuals and groups from diverse racial, ethnic, cultural, geographic, religious, linguistic, and class backgrounds, and different genders and sexual orientations; (2) has knowledge and understanding of the concerns of individuals and groups from diverse backgrounds; (3) will prioritize cultural and linguistic competency for any programs assisted under the grant; (4) will provide the Secretary with data and information as required; and (5) will pay liquidated damages for any violation of the agreement.

The following programs and entities qualify for support (1) programs of social work, which are offered at the baccalaureate, master's, and doctoral degree levels of study; (2) accredited psychology programs for developing and implementing interdisciplinary training for psychology graduate students, including substance abuse prevention and treatment services (which may be offered at the master's, doctoral, internship, and post-doctoral residency levels of study); (3) accredited institutions of higher education or accredited professional training programs that are establishing or expanding internships or other field placement programs in child and adolescent mental health in psychiatry, psychology, school psychology, behavioral pediatrics, psychiatric nursing, social work, school social work, substance abuse prevention and treatment, marriage and family therapy, school counseling, or professional counseling; and (4) state-licensed mental health nonprofit and for-profit organizations that pay for training programs for paraprofessional child and adolescent mental health workers.

Also, this section establishes institutional requirements for grant awards to support students and/or faculty in social work. It requires that at least four of the grant recipients be historically black colleges or universities or other minority-serving institutions. In selecting grants for social work, priority is established for applicants that (1) are accredited by the Council on Social Work Education; (2) have a graduation rate of not less than 80% for social work students; and (3) exhibit an ability to recruit social workers from and place social workers in areas with a high-need and high-demand population.

In selecting grant recipients in graduate psychology, priority is established for institutions that focus training needs on vulnerable groups such as individuals with mental health or substance-related disorders. In selecting the grant recipients in training programs for child and adolescent mental health, the Secretary is required to give priority to applicants that (1) have demonstrated the ability to collect data on the number of students trained in child and adolescent mental health and the populations served by such students after they have graduated or completed service training; (2) have demonstrated familiarity with evidence-based methods in child and adolescent mental health services (including substance abuse prevention and treatment services); (3) have programs designed to increase the number of professionals and paraprofessionals serving high-priority populations and to applicants who come from high-priority communities and plan to serve medically underserved populations in health professional shortage areas or in medically underserved areas; (4) offer a curriculum taught collaboratively on the importance of family-professional or family-paraprofessional partnerships; and (5) provide services through a community mental health program described in the Block Grants for Prevention and Treatment of Substance Abuse.⁵³

For FY2010 through FY2013, this section authorizes the following: (1) $8 million for training in social work; (2) $12 million for training in graduate psychology, of which not less than $10 million is to be allocated for doctoral, postdoctoral, and internship level training; (3) $10 million for training in professional child and adolescent mental health; and (4) $5 million for training in paraprofessional child and adolescent work.

Advisory Committee on Interdisciplinary, Community-Based Linkages (§757)

This section requires the Secretary to establish the Advisory Committee on Interdisciplinary, Community-Based Linkages (in this section referred to as the ''Advisory Committee''). It also requires the Secretary to determine the appropriate number of individuals to serve on the Advisory Committee. In establishing the Advisory Committee, the Secretary is required to ensure that at least 75% of its members are health professionals, representing a broad geographic representation of members and a balance between urban and rural members; in addition, women and minorities must be adequately represented. Finally, the Secretary is required to appoint health professionals who are from a school of medicine or osteopathic medicine; an incorporated consortium of such schools, or the parent institutions of such a school, possibly a nursing school that receives an AHEC award;⁵⁴ teaching hospitals and graduate medical education programs;⁵⁵ and programs that support the allied health professions.

The Advisory Committee is required to (1) provide advice and recommendations to the Secretary concerning policy and program development and other matters of significance concerning the activities under this part; (2) submit to Congress and the Secretary a report describing the activities of the committee, including findings and recommendations made by the committee concerning the activities under this part; (3) develop, publish, and implement performance measures for programs under this part; (4) develop and publish guidelines for longitudinal evaluations for programs under this part; and (5) recommend appropriation levels for programs under this part.

The section requires the Advisory Committee to (1) meet at least three times yearly; (2) hold meetings jointly with other related entities established under this title, where appropriate; and (3) carry out preparations for meetings, including agenda preparation and material distribution. In addition to specifying requirements for membership appointments, terms, and vacancies, this section specifies requirements for Advisory Committee meetings, documents, compensation, and expenses.⁵⁶

Interdisciplinary Training and Education on Domestic Violence and Other Types of Violence and Abuse (§758)

This section requires the Secretary, acting through the Director of HRSA, to award grants to eligible entities to develop interdisciplinary training and education programs. The programs are to provide undergraduate, graduate, post-graduate medical, nursing, and other health professions students with an understanding of, and clinical skills pertinent to, domestic violence, sexual assault, stalking, and dating violence.

An eligible entity is an accredited school of allopathic or osteopathic medicine. An entity must demonstrate that the project includes (1) participation by a school of nursing and at least one other school of health professions or graduate program in public health, dentistry, social work, midwifery, or behavioral and mental health; (2) strategies for disseminating and sharing curricula and other educational materials that the project will develop on domestic violence and abuse; and (3) a plan for consulting with community-based coalitions or individuals who have experience and expertise in issues related to domestic violence, sexual assault, dating violence, and stalking.

This section specifies required uses and permissive uses for the grant. Required uses are to (1) fund interdisciplinary training and education projects designed to train health professions students and residents to identify and provide health care services to individuals who are experiencing or who have experienced domestic violence, sexual assault, and related abuse and violence; and (2) plan and develop culturally competent clinical components that may be integrated into residency training programs that address domestic violence, sexual assault, and related abuse and violence. Permissive uses are to offer community-based training opportunities in rural areas for health professional students and residents on domestic violence, sexual assault, and related abuse and violence; or provide stipends to students who are underrepresented in the health professions to promote and enable their participation in offsite training experiences designed to develop health care clinical skills related to domestic violence, sexual assault, and related abuse and violence.

Grantees must ensure that programs address issues of confidentiality and patient safety, and that faculty and staff are fully trained in procedures that will protect the immediate and ongoing security for patients, patient records, and staff. Not more than 10% of the amount of the grant is to be used for administrative expenses. A grantee that receives assistance for training and education must contribute non-federal funds, either directly or through in-kind contributions, in an amount that is not less than 25% of the total cost of such activities. This section authorizes $3 million for each of FY2007 through FY2011.

Program for Education and Training in Pain Care (§759)

The Secretary is authorized to award grants, contracts and cooperative agreements to health professions schools, hospices, and other public and private entities to develop and implement programs to provide education and training to health care professionals in pain care.⁵⁷

The grant applicant must agree that the program will include information and education on (1) the means for pain assessment, diagnosis, treatment, and management, and the medically appropriate use of controlled substances; (2) applicable laws, regulations, rules, and policies on controlled substances; (3) interdisciplinary approaches to pain care delivery; (4) barriers to care—including cultural, linguistic, literacy, geographic—in underserved populations; and (5) recent findings, developments, and improvements in providing pain care.

The Secretary must provide for an evaluation to determine the effect of the grant program(s) on the knowledge and practice of pain care. This section authorizes SSAN for each of FY2010 through FY2102. Amounts appropriated under this subsection must remain available until expended.

Part E: Health Professions and Public Health Workforce (§§761-768)

Part E authorizes grants for the public health workforce within three subparts. Subpart 1 establishes a national center for health workforce analysis, authorizes grants to state and regional centers for health workforce analysis and longitudinal analysis, and establishes an advisory council on medical education. Subpart 2 authorizes grants to institutions to develop the public health and preventive health workforce, and provides for training centers, traineeships, and special projects. Subpart 3 establishes recruitment and retention programs for the public health, pediatric, and allied health workforce, including a fellowship program for the development of public health specialists in epidemiology, laboratory science, and informatics.

Subpart 1: Health Professions Workforce Information and Analysis (§§761-763)

This subpart establishes a center to encourage states, health professions organizations, and other public and private groups to collect and analyze health workforce data; and establishes an advisory council to make recommendations to the Secretary and Congress on graduate medical education.

Health Professions Workforce Information and Analysis (§761)

The purpose of this section is to provide for (1) the development of information describing the health professions workforce, and the analysis of related issues; (2) and information needed to make strategic decisions for health professions and nursing workforce programs.

This section requires the Secretary to establish the National Center for Health Workforce Analysis (referred to as the National Center). The National Center,⁵⁸ in coordination with the National Health Care Workforce Commission⁵⁹ and relevant regional and state centers and agencies, is required to (1) provide for the development of information that describes and analyzes the health care workforce and related issues; (2) carry out activities under Section 792(a);⁶⁰ (3) annually evaluate programs under this title; (4) develop and publish performance measures and benchmarks for programs under this title; and (5) establish, maintain, and publicize a national Internet registry of each grant awarded under this title, and a database to collect data from longitudinal evaluations and performance measures. In addition, the National Center is required to collaborate and share data with federal agencies and relevant professional and educational organizations to link data regarding grants awarded under this title.

This section also requires the Secretary to award grants to, or enter into contracts with, eligible entities to (1) collect, analyze, and report data regarding programs under this title to the National Center, and (2) provide technical assistance to local and regional entities on the collection, analysis and reporting of data. An eligible entity is a state, a state workforce investment board,⁶¹ a public health or health professions school, an academic health center, or an appropriate public or private nonprofit group.

The Secretary is required to increase the amount awarded to an eligible entity for a longitudinal evaluation to study practice patterns and to count, collect, and report data on performance measures.⁶² An eligible entity is one that has received a grant or contract under this title.

This section authorizes funds for the National Center, state and regional centers, and longitudinal evaluations. It authorizes the following appropriations: $7.5 million for each of FY2010 through FY2014 to establish the National Center; $4.5 million for each of FY2010 through FY2014 to provide awards and grants to state and regional centers; and SSAN for the period FY2010 through FY2014 to provide an increase in grants for longitudinal evaluations.

Of the amounts appropriated for this section, the Secretary is required to reserve no less than $600,000 for conducting health professions research and for carrying out data collection and analysis in accordance with Section 792.⁶³ Amounts otherwise appropriated for programs or activities under PHSA Title VII may be used for activities related to the National Center.

Advisory Council on Graduate Medical Education (§762)

This section establishes the Council on Graduate Medical Education (COGME),⁶⁴ which is required to make recommendations to Congress and the Secretary of HHS about related matters including (1) the physician supply and distribution in the United States; (2) current and future shortages or excesses of physicians in medical specialties and subspecialties; and (3) foreign medical school graduates, among other topics.

In addition, this section requires COGME to (1) encourage entities providing graduate medical education to conduct activities to voluntarily achieve COGME's recommendations; (2) develop, publish, and implement performance measures for relevant programs under this title; (3) develop and publish guidelines for longitudinal evaluations for relevant programs under this title;⁶⁵ and (4) recommend appropriation levels for relevant programs under this title.

This section specifies requirements for COGME including membership, membership terms, quorum, and compensation. COGME membership must include administrators from the following agencies and offices: (1) HHS, Office of the Assistant Secretary; (2) HHS, Centers for Medicare and Medicaid Services; and (3) Department of Veterans Affairs. In addition, membership must include appointments by the Secretary that represent practicing primary care physicians, national and specialty physician organizations, foreign medical graduates, medical student and house staff associations, medical schools, public and private teaching hospitals, and health insurers, business, and labor. The term of office for appointed members is four years, and it follows a schedule of staggered rotation as the Secretary designates. Non-federal employees who are COGME members must receive a compensation rate equal to the daily rate for GS-18 employees; and federal employees must serve without additional compensation.

Duties and authorities for COGME include information collection, attendance at hearings, records and document production, correspondence, and assistance from and cooperation with federal departments and agencies. This section requires COGME to coordinate its activities with the Secretary, and the Secretary to take steps to eliminate deficiencies in its health professions data program(s). The Secretary may use amounts otherwise appropriated under this title to support COGME'S activities.

Although the statute required the COGME to terminate on September 30, 2003, annual appropriation acts have extended COGME. Currently, COGME meets periodically throughout the year.⁶⁶

Pediatric Rheumatology (§763)

This section required the Secretary to submit a report to Congress, by October 2001, on the number of pediatric rheumatologists and the level of sufficiency needed to address the health care needs of children with arthritis and related conditions. In 2007, the Secretary submitted a report to Congress on The Pediatric Rheumatology Workforce: A Study of the Supply and Demand for Pediatric Rheumatologists.⁶⁷ SSAN were authorized to be appropriated for each of FY2001 through FY2005.

Subpart 2: Public Health Workforce (§§765-770)

This subpart authorizes grants, contracts, and cooperative agreements to provide training and education programs and activities to develop the public health workforce. It authorizes programs and activities to establish or sustain training centers, traineeships, and special projects, and it makes a requirement for grants or contracts to train graduate medical residents in preventive medicine. Eligible institutions include health professions schools, academic health centers, state or local governments, and public or private nonprofit entities.

General Provisions (§765)

This section authorizes the Secretary to award grants or contracts to eligible entities to increase the number of individuals in the public health workforce; enhance the quality of the workforce; and enhance the ability of the workforce to meet national, state, and local health care needs. Eligible entities include health professions schools, academic health centers, state or local governments, and other public or private nonprofit entities. A grant or contract may cover the costs of a broad range of activities, including planning, development, or operations for demonstration training programs; faculty development; trainee support; and technical assistance. Traineeships must be designed to increase access to public health education; increase the relevance of public health academic preparation to public health practice; provide education or training for students from traditional on-campus programs in practice-based sites; or develop educational methods and distance technology to address adult learning requirements and increase diversity awareness in public health. Grants or contracts may be used to operate programs that serve students who are in accredited schools of public health and who are studying to enter in fields where there is a severe shortage of public health professionals. These fields include epidemiology, biostatistics, and environmental health, among others.

The Secretary may grant preference to entities that serve individuals who are from disadvantaged backgrounds (including underrepresented racial and ethnic minorities), and graduate large proportions of individuals who serve in underserved communities.

Public Health Training Centers (§766)

This section authorizes the Secretary to award grants or contracts to eligible entities to operate public health training centers. Eligible entities are accredited schools of public health and public or nonprofit private institutions that provide graduate or specialized training in public health. An operator of a public health training center must establish or strengthen field placements for students in public or nonprofit private health agencies or organizations; involve faculty members and students in collaborative projects to enhance public health services to medically underserved communities; and specifically designate a geographic area or medically underserved population to be served by the center. The public health training center must be remotely located from the main location of the teaching facility for the school that is participating in the program. In addition, an operator of a public health training center must assess the health personnel needs of the area that the center will serve, and assist in planning and developing training programs to address those needs. The Secretary is required to give preference to accredited schools of public health.

Public Health Traineeships (§767)

This section establishes general and specific requirements for public health traineeships. In general, the Secretary is authorized to award grants or contracts to accredited schools of public health, and other accredited public or nonprofit private institutions, to provide graduate or specialized public health traineeships. Grants must provide tuition, fees, stipends, and allowances as the Secretary determines. Eligible individuals are those pursuing a course of study in a public health field where there is a severe shortage of health professionals. The Secretary is required to determine the amount of a grant for a public health traineeship.

Preventive Medicine and Public Health Training Grant Program (§768)

This section requires the Secretary of HHS, acting through the Administrator of HRSA, in consultation with the Director of the Centers for Disease Control and Prevention (CDC), to award grants or contracts to eligible entities for the purpose of providing training to graduate medical residents in preventive medicine and public health. Eligible entities are an accredited school of public health or school of medicine or osteopathic medicine; an accredited public or private nonprofit hospital; a state, local, or tribal health department; or a consortium of two or more eligible entities.

Funds must be used to (1) plan, develop, operate, or participate in an accredited residency or internship program in preventive medicine or public health; (2) defray the costs of practicum experiences; and (3) establish, maintain, or improve academic administrative units in preventive medicine and public health. The Secretary is required to submit to Congress an annual report on the programs carried out under this section.

Health Administration Traineeships and Special Projects (§769)

The Secretary is authorized to make grants to state or local governments (that have preventive medical and dental public health residency programs) or public or nonprofit private educational entities (including graduate schools of social work and business schools that have health management programs). Grants may be used to provide student traineeships, and to assist accredited health administration programs in developing or improving programs to prepare students for employment with public or nonprofit private entities. Programs must be accredited in teaching health administration, hospital administration, or health policy analysis and planning, or must meet other quality standards as the Secretary may require. Traineeships must provide tuition, fees, and stipends for trainees, at the Secretary's discretion.

Preference is established for eligible entities that (1) produce classes of graduates in which no less than 25% are engaged in full-time practice settings in medically underserved communities; (2) recruit and admit students from medically underserved communities; (3) have established relationships with public and nonprofit health care providers in the community involved; and (4) emphasize employment with public or nonprofit private entities. Traineeship grant applicants must assure the Secretary that they will give priority to trainees who demonstrate a commitment to being employed with public or nonprofit private entities.

Authorization of Appropriations (§770)

This section authorizes $43 million for Subpart 2 for FY2011 and SSAN for each of FY2012 through FY2015. The Secretary may not obligate more than 30% of the total appropriation for Section 767, Public Health Traineeships.

Subpart 3: Recruitment and Retention Programs (§§775-778)

This subpart authorizes programs for loan repayments, scholarships, and fellowships to increase education and training support to build the public health workforce. Its programs target individuals, including pediatric medical specialists and public health professionals.

Investment in Tomorrow's Pediatric Health Care Workforce (§775)

This section requires the Secretary to establish and carry out a program for pediatric specialty loan repayment for eligible individuals. Qualified health professionals must agree to provide full-time services for a minimum of two years in one of the following specialty areas: pediatric medicine, pediatric surgery, or child and adolescent mental and behavioral health care, including substance abuse prevention and treatment.

The Secretary must enter into a contract with eligible individuals and agree to make payments on the principal and interest of qualified undergraduate, graduate, or graduate medical education loans. Payments may not exceed more than $35,000 a year for each year of service for a maximum of three years.

For pediatric medical or surgical specialists, the term "qualified health professional" means a licensed physician who is entering or receiving training in an accredited pediatric medical subspecialty, or entering a residency or receiving a fellowship for a pediatric surgical specialty, or who has completed training for child and adolescent mental and behavioral health.⁶⁸

With respect to child and adolescent mental and behavioral health, the term "qualified health professional" includes a health care professional who received specialized training or clinical experience in child and adolescent mental health in psychiatry, psychology, school psychology, behavioral pediatrics, psychiatric nursing, social work, school social work, substance abuse disorder prevention and treatment, marriage and family therapy, school counseling, or professional counseling; has a license or certification in a state to practice allopathic medicine, osteopathic medicine, psychology, school psychology, psychiatric nursing, social work, school social work, marriage and family therapy, school counseling, or professional counseling; or is a mental health service professional who completed specialized training or clinical experience in child and adolescent mental health.

Additionally, an individual must agree to work either within, or for a provider who is serving within, a health professional shortage area or medically underserved area. The individual must be enrolled in an accredited graduate program at an acceptable level of academic standing. The Secretary must give priority to applicants who (1) are working or will work in an academic setting for children or adolescents; (2) have familiarity with evidence-based methods and cultural and linguistic competence health care services; and (3) demonstrate financial need.

This section authorizes the following appropriations: (1) $30 million for each of FY2010 through FY2014 to carry out the loan repayment program for pediatric specialists;⁶⁹ and (2) $20 million for each of FY2010 through FY2013 to carry out the loan repayment program for child and adolescent mental and behavioral health.⁷⁰

Public Health Workforce Loan Repayment Program (§776)

This section requires the Secretary to establish the Public Health Workforce Loan Repayment Program for direct assistance to individuals. It specifies requirements for eligibility, contracts, payments, obligated service, and breach of contract.

An eligible individual must be accepted for enrollment, or be enrolled, as a student in an accredited academic educational institution in a state or territory. The individual must be in the final year of a course of study or program leading to a public health or health professions degree or certificate; and have accepted employment with a federal, state, local, or tribal public health agency, or a related training fellowship to begin upon graduation. Alternatively, an individual may be eligible to participate in the loan repayment program if he or she has graduated from an accredited educational institution in a state or territory during the 10-year period preceding application to the program. In addition, an individual must not have received a loan reduction for the same service from selected programs under the Higher Education Act of 1965.⁷¹

This section specifies requirements for the contract between the Secretary and an individual. The contract must specify terms for loan repayments, obligated service, service locations (including areas for priority of service), federal financial obligations, and rights and responsibilities of the individual and the Secretary.

A loan repayment must consist of the principal, interest, and related expenses on government and commercial loans that an individual has received to pay tuition costs for undergraduate or graduate education. For each year of obligated service, the Secretary may pay up to $35,000 for qualified loans. For eligible loans that are less than $105,000, the Secretary is required to pay an amount that does not exceed one-third of the eligible loan balance for each year of obligated service of the individual. The Secretary is authorized to approve or postpone the date when an individual begins a period of obligated service. An individual who fails to comply with the loan repayment contract is subject to the same financial penalties as under the federal loan repayment program established in PHSA, Section 338B.⁷² This section authorizes $195 million for FY2010 and SSAN for each of FY2011 through FY2015.

Training for Mid-Career Public and Allied Health Professionals (§777)

This section authorizes the Secretary to award grants or contracts to eligible entities to provide scholarships to eligible individuals to enroll in public health or allied health degree-granting or professional training programs.

An eligible entity is an accredited educational institution that offers a course of study, a certificate program, or professional training program in public health or allied health. An eligible individual must be employed in a public health or allied health position at the federal, state, tribal, or local level.

An appropriation of $60 million is authorized for FY2010 and SSAN for each of FY2011 through FY2015. Of the total appropriation, 50% must be allotted to public health mid-career professionals and 50% must be allotted to allied health mid-career professionals.

Fellowship Training in Applied Public Health Epidemiology, Public Health Laboratory Science, Public Health Informatics, and Expansion of the Epidemic Intelligence Service (§778)

This section establishes requirements for public health fellowships in specialized areas. It authorizes the Secretary to carry out activities to address workforce shortages in state and local health departments within the critical areas of applied public health epidemiology and public health laboratory science and informatics. It establishes fellowships within specialized areas of public health. It requires the Secretary to provide for the expansion of existing fellowship programs, including the Epidemic Intelligence Service operated through the CDC,⁷³ and the Secretary may also expand other relevant applied epidemiology training programs. Funds may be used to expand the Public Health Informatics Program at the CDC. Participation in fellowship training programs under this section may satisfy work obligations required in contracts under Section 338I(j).⁷⁴

This section authorizes an appropriation of $39.5 million, for each of FY2010 through FY2013, which must be applied as follows: $5 million for epidemiology fellowship training program activities; $5 million for laboratory fellowship training programs; $5 million for the Public Health Informatics Fellowship Program; and $24.5 million to expand the Epidemic Intelligence Service.

Part F: General Provisions (§§791-799B)

This part specifies general provisions for Title VII programs and activities, including preferences and prohibitions.

Preferences and Required Information in Certain Programs (§791)

In awarding grants or contracts under Section 747⁷⁵ and Section 750,⁷⁶ the Secretary is required to give preference to any qualified applicant that (1) has a high rate of placing graduates in practice settings where the principal focus is to serve medically underserved communities; (2) has significantly increased the rate of graduate placements in medically underserved communities during the two-year period before the prospective grant period; and (3) uses a longitudinal evaluation and submits it to the national workforce database. The Secretary may not give an applicant preference if the peer review group ranks the applicant's proposal at or below the 20^th percentile of proposals that have been recommended.

This section provides an exception for new programs to be funded under this section, if those programs meet specific criteria. The term ''new program'' means any program that has graduated less than three classes. To receive preference for grants, a new program must meet at least four of the following criteria: (1) have a mission to prepare health professionals to serve underserved populations; (2) include curriculum content that will help prepare practitioners to serve underserved populations; (3) provide substantial clinical training experience in medically underserved communities; (4) have a minimum of 20% of the clinical faculty of the program spend at least 50% of their time providing or supervising care in medically underserved communities; (5) have its entire program or a substantial portion of the program physically located in a medically underserved community; (6) provide student assistance that is linked to service in medically underserved communities following graduation; and (7) provide a placement mechanism to deploy graduates to medically underserved communities.

Health Professions Data (§792)

This section requires the Secretary to establish a program, including a uniform health professions data reporting system, to collect, compile, and analyze data on health professions personnel. The program must initially include data on all physicians and dentists in the states. The Secretary is authorized to expand the program to include data collection, compilation, and analysis on a broad range of health professionals, including pharmacists, optometrists, and podiatrists. Data sets for health professionals must include the following: the training, licensure status, places of practice, professional specialty, practice characteristics, place and date of birth, sex, and socioeconomic background. The Secretary is authorized to require other demographic information.

The Secretary is required to collect information from local, state, and federal agencies and other appropriate sources for the health professions data reporting system. In addition, the Secretary must conduct or enter into contracts to conduct analytic and descriptive studies of health professions. Studies must include methods to determine by specialty and geographic location the number of health professionals who are members of minority groups, including Hispanics. In addition, they must provide, by specialty and geographic location, evaluations and projections of the demand for and supply of health professionals to serve minority groups, including Hispanics. Studies may include evaluations and projections of the supply of, and requirements for, the health professions by specialty and geographic location.

This section authorizes the Secretary to make grants and to enter into contracts with states (or an appropriate nonprofit private entity in any state) to participate in the health professions data program. (The Secretary had been required to report to Congress on October 1, 1993, and biennially thereafter, on the status of health personnel by profession. The report was to include analytic and descriptive studies conducted under this section, and provide information about applicants who take part in Title VII programs. However P.L. 104-66, enacted on December 21, 1995, terminated this reporting requirement.)⁷⁷

Regarding personal data, the Secretary and each program entity must inform individuals of the right to refuse to supply personal data, and any specific consequences related to surrendering or withholding personal data. At the request of an individual, the Secretary and each program entity must inform an individual if he or she is the subject of a request for personal data. The Secretary and program entity must make the data available to the individual in a comprehensible form. The Secretary and program entity are required to ensure that personal data are not used in a matter that is inconsistent with the purposes of this section unless the individual has provided informed consent for doing so. Finally, upon request, the Secretary and program entity are required to inform any individual of how the data will be used, and who will use the data, relative to the programs under this section.

Personal data collected by the Secretary or any program entity under this section may not be made available or disclosed by the Secretary or any program entity to any person other than the individual who is the subject of the data, unless the person requires such data for purposes of this section, or the disclosure is in response to a demand through the compulsory legal process.

In carrying out the health professions data program, the Secretary may make grants to, or enter into contracts and cooperative agreements with, and provide technical assistance to, any nonprofit entity in order to establish a uniform allied health professions data reporting system. With respect to required reports in this section, each report made on or after October 1, 1991 must include a description and analysis of data on allied health professions personnel.

Prohibition Against Discrimination on Basis of Sex (§794)

The Secretary is prohibited from making a grant, loan guarantee, or interest subsidy payment under this title to any eligible entity unless the application contains assurances that the school or training center will not discriminate on the basis of sex. The Secretary may not enter into a contract under this title with any such school or training center unless the entity assures the Secretary that it will not discriminate on the basis of sex in admissions to its training programs.

Application (§796)

To be eligible to receive a grant or contract under this title, an entity must prepare and submit an application to the Secretary. An application must specify the plan for carrying out a project with amounts received under this title and the plan must be consistent with relevant federal, state, or regional health professions program plans. The application must specify performance outcome standards that will measure the project, and contain a description of the linkages with relevant educational and health care entities. To the extent practicable, grantees must establish linkages with health care providers who provide care for underserved communities and populations.

Use of Funds (§797)

Grants or contracts may be used to develop and support training programs for faculty and trainees (including tuition, books, program fees, and reasonable living expenses incurred during the period of training). Grants or contracts may also support technical assistance, workforce analysis, information dissemination, and policy planning. An entity is required to maintain non-federal expenditures for activities at a level that is equal to or greater than the level maintained preceding the fiscal year for which the grant was received.

Matching Requirement (§798)

The Secretary may require that an entity provide non-federal matching funds to ensure that the entity is committed to the project funded under the grant. The source of such funds may be direct or indirect and may include donations from public or private entities, and be in cash or in-kind, including plant, equipment, or services.

Generally Applicable Provisions (§799)

The Secretary is required to ensure that grants and contracts are awarded on a competitive basis to carry out innovative demonstration projects or provide for strategic workforce supplementation activities. Unless otherwise required, the Secretary must accept applications for grants or contracts from health professions schools, academic health centers, state or local governments, or other appropriate public or private nonprofit entities for funding and participation in health professions and nursing training activities. The Secretary may also accept applications from for-profit private entities.

The Secretary is required to establish procedures to ensure that, with respect to any data collection required under this title, such data must account for age, sex, race, and ethnicity. The Secretary is required to establish procedures to allow the use of appropriations for data collection purposes, and to ensure that grants, contracts, programs and projects are evaluated annually. Funding periods for grants and contracts may not exceed five years.

The Secretary, acting through HRSA, must carry out peer review functions. For certain programs, each grant application must be submitted to a peer review group. Each peer review group must be composed principally of individuals who are not officers or employees of the federal government. In providing for peer review groups and procedures, the Secretary is required to ensure gender, racial, ethnic, and geographic balance among members of the peer review group.

The Secretary is required to ensure that cross-cutting workforce analytical activities are carried out under Section 761,⁷⁸ and that discipline-specific workforce information and analytical activities are carried out as part of the community-based linkage program⁷⁹ and the health workforce development program.⁸⁰ Any reference to medical schools and medical students must include osteopathic medical schools and osteopathic medical students, respectively.

Technical Assistance (§799A)

The Secretary may use appropriated to provide technical assistance to any authorities included in this title.

Definitions (§799B)

This section defines a variety of terms that are used throughout Title VII.

Appendix. Health Workforce Related Authorizations in the Affordable Care Act (ACA) (§§5101-5102)

The Patient Protection and Affordable Care Act (ACA)⁸¹ authorizes health workforce-related provisions in Sections 5101 and 5102, described below. In addition, ACA created Section 5103, which was enacted as Section 761, Health Professions Workforce Information and Analysis, within the Public Health Service Act (PHSA) and is described in the body of this report.

National Health Care Workforce Commission (§5101)⁸²

This provision authorizes a National Health Care Workforce Commission (Commission) to serve as a national resource for Congress, the President, state and local governments on health workforce issues; to coordinate among relevant federal agencies; to determine whether the demand for health care workers is being met; and to identify and address any barriers to coordination at the federal, state or local level. The Commission is directed to encourage innovation to address needs of different populations, changes in technology, and other environmental factors.

The Comptroller General is directed to appoint Commission members (numbering 15), who must be national experts in their fields but a majority of whom may not be health care educators or practitioners. Certain sectors must be represented, including the health care workforce, employers, third-party payers, researchers, consumers, labor unions, state or local workforce investment boards, and educational institutions. Members will serve three-year terms, and the expiration date of their terms will be staggered.

The Commission is directed to undertake a wide range of studies and make recommendations to Congress and the Administration annually. Among the specific topics to be reviewed are: the current health care workforce supply and demand, and projections for the next 10 and 25 years; the current health care workforce education and training capacity, and projected demands for such education and training over the next 10 and 25 years; education loan and grant programs authorized in Titles VII and VIII of the PHSA and whether they should be authorized under the Higher Education Act; the implications of new and existing federal policies on the health care workforce; the health care workforce needs of special populations; and recommendations for creating or revising loan repayment and scholarship programs to require low-income minority medical students to serve in their home communities, if designated as a medically underserved community.

The Commission also must make recommendations on at least one "high priority" topic each year. Such topics include integrated health care workforce planning that maximizes skill sets across disciplines; an analysis of health care workers in enhanced information technology and management workplace; recommendations for alignment of Medicare and Medicaid graduate medical education policies with national workforce goals; and education and training capacity, projected demands, and integration with the health care delivery system for specific types of health care providers. The Commission may designate additional future high priority topics. The Commission also is charged with reviewing implementation of the State Health Care Workforce Development Grant program, also created by ACA (see description of this grant program, below).

Such sums as necessary are authorized to be appropriated for the Commission. In September 2010, the Government Accountability Office announced the appointment of 15 members to the new National Health Care Workforce Commission. However, the Commission has not received funding, and has not met.

State Health Care Workforce Development Grants (§5102)⁸³

This provision establishes a competitive grant program to enable state partnerships to complete comprehensive planning and to carry out activities leading to strategies for health care workforce development at the state and local levels. It authorizes grants for planning⁸⁴ and implementation.⁸⁵

HRSA is authorized to carry out the program in consultation with the National Health Care Workforce Commission (described above), which is charged with reviewing reports on the development, implementation, and evaluation activities of the grant program.

Planning Grants

Planning grants may be awarded for up to one year, with a maximum award of $150,000. An eligible entity must be an eligible partnership, which is a state workforce investment board with adequate representation from a health care employer, labor organization, public two-year institution of higher education, public four-year institution of higher education, recognized state federation of labor, or other specific entity.

A state partnership must perform several required activities, including but not limited to (1) analyzing state labor market information in order to create health care career pathways for students and adults, including dislocated workers; (2) identifying current and projected high demand state or regional health care sectors for purposes of planning career pathways; and (3) identifying existing federal, state, and private resources to recruit, educate or train, and retain a skilled health care workforce and strengthen partnerships.

Before the state partnership receives a planning grant, the partnership and HRSA must jointly determine the performance benchmarks that will be established for the planning grant. Matching grant requirements direct each state partnership to provide an amount of no less that 15% of the total grant amount.

Within a year of receiving a grant, a state partnership must submit a report to HRSA on the state's performance of the activities under the grant, including the use of funds and matching funds, and a description of the progress that the state workforce investment board has made in meeting the performance benchmarks. In addition, HRSA must submit a report to Congress analyzing the planning activities, performance, and fund utilization of each state grant recipient, including an identification of promising practices and a profile of the activities of each state grant recipient. The section authorizes $8 million for planning grants in FY2010 and SSAN for each subsequent fiscal year.

Implementation Grants

This provision requires HRSA to competitively award implementation grants to state partnerships to enable them to carry out activities that result in a comprehensive plan for health workforce development within the state. An implementation grant is awarded for a period of no more than two years, with some exceptions.

To be eligible for an implementation grant, the state partnership must have received a planning grant and completed all requirements for that grant. Alternatively, the state partnership must have completed an application, including a plan to coordinate with required partners and complete required activities during the two-year period of the implementation grant. A state partnership may reserve no less than 60% of total funds to make competitive grant awards to regional partnerships.

A state partnership receiving an implementation grant must perform specific duties, among them: (1) identify and convene regional leadership to discuss opportunities to engage in statewide health care workforce development planning; (2) in consultation with key stakeholders and regional leaders, take appropriate steps to reduce federal, state, or local barriers to a comprehensive and coherent strategy, including changes in state or local policies to foster coherent and comprehensive health care workforce development activities; (3) develop, disseminate, and review with key stakeholders a preliminary statewide strategy that addresses short- and long-term health care workforce development supply versus demand.

Before the state partnership receives an implementation grant, the state and HRSA must jointly establish performance benchmarks. Each state partnership receiving a grant must provide a minimum of 25% of the implementation grant amount to meet matching requirements.

For each year of the implementation grant, the state partnership must submit a report to HRSA. Also, HRSA must submit a report to Congress analyzing implementation activities, performance, and fund utilization of the state grantees. The section authorizes $150 million for implementation grants in FY2010 and SSAN for each subsequent fiscal year.⁸⁶

Acknowledgments

Special thanks to Elayne Heisler, Analyst in Health Services, for contributions to this report.

Footnotes

1.	42 U.S.C. 201 et seq.
2.	The PHSA also establishes requirements for protecting and/or improving the public's health on a broad range of topics. For example, it requires standards for water safety and sanitation, and protocols for public health preparedness.
3.	42 U.S.C. Chapter 6A, Subchapter V.
4.	ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). On March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which amended several provisions in the ACA. All references to ACA in this report refer to the law as amended.
5.	Appendix A contains details about these two statutory provisions, which are related to but not part of Title VII.
6.	For more information on this topic, see CRS Report R43048, Overview of Private Health Insurance Provisions in the Patient Protection and Affordable Care Act (ACA), by [author name scrubbed]; and CRS Report R43066, Status of Federal Funding for State Implementation of Health Insurance Exchanges, by [author name scrubbed] and Charles S. Redhead.
7.	For more information on this topic, see CRS Report RL32237, Health Insurance: A Primer, by [author name scrubbed].
8.	Stephen M. Peterson et al., "Projecting US Primary Care Physician Workforce Needs: 2010-2025," Annals of Family Medicine, vol. 10, no. 6 (November/December 2012), pp. 503-509. Also see CRS Report R42029, Physician Supply and the Affordable Care Act, by [author name scrubbed].
9.	Most recently available data are at Congressional Budget Office, Medicare, May 2012, Baseline (estimate), http://www.cbo.gov/sites/default/files/cbofiles/attachments/43060_Medicare.pdf.
10.	CRS analysis of CMS-64 data, by [author name scrubbed]. CMS-64 are quarterly expense reports that states are required to submit to CMS in order to receive federal reimbursements. The amounts reported on the CMS-64 must be actual expenditures for which all supporting documentation is provided to CMS. For description, see http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MBES/CMS-64-Quarterly-Expense-Report.html.Beginning in FY2010, CMS added a line to the CMS-64 form for states to break out their GME payment information from their inpatient hospital expenditures (where it had been captured previously).
11.	Each year, Congress considers the Title VII budget, which is funded through appropriations for the Health Resources and Services Administration (HRSA), an agency within the Department of Health and Human Services (HHS). HRSA receives appropriated funds through the annual HHS appropriation, which is mostly included in the appropriations bill for Departments of Labor, Health and Human Services, and Education, and Related Agencies (L-HHS-ED).
12.	Features of the HEAL program included (1) a low-interest rate loans; (2) loan repayment beginning nine months after graduation, or after the completion of an accredited residency or other deferment not to exceed four years; and (3) a maximum loan repayment period of 25 years. Source: Health Education Assistance Loan (HEAL), No. OEI-02-90-00980, February 1990, http://oig.hhs.gov/oei/reports/oei-02-90-00980.pdf.
13.	The $609 million portfolio is the value of outstanding loans as of March 2013. Details on the current status of the HEAL program, including information on interest, total and permanent disability, deferment, and litigation, are available at About the Health Education Assistance Loan (HEAL) Program, http://bhpr.hrsa.gov/scholarshipsloans/heal/aboutheal.html.
14.	Within PHSA Title VII, there is no statutory authority for Sections numbered 729,730, 731, 732, 733, and 734.
15.	A description of interest rates for compliant and noncompliant for borrowers with the Primary Care Loan program is available at HHS, HRSA, Primary Care Loans, http://www.hrsa.gov/loanscholarships/loans/primarycare.html.
16.	Section 724(f) established appropriation authority for federal capital contributions to student loan funds for individuals from disadvantaged backgrounds. However, this subsection was repealed by Section 132(b) of P.L. 105-392. The objective was to allow institutions to continue loan funds through revolving loan programs that received federal capital contributions to establish those funds. See, U.S. Congress, Senate Labor and Human Resources, Health Professions Education Partnerships Act of 1998, Report to Accompany S. 1754, 105th Cong., 2nd sess., June 23, 1998, 105-220, p. 27.
17.	See LDS program, http://bhpr.hrsa.gov/scholarshipsloans/tools/guidelines/lds.pdf.
18.	PHSA §§736(c)(1)(A); and 736(c)(1)(B).
19.	For example, a Native American Center of Excellence may be exempt from the definition of a "designated health professions school" if it is part of a consortium that fulfills the requirements for a COE.
20.	These may include Historically Black Colleges and Universities (HBCUs).
21.	PHSA §736(b).
22.	A "school of nursing" is defined in PHSA Section 801.
23.	This provision refers to scholarships authorized in PHSA, Sections 736 and 740(d)(2)(B), prior to enactment of the Health Professions Education and Training Act in 1998 (P.L. 105-392).
24.	See http://bhpr.hrsa.gov/scholarshipsloans/tools/guidelines/sds.pdf.
25.	This provision refers to PHSA requirements for the National Health Service Corps Loan Repayment Program, and includes the following statutes: Section 338C, Obligated Service; Section 338G, Special Loans for Former Corps Members to Enter Private Practice; and, Section 338I, Grants to States for Loan Repayment Programs. See HHS, NHSC Loan Repayment Program, FY2013, Application and Guidance, February 2013. See http://nhsc.hrsa.gov/downloads/lrpapplicationguidance.pdf.
26.	The stipend is not to exceed 50% of the regular salary of a similar faculty member, and the allowance is for other expenses, including travel and training.
27.	Some federal reports and documents refer to this program as the Health Careers Opportunity Program (HCOP). See http://www.asph.org/userfiles/HRSA-11-065%20Final[1].pdf.
28.	Of the amounts appropriated in any fiscal year, the Secretary is required to distribute no less than 16% to schools of nursing.
29.	Scholarship awards to individuals under PHSA Section 739(a)(2)(F) may not exceed 20% of the amount appropriated for a fiscal year.
30.	Reports on these programs include HHS, Evaluating Programs to Recruit Minorities into the Health Professions: Report of Two Evaluation Studies (Study 1:Evaluation of College Enrichment Programs at Four California Community Colleges; and Study 2: Linking National Administrative Databases to Track Medical and Dental School Matriculation for Health Careers Opportunity Program and Center of Excellence Program Participants, U.S.), April 2009, at http://bhpr.hrsa.gov/healthworkforce/reports/evalprogrecruitminority.pdf.
31.	PHSA Section 807 authorizes "Grants for Health Professions Education," Title VIII, Nursing Workforce Development.
32.	Although it is referenced in Section 741, PHSA Section 270 does not exist.
33.	This authority has never received appropriated funds, and the Secretary has not evaluated it.
34.	PHSA §747(b).
35.	This amount includes dental support and training as well as faculty loan repayments.
36.	See CRS Report R42433, Federal Health Centers, by [author name scrubbed].
37.	CRS Report R41152, Indian Health Care: Impact of the Affordable Care Act (ACA), by [author name scrubbed].
38.	CRS Report RL33644, Title X (Public Health Service Act) Family Planning Program, by [author name scrubbed].
39.	42 CFR 5a.3.
40.	"Community-based linkages are a part of strategies that involve integrated health services, spanning organizations and clinicians, and they are an example of the evolving definition of communities—in this case focused on care coordination. Community-based teams support patient-centered services, helping to better coordinate and more seamlessly transition care across a spectrum of services in a community." Source: Institute of Medicine (IOM), Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, Washington, DC, September 6, 2012, pp. 7-19, http://www.hrsa.gov/advisorycommittees/bhpradvisory/acicbl/Reports/eighthreport.pdf.
41.	Community-based, interdisciplinary training opportunities serve to improve the ability of participants to deliver health services within the community, and to provide an alternative means of linking health professions education across the health professions. Advisory Committee on Interdisciplinary Community-Based Linkages (ACICBL), An Examination of the Healthcare Workforce Issues in Rural America, 8th Annual Report to the Secretary of the United States Department of Health and Human Services and the United States Congress, Washington, DC, September 2008, p. 72, http://www.hrsa.gov/advisorycommittees/bhpradvisory/acicbl/Reports/eighthreport.pdf.
42.	As defined in PHSA Section 799B(13), an Area Health Education Center (AHEC) Program is a school of medicine or a school of nursing that has received a grant through HRSA to contract with AHEC centers to implement educational activities that involve several health professions/disciplines and expose students to primary care and public health needs of underserved populations. An AHEC Program trains health care personnel in the context of primary care delivery in rural and other underserved areas and works closely with state and local workforce investment boards to identify and address health care personnel issues. AHEC programs do the following: (1) implement community-based training programs for health professions students; (2) implement continuing education for health care providers; and (3) address service delivery and access needs of underserved populations.
43.	As defined in PHSA Section 799B(12), an AHEC is a hospital, health organization with an accredited primary care training program, or accredited physician assistant educational program associated with a college or university that does not operate a school of medicine or osteopathic medicine; that meets statutory requirements for the structure, function, and mission of community-based, interdisciplinary health care; and receives a grant under PHSA Section 751. An AHEC is required to work in tandem with one-stop delivery systems to recruit and retain health workers, as the Work Investment Act (Sec. 134(c)) requires. Other requirements are to foster and provide community-based, health professions training and education; facilitate experiences for health education and training, such as field placements or preceptorships; and create youth public health programs to inform high school students about health professions careers.
44.	CRS Report R41135, The Workforce Investment Act and the One-Stop Delivery System, by [author name scrubbed].
45.	The statute refers to "entities described in paragraphs (1), (3), or (4) of section 799B, and section 801(2)" as those eligible to receive grants under this section. Those entities are, in general, schools of medicine, public health, allied health, and nursing. Physician assistant education programs and graduate programs in behavioral health and mental health practice are also included.
46.	This section authorizes "Geriatric Training Regarding Physicians and Dentists."
47.	This section authorizes "Geriatric Academic Career Awards."
48.	PHSA §753(a)(1) authorizes Geriatric Education Centers.
49.	PHSA §753(d)(4).
50.	PHSA §753(d)(5).
51.	In FY2010, the Catalog of Federal Domestic Assistance archived this program. See Office of Management and Budget, and General Services Administration, 2010 Catalog of Federal Domestic Assistance (CFDA), https://www.cfda.gov/downloads/CFDA_2010.pdf, p. A2.
52.	This section does not specify the meaning of an "eligible entity."
53.	PHSA §1931(b)(1) defines criteria for selected mental and behavioral services that are provided within the community health setting through block grants. (PHSA, Title XIX, Part B—Block Grants Regarding Mental Health and Substance Abuse, Subpart II, Block Grants for Prevention and Treatment of Substance Abuse.) The Substance Abuse and Mental Health Services Administration's (SAMHSA) of the HHS coordinates these programs.
54.	PHSA §751(b)(1)(A) defines the types of nursing schools that may receive an AHEC award.
55.	PHSA §753(b) identifies these types of programs.
56.	As of this writing, the Advisory Committee on Interdisciplinary, Community-Based Linkages is active and last met on December 7, 2012. Recent publications are published at http://www.hrsa.gov/advisorycommittees/bhpradvisory/acicbl/acicbl.html.
57.	The term "pain care" means the assessment, diagnosis, treatment, or management of acute or chronic pain, regardless of causation or body location.
58.	The website for the National Center is http://bhpr.hrsa.gov/healthworkforce/index.html.
59.	See Appendix A.
60.	PHSA Section 792(a) authorizes the Secretary of HHS to collect, compile, and analyze data on health professionals.
61.	These boards are established pursuant to the Workforce Investment Act (WIA). See CRS Report R41135, The Workforce Investment Act and the One-Stop Delivery System, by [author name scrubbed].
62.	This refers to performance measures that are to be developed under PHSA §§749(d)(3); 757(d)(3); and 762(a)(3).
63.	PHSA Section 792 provides that "the Secretary shall establish a program, including a uniform health professions data reporting system, to collect, compile, and analyze data on health professions personnel which program shall initially include data respecting all physicians and dentists in the states."
64.	For more about the COGME, see http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/About/index.html.
65.	PHSA §761(d)(2).
66.	Additional information on this group is published at http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/index.html.
67.	This publication is available at http://bhpr.hrsa.gov/healthworkforce/reports/pedrheumatology.pdf.
68.	This program is described in PHSA Section 775 (c)(1)(B).
69.	PHSA §775 (c)(1)(A).
70.	PHSA §775 (c)(1)(B).
71.	These programs refer to the Higher Education Act of 1965, Sections 455(m), 428J, 428K, 428L, or 460.
72.	PHSA Section 338B establishes the NHSC loan repayment program, and Section 338E establishes requirements for breach of loan repayment contract.
73.	For information on the Epidemic Intelligence Service (EIS), go to http://www.cdc.gov/eis/index.html.
74.	PHSA Section 338I(j) authorizes the NHSC Public Health Loan Repayment Program.
75.	This section authorizes grants and contracts for Primary Care Training and Enhancement.
76.	This section authorizes General Provisions for activities under Part D, Interdisciplinary, Community-Based Linkages.
77.	Email communication, HHS, HRSA, Office of Legislation, Monday August 5, 2013.
78.	PHSA Section 761 authorizes "Health Professions Workforce Information and Analysis."
79.	PHSA Sections 750 through 759 authorize community-based linkage programs.
80.	PHSA Section 768 authorizes the "Preventive Medicine and Public Health Training Grant Program."
81.	ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). On March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which amended several provisions in the ACA. All references to ACA in this report refer to the law as amended.
82.	42 USC §294q.
83.	42 USC §294r.
84.	42 USC §294r(c).
85.	42 USC §294r(d).
86.	For information on the status of these and other discretionary grants, see CRS Report R41390, Discretionary Spending in the Patient Protection and Affordable Care Act (ACA), coordinated by Charles S. Redhead.