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Public Statements

Repealing Mandatory Funding for Graduate Medical Education

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Date:
Location: Washington, DC

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Mr. GENE GREEN of Texas. I yield myself such time as I may consume.

Mr. Chairman, I rise today in strong opposition to H.R. 1216, legislation to convert mandatory funding authorized under the Affordable Care Act for Teaching Health Centers to authorized funding.

The Affordable Care Act authorized and appropriated $230 million for a 5-year payment program to support accredited primary care residency training operated by community-based entities, including community-based health centers. This training takes place in community-based settings such as community health centers.

Research shows that CHC-trained physicians, for example, are more than twice as likely as their non-CHC-trained counterparts to work in underserved areas, ensuring that that kind of training takes place, which is what mandatory spending support for programs does. It will help strengthen the primary care workforce in underserved areas, particularly in areas that struggle to recruit and retain a sufficient workforce.

The Teaching Health Center program supports the training of individuals who will practice family medicine, internal medicine, pediatrics, internal medicine pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, and geriatrics--those disciplines where we're experiencing significant physician shortages.

It's hypocritical for my Republican colleagues to take away this funding. They continue to argue that there are not enough physicians to provide care to people who need them in primary care services. This program is designed to help address this very problem. But they keep trying to have it both ways in health reform debate, and this is just another example.

Today, the majority is going to say they have an obligation to ensure this program is subject to the appropriations process due to the need for transparency in our spending process and current budget process. Let me remind the majority that we're not the only party who's directed mandatory funding for programs. The majority must have certainly supported autopilot spending, as Representative Foxx described the Teaching Health Center program earlier this afternoon, when they passed the Medicare Modernization Act of 2003, which required mandatory funding for transitional programs. I suppose at that time, the majority certainly felt they knew better than the appropriators that the MMA was a worthy program and deserved mandatory funding, even though they passed it under the cover of night with a lot of arm-twisting.

I can't understand the opposition, particularly from my Republican colleagues. They repeatedly and inaccurately complain that we don't do enough to promote health workforce expansions, and now they're going to cut funding for the health workforce expansion.

Turning the Health Center program into a discretionary one will make it challenging for these 11 programs that have already made the decision to participate in consultation with key stakeholders, like teaching hospitals and their boards, and based on the expectation that continued funding will be available. Converting this program to discretionary funding will also deter other entities from making the business decision necessary to expand residency training, since funding over the next few years could be subject to the annual appropriations fight.

This is yet another political stunt by the majority to attempt to defund health reform--this, through their playing games with funds dedicated to ensure that we have physicians in our country.

Several weeks ago, they couldn't stop talking about how Medicaid will be greatly improved with the Ryan budget because it provides States with block grants to run their Medicaid programs. How great would it be to eliminate Medicare by giving seniors vouchers to purchase health insurance? And this week, we're busy taking away funds to ensure that we train enough physicians to ensure all Americans have access to affordable care. Once again, the majority has their own priorities.

Mr. Chairman, I reserve the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I yield 2 minutes to the gentleman from Pennsylvania (Mr. Pitts), the chairman of the subcommittee.

Mr. PITTS. I would like to thank the gentleman from Kentucky for his leadership on this issue.

Section 5508 of PPACA authorizes the Secretary to award grants to teaching health centers to establish newly accredited or expanded primary care residency training programs. The new health care law, PPACA, provides a mandatory appropriation of $230 million for this purpose for the period from FY 2011 through FY 2015.

You may recall that in the President's fiscal year 2012 budget, he eliminated funding for training at children's hospitals. Because of this, I and the ranking member of the Health Subcommittee, the gentleman from New Jersey (Mr. Pallone) have introduced H.R. 1852, a bill to reauthorize the Children's Hospitals Graduate Medical Education program for an additional 5 years at the current funding levels.

While the administration couldn't find money in its budget for training at children's hospitals, PPACA somehow was able to provide a direct mandatory appropriation of $230 million for other teaching health centers, with no further action, input, or approval required by Congress. And PPACA did this with a number of funds, mandatory appropriations.

The bill before us today, H.R. 1216, simply converts PPACA's mandatory appropriations to an authorization, subject to the annual appropriations process, just like the Children's Hospital GME program, making it discretionary. Passage of the bill will also save $215 million over 5 years.

I urge support of the bill.

Mr. GENE GREEN of Texas. Mr. Chairman, I yield 2 minutes to my colleague from the Energy and Commerce Committee, the gentlewoman from California (Mrs. Capps).

Mrs. CAPPS. I thank my colleague for yielding.

Mr. Chairman, I rise in strong opposition to this reckless bill. I cannot count the number of times Members on both sides of this aisle have decried shortages in the primary care workforce of our communities, and working, often in a bipartisan manner, to develop ways to increase the primary
care ranks. Yet today, the next victim in the Republican obsession with repealing the Affordable Care Act is a program that does deal with these shortages. It increases our primary care physician ranks, and trains them with special expertise in serving the community.

The bill before us would defund this program, taking many qualified Americans out of the primary care workforce before they even have an opportunity to join it. Moreover, cutting these training programs would also affect already existing jobs at the 11 community-based entities that have already expanded their programs to train these new doctors. Taking away this funding will force possible layoffs and have a chilling effect on other sites developing this type of program.

Yes, it is paid for through mandatory funding. But that is not unheard of or even unusual. In fact, the federally funded Graduate Medical Education program, which has had measured success in strengthening our health care workforce, is a mandatory spending program. The program the Republicans are trying to cut today is simply a complement to this GME program, focused on community-based care and prevention.

The choice on H.R. 1216 is clear: if you believe that we do not have a jobs problem and that we have all the doctors we will ever need, then go ahead and vote for this bill. But if you believe that we need to create good jobs and the professionals to fill them, that we need more primary care providers, you must vote against H.R. 1216 and protect this very important program. We can't have it both ways.

I urge a ``no'' vote.

Mr. GUTHRIE. Mr. Chairman, I yield 4 minutes to my friend from Tennessee (Mrs. Blackburn).

Mrs. BLACKBURN. I thank the gentleman from Kentucky for his leadership on this bill.

Mr. Chairman, it is so interesting to me. We had a 2,700-page health care bill that basically was a government takeover of health care. What we have heard from so many people in this country is gosh, you know, I wish somebody would have read that bill before they passed it. And the former Speaker said we need to pass the bill, and then we can read it and find out what is in it.

One of the things that many of the people did not like that was in that bill was many of these mandatory provisions that were put in place, programs that had been on the books for years that were discretionary programs that all of a sudden became mandatory. And the confusing thing, Mr. Chairman, is there didn't seem to be any consistency. As the subcommittee chairman who spoke before me had said, Mr. Pitts had said, you know, you don't tend to children's hospitals in the same way, you don't tend to nurses and technicians in the same way. But here was this conversion from discretionary to mandatory for teaching hospitals, a total of $230 million, over $40 million a year.

Now, it doesn't matter if you need the money or not. It doesn't matter if you know exactly where you are going to use it or not. The money is going to be appropriated. It's put on autopilot. Doesn't matter what we say is going to happen with the government, if we need to reduce it. They're going to get that money. That is why this bill is so important.

You will notice, Mr. Chairman, that 2,700-page bill, we are able to delete $230 million of that appropriation, mandatory appropriation with a bill that basically is about 2 pages long. What we do in this 2 pages is responsibly address what the American people want to see us address. They know that the Federal mandates are costing private sector jobs. They know that the Federal Government coming in and taking over health care is costing private sector health care jobs. Indeed, we have study after study that is saying we have already lost over a million jobs.

It seems like every time we turn around, whether it is our health care delivery systems, whether it is our hospitals, whether it is our physicians' offices, we are hearing about the loss of jobs to health care providers and in the health care sector because of the passage of PPACA, or ObamaCare, as many people in our country refer to the bill.

One of the reasons we have to go about repealing these slush funds, Mr. Chairman, is because we simply can't afford this. Every second of every day, every single second of every single day we are borrowing $40,000. We are borrowing 41 cents of every single dollar that we spend. This government is so overspent, we are spending money we don't have for programs that our constituents don't want. And instead of eliminating, what we are saying is, look, let's eliminate a mandatory program and turn it back to what it was for years, discretionary, so that Members of this body bring their discretion to bear on the issues of the day and bring the opinions of their constituents to bear on how this Chamber spends the taxpayers' money.

Mr. Chairman, it is not Federal money; it is the taxpayers' money. This government is overspent. We cannot afford all these Federal mandates. It is time to move these programs back to the discretion of this Chamber.

Mr. GENE GREEN of Texas. Mr. Chairman, I gladly yield 3 minutes to our ranking member of the full Energy and Commerce Committee, the gentleman from California (Mr. Waxman).

Mr. WAXMAN. Mr. Chairman, there was so much misinformation just given out by the previous speaker that it's hard to know where to start. The Republicans have said they don't like the Affordable Care Act. But what do they have to replace it with? They said they're going to repeal it and replace it. What are they going to do about the uninsured in this country, about the high cost of health care, about the people who can't even buy insurance even if they have the money because they have preexisting medical conditions?

We have had no proposal from the Republicans, except in their budget they want to take Medicare away from future seniors by making it a block grant. And they want to cut the Medicaid program, which cuts a big hole in the safety net for the poor to get their health care needs, which means people in nursing homes would be dumped out of those nursing homes.

But the bill before us now is to stop the program that would train primary care physicians. Does anybody disagree with the notion that we need more primary care physicians? Evidently, the Republicans do because as we heard from the last speaker, she wants to make it an appropriated program, not a mandatory spending program.

Well, it's been in the mandatory program in spending in Medicare and Medicaid since 1965. Training physicians should be supported with assured funding that we could rely on. We can't train a doctor in just 1 year. Doctors need a number of years where they are going to be assured of their continuation in medical schools, and that's why we have had a short funding through Medicare and Medicaid. And in the The Affordable Care Act, the purpose was to train physicians for primary care in community settings.

That's what the Republicans want to repeal. And if they can afford it from one year to the next, they will put in funds; but if they can't and their mood is to give another tax break to the wealthy, we won't be able to afford it. With all the costs to go to medical school and all the loans that are required, we ought to ensure spending for primary care doctors.

I urge my colleagues to oppose this bill. It's incomprehensible to me why we even have it on the House floor. It's another one of those efforts that Republicans have been putting up to chip away at health care reform. They want to repeal it, they want to chip away at it, but we don't even know what they want to replace it with.

And the American people and our constituents are entitled to know, are they just going to leave people on their own without the ability to buy health insurance because of preexisting conditions? Are they going to tell the elderly they are on their own and see who they want to insure them?

I urge a ``no'' vote on this bill.

Mr. GUTHRIE. Mr. Chairman, I yield myself such time as I may consume.

First there were a number of amendments, I think over 100 amendments, to the health care bill that were offered by the Republicans. An alternative was offered by the Republicans as voted on as we went forward.

Block grants, several Governors have come to Washington and talked about block granting Medicaid to give them the opportunity to not just deal with Medicaid in their States but there was the other part of their budget.

But I can tell in Kentucky, because I used to be a member of the State legislature, as Medicaid has continued to consume more of the State budget, it becomes more difficult to adequately fund. Higher education tuition rates are going up directly because of the pie of Medicaid that's moving forward.

We passed medical liability reform, which saves the Federal Government $54 billion, as estimated by the Congressional Budget Office. We are going to have the bill tomorrow to purchase health insurance across State lines to make health insurance more affordable instead of more expensive on those who spend money out of their own pocket, as we have seen the estimates for the health care bill.

Now, the one thing about relying on funding for 1 year, we do appropriations for everything from defense to other things on an annual basis. And I will tell you there are not people turning down Federal money because you are only appropriating it for 1 year, we don't want to commit to a long-term program.

But if you buy that argument, you look at what's in the bill. All we are saying is we want the teaching health centers to be treated equally to other parts of the bill. So if the argument is if you don't do it automatically, you are not going to have anybody participating in the program, which I think is what I just heard, then it means training in general in pediatric and public health dentistry, section 5303, is an annual appropriation; geriatric education and training, mental and behavioral health education training; nurse retention, section 5309; section 5316, family nurse practitioner training; section 2821, epidemiology laboratory capacity grants; research and treatment for pain care management, 4305; section 775 investment in tomorrow's pediatric health care workforce.

I mean, obviously, the argument that was made was if we don't have the teaching health centers on a 5-year automatic appropriation, then people aren't going to participate in the program. That argument would have to apply to these directly. And I guarantee you, I would be willing to say, without fear of contradiction, that people will be applying for these programs as this moves forward.

I reserve the balance of my time.

Mr. GENE GREEN of Texas. Mr. Chairman, I yield 2 minutes to a classmate and also the vice chair of our Democratic Caucus, the gentleman from California (Mr. Becerra).

Mr. BECERRA. I thank the gentleman from Texas for yielding me the time.

Mr. Chairman, to put everything in perspective, we are told by the American Academy of Family Physicians that today, today we can foresee a shortage of some 40,000 primary care physicians in this country in less than 10 years. Within another 5 years, that shortage will grow to about 42,000 to 46,000 primary care physicians.

Graduate medical education funds does something very simple. It says to some of these clinics, some of these health care providers, that if you guarantee that you will make graduate medical training available to our future doctors, then we will guarantee that there will be money behind that training so that there will be a consistency so that medical students can finish training.

Well, we just heard that this money that's available to these health care providers, these clinics, should no longer be guaranteed. And so the question you have to ask, if you want to become a physician and you are going to medical training, and certainly the question you have to ask if you are one of these clinics throughout the entire country where you want to train someone to be a family medical doctor, an internist, a pediatrician, an obstetrician/gynecologist, a psychiatrist, a dentist, a pediatric dentist, someone who specializes in gerontology, you have to ask yourself, if I am going to try to train someone, but I don't have the resources to fully provide the education, how do I guarantee that medical student that I could be there with the funds to pay them for education, to pay them for the work they are going to be doing? You can't. And that's why GME is so important.

But we were just told a second ago that this is a slush fund pot of money. Furthest thing from the truth. We are told the real truth, when we heard one of the speakers on the Republican side say we are going to delete this money--that's exactly what's going to happen, because if you don't guarantee it, it's gone.

So, Mr. Chairman, the truth is we have to make sure we can train the next generation of medical leaders; and, therefore, I urge my colleagues to vote against this legislation.

Mr. GUTHRIE. Mr. Chairman, I yield myself 1 minute.

The merits of having training in general in pediatric and public health dentistry, I agree that we have to have that training. The issue here is if you do it in a teaching health center, then you guarantee funding for 5 years. If you do it in a children's hospital, if you do it in a regular hospital, profit or nonprofit, then you are subject to the annual appropriations.

Someone came before our committee to testify, a State Senator from New Jersey, said we need this provision because we need more nurses.

I will agree with that. However, this provision doesn't cover nurses. If you are going through a nurse training program, it's authorized in the bill, and you go through an annual appropriations process.

All we are saying here is that we should treat graduate medical education at children's hospitals, hospitals and teaching health centers exactly the same and not give one an advantage over the other two.

I reserve the balance of my time.

Mr. GENE GREEN of Texas. Mr. Chairman, I yield myself 15 seconds.

I will be glad to cosponsor the bill to make it mandatory funding for children's hospitals. I think if health care is a priority, we ought to do that.

I reserve the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I have no further requests for time, and I reserve the balance of my time.

Mr. GENE GREEN of Texas. Mr. Chairman, how much time remains on each side?

The CHAIR. The gentleman from Texas has 19 1/4 minutes remaining, and the gentleman from Kentucky has 18 1/2 minutes remaining.

Mr. GENE GREEN of Texas. I yield myself such time as I may consume.

When Congress dealt with The Affordable Care Act last year and the year before, our subcommittee on Energy and Commerce spent exhaustive hearings, late-night hearings, we had markups overnight, and so we knew what we were doing. We knew we were going to make a priority in providing primary care for our country.

That's why it's mandatory spending. I would assume in 2003, when we passed the provision for the prescription drug act for Medicare, my Republican colleagues did the same thing at the time in the majority: they wanted to make sure that that was mandatory spending.

And here we are today trying to take away mandatory spending from primary care physicians in community-based settings. I have a great example of this in our own district, and I know the chairman knows this.

We have a community-based health center in Denver Harbor in east Harris County. They have had a partnership with the Baylor College of Medicine for a number of years, and what they have been able to do is provide those residencies to come out to a nonwealthy area of town so those doctors can learn that they can make a living serving folks that are not wealthy. That's what this is all about. We found out that the statistics showed that if they do their residency through a community-based health center, they will actually be more likely to come back and serve those communities. And that's why there needs to be mandatory spending, Mr. Chairman.

I reserve the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I yield 2 minutes to the gentleman from California (Mr. Bilbray).

Mr. BILBRAY. Mr. Chairman, I wasn't planning on addressing this item, but I heard so many of my colleagues, especially those on the other side, talk about the crisis of providing the doctors that are going to be essential for health care, and finally we are talking about health care, not health care insurance.

As somebody who spent 10 years supervising the safety net for a community of 3 million in San Diego County, I just wish my colleagues on the other side, when they're worried about pediatricians and primary health care people, would understand that if you really want to protect those providers, why don't we sit down and talk about true tort reform, especially for the pediatricians. This is a cost that is bearing down. And when you're asking young people to get an education to be a primary health care provider, especially a pediatrician, explain to them why somebody on public assistance, on welfare, has more right to sue their physician than those men and women who are serving in uniform.

The fact is there is no way that we should be sitting up here saying that we really want the next generation to get into health care unless we're willing to tell our friends who are the trial lawyers that we're going to take the physicians off the counter; we're not going to allow lawsuits to be part of the overhead that is driving people out of the health care business.

And I hope to say to both sides, if you really want to make sure there are future doctors, then let's have the bravery to stand up today and do something about the tort that those future doctors are looking at before they go into school.

Mr. GENE GREEN of Texas. Mr. Chairman, I yield myself as much time as I may consume.

My colleague from California must have this bill confused with medical malpractice. In fact, the State of California and the State of Texas already have medical malpractice reform. That's not what this bill is about. This bill is about training primary care physicians to be able to serve everyone. I want them to serve the military. I want them to serve our veterans.

In fact, again, I have a VA hospital in Houston that has a cooperative arrangement with the Baylor College of Medicine for a residency program. That's great. I want them also to be able to do that in their clinics. But I also want it for community-based health centers. And our statistics show us that if we have that example and it's mandatory spending that they make these agreements, that those folks will come back. They may go back to a military clinic, they may come back to a community-based health center, or they may come back and open up their practice in an area that's not the wealthiest part of town. That's why this mandatory legislation is so important.

If you put a priority on making sure our constituents can go see a doctor, I can't imagine repealing this--voting for this bill.

I reserve the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I yield an additional 2 minutes to the gentleman from California (Mr. Bilbray).

Mr. BILBRAY. Mr. Chairman, I want the gentleman from Texas to understand that when a physician or a student is planning on getting into a field, they not only look at will the government guarantee that I'll be able to get the tuition, but they're looking at what field am I moving into. And let me just tell you, as a fact, in California, even with our tort reform, somebody who wants to volunteer as a Medicaid volunteer has to file an $80,000 or $90,000 insurance policy just for volunteering.

So when the gentleman talks about the educational side, that it's essential that we encourage people to get into the field, my point for being here is you cannot talk about the educational when you ignore the environment that you're asking them to go into. And the fact is: What parent would ask somebody to go into this field and be a physician with all the education and all the expenses when they can tell their kids to be a lawyer and sue those physicians for every cent they have ever been able to earn?

That's why we've got to talk about both of these together. But you can't stand up and say we want these essential services but not be willing to get the trial lawyers off the backs of these physicians so they can provide those essential services.

Mr. GENE GREEN of Texas. Will the gentleman yield?

Mr. BILBRAY. I will yield to the gentleman.

Mr. GENE GREEN of Texas. I thank the gentleman for yielding.

Again, this is not a medical malpractice bill, but I would be glad to offer you to be a cosponsor. We passed the bill out of this House twice and sent it to the Senate which would allow volunteers to go into community-based health centers and be covered under the Federal Tort Claims Act. Congressman Murphy from Pennsylvania is a lead sponsor of this Congress. I've been the lead sponsor when Democrats have been in control because we need to do that. If I could do it under this bill, I would do it. But this came out of your conference that you want to repeal mandatory spending to try and train primary care doctors to serve in primary care clinics or whatever.

Mr. BILBRAY. Reclaiming my time, look, the fact is these physicians are being held with a liability that is inappropriate, way over the head, and it is not justifiable----

The Acting CHAIR (Mr. Fortenberry). The time of the gentleman has expired.

Mr. GUTHRIE. I yield the gentleman 1 additional minute.

Mr. BILBRAY. We're talking about the fact that those who want to stand up and say we'll spend Federal funds to create an environment to provide health care but then are not willing to say, not just the fact that we find special tort coverage--and I know that the gentleman from Texas knows because I was at a county level providing those services. We have Federal programs that protect those in the community clinic. But we're not just talking about the little bit of protection we get with our Federal protection. We're talking about the whole tort exposure needs to be considered.

And if you want to talk about access and stand up here and have the moral high ground on access, you've got to be willing to take on the big guy, the powerful trial lawyers, and say, look, physicians are going to be held harmless from your lawsuits. We're going to find a reason to encourage young people to go to school not just by providing Federal subsidies to their tuition, but also telling them, once you get your degree, you'll be able to go into a field where you'll be able to practice your art of medicine without having somebody who has never had to make a life-and-death decision drag you before a judge and a jury and attack you for your decisions.

Mr. GENE GREEN of Texas. Mr. Chairman, my colleague from California again is confused. We have H.R. 5 that the majority has to federalize medical malpractice insurance in our country. Some States have taken care of it. The State of Texas has done it by constitutional amendment. And that debate may come up if the majority brings up their H.R. 5.

With that, Mr. Chairman, I yield 2 minutes to my colleague from New York, Congressman Tonko.

Mr. TONKO. Mr. Chair, the underlying legislation guts funding for vital teaching health centers across the country. Teaching health centers are residency programs for primary care physicians. They provide community-based training for doctors who will go on to work in rural and our underserved areas.

Mr. Chair, my amendment is very simple. It requires that we find out exactly how many primary care physicians we will lose if Republicans succeed in cutting teaching health centers across the country. My amendment commissions the Government Accountability Office to report on these findings so that the American people can see how drastically these cuts will eliminate jobs and hurt the quality, access, and affordability of primary care health options.

I'm interested to know, Mr. Chair, if some of my Republican colleagues are aware that if H.R. 1216 is adopted, there will be fewer primary care doctors working in their communities. For example, this bill guts funding for 23 physicians at the teaching health center in the heart of Scranton, Pennsylvania. These 23 individuals are being trained to provide basic health care for constituents in the greater Scranton area. If my Republican colleague from the Scranton area joins the Republican leadership in eliminating this program, his community will lose training for 23 new primary care physicians. That's 23 jobs, jobs that they support, and 23 individuals who help serve constituents with their health care needs.

Again, Mr. Chair, my amendment is a matter of effective oversight. It asks that we find out from a nonpartisan source exactly how many primary care physicians we will lose if the Republican leadership moves forward to cut teaching health centers across the country.

Mr. GUTHRIE. Mr. Chair, I yield myself as much time as I may consume.

I want to point out, as we went through, what we're talking about doing is graduate medical education in teaching health centers will be identical to the graduate medical education in hospitals and children's hospitals.

And I remember, I was not on the Energy and Commerce Committee but in Education and Labor. We worked on the health care bill. And the description that we went in through the night and went through the bill line by line is absolutely true. I think we were 24 or 25 hours direct on that. And I wasn't on Energy and Commerce when you went, but they went through the night, as well, Mr. Chairman. And when this bill passed out of the House of Representatives, the teaching health centers were authorized subject to appropriation.

The change was made in the Senate. So working late into the night and going through the bill, we are just asking and what we are proposing is to treat teaching health centers as the House-passed version of the health care bill did, which is exactly the same as hospitals and children's hospitals and many of the other programs, nurse training and other things as well.

I reserve the balance of my time.

Mr. GENE GREEN of Texas. Mr. Chairman, I yield myself such time as I may consume.

I have no problem with including children's hospitals , and I think we could probably pass it on the suspension calendar if we had legislation that would expand that mandatory funding for teaching hospitals, and particularly children's hospitals, but that is not what this legislation does today. It takes away that help we are providing to train more primary care physicians in our country. That is what this bill does: It takes away the mandatory funding.

Now there have been examples all through history of mandatory funding. We realized during the Affordable Care Act that we need more primary care physicians. We need a lot more health care providers. We need more nurses. We need everything. In fact, it is a great job growth area. But we know we need primary health care providers because we know when somebody needs a doctor, they will see that primary care doctor. They may need a specialist, but they still need to go to that primary care doctor. That is why this mandatory funding is so important, and that is why this bill is the wrong way to deal with it. That is why it shouldn't be considered today. I would hope everybody would realize that if you support health care and primary care physicians, you would want that mandatory training so we can get those physicians out in the community where they are really needed.

Numbers show that if we have a program like this where primary care physicians will go into a community based health care center, they will go into that area as part of their residency program, they are more likely to come back to that community. That is why that was part of the Health Care Act. We have people who their primary care physicians now are the emergency rooms in hospitals in my district. I would much rather they be able to go see a doctor down the street for their sinus infection than showing up at midnight in an emergency room where we are going to end up having to pay for it, even at a public hospital, where the local taxpayers are paying for it. That is why this mandatory spending is so important. And that is why I think it is so the wrong way to go in health care, to take away mandatory spending for primary care physicians. That is something that is so important in our country, it should be mandatory.

I reserve the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I want to point out again, the mandatory spending was not in the House version of the health care bill that was passed. Teaching health centers were treated exactly like general pediatric and primary care physicians are in hospital settings and in children's hospital settings--general hospitals and children's hospitals. We are saying we are going back to the way it was established in the Affordable Care Act as it was passed out of the House of Representatives.

We are talking about primary care physicians as well. I agree we need more primary care physicians. Their training at children's hospitals and hospitals is in geriatric, pediatric, internal medicine, all the primary care physician specialties that we know. We are just saying one shouldn't be treated differently than the other. They are important, and we should go through the annual appropriations process and present the validity of programs and let the appropriations process determine the level of funding.

Mr. Chairman, I yield 4 minutes to the gentleman from Georgia (Mr. Gingrey).

Mr. GINGREY of Georgia. I thank the gentleman from Kentucky for yielding me this time.

As everyone knows, the financial health of this Nation is in a very precarious State. Unfortunately, it was made worse by the spending decisions and actions of this last Congress. Today, the Federal Government borrows 41 cents of every dollar it spends. We are facing a $1.6 trillion deficit for this fiscal year, the third straight year of trillion-dollar deficits, an all-time record in nominal terms and a new post-World War II record as a share of the economy.

The reckless spending of the last Congress has only exacerbated this problem. The so-called stimulus bill--that didn't stimulate much besides a lot of wasteful spending--and ObamaCare, the Patient Protection and I think un-Affordable Care Act, are two such examples of legislation that spent recklessly.

Mr. Chairman, among the 2,400 pages of ObamaCare, the last Congress created $105 billion in secret slush funds that can be used to advance the political goals of President Obama and his administration without our oversight, congressional oversight.

At a time when our country is facing financial ruin, my concern is how much damage to our national budget the White House can do with these funding streams. The time for blank checks is over. The time for leadership is now.

Section 5508 of ObamaCare provides a $230 million direct appropriation for teaching health centers residency programs. H.R. 1216 would simply convert the direct appropriations into an authorization of appropriations. The legislation allows for teaching health centers to receive funding through the normal appropriations process with proper Congressional oversight.

Mr. Chairman, many Members of this Congress have supported medical education--I certainly count myself among them--including graduate medical education for children's hospital programs. However, in her testimony before the House Energy and Commerce Health Subcommittee earlier this year, HHS Secretary Sebelius stated that the President's fiscal year 2012 budget eliminates children's hospital graduate medical education programs because they duplicate the teaching center funds in ObamaCare.

Mr. Chairman, is this the future of medical education that we want for our children? Teaching our medical professionals in clinics that might not be equipped to properly train them to handle emergency situations versus in hospitals regarded as centers of excellence like Children's Healthcare of Atlanta in my own home State of Georgia. This is why the appropriations process is so important--we need congressional oversight to help decide what the priorities of tomorrow should be.

This Congress, the 112th Congress--is focused on reining in spending and reducing our deficit. We cannot do the job of the American people and make the spending cuts necessary unless the legislative branch has oversight over Federal spending. If this is truly the people's House, give back what the last Congress gave away--control over the budget. If this body is sincere in its wishes to restore fiscal sanity in this country, I see no reason why this body should not be voting in a bipartisan manner to prevent this President--or any President, for that matter--from spending our Nation into insolvency.

So I urge all of my colleagues to support H.R. 1216. I thank the gentleman from Kentucky for his bill and for yielding me this time.

Mr. GENE GREEN of Texas. Mr. Chairman, I yield myself such time as I may consume.

Let me correct some of the statements that have been made. We have had mandatory hospital training residency programs since 1965. By taking away direct or mandatory spending for community-based residency programs, it is a direct attack on community-based programs. Let me list for you the teaching hospital programs that are under mandatory that was part of the Affordable Care Act. I joked on the floor one night to my colleague from Georgia, I wish they would name it the Green Act, GreenCare instead of ObamaCare, because I am so proud of that law.

The teaching hospital program supports the training of individuals who practice in family medicine, internal medicine, pediatrics, internal medicine pediatrics, obstetrics, gynecology, psychiatry, general dentistry, pediatric dentistry, or geriatrics. These are disciplines where we are experiencing significant physician shortages. That is why we need the mandatory spending. It does cover children.

Now, we have had mandatory spending for hospital training, again, since 1965. All this bill would do would be to take it away from community-based health centers where we know there is a shortage. The statistics show, if you have doctors who do their residencies or residency programs through community-based centers, they are more likely to go back there and practice, whether they be pediatricians, whether they be in family practice, whether they be in internal medicine. That's where we need the growth and to have primary care physicians. This is a direct attack on health care in our own country.

Why wouldn't we want it mandatory for community-based facilities if it's already mandatory for hospital-trained physicians? We need physicians in the community, not just in the hospitals.

Mr. Chairman, I yield back the balance of my time.

Mr. GUTHRIE. Again, Mr. Chairman, it is important that we have an adequate supply of primary care physicians, and it is important public policy for this country. It is important that we also have oversight and control over the budget in the way the money is spent, and we do that through the appropriations process.

I just want to point out, in the last Congress, there was great effort in putting together the health care bill. When we passed out of this Congress the House-passed version, this was an authorized ``subject to appropriations'' section of the bill. I know it has been described as being against health care throughout the country, but that was the way, through much debate, it passed out of this House of Representatives. It treats it similarly to hospital-based education in primary care and to children's hospital-based. It puts it on an equal footing with nurses' programs, nurse practitioner programs and other programs, which we all agree have shortages. We need more people in those fields.

I just want to reiterate that this does not eliminate the program. It authorizes it. It changes it from a direct appropriation to an authorized appropriation through the regular appropriations process.

* [Begin Insert]

Mr. DINGELL. Mr. Chair, I rise today in strong opposition to H.R. 1216. As a declining number of physicians in our Nation are entering into primary care fields, my colleagues on the other side of the aisle are working to pass legislation that will irresponsibly impede critical training of the next generation of primary care physicians.

A primary care physician shortage is a very real and alarming problem looming before us. The Association of American Medical College's Center for Workforce Studies anticipates a shortage of 45,000 primary care physicians and a shortage of 46,000 surgeons and medical specialists in the next decade.

Since 1965, the Medicare Graduate Medical Education program, which has been supported by mandatory funding, has trained the majority of resident trainees across the country in a hospital-based setting. The Teaching Health Center program is the first medical graduate program of its kind to allow future physicians in primary care fields to train in the actual setting they will be practicing in--community-based health centers.

My colleagues claim that converting the Teaching Health Center program from a mandatory appropriation to an authorization--subject to the annual appropriations process--will not endanger the program. We saw during the debate on the fiscal year 2011 budget that could not be further from the truth.

During that dreadful debate it became painstakingly clear that my colleagues know the cost of everything, but the value of nothing.

Subjecting this program to the annual appropriations process will not allow for a predictable and stable funding stream needed to assist community-based health centers and resident trainees in planning and preparing for this training.

We all recognize and agree with the need to reduce federal government spending, but making the Teaching Health Center program a pawn in the appropriations game is foolish at best.

Further, I find it ironic that during debate in the Energy and Commerce Committee my colleagues expounded on their desires for more investment in our health workforce, yet at the first opportunity they are placing the Teaching Health Center program in the vulnerable position of future funding reductions.

Mr. Chair, H.R. 1216 is another plan in the Republicans' repeal health reform platform. Passing this legislation will jeopardize funding for the Teaching Health Center program, further delaying the fundamental training needed for our primary care physicians.

I urge my colleagues to stand up for the training of our primary care physicians and vote no against this reckless piece of legislation.

Mrs. CHRISTENSEN. Mr. Chair, I rise today, fully disappointed that my colleagues on the other side of the aisle are trying to move forward with this bill. This bill has no merit; in fact, it is little more than a part of a larger, ill-conceived strategy to undermine the progress we have made and will likely continue to make as a result of the historic health care reform bill that was enacted last year.

While on its face it seems harmless, we all know the reality of what this bill will do. And, it is crucial that the very individuals who elected us to represent them--the large majority of whom will be directly and indirectly affected by this and in a very negative way--also know that this bill does nothing to ensure fiscal responsibility or improve the medical education system in health centers, and does even less to ensure that there are trained and qualified health care providers in their communities to serve their communities.

In fact, it jeopardizes ongoing and forthcoming efforts to ensure that there are highly-trained and qualified health care providers practicing in every community--especially those that suffer due to a shortage of health care providers--across the country.

If this bill were to pass and become law, then the already-planned primary care training programs that will be operated by community-based entities, like community health centers, will not likely continue beyond their first planned year because turning this program into a discretionary one offers no guarantee of future funding. Further, making this program discretionary will serve as a disincentive to other community-based entities that are considering launching similar graduate medical education programs for the same reasons.

The unfortunate element in all of this is this: These programs train individuals who will practice in family medicine, internal medicine, pediatrics, obstetrics and gynecology, general dentistry and geriatrics--the very areas of medical care where the provider shortages are the greatest.

Further, the individuals trained by these programs are very likely to serve most underserved communities--a disproportionate number of which are rural, low-income and/or racial and ethnic minority--across the Nation.

Why, I must ask, would we want to end these programs, when provider shortages are not issues that affect only our side of the aisle; it is a public health crisis that touches every district across the Nation. In fact, during the health care reform debates, my friends on the other side of the aisle continually argued that there are not enough physicians in the country to meet our current primary health care needs and to address our current primary health care challenges. So, it seems counterintuitive to, then, seek to compromise and put an end to the very programs that were designed and funded to address this very problem.

We have had and continue to have very serious health care challenges in this country, and our primary care workforce shortages fall into that category. All of these serious health care challenges warrant even more serious solutions--many of which are being implemented thanks to the Patient Protection and Affordable Care Act.

However, this bill--H.R. 1216--is not a serious solution and, if passed, will only become a serious part of a serious problem.

I, therefore, urge my colleagues to vote, ``no'' on this bill. And, in doing so, you will be voting yes for the improved and strengthened primary health care workforce across the Nation.

Mr. BLUMENAUER. Mr. Chair, I rise in opposition to H.R. 1216, which rescinds funding for graduate medical education in qualified teaching health centers. The Affordable Care Act provides funding for the training of medical residents in qualifying health centers, which will strengthen the health care workforce and support an increased number of primary care medical residents trained in community-based settings across the country. This bill undermines that key objective and in so doing, undermines public health efforts, limits access to doctors in communities around the country, and weakens our medical workforce.

Teaching health centers are community-based patient care centers that operate primary care residency programs, such as family medicine, internal medicine, pediatrics, and general and pediatric dentistry. Physicians trained in health centers are more than three times as likely to work in a health center and more than twice as likely to work in an underserved area than are those not trained at health centers.

Oregon's community health centers--29 clinics offer care at more than 150 delivery sites--provide high-quality, comprehensive health care to more than a quarter-million people across my state. Services range from medical and dental care to prescription medications to behavioral health care. Many centers also provide such support services as transportation and translation to ensure that everyone who needs healthcare can access it. This legislation, however, would undermine the ability of these centers to attract doctors and other health professionals so vital to providing community-based care.

The Institute of Medicine reports that already there is a need for more than 16,000 new physicians in currently underserved areas. Unless we invest in medical education that closes this shortfall, it will worsen in future years. The Association of American Medical Colleges estimates that, by 2024, we will need 46,000 additional primary care physicians. This legislation makes it more difficult to close this gap.

A recent study by Dartmouth investigators published in the Journal of the American Medical Association found that beneficiaries living in areas with better access to primary care physicians had lower mortality and fewer hospitalizations. By eliminating funding to train doctors in community-based settings, this legislation makes it less likely that patients in underserved areas will be able to see a doctor or to get the care that they need. This legislation will worsen health outcomes in underserved areas.

Rather than making refinements to improve the Affordable Care Act, H.R. 1216 merely eliminates funding. It fails to advance the key objectives of the law to improve healthcare while lowering costs and it fails to offer alternative solutions to meet these important objectives. I oppose this legislation.

* [End Insert]

Mr. GUTHRIE. I yield back the balance of my time.

The Acting CHAIR. All time for general debate has expired.

Pursuant to the rule, the bill shall be considered read for amendment under the 5-minute rule.

The text of the bill is as follows:

H.R. 1216

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. CONVERTING FUNDING FOR GRADUATE MEDICAL EDUCATION IN QUALIFIED TEACHING HEALTH CENTERS FROM DIRECT APPROPRIATIONS TO AN AUTHORIZATION OF APPROPRIATIONS.

(a) In General.--Section 340H of the Public Health Service Act (42 U.S.C. 256h), as added by section 5508(c) of the Patient Protection and Affordable Care Act (Public Law 111-148), is amended--

(1) in subsection (b)(2)(A), by striking ``under subsection (g)'' each place it appears and inserting ``pursuant to subsection (g)'';

(2) in subsection (d)(2)(B), by striking ``in subsection (g)'' and inserting ``pursuant to subsection (g)''; and

(3) by amending subsection (g) to read as follows:

``(g) Authorization of Appropriations.--To carry out this section, there are authorized to be appropriated $46,000,000 for each of fiscal years 2012 through 2015.''.

(b) Rescission of Unobligated Funds.--Of the amounts made available by such section 340H (42 U.S.C. 256h), the unobligated balance is rescinded.

(c) Technical Correction.--The second subpart XI of part D of title III of the Public Health Service Act (42 U.S.C. 256i), as added by section 10333 of the Patient Protection and Affordable Care Act (Public Law 111-148), is amended--

(1) by redesignating subpart XI as subpart XII; and

(2) by redesignating section 340H of the Public Health Service Act (42 U.S.C. 256i) as section 340I.

The Acting CHAIR. No amendment to the bill shall be in order except those received for printing in the portion of the Congressional Record designated for that purpose in a daily issue dated May 23, 2011, and except pro forma amendments for the purpose of debate. Each amendment so received may be offered only by the Member who caused it to be printed or a designee and shall be considered read.

AMENDMENT NO. 2 OFFERED BY MR. TONKO

Mr. TONKO. Mr. Chair, I have an amendment at the desk.

The Acting CHAIR. The Clerk will designate the amendment.

The text of the amendment is as follows:

Page 4, after line 12, add the following:

(d) GAO Study on Impact on Number of Primary Care Physicians to Be Trained.--The Comptroller General of the United States shall conduct a study to determine--

(1) the impacts that expanding existing and establishing new approved graduate medical residency training programs under section 340H of the Public Health Service Act (42 U.S.C. 256h), using the funding appropriated by subsection (g) of such section, as in effect on the day before the date of the enactment of this Act, would have on the number of primary care physicians that would be trained if such funding were not repealed, rescinded, and made subject to the availability of subsequent appropriations by subsections (a) and (b) of this section; and

(2) the amount by which such number of primary care physicians that would be trained will decrease as a result of the enactment of subsections (a) and (b).

The Acting CHAIR. The gentleman from New York is recognized for 5 minutes.

Mr. TONKO. Mr. Chair, my friends on the other side of the aisle seem steadfast and determined in their attack on access to affordable, quality health care. Couple that with their plan to end Medicare, and our Nation's seniors are put in quite a bind. Meanwhile, they want to place our health in the hands of Wall Street and Big Insurance, not between doctors and their patients. The seniors in my district and across the country know that vouchers will not cover their health care needs. They see the tax breaks for millionaires and billionaires and handouts for Big Oil, and are vehemently opposed to this plan.

Today, we have yet another assault on affordable access to health care. My Republican colleagues have found their next boogeyman: family practice physicians. This is surprising as we have a dire shortage of primary care physicians in our country.

The American Association of Medical Colleges has estimated that an additional 45,000 primary care physicians are required by 2020 just to meet America's health care needs. A few short months ago, both sides of the aisle agreed on the need to build our Nation's primary care workforce. This is a proven way to bend the health care cost curve by decreasing health spending through prevention and early, simple treatment.

Unfortunately, Republicans have since changed their tune. They have declared that the problem is not that we have a shortage of these crucial doctors. Instead, they must believe we have too many primary care physicians, and so we face this call to eliminate training for those on the front lines of the fight for quality care.

The underlying legislation guts funding for vital teaching health centers across our country. Teaching health centers are residency programs for primary care physicians, providing community-based training for doctors who will go on to work in rural and in our underserved areas. From Medicare to high gas prices to tax rates, my friends on the other side have proposed time and time again policies that put middle class Americans on the line and let Wall Street, Big Oil and Big Insurance take over and earn big. The constituents in my home district, in the Capital Region of New York State, need a break. They are looking at the price of gas, at the price of food and at the price of prescription drugs, and are just wondering how they will make it through the month.

Do we need to balance the budget? Yes. Do we need to balance the budget on the backs of hardworking Americans who play by the rules? Absolutely not.

Mr. Chair, my amendment is very simple. It requires that we find out exactly how many primary care physicians we will lose if Republicans succeed in cutting teaching health centers across the country. My amendment commissions the Government Accountability Office to report on these findings so that the American people can see how drastically these cuts will eliminate jobs and will hurt the quality, access and affordability of primary care health options.

I am interested to know, Mr. Chair, if some of my Republican colleagues are aware that, if H.R. 1216 is adopted, there will be fewer primary care doctors working in their communities. For example, this bill cuts funding for 23 physicians at the teaching health center in the heart of Scranton, Pennsylvania. These 23 individuals are being trained to provide basic health care for constituents in the greater Scranton area.

If my Republican colleague from the Scranton area joins the Republican leadership in eliminating this program, his community will lose training for 23 new primary care physicians. That's 23 jobs, the many jobs they support and 23 individuals who will serve constituents in need.

Mr. Chair, if my colleague from Pennsylvania would like to come to the floor to defend the rights of the teaching health center in Scranton against this shortsighted and unjust attack by the Republican leadership, I would gladly yield him time.

The same challenge is faced by my colleague from the Billings, Montana, area, whose district will lose funding to train seven primary care physicians specifically for the health care needs of rural Montanans. In Idaho, Illinois, Texas, and Washington, it's the same story. All of these communities are seeing good American jobs put at risk--and for what?--to fund handouts to insurance and oil companies? to pay for even more tax breaks to millionaires, billionaires and some of the wealthiest corporations on Earth?

I would gladly yield my Republican colleagues from these districts time to defend their constituents.

Again, Mr. Chair, my amendment is a matter of effective oversight. It asks that we find out from a nonpartisan source exactly how many primary care physicians we will lose if the Republican leadership moves forward to cut teaching health centers across our country.

When it comes to ensuring our constituents have access to basic primary health care, when it comes to protecting Medicare and Social Security for our seniors and to ensuring they have healthy and comfortable retirements, there should be no disagreement.

Please join me in supporting this amendment and in standing with middle class Americans across the country.

With that, I yield back the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I rise in opposition to the amendment.

The Acting CHAIR (Mr. Campbell). The gentleman from Kentucky is recognized for 5 minutes.

Mr. GUTHRIE. Mr. Chairman, first, I want to point out the list that was read of teaching health centers.

The text of the bill is very clear: that we only rescind unobligated funding. If the funding has been obligated, then it continues to move forward. So, as to the list that was read, those will be funded.

The amendment before us directs the GAO to determine the number of physicians who will be trained by this program if funds are not kept mandatory. I oppose the general premise that a program must have mandatory funding in order to be effective. This type of thinking has led us to massive budget deficits as far as the eye can see.

During the debate on the continuing resolution, I can remember more than a few Members complaining that reductions in discretionary spending would have little impact on the deficit. There is some truth to the fact that discretionary spending which Congress has more control over comprises an increasingly smaller share of the Federal budget.

It seems to me that some people's solutions to reining in the discretionary ledger of our Federal budget is to simply shift programs from discretionary to mandatory and let the spending cruise on auto pilot. That is not responsible governing. In a time of $1.5 trillion annual deficits, we must make spending priorities. However, setting priorities involves tough choices. The people that oppose this bill do so because they are unwilling to make the tough choices on what programs the Federal Government should fund and what they should not.

So let's review what happened. Certain programs for training were made mandatory in the health care act and others were subject to future appropriations. Listening to the debate today, it is apparent that some believe any provision in the health care act that authorized a program subject to appropriations is essentially meaningless and did nothing at all. I have heard Members extol the virtues of dental education programs or training for nurse education contained in the health care act, but they are subject to further appropriations.

Where was the amendment to the health reform bill that asked GAO to look into how the lack of mandatory spending in section 5305 of the health care act would affect geriatric education? There wasn't one, and not a single Member of the other side brought the issue up. The reason the other side didn't bring it up is because the programs were constructed in a way to go through the normal authorization and appropriations process. The underlying bill simply puts teaching health centers on equal footing with a myriad of other programs.

I also oppose the amendment because it is a waste of Federal resources. We are asking the GAO to conduct a study that is almost impossible for it to complete. The GAO cannot determine the number of physicians that will be trained because so much of the program is under the discretion of the Secretary. In fact, the contours of the program have not yet even been set. The Health Resources and Services Administration does not even anticipate issuing a Notice of Proposed Rulemaking on the Teaching Health Center Graduate Medical Education Program until December.

Under my bill, supporters of the program will continue to be able to make the case on an annual basis that the program is not duplicative, it is effective, and warrants continued funding over other programs like children's hospitals which the President's budget zeroed out.

I urge my colleagues to vote ``no.''

I yield back the balance of my time.

The Acting CHAIR. The question is on the amendment offered by the gentleman from New York (Mr. Tonko).

The question was taken; and the Acting Chair announced that the noes appeared to have it.

Mr. TONKO. Mr. Chairman, I demand a recorded vote.

The Acting CHAIR. Pursuant to clause 6 of rule XVIII, further proceedings on the amendment offered by the gentleman from New York will be postponed.

AMENDMENT NO. 9 OFFERED BY MR. CARDOZA

Mr. CARDOZA. Mr. Chairman, I have an amendment at the desk.

The Acting CHAIR. The Clerk will designate the amendment.

The text of the amendment is as follows:

Page 4, after line 12, add the following:

(d) GAO Study and Report on Physician Shortage.--The Comptroller General of the United States shall conduct a study to determine--

(1) the impact that expanding existing and establishing new approved graduate medical residency training programs under section 340H of the Public Health Service Act (42 U.S.C. 256h), using the funding appropriated by subsection (g) of such section, as in effect on the day before the date of the enactment of this Act, would have on the number of physicians that would be trained if such funding were not rescinded and made subject to the availability of subsequent appropriations by subsections (a) and (b) of this section; and

(2) the impact that the enactment of subsections (a) and (b) will have on the number of physicians who will be trained under approved graduate medical residency training programs pursuant to such section 340H.

The Acting CHAIR. The gentleman from California is recognized for 5 minutes.

Mr. CARDOZA. Mr. Chairman, I rise today to offer an amendment that would require the GAO to conduct a study that highlights the impact that elimination of funding would have on the number of physicians that would be trained if this program were allowed to continue as intended.

Countless studies have demonstrated a serious and growing shortage of health professionals facing the United States--most critically a shortage of primary care physicians and dentists. However, where I come from, there is a
shortage of specialties as well. With an existing shortage well established and an aging population increasing, our country desperately needs investments in the health care workforce, not rescissions.

In my home State of California alone there are 567 designated health professional shortage areas, which include a population of more than 3.8 million medically underserved individuals. In California's San Joaquin Valley, there are already fewer than 87 primary care physicians for 100,000 patients of population. The doctor/patient ratio in my region is not getting better; it is getting significantly worse. That is why I have consistently advocated for the need to improve access to care and address this vital shortage.

All eight counties in the San Joaquin Valley have been designated as medically underserved by the Department of Health and Human Services, including Merced, Stanislaus, San Joaquin, Madera, and Fresno Counties. At one point a few years ago, we were down to one pediatrician for the entire county of Merced. With the passage of the Affordable Care Act, we were able to include additional funding for these medical residency programs to help address the mounting health care profession shortage in already established underserved areas.

The new Teaching Health Centers Graduate Medical Education Program is intended to be an investment that helps struggling underserved communities deal with the reality of increasing demands on an already strained health care system. Studies have shown that the most effective way to attract and retain new doctors in underserved areas is to allow medical students to complete their medical residency programs in the communities that are in need. Graduating physicians most often practice in the communities where they have completed their residency training, which is why this program is uniquely important. My wife is a perfect case in point, a primary care physician who stayed in our community and practiced for 18 years after she finished the program.

Without these critical investments, the lack of care will most certainly have a costly price on the health and well-being of many rural underserved communities, including those I represent.

Mr. Chairman, I yield back the balance of my time.

Mr. GUTHRIE. Mr. Chairman, I move to strike the last word.

The Acting CHAIR. The gentleman from Kentucky is recognized for 5 minutes.

Mr. GUTHRIE. Mr. Chairman, this amendment is very similar to the previous amendment we discussed, so I will be brief.

One, as I said before, it is difficult for the Government Accountability Office--almost impossible for them--to perform this study moving forward because there is so much discretion that is given to the Health and Human Services Secretary. And as I said before, the Health Resources and Service Administration does not even anticipate issuing a Notice of Proposed Rulemaking on teaching health graduate centers until December.

And then again, as a lot of the comments today, I don't think that moving an authorized and mandatory spending program to an authorized and discretionary spending program renders that program meaningless. If it does do that, then all the other programs that I have listed earlier in the debate--training in general hospitals, training in children's hospitals, training in behavioral education and health, training in nurse retention, training in nurse practitioners--that means that those programs that were in the health care act would not have as much strength as well. And so the comment that by moving this from one part of the budget to the other makes it meaningless, to me, is just not accurate.

And, second, I also want to stress again that the language of the bill is clear: we do not rescind obligated funds; it is only unobligated funds. So again, it wasn't my friend from California, but someone earlier mentioned that there were programs that have already been in place that would be hurt by that. If the funds have been obligated, those programs move forward.

Mr. Chairman, I yield back the balance of my time.

Mr. GENE GREEN of Texas. Mr. Chairman, I move to strike the last word.

The Acting CHAIR. The gentleman is recognized for 5 minutes.

Mr. GENE GREEN of Texas. Mr. Chairman and Members, I know there has been talk only about obligated money. I would like to introduce into the Record a press release issued on January 25 of this year from Health and Human Services announcing the new Teaching Health Center Graduate Medical Education Program. And of those programs, it lists the ones; and that money is obligated, but there will be no future funding for them. So you get a few months of funding, but you don't get any more funding.

These centers--six of them are in Republican districts, five in Democratic districts--will get a very short 3 months' worth of funding if this bill becomes law. And it doesn't do any good. The graduate medical education pays for the training of that physician. These community centers will only receive a short term funding. So it may only be talking about that obligated money, but they won't get any more after this year if this bill becomes law. That's why it is so important that this bill be defeated or that we adopt an amendment similar to our colleague from California.

HHS Announces New Teaching Health Centers Graduate Medical Education Program

ELEVEN CENTERS WILL SUPPORT PRIMARY CARE RESIDENCY TRAINING IN COMMUNITY-BASED SETTINGS

HHS Secretary Kathleen Sebelius today announced the designation of 11 new Teaching Health Centers in the Teaching Health Center Graduate Medical Education program, a 5-year program that will support an increased number of primary care medical and dental residents trained in community-based settings across the country. These Teaching Health Centers will be supported by funds made available through the Affordable Care Act and will help address the need to train primary care physicians and dentists in our nation's communities.

With the funds, these Teaching Health Centers can seek additional primary care residents through the National Resident Matching program this month and will train 50 additional resident full-time equivalents beginning in July 2011. While 3 months of funding totaling $1,900,000 is being awarded this first program year, in future years the annual funding will increase to cover the full-year costs, as well as additional residents. These investments provide an important platform for expanding the primary care workforce and creating more opportunities to prepare physicians to practice primary care in community-based settings, while ensuring primary care services are available to our nation's most underserved communities.

``The Teaching Health Center program is an integral part of our mission to strengthen the nation's primary care workforce and ensure that all Americans have adequate access to care,'' said Secretary Sebelius.

The new Teaching Health Centers are distributed around the nation and will train residents in family medicine, internal medicine, and general dentistry. Teaching Health Centers will receive up to 5 years of ongoing support for the costs associated with training primary care physicians and dentists. HHS' Health Resources and Services Administration (HRSA) will administer the program.

``Participating in this program not only provides top-notch training to primary care medical and dental residents, but also motivates them to practice in underserved areas after graduation,'' said HRSA Administrator Mary Wakefield, Ph.D., R.N.

Eligible Teaching Health Centers are community-based ambulatory patient care centers that operate a primary care residency program, including federally-qualified health centers; community mental health centers; rural health clinics; health centers operated by the Indian Health Service, an Indian tribe or tribal organization; and entities receiving funds under Title X of the Public Health Service Act.

For additional information, visit Teaching Health Centers.


2011 TEACHING HEALTH CENTERSOrganization City State Award
Valley Consortium for Medical Education Modesto Calif. $625,000
Family Residency of Idaho Boise Idaho 37,500
Northwestern McGaw Erie Family Health Center Chicago III. 300,000

Penobscot Community Health Center Bangor Maine 150,000
Greater Lawrence Family Health Center Lawrence Mass. 112,500
Montana Family Medicine Residency Billings Mont. 37,500
Institute for Family Health New York N.Y. 150,000
Wright Center for Graduate Medical Education Scranton Pa. 225,000
Lone Star Community Health Center Conroe Texas 37,500
Community Health of Central Washington Yakima Wash. 75,000
Community Health Systems Beckley W. Va. 150,000
Total 1,900,000

Mr. ELLISON. Mr. Chairman, I move to strike the last word.

The Acting CHAIR. The gentleman from Minnesota is recognized for 5 minutes.

Mr. ELLISON. Mr. Chairman, I rise in opposition to this underlying bill.

As the Senate votes this week on the Republican scheme to end Medicare, I am standing up to protect health care for our seniors. Our seniors, they blazed the trail for all of us. They fought the wars, they've earned the money, they've come and made America a great place; and we have inherited what they've done. We have inherited what our senior citizens have made for us. And now we see our Republican colleagues want to end Medicare for these same seniors. To spend nearly $1 trillion on handouts to millionaires not only harms American seniors, but threatens our economic future.

Medicare guarantees a healthy and secure retirement for Americans who pay into it their whole lives, Mr. Chairman. It represents the basic American values of fairness, decency and respect for our seniors that all Americans should cherish.

Last month, our Republican colleagues voted to end Medicare as we know it. According to the Congressional Budget Office--and, Mr. Chairman, that's the office that is bipartisan and calls it straight as they see it--this plan, this Republican plan, would raise seniors' health care costs by more than $6,000 a year--that's a lot of money, Mr. Chairman--more than doubling their costs. Instead of fulfilling a promise to our seniors, a promise that the people who gave everything for us would have something in their golden years, the plan would bring about a corporate takeover of our health care. Insurance company bureaucrats would be able to deny seniors care that they had paid into for their entire lives. The GOP plan no longer guarantees seniors the same level of benefits and choice of a doctor that they have today under Medicare.

Mr. Chairman, this debate is not about the deficit. Only if it were. This debate is about something else, and it is about whether we are going to meet the promises of our seniors, of our children, of our students, of our public employees, or not. It's a choice of whether we're going to put America to work or not. It's a basic choice about how we're going to live together.

Mr. Chairman, this debate is not about a deficit. And as my fellow colleagues pound on this idea that we're broke, we're not broke. What we are is unwilling to do the basics for people who have given America so much. This debate is not about a deficit, because we can reduce the deficit by putting America back to work. Two-thirds of American corporations don't pay any taxes, including General Electric, Bank of America, and others. If we ask people to just do their fair share, America's not broke.

By siding with insurance industry lobbyists to raise Medicare costs only increases the burden on our seniors while doing nothing to address the deficit. As I said, this is not about the deficit.

Raising taxes for 95 percent of Americans to pay for a trillion-dollar tax cut for CEOs who ship American jobs overseas sides with the rich at the expense of the middle class.

Spending billions on handouts for corporate special interests, including $40 billion on Big Oil, only drives up prices at the pump for families who are already hurting the most.

The Progressive Caucus, Mr. Chair, has a plan that puts people's priorities first. Our budget, which we call ``The People's Budget,'' strengthens Medicare and Social Security. It lets Medicare negotiate cheaper drug prices so insurance company bureaucrats can't deny you the medication you need. And it creates jobs by eliminating the deficit by 2021. That's right. The Progressive Caucus eliminates the deficit. That is the fiscally responsible budget. That's a budget that Americans can get behind. Not some budget that rewards the rich at the expense of everybody else and doesn't do anything to end the deficit.

I'll not stand for a vision of America that throws American seniors under the bus. We have a vision of honoring our seniors, honoring those people, the Greatest Generation, the generation that brought us civil rights, women's rights, human rights, the generation that brought us Medicare. We are in a generational fight, Mr. Chairman, and generations in the future will look back on us and ask us why did we let the Republican Caucus take away the basic promises of America, and we will be able to stand now and say, We didn't. We fought them back and we fought for America where everybody does better because everybody does better, including our seniors.

I yield back the balance of my time.

The Acting CHAIR. The question is on the amendment offered by the gentleman from California (Mr. Cardoza).

The question was taken; and the Acting Chair announced that the noes appeared to have it.

Mr. CARDOZA. Mr. Chairman, I demand a recorded vote.

The Acting CHAIR. Pursuant to clause 6 of rule XVIII, further proceedings on the amendment offered by the gentleman from California will be postponed.

AMENDMENT NO. 7 OFFERED BY MS. FOXX

Ms. FOXX. Mr. Chair, I have an amendment at the desk.

The Acting CHAIR. The Clerk will designate the amendment.

The text of the amendment is as follows:

Page 4, after line 12, add the following:

(d) Prohibition Against Abortion.--Section 340H of the Public Health Service Act (42 U.S.C. 256h) is amended by adding at the end the following new subsection:

``(k) Prohibition Against Abortion.--

``(1) None of the funds made available pursuant to subsection (g) shall be used to provide any abortion or training in the provision of abortions.

``(2) Paragraph (1) shall not apply to an abortion--

``(A) if the pregnancy is the result of an act of rape or incest; or

``(B) in the case where a woman suffers from a physical disorder, physical injury, or physical illness, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed including a life endangering physical condition caused by or arising from the pregnancy itself.

``(3) None of the funds made available pursuant to subsection (g) may be provided to a qualified teaching health center if such center subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions.

``(4) In this subsection, the term `health care entity' includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.''.

The Acting CHAIR. The gentlewoman from North Carolina is recognized for 5 minutes.

Ms. FOXX. Thank you, Mr. Chairman.

My amendment is designed to protect life and the livelihood of those who defend it.

Since 1973, approximately 50 million children have been aborted in the United States. This is a tragedy. According to a CNN poll last month, more than 60 percent of Americans oppose taxpayer funding for abortion. This number includes many of my constituents and is consistent with my strong
pro-life convictions. I am offering my amendment today to ensure that their hard-earned money will not be used to pay for elective abortions or given to organizations that discriminate against pro-life health care providers.

Earlier this month, the House passed H.R. 3, the No Taxpayer Funding for Abortion Act, which codifies many longstanding pro-life provisions and ensures that taxpayer money is not being used to perform elective abortions. H.R. 3 is now awaiting consideration in the Senate, but I will not cease to fight to protect the unborn children in America at every turn.

This amendment ensures that the grants being provided to teaching health centers are not being used to perform elective abortions and makes it crystal clear that taxpayer money is not being used to train health care providers to perform abortion procedures.

Mr. Chair, when the liberal Democrats rammed through their government takeover of health care, in an unprecedented fashion, they refused to include longstanding pro-life provisions. With this bill, House Republicans are seeking to restore a grant program for residency programs to the regular appropriations process, and my amendment explicitly and permanently ensures that should the appropriations committee fund this program, taxpayer money will not be used to pay for elective abortions or train abortion providers.

In addition to the need for a permanent prohibition of taxpayer funding for elective abortions, it is also important that scarce resources are allocated to the most worthy applicants. An applicant that demands that individuals and institutions provide or refer for abortions is simply not the kind of applicant that should be funded under this program. Numerous doctors, nurses and other health care providers refuse to perform or participate in abortions because they believe it is wrong to kill a child. Congress should ensure that these individuals are not discriminated against because of their beliefs. Any form of discrimination is abhorrent, and individuals should not be forced to act against their convictions. This amendment is similar to previous efforts to protect pro-life health care providers and is consistent with these efforts.

To be eligible for funding under this grant program, centers have to agree that they will not discriminate against pro-life health care providers.

My colleagues across the aisle may argue that we already have the Hyde amendment that prohibits taxpayer funding for elective abortion for programs that are included in the Labor, Health and Human Services and Education appropriations legislation. However, this amendment must be included every year. My amendment ends the uncertainty for this program by providing a permanent prohibition on taxpayer funded elective abortions and protects pro-life health care providers. Until we have a permanent prohibition on taxpayer funding of elective abortion and protections for health care providers who cherish life, I will continue to offer and support efforts to support taxpayers, families and children from the scourge of abortion.

The unborn are the most innocent and vulnerable members of our society and their right to life must be protected. Therefore, I urge my colleagues to vote in favor of this amendment.

Mr. Chairman, I yield back the balance of my time.

Ms. DeGETTE. Mr. Chairman, I rise in opposition to the amendment.

The Acting CHAIR. The gentlewoman from Colorado is recognized for 5 minutes.

Ms. DeGETTE. Thank you, Mr. Chairman.

Well, here we are again, forced to stand up again to protecting women's health care against an extreme agenda. I disagree with the whole underlying bill, Mr. Chairman, but even so, even so, how one could tie restricting a woman's right to choose to graduate medical education is sort of beyond me. Let me explain why this is just an extreme and direct attack on women's health.

What it would mean is that across the country residents would be barred from learning how to perform even a basic medical procedure required for women's health. This amendment would jeopardize both education and women's health care by obliterating funding for a necessary full range of medical training by health care professionals.

And here's the thing. The Hyde amendment is the law of the land right now. I don't like the Hyde amendment. I would repeal the Hyde amendment. But frankly, the Hyde amendment has been in place for over 30 years, and it's not going away. And what it says is no Federal funds shall be used for abortions except in the case of rape, incest, or the life of the mother.

Now, there is nothing in the Hyde amendment about restricting medical doctors' training to legal medical procedures. There's nothing about graduate medical education in the Hyde amendment whatsoever. And if we pass this amendment, we will not allow basic medical training that would even allow doctors to provide the procedures that are allowed under the Hyde amendment--life, rape, or incest.

And let me talk about why this is so incredibly dangerous for women's health.

Ensuring that doctors and nurses are fully trained in abortion procedures is essential to ensuring that they can be providing lifesaving care when abortion is a medically necessary procedure to save the life of a pregnant woman.

Now, most pregnancies, thank goodness, progress safely. But sometimes there's an emergency. And sometimes a medical abortion is necessary to protect a woman's health or life. For example, Mr. Chairman, in cases of preeclampsia, hemorrhage, and severe pulmonary hypertension, or bleeding placenta previa, which can be fatal if left untreated, an abortion is a life-saving procedure. In addition, in managing a miscarriage, sometimes an abortion procedure is essential to saving the woman's life.

Now, under this amendment, virtually any type of health care facility could face the loss of funding if they needed to provide abortion care in an emergency situation. And moreover, Mr. Chairman, residents need to be trained in how to handle these very complicated conditions that could necessitate an abortion.

I'm afraid to say these examples are tragically real. The case involving a woman experiencing severe hypertension that threatened her life at St. Joseph's Hospital made the news when a nun, Sister McBride, was excommunicated last year for allowing the woman's life to be saved through an abortion.

The Foxx amendment would also greatly expand the reasons why health care entities should give in to refusing care.

So, Mr. Chairman, here's the thing. Maybe we don't like abortions, and all of us wish abortions would be rare. But sadly, even in the case of a wanted child with a loving home and everything else, even in the case of an exception under the Hyde amendment, sometimes abortions are necessary. And if we say we are not going to train doctors how to provide a range of women's health care services, then we are basically allowing women to bleed to death in the emergency rooms of this country. And I don't think that's what this Congress is about. It is certainly not what the medical profession is about.

I would urge just for reasons of mercy for this House to reject this amendment. It's mean-spirited and it's far, far beyond current law.

With that, Mr. Chairman, I yield back the balance of my time.

Mr. GARAMENDI. Mr. Chair, I move to strike the last word.

The Acting CHAIR. The gentleman from California is recognized for 5 minutes.

Mr. GARAMENDI. Mr. Chairman, I find myself in opposition to the underlying bill and the amendment.

You just heard a very cogent argument. I don't understand why we ought to have ignorant doctors. It doesn't make any sense to me. Abortions are sometimes necessary for saving the life of a pregnant woman. And to have a medical system in which the doctors don't know about that procedure is really stupid. I won't say this amendment is that, but it's really not wise to have ignorant physicians. And it's really not wise not to have physicians at all.

What in the world are we thinking here? What's the purpose of this
amendment and this particular resolution? To deny American men, women, and children the opportunity to go to a doctor? We know all across this Nation that there is a shortage of primary care physicians. In most every community of California, there is a shortage of primary care physicians. Plenty of dermatologists, but not primary care physicians.

So what are we going to do here? Eliminate the funding to train primary care physicians.

Now, that in itself is bad enough. But this is just one piece of a much larger plan to dismantle health care in America. The repeal of the Affordable Health Care Act will increase the cost of medical services all across this Nation and particularly increase the cost to government. Not my projection. The independent Congressional Budget Office said clearly that the Affordable Health Care Act will reduce the cost of Medicare and Medicaid.

So repeal it. Increase the deficit. Huh? Is that what this is all about? I don't get it guys and women. Makes no sense to me.

And now in your budget, the Republicans go after Medicare and terminate Medicare for every American who is not yet over 55 years of age? Terminate it. And turn it over to the rapacious, greedy, profit-before-people health insurance industry, an industry that I know a great deal about. I was the insurance commissioner in California for 8 years, and I know those characters. It is about profit. It's not about caring for people.

And when you say the government shouldn't make decisions, the government does not make decisions in Medicare. The physicians make decisions. But if you turn Medicare over to the insurance companies, it will be the insurance companies that make decisions about medical services.

And by the way, you also voted to repeal those sections of the Affordable Health Care Act that protect all of us from the rapaciousness of the health insurance industry. Eliminating a law which eliminates such things as preexisting conditions, age, sex discrimination, and the rest. So you repeal that and give back to the insurance companies the opportunity to discriminate. And now you want to throw tomorrow's seniors into that same pool of sharks.

I don't get it. It makes no sense whatsoever. It perhaps is the worst idea I've heard in the 35 years I have been involved in public health and in public policy. It makes no sense whatsoever.

And this bill on top of it? Come on. We're not going to train primary care physicians? What in the world are you thinking? I don't get it. I don't get the whole strategy. It is a strategy that will put America's health at risk. It is a strategy that will deny benefits. It is a strategy that will provide us, with this latest amendment, doctors that are ignorant about basic women's health. And it is a strategy that will deny us the necessary primary care physicians.

What in the world are my Republican colleagues doing here about the deficit? Come on now. What you're doing is going to increase the deficit. You're going to increase the deficit. If there are not primary care physicians, then you'll go to the emergency room. And everybody knows that the emergency room is more expensive than a doctor's office.

What are you doing? I don't get it, guys. I don't understand. You're worried about the deficit; yet you take action that increases the deficit? It makes no sense to me.

Madam Chair, I yield back the balance of my time.

Mr. GENE GREEN of Texas. Madam Chair, I move to strike the last word.

The Acting CHAIR (Mrs. Capito). The gentleman is recognized for 5 minutes.

Mr. GENE GREEN of Texas. First of all, I have utmost respect for Congresswoman Foxx of North Carolina. But her amendment is a solution in search of a problem. Graduate medical education does not do abortions.

The teaching hospital center program funds training for primary care residents. There is no payment for services in the law. It's about salaries, benefits, and paying faculty. Teaching health centers will pay for abortions no more than Medicare Graduate Medical Education has paid for abortions for the last 45 years.

The President signed the executive order to make all the provisions subject to the Hyde amendment, all the provisions of the Affordable Care Act subject to the Hyde amendment. The executive order establishes a set of policies for all provisions of the Affordable Care Act to ``ensure Federal funds are not used for abortion services'' consistent with the Hyde amendment. The Presidential order reinforces what we all agree on. No one is here claiming that we should use Federal funds for abortion, except in very limited circumstances, whether they are under this program or elsewhere.

There is another layer of protection codified in permanent law under section 245 of the Public Health Service Act. The Coats amendment clearly prohibits the Federal Government from discriminating against any physician, post-graduate physician training program, or participant in a program of training in the health care professions because the entity refuses to participate in abortion training. That's not an appropriations vehicle; it's not an executive order. It's the law of the land.

That's why I say this amendment is a solution in search of a problem. There is not a problem with Graduate Medical Education, whether they be teaching hospitals, whether they be community-based centers that this bill is subject to.

I yield back the balance of my time.

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