Pursuing Medicaid Block Grants with the Healthy Adult Opportunity Initiative: Dressing Up Old Ideas in New Clothes

The Trump administration's Healthy Adult Opportunity waiver follows a long history of Republican attempts to retrench the Medicaid program through block grants and to markedly reduce federal spending while providing states with substantially greater flexibility over program structure. Previous block grant proposals were promulgated during the presidential administrations of Ronald Reagan and George W. Bush and majorities in Congress led by House Speaker Newt Gingrich and House Budget Committee Chair and then Speaker Paul Ryan. Most recently, Medicaid block grants featured prominently in Republican efforts to repeal and replace the Affordable Care Act. This essay traces the history of Republican Medicaid block grant proposals, culminating in the Trump administration's Healthy Adult Opportunity initiative. It concludes that the Trump administration's attempt to convert Medicaid into a block grant program through the waiver process is illegal and, if implemented, would leave thousands of people without necessary medical care. This fact, combined with failed legislative efforts to block grant Medicaid during the last forty years, highlights the substantial roadblocks to radically restructuring a popular program that helps millions of Americans.

History of hospital care in São Paulo: State grants to the misericórdia charitable associations

This article investigates how the santas casas de misericórdia charitable associations in the state of São Paulo were subsidized by the municipal, provincial, and state governments at the turn of the twentieth century. Budget appropriations from 1838 to 1915 were examined to evaluate these charitable grants as well as the growth in funding during this period. While a care network created with strong state backing, it was put into action by philanthropic assistance. This network of hospital care retained the same format until at least the first third of the twentieth century, and included misericórdia establishments created within the interior of the state of São Paulo.

Obligation and the Changing Nature of Publicly Funded Healthcare

This article explores the relationship between obligation and publicly funded healthcare. Taking the National Health Service (NHS) as the focal point of discussion, the article presents a historical analysis of the shifting nature and function of obligation as it relates to this institution. Specifically, and drawing inspiration from recent literature that takes seriously the notion of the tie or bond at the core of obligation, the article explores how the forms of social relation and bonds underpinning a system like the NHS have shifted across time. This is undertaken via an analysis of Aneurin Bevan's vision of the NHS at its foundation, the importance today of the patient (and the individual generally) within publicly funded healthcare, and the role of contract as a contemporary governance mechanism within the NHS. A core feature of the article is its emphasis on the impact that a variety of economic factors-including privatisation, marketisation, and the role of debt and finance capital-are having on previously settled understandings of obligation and the forms of social relation underpinning them associated with the NHS. It is therefore argued that an adequate analysis of obligation in healthcare law and related fields must extend beyond the doctor-patient relationship and that of state-citizen of the classical welfare state in order to incorporate new forms of relation, such as that between creditor and debtor, and new actors, including private healthcare providers and financial institutions.

Rothschild reversed: explaining the exceptionalism of biomedical research, 1971-1981

The 'Rothschild reforms' of the early 1970s established a new framework for the management of government-funded science. The subsequent dismantling of the Rothschild system for biomedical research and the return of funds to the Medical Research Council (MRC) in 1981 were a notable departure from this framework and ran contrary to the direction of national science policy. The exceptionalism of these measures was justified at the time with reference to the 'particular circumstances' of biomedical research. Conventional explanations for the reversal in biomedical research include the alleged greater competence and higher authority of the MRC, together with its claimed practical difficulties. Although they contain some elements of truth, such explanations are not wholly convincing. Alternative explanations hinge on the behaviour of senior medical administrators, who closed ranks to ensure that de facto control was yielded to the MRC. This created an accountability deficit, which the two organizations jointly resolved by dismantling the system for commissioning biomedical research. The nature and working of medical elites were central to this outcome.

Breaking the taboo: a history of monetary financing in Canada, 1930-1975

Monetary financing - the funding of state expenditure via the creation of new money rather than through taxation or borrowing - has become a taboo policy instrument in advanced economies. It is generally associated with dangerously high inflation and/or war. Relatedly, a key institutional feature of modern independent central banks is that they are not obligated to support government expenditure via money creation. Since the financial crisis of 2007-2008, however, unorthodox monetary policies, in particular quantitative easing, coupled with stagnant growth and high levels of public and private debt have led to questions over the monetary financing taboo. Debates on the topic have so far been mainly theoretical with little attention to the social and political dynamics of historical instances of monetary financing. This paper analyses one of the most significant twentieth-century cases: Canada from the period after the Great Depression up until the monetarist revolution of the 1970s. The period was a successful one for the Canadian economy, with high growth and employment and manageable inflation. It offers some interesting insights into the relationship between states and central banks and present-day discussions around the governance of money creation.

The origin of the medical research grant in the United States: the Rockefeller Foundation and the NIH Extramural Funding Program

The establishment of National Institutes of Health (NIH) extramural grants in the second half of the twentieth century marked a signal shift in support for medical research in the United States and created an influential model for the rest of the world. A similar landmark development occurred in the first half of the twentieth century with the creation of the Rockefeller Foundation and its funding programs for medical research. The programs and support of the foundation had a dramatic impact on medical research in the United States and globally. This paper examines early connections between these two developments. The NIH grants have usually been seen as having their roots primarily in the government programs of the Second World War. This article finds direct and indirect influence by the Rockefeller Foundation, as well as parallel developments in these two monumental programs of support for medical research.

[The Continuity Between World War II and the Postwar Period: Grant Distribution by the Japan Society for the Promotion of Science and the Subsidiary Fund for Scientific Research]

This paper analyzes the distribution of the Subsidiary Fund for Scientific Research, a predecessor to the Grant-in-Aid for Scientific Research (KAKENHI), which operated in Japan from the 1930s to 1950s. It reveals that the Japanese government maintained this wide-ranging promotion system since its establishment during the war until well into the postwar period. Previous studies insist that, at the end of the war, the Japanese government generally only funded the research that it considered immediately and practically useful. In contrast to this general perception, my analysis illustrates that both before and after the war, funding was allotted to four research areas: natural science, engineering, agriculture, and medicine. In order to illuminate this continuity, I compare the Subsidiary Fund with another research fund existing from 1933 to 1947: the Grant of the Japan Society for the Promotion of Science (JSPS). The comparison demonstrates that the JSPS received externally raised capital from the military and munitions companies. However, while this group focused upon engineering and military-related research as the war dragged on, the Subsidiary Fund has consistently entrusted scientists with the authority to decide the allocation of financial support.

Ahead of its time? Reflecting on New Zealand's Pharmac following its 20th anniversary

New Zealand's Pharmaceutical Management Agency (Pharmac) was created in 1993. Unusual in international terms, Pharmac's objective is to work within a fixed budget while ensuring the New Zealand public receives an adequate range of government-subsidised medicines. Following its 20th anniversary, this article reflects on Pharmac's development and role within the New Zealand health system, various changes over time to the agency's scope and activities, its performance and its present challenges.

Forensic services, public mental health policy, and financing: charting the course ahead

High-quality forensic evaluations can be critical for criminal cases brought before the court. In addition, forensic practitioners and mental health and forensic administrators have increasingly taken a broader view of the revolving door between the mental health and criminal justice systems. More attention is now paid to why individuals with mental disorders, including co-occurring substance use, come into the criminal justice system and the challenges that they face on re-entry into the community. In particular, individuals who receive care across civil, forensic, and correctional systems are at especially increased risk of disrupted health care access and coverage. With health care reform on the horizon, it is important to understand public financing and its impact on forensic services for this crossover population. This article is a review of historical and future trends in public mental health funding focused on Medicaid and other federal resources, the movement toward community-based services, and the impact of these areas on forensic practice and forensic systems. Tensions between recovery principles and legal mandates are also addressed as community services are emphasized, even in forensic contexts. This article calls forensic practitioners to action and offers suggested areas of focus for training to increase knowledge of public mental health funding, policy, and practice from a forensic perspective.

Between prevention and therapy: Gio Batta Gori and the National Cancer Institute's Diet, Nutrition and Cancer Programme, 1974-1978

This paper explores the origins of the Diet, Nutrition and Cancer Programme (DNCP) of the National Cancer Institute (NCI) and its fate under its first director, Gio Batta Gori. The DNCP is used to explore the emergence of federal support for research on diet, nutrition and cancer following the 1971 Cancer Act, the complex relations between cancer prevention and therapeutics in the NCI during the 1970s, the broader politics around diet, nutrition and cancer during that decade, and their relations to Senator George McGovern's select committee on Nutrition and Human Needs. It also provides a window onto the debates and struggles over whether NCI research should be funded by contracts or grants, the nature of the patronage system within the federal cancer research agency, how a director, Gio Gori, lost patronage within that system and how a tightening of the budget for cancer research in the mid-to-late 1970s affected the DNCP.

Hospitals, finance, and health system reform in Britain and the United States, c. 1910-1950: historical revisionism and cross-national comparison

Comparative histories of health system development have been variously influenced by the theoretical approaches of historical institutionalism, political pluralism, and labor mobilization. Britain and the United States have figured significantly in this literature because of their very different trajectories. This article explores the implications of recent research on hospital history in the two countries for existing historiographies, particularly the coming of the National Health Service in Britain. It argues that the two hospital systems initially developed in broadly similar ways, despite the very different outcomes in the 1940s. Thus, applying the conceptual tools used to explain the U.S. trajectory can deepen appreciation of events in Britain. Attention focuses particularly on working-class hospital contributory schemes and their implications for finance, governance, and participation; these are then compared with Blue Cross and U.S. hospital prepayment. While acknowledging the importance of path dependence in shaping attitudes of British bureaucrats toward these schemes, analysis emphasizes their failure in pressure group politics, in contrast to the United States. In both countries labor was also crucial, in the United States sustaining employment-based prepayment and in Britain broadly supporting system reform.

The money trail: a new historiography for networks, patronage, and scientific careers

Money is everywhere in science. Yet historians have only rarely placed the money trail at the center of their analyses. The essays in this Focus section demonstrate that following the money offers a historiographical path for investigating a number of key issues across disciplinary boundaries in the nineteenth and twentieth centuries. Drawing on cases and materials relating to a number of scientific fields, including electrical engineering, aeronautics, agriculture, and paleontology, the essays examine the continuous role of money in industrial and military patronage, personal connections and networks, and spatial and geographical dimensions of science, as well as in relation to state funding and ownership. Together, the contributions demonstrate how following the money offers a way of overcoming hyperprofessionalism in the history of science.

Reluctant entrepreneurs: patents and state patronage in new technosciences, circa 1870-1930

At a time when neoliberalism and financial austerity are together encouraging academic scientists to seek market alternatives to state funding, this essay investigates why, a century ago, their predecessors explicitly rejected private enterprise and the private ownership of ideas and inventions available to them through the patent system. The early twentieth century witnessed the success of a long campaign by British scientists to persuade the state to assume responsibility for the funding of basic research ("pure science"): their findings would enter the intellectual commons; their rewards would be primarily reputational (financial only secondarily, through consequent career advancement). The essay summarizes recent research in three separate fields of British techno-science--electricity, aviation, and agricultural botany--all of which were laying claim, at this time, to a heightened commercial or military importance that raised new questions about the ownership of scientific ideas. It suggests that each of the three established an idiosyncratic relationship with the patent system or with other forms of "intellectual property," which would both influence their emergent disciplines and affect the extent to which commercial enterprise could remain a viable funding strategy.

The mental health sector and the social sciences in post- World War II USA. Part 2: The impact of federal research funding and the drugs revolution

The second of two linked papers examining the interactions of psychiatry and the social sciences since World War II examines the role of NIMH on these disciplines. It analyses the effects of the prominence and the decline of psychoanalysis, and the impact of the psychotropic drugs revolution and the associated rise of biological psychiatry on relations between psychiatry and clinical psychology; and it explores the changing relationships between psychiatry and sociology, from collaboration to conflict to mutual disdain.

Psychic aftershocks: crisis counseling and disaster relief policy

Though crisis counseling following disasters has become a commonplace in the 21st century, we have little to no sense of how and when it became part of federally supported disaster relief services. In 1974, as part of a broad overhaul of federal disaster policy, an authorization to fund counseling services, and mental health training to disaster relief workers, was inserted into the Disaster Relief Act passed in that year--despite little to no empirical evidence that such counseling was necessary or effective. As this article demonstrates, unlike the drive for community mental health programs at mid-century, federal support for disaster mental health did not come as a result of a long campaign waged from well-connected institutions. Rather, it was largely the result of local practitioners, informed by larger currents in thinking about crisis intervention, who discerned these needs in a spontaneous and ad hoc manner. Disaster mental health services came into being thanks to the flourishing of a broad network of therapeutic practitioners in places as far flung as Rapid City, South Dakota, Wilkes-Barre Pennsylvania, and Logan County, West Virginia, who implemented mental health pilot projects in response to disasters in the early 1970s. Their efforts caught the attention of journalists already attuned to therapeutic discourse, and to sympathetic national legislators, to whom the proposition that disaster victims would suffer from psychological damage simply seemed like common sense and a logical service to include as part of a general broadening of federal assistance to disaster victims.

The crisis, the humanities and medical history

Non-controversially, the full version of this article argues that the crisis in British higher education will impoverish teaching and research in the arts and humanities; cut even more deeply into these areas in the post-1992 sector; and threaten the integrity of every small sub-discipline, including the history of medicine. It traces links between the Thatcherite reforms of the 1980s and the near-privatisation of universities proposed by the Browne Report and partly adopted by the coalition. The article ends by arguing that it would be mistaken to expect any government-driven return to the status quo ante. New ideas and solutions must come from within. As economic and cultural landscapes are transformed, higher education will eventually be rebuilt, and the arts and social sciences, including medical history, reshaped in wholly unexpected ways. This will only happen, however, if a more highly politicised academic community forges its own strategies for recovery.

Spring cleaning: rural water impacts, valuation, and property rights institutions

Using a randomized evaluation in Kenya, we measure health impacts of spring protection, an investment that improves source water quality. We also estimate households' valuation of spring protection and simulate the welfare impacts of alternatives to the current system of common property rights in water, which limits incentives for private investment. Spring infrastructure investments reduce fecal contamination by 66%, but household water quality improves less, due to recontamination. Child diarrhea falls by one quarter. Travel-cost based revealed preference estimates of households' valuations are much smaller than both stated preference valuations and health planners' valuations, and are consistent with models in which the demand for health is highly income elastic. We estimate that private property norms would generate little additional investment while imposing large static costs due to above-marginal-cost pricing, private property would function better at higher income levels or under water scarcity, and alternative institutions could yield Pareto improvements.

The psychologization of humanitarian aid: skimming the battlefield and the disaster zone

Humanitarian aid's psycho-therapeutic turn in the 1990s was mirrored by the increasing emotionalization and subjectivation of fund-raising campaigns. In order to grasp the depth of this interconnectedness, this article argues that in both cases what we see is the post-Fordist production paradigm at work; namely, as Hardt and Negri put it, the direct production of subjectivity and social relations. To explore this, the therapeutic and mental health approach in humanitarian aid is juxtaposed with the more general phenomenon of psychologization. This allows us to see that the psychologized production of subjectivity has a problematic waste-product as it reduces the human to 'Homo sacer', to use Giorgi Agamben's term. Drawing out a double matrix of a de-psychologizing psychologization connected to a politicizing de-politicization, it will further become possible to understand psycho-therapeutic humanitarianism as a case of how, in these times of globalization, psychology, subjectivity and money are all interrelated.

Land rent and housing policy: a case study of the San Francisco Bay area rental housing market

In the San Francisco Bay Area, where residential rent is among the highest in the United States, an analysis of data from several sources demonstrates that high rent cannot be accounted for by higher quality, higher operating costs, or higher construction costs. At least one-third of the total rent paid is land rent. Despite increases in real incomes, very-low-income tenants in the Bay Area today have less income remaining after payment of rent than tenants did in 1960. High land rent is a long-term feature of the Bay Area rental market that results mostly from its geography, the density of its urban centers, and a strong economy, rather than from regulatory barriers to new multifamily construction. Deregulation is not a sufficient response to the effects of land rent on low-income tenants. Government should subsidize non-profit housing organizations, particularly land trusts that remove residential land from the market. Taxes on land rent would be a particularly appropriate funding source.

The role of the public sector in the provision of housing supply in Turkey, 1950–2009

This study examines the changing role of the public sector in Turkey with regard to housing provision since 1950, and particularly since 2000, and seeks to clarify how public intervention has affected housing provision and urban development dynamics in major cities. Three periods may be identified, with central government acting as a regulator in a first period characterized by a ‘housing boom’. During the second period, from 1980 to 2000, a new mass housing law spurred construction activity, although the main beneficiaries of the housing fund tended to be the middle classes. After 2000, contrary to emerging trends in both Northern and Southern European countries, the public sector in Turkey became actively involved in housing provision. During this process, new housing estates were created on greenfield sites on the outskirts of cities, instead of efforts being made to rehabilitate, restore or renew existing housing stock in the cities. Meanwhile, the concept of ‘urban regeneration’ has been opportunistically incorporated into the planning agenda of the public sector, and — under the pretext of regenerating squatter housing areas — existing residents have been moved out, while channels for community participation have been bypassed.

Why the Medical Research Council refused Robert Edwards and Patrick Steptoe support for research on human conception in 1971

BACKGROUND

In 1971, Cambridge physiologist Robert Edwards and Oldham gynaecologist Patrick Steptoe applied to the UK Medical Research Council (MRC) for long-term support for a programme of scientific and clinical 'Studies on Human Reproduction'. The MRC, then the major British funder of medical research, declined support on ethical grounds and maintained this policy throughout the 1970s. The work continued with private money, leading to the birth of Louise Brown in 1978 and transforming research in obstetrics, gynaecology and human embryology.

METHODS

The MRC decision has been criticized, but the processes by which it was reached have yet to be explored. Here, we present an archive-based analysis of the MRC decision.

RESULTS

We find evidence of initial support for Edwards and Steptoe, including from within the MRC, which invited the applicants to join its new directly funded Clinical Research Centre at Northwick Park Hospital. They declined the offer, preferring long-term grant support at the University of Cambridge, and so exposed the project to competitive funding mode. Referees and the Clinical Research Board saw the institutional set-up in Cambridge as problematic with respect to clinical facilities and patient management; gave infertility a low priority compared with population control; assessed interventions as purely experimental rather than potential treatments, and so set the bar for safety high; feared fatal abnormalities and so wanted primate experiments first; and were antagonized by the applicants' high media profile. The rejection set MRC policy on IVF for 8 years, until, after the birth of just two healthy babies, the Council rapidly converted to enthusiastic support.

CONCLUSIONS

This analysis enriches our view of a crucial decision, highlights institutional opportunities and constraints and provides insight into the then dominant attitudes of reproductive scientists and clinicians towards human conception research.

Surreptitious surgery on Long Island Sound: The oral cancer surgeries of President Grover Cleveland

Grover Cleveland rose from being the mayor of Buffalo to the governor of New York to the president of the United States. At the start of Cleveland's second term as president, the nation was involved in a severe financial crisis, the extent of which was not known by the general public. President Cleveland was to make a strong appeal to Congress in the coming months to repeal the Sherman Silver Purchase Act of 1890. He thought this would set the nation on the road to fiscal recovery. However, his vice president, Adlai Stevenson, strongly opposed repeal of the Sherman Act. Prior to scheduling his appearance before Congress, President Cleveland noticed a rough spot on his palate. A biopsy confirmed that it was cancer, and it was determined that surgery was needed. Cleveland and his advisors thought the nation would be thrown into a panic if the President's health did not remain a secret. A surgical team, which included a dentist, performed the surgery in secrecy while traveling aboard a yacht. A prosthetic obturator was fabricated by a New York prosthodontist to close the surgical defect. Cleveland recovered well, made a forceful speech before Congress, had the Sherman Act repealed and lived without a recurrence of his oral cancer for the rest of his life. The public remained unaware, for the most part, of the gravity of President Cleveland's health for decades.

Race, urban governance, and crime control: creating model cities

In the late 1960s and early 1970s, the city of Seattle received federal Department of Housing and Urban Development “Model cities” funds to address issues of racial disenfranchisement in the city. Premised under the “Great Society” ethos, Model cities sought to remedy the strained relationship between local governments and disenfranchised urban communities. Though police-community relations were not initially slated as an area of concern in the city's grant application, residents of the designated “model neighborhood” pressed for the formation of a law and justice task force to address the issue. This article examines the process and outcome of the two law-and-justice projects proposed by residents of the designated “model neighborhood”: the Consumer Protection program and the Community Service Officer project. Drawing on the work of legal geographies scholars, I argue that the failure of each of these efforts to achieve residents' intentions stems from the geographical imagination of urban problems. Like law-and-order projects today, the geographical imagination of the model neighborhood produced a discourse of exceptionality that subjected residents to extraordinary state interventions. The Model cities project thus provides an example of a “history of the present” of mass incarceration in which the geographical imagination of crime helps facilitate the re-creation of a racialized power structure.

A greater society: the transformation of the federal role in education

The federal role in education will soon be transformed in ways that could produce an even greater society than President Lyndon B. Johnson envisioned. The authors identify underlying principles of this new role and describe how it represents a significant departure from the past. Historically, for example, the federal government has been prescriptive about the kinds of practices that states and districts must adopt as a condition of receiving federal funds, but it has not specified outcomes. Under the new approach, the federal government would specify the goals and outcomes while allowing states, districts, and schools flexibility in how they use federal funds to innovate and adopt best practices. The authors argue for immediate action. Every day of delay, they note, yields another seven thousand dropouts and leaves schools and communities without the tools and resources that can help turn the situation around.

Forty six years of health financing in Fiji (1962 - 2008)

This paper provides an analysis of the Fiji Ministry of Health (MoH) budget for the last 46 years, its share of the national budget and annual percentage of GDP, its revenues, per-capita health expenditure, staff costs, and the performance on key population health indicators and Millennium Development Goals (MDGs). Despite annual increases in dollar terms, the proportion of GDP allocated to the national public health system has fallen from 4% to 2.6% over the last 15 years. Consequently the national performance on key health service indicators and MDGs is declining and health staff are migrating. We outline factors to retrieve the public health system in Fiji, such as the need for political commitment to the health of the people, public policy debate on the nature of the health system, the revision of hospital charges, the need to protect the poor by strengthening means testing, and propose compulsory health insurance for the employed.

The value of tuberculosis elimination and of progress in tuberculosis control in twentieth-century England and Wales

OBJECTIVE

To calculate the monetary value of tuberculosis (TB) elimination and of progress in TB control in twentieth-century England and Wales.

METHODS

An original methodology that utilises original data is used, which facilitates the calculation of the number of life years that have been saved as a result of the decline in the TB mortality rate, prevalence rate and quality of life burden.

RESULTS

The magnitude of the decline in the mortality and morbidity burden of TB is estimated at 104,425 life years, which is valued to be worth in excess of US$127 billion. The value of improvements in morbidity contributes nearly as much as the more obvious gains for mortality.

CONCLUSION

Such significant results indicating the value of improvements in TB control have important implications for our understanding of these achievements and justify increased spending in developing countries that continue to be plagued by high rates of TB prevalence.

Radioisotopes "economy of promises": on the limits of biomedicine in public legitimization of nuclear activities

This paper aims to examine the rise and the fall of biomedicine in the public legitimization of the development of nuclear energy. Until the late 1950s, biological and medical applications of radioisotopes were presented as the most important successes of the peaceful uses of atomic energy. I will argue that despite the major financial investment, the development of the uses of radioisotopes and their important impact on biology and clinical practices, the assessment of medical uses remained relatively limited. As consequence, the place of biomedicine in the public legitimization of financial investment and civilian uses of nuclear energy began to decline from the late 1950s.

Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States

The Title VII, Section 747 (Title VII) legislation, which authorizes the Training in Primary Care Medicine and Dentistry grant program, provides statutory authority to the Health Resources and Services Administration (HRSA) to award contracts and cooperative agreements aimed at enhancing the quality of primary care training in the United States.More than 35 contracts and cooperative agreements have been issued by HRSA with Title VII federal funds, most often to national organizations promoting the training of physician assistants and medical students and representing the primary care disciplines of family medicine, general internal medicine, and general pediatrics. These activities have influenced generalist medicine through three mechanisms: (1) building collaboration among the primary care disciplines and between primary care and specialty medicine, (2) strengthening primary care generally through national initiatives designed to develop and implement new models of primary care training, and (3) enhancing the quality of primary care training in specific disease areas determined to be of national importance.The most significant outcomes of the Title VII contracts awarded to national primary care organizations are increased collaboration and enhanced innovation in ambulatory training for students, residents, and faculty. Overall, generalist competencies and education in new content areas have been the distinguishing features of these initiatives. This effort has enhanced not only generalist training but also the general medical education of all students, including future specialists, because so much of the generalist competency agenda is germane to the general medical education mission.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The American Medical Student Association's contributions to advancing primary care

The American Medical Student Association (AMSA) Foundation is the programming arm of AMSA. The AMSA Foundation has administered several Title VII contracts designed to enhance the primary care education, leadership development, and cultural competence of the next generation of physicians, dentists, and other graduate-level health professionals. The authors discuss several AMSA programs developed with Title VII funding: Generalist Physicians in Training; Promoting, Reinforcing, and Improving Medical Education; National Primary Care Week; Leadership Seminar Series; and Achieving Diversity in Dentistry and Medicine. This article summarizes the work of these programs and discusses the impact that decreased funding has had on the training of our nation's future health professionals.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The impact of Title VII on general and pediatric dental education and training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Two decades of Title VII support of a primary care residency: process and outcomes

PURPOSE

To assess 23 years of Health Resources and Services Administration (HRSA) Title VII Training in Primary Care Medicine and Dentistry funding to the New York University School of Medicine/Bellevue Primary Care Internal Medicine Residency Program. The program, begun in 1983 within a traditional, inner-city, subspecialty-oriented internal medicine program, evolved into a crucible of systematic innovation, catalyzed and made feasible by initiatives funded by the HRSA. The curriculum stressed three pillars of generalism: psychosocial medicine, clinical epidemiology, and health policy. It developed tight, objectives-driven, effective, nonmedical specialty blocks and five weekly primary care activities that created a paradigm-driven, community-based, role-modeling matrix. Innovation was built in. Every block and activity was evaluated immediately and in an annual, program-wide retreat. Evaluation evolved from behavioral checklists of taped interviews to performance-based, systematic, annual objective structured clinical examinations.

METHOD

The authors reviewed eight grant proposals, project reports, and curriculum and program evaluations. They also quantitatively and qualitatively surveyed the 122 reachable graduates from the first 20 graduating classes of the program.

RESULTS

Analysis of program documents revealed recurring emphases on the use of proven educational models, strategic innovation, and assessment and evaluation to design and refine the program. There were 104 respondents (85%) to the survey. A total of 87% of the graduates practice as primary care physicians, 83% teach, and 90% work with the underserved; 54% do research, 36% actively advocate on health issues for their patients, programs, and other constituencies, and 30% publish. Graduates cited work in the community and faculty excitement and energy as essential elements of the program's impact; overall, graduates reported high personal and career satisfaction and low burnout.

CONCLUSIONS

With HRSA support, a focused, innovative program evolved which has already met each of the six recommendations for future innovation of the Alliance for Academic Internal Medicine Education Redesign Task Force. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Excellence in physician assistant training through faculty development

Once again, experts predict a shortage of health care providers by 2020. The physician assistant (PA) profession was created in the 1960s to address a similar need. Currently, there are 141 accredited PA training programs in the United States, 75 of them established in the 10 years between 1993 and 2002. Historically, PA education and practice models have been responsive to the ever-changing landscape of health care. It may be the profession's flexibility and adaptability that has enabled it to survive and flourish in a competitive service environment. The growth of new PA programs mandates a need for continuing faculty development, as increasing numbers of educators hail primarily from clinical practice and come equipped with minimal teaching experience. PA faculty development addresses these new recruits' needs to develop model curricula, implement new courses, and enhance instruction-all with the goal of improving both access to and quality of health care.The author describes the impact of Health Resources and Service Administration Title VII, Section 747 (Title VII) contracts in addressing this need. Title VII-funded PA education projects, considered innovative at the time of implementation, included both faculty development workshops that promoted active learning of basic teaching and administrative skills and new curricula designed to enhance faculty teaching in genomics and practice management. These projects and others resulted in enduring professional resources that have not only strengthened the PA community but also enjoyed broad applicability within other health professions groups.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.