[Senate Hearing 113-831]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 113-831

 ADDRESSING PRIMARY CARE ACCESS AND WORKFORCE CHALLENGES: VOICES FROM 
                               THE FIELD

=======================================================================

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                                   ON

EXAMINING PRIMARY CARE ACCESS AND WORKFORCE CHALLENGES: VOICES FROM THE 
                                 FIELD

                               __________

                             APRIL 9, 2014

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions







[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]














      Available via the World Wide Web: http://www.gpo.gov/fdsys/

                         U.S. GOVERNMENT PUBLISHING OFFICE 

22-609 PDF                     WASHINGTON : 2017 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Publishing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001














          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

BARBARA A. MIKULSKI, Maryland         LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington              MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont          RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania    JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina          RAND PAUL, Kentucky
AL FRANKEN, Minnesota                 ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado           PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island      LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin              MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut    TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts

                      Derek Miller, Staff Director
        Lauren McFerran, Deputy Staff Director and Chief Counsel
               David P. Cleary, Republican Staff Director

                                 ______

                Subcommittee on Primary Health and Aging

                 BERNARD SANDERS (I), Vermont, Chairman

BARBARA A. MIKULSKI, Maryland        RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina         PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island     LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin             MICHAEL B. ENZI, Wyoming
CHRISTOPHER S. MURPHY, Connecticut   MARK KIRK, Illinois
ELIZABETH WARREN, Massachusetts      LAMAR ALEXANDER, Tennessee (ex 
TOM HARKIN, Iowa (ex officio)        officio)
                                       

                     Sophie Kasimow, Staff Director

               Riley Swinehart, Republican Staff Director

                                  (ii)

  















                            C O N T E N T S

                               __________

                               STATEMENTS

                        WEDNESDAY, APRIL 9, 2014

                                                                   Page

                           Committee Members

Sanders, Hon. Bernard, Chairman of the Subcommittee on Primary 
  Health and Aging, opening statement............................     1
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina, opening statement....................................     3
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    13
Murphy, Hon. Christopher, a U.S. Senator from the State of 
  Connecticut....................................................    14

                            Witness--Panel I

Spitzgo, Rebecca, Associate Administrator Bureau of Health 
  Professions, Health Resources and Services Administration, U.S. 
  Department of Health and Human Services, Rockville, MD.........     5
    Prepared statement...........................................     7

                          Witnesses--Panel II

Brock, Stan, Founder and President, Remote Area Medical, 
  Rockford, TN...................................................    17
    Prepared statement...........................................    18
Wiltz, Gary, M.D., Executive Director and Clinical Director, 
  Teche Action Clinic, Franklin, LA..............................    19
    Prepared statement...........................................    21
Flinter, Margaret, APRN, Ph.D., c-FNP, FAAN, FAANP, Senior Vice 
  President and Clinical Director, Community Health Center, Inc., 
  Middleton, CT..................................................    24
    Prepared statement...........................................    25
Dobson, L. Allen, Jr., M.D., President and CEO, Community Care of 
  North Carolina, Raleigh, NC....................................    29
    Prepared statement...........................................    30
Nichols, Joseph, M.D., MPH, Family Medicine Resident, MedStar 
  Franklin Square Family Health Center, Baltimore, MD............    36
    Prepared statement...........................................    38
Kohn, Linda T., Ph.D., Director of Health Care, Government 
  Accountability Office, Washington, DC..........................    43
    Prepared statement...........................................    45
Edberg, Deborah, M.D., Program Director, McGaw Northwestern 
  Family Medicine Residency Program, Erie Family Health Center; 
  Assistant Professor of Clinical Family and Community Medicine, 
  Northwestern University Feinberg School of Medicine, Chicago, 
  IL.............................................................    51
    Prepared statement...........................................    53
Hotz, James, M.D., Clinical Services Director, Albany Area 
  Primary Care, Albany, GA.......................................    55
    Prepared statement...........................................    57

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Letter from Margaret Flinter, APRN, Ph.D., c-FNP, FAAN, FAANP 
      in Response to question from Senator Warren................    73
    Response to questions of Senator Warren by:
        Joseph S. Nichols, M.D., MPH.............................    75
        James Hotz, M.D..........................................    76

                                 (iii)

  

 
 ADDRESSING PRIMARY CARE ACCESS AND WORKFORCE CHALLENGES: VOICES FROM 
                               THE FIELD

                              ----------                              


                        WEDNESDAY, APRIL 9, 2014

                                       U.S. Senate,
                  Subcommittee on Primary Health and Aging,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Bernard 
Sanders, chairman of the subcommittee, presiding.
    Present: Senators Sanders, Burr, Murphy, and Warren.

                  Opening Statement of Senator Sanders

    Senator Sanders. Thank you all very much for being here for 
what is, I think, going to be a very interesting and important 
hearing. It is a busy day here in the Senate, and I think 
you're going to see members gravitating in and out, but we want 
to thank all of the panelists who are here with us.
    The issue that we're dealing with today is of profound 
importance and, I think, addresses some of the significant 
problems facing our dysfunctional healthcare system. The first 
issue that I would raise and that I hope we'll get some good 
discussion on today is how it happens that the United States of 
America ends up spending almost twice as much per person on 
healthcare and yet our end results, our healthcare outcomes are 
not particularly good compared to many other countries around 
the world.
    I think one of the reasons for that, that virtually every 
study that I have seen tells us, is that we are much, much 
weaker in terms of primary healthcare, and we put much less 
resources into primary healthcare, comparatively speaking, than 
do most other nations. Today, in fact, 60 million people in the 
United States, nearly one in five, live in areas where there is 
a shortage of primary care providers.
    In fact, while the problem we're discussing is clearly a 
national problem, it is even more so a rural problem, in that 
there are many, many rural communities in this country where it 
is very hard for people, especially people who do not have a 
lot of money, to find a doctor or to find a dentist. In fact, 
we are going to be hearing later this morning from Stan Brock, 
who founded a wonderful organization called Remote Area 
Medical, RAM, that sets up free medical clinics at fairgrounds 
and stadiums in underserved areas to provide healthcare and 
dental care to people who cannot otherwise find a doctor or a 
dentist.
    A couple of weeks ago, at our most recent subcommittee 
hearing, we saw some of the photographs where in the United 
States of America, people are waiting hours, and sometimes they 
sleep overnight in their cars in order to gain access to free 
healthcare or dental care. I hope that we can all agree that in 
this Nation, presumably the wealthiest nation on earth, this 
should not be happening.
    But the issue is not only one of healthcare and what 
happens to people when they get sick who cannot access a doctor 
or a healthcare provider--what happens to those people? And the 
answer is pretty obvious. They get sicker and sicker, and then 
they end up either in the emergency room or in a hospital at 
far more cost to the system than otherwise would have been the 
case if they could have accessed healthcare when, in fact, they 
needed it.
    One of the great ironies of the moment is that while there 
are some people who think we save money by cutting back on 
public health programs, whether it's Medicare, Medicaid, or 
whatever it may be, the truth of the matter is we end up 
spending more money by not providing access to healthcare and 
dental care when people actually need it. So it's a question of 
easing suffering, human suffering; it's a question of 
preventing death; it's a question of preventing serious 
illness; and it is a question of saving money.
    To compound the problem that we have right now, by 2025, we 
will need over 50,000 new primary care physicians in our 
country and thousands of other providers, including dentists, 
nurse practitioners, and physician assistants, to ensure access 
to the cost-effective primary care services people need. And 
that comes from the Annals of Family Medicine.
    How do we educate those practitioners? How do we get them 
to the places that we need? It's not just the question of 
needing more doctors. Frankly, we don't need more doctors on 
Park Avenue in New York. We do need more doctors in rural 
underserved areas in the country. How do we educate those 
people? How do we get them to the areas where we need them?
    Here's a startling fact that I hope we will have serious 
discussion about. In 2011, about 17,000 doctors graduated from 
American medical schools. Despite the fact that over half of 
patient visits are for primary care--half of patient visits are 
for primary care--only 7 percent--7 percent--of the Nation's 
medical school graduates now choose a primary care career--7 
percent. Why is that? How do we turn that around? And to 
compound that issue, the average primary care physician in the 
United States is 47 years of age today, and one-quarter are 
near retirement. So why that is going on and how we transform 
it is an issue I hope we will discuss today.
    I think some of the answers are fairly obvious. First, we 
need to change the culture in our medical schools. Medical 
schools, in my view, especially given the fact that they 
receive substantial sums of Federal money, should be training 
and graduating doctors to serve in areas where they are most 
needed. That should be a major focus. Frankly, many medical 
schools are doing a good job, but many others are doing a very, 
very poor job in making sure that we get those health care 
providers to the areas where we need them.
    Second, we are almost unique in the world in saying to 
young people,

          ``If you want to go to medical school, fine. If 
        you're smart enough, you can go to medical school. But 
        guess what? On average, you're going to graduate 
        $160,000 in debt, and a third of you are going to 
        graduate with more than $200,000 in debt.''

    That's the system we now have.
    Well, guess what? If you are a young person graduating with 
$200,000 of debt, and you want to have a family, you are 
probably not going to go to rural Vermont or rural North 
Carolina to practice--probably not. You're going to probably 
figure out where you can make the most money possible in order 
to pay back that debt, and that becomes a huge disincentive in 
terms of getting doctors to the places where we need them.
    In the midst of all of those serious problems, here's some 
good news, and I look forward to hearing Rebecca Spitzgo talk 
about this. In recent years, we have made significant progress 
in increasing funding in a variety of ways to those entities 
who are doing a really, really good job in addressing some of 
the problems that we're talking about.
    I am very proud that in the Affordable Care Act and in the 
stimulus package--and I worked particularly hard in those 
areas--we have doubled funding for federally qualified health 
centers, and we're going to hear about what they are doing all 
over America. More and more people are now able to access them. 
The President's new budget is, I think, a good budget in 
helping us to expand that. Let's talk about that.
    But what Ms. Spitzgo is going to talk about in a moment is 
also one of the important ways that we improve primary 
healthcare in America, addressing the problem of students 
graduating with deep debt, and that is the National Health 
Service Corps. And I look forward to hearing Ms. Spitzgo talk 
about some of the successes that we've had and where we should 
be going in the future.
    Another issue that I hope we will talk about today is that 
we need to change the salaries and reimbursement rates, in my 
humble opinion. Primary healthcare is as important as any other 
area of medicine, and we have got to reward those people who go 
into primary healthcare. That means changing reimbursement 
rates.
    Fourth, we have got to address the fact that Medicare has 
promoted the growth of residencies in specialty fields rather 
than primary healthcare by providing over $10 billion each year 
to teaching hospitals without requiring any emphasis on 
training primary care physicians.
    Those are some of the issues that I hope we will be 
addressing today. And, again, I want to thank all of our 
panelists and Ms. Spitzgo for being here. Now, I'll give the 
mic to Senator Burr.

                       Statement of Senator Burr

    Senator Burr. Thank you, Mr. Chairman. Thank you for 
holding this hearing, which I believe is vitally important. And 
I appreciate the opportunity to continue our discussion 
regarding primary care and workforce challenges. I'd like to 
thank the witnesses for being here today, particularly Allen 
Dobson, who is a family physician in North Carolina and 
president and CEO of Community Care of North Carolina, an 
entity that's known far outside of North Carolina with a great 
track record thus far. With so many witnesses today, I suspect 
we'll hear a wide range of perspectives from the primary care 
trenches. And I'm glad that Allen is here to help share our own 
experiences from North Carolina.
    As we've discussed before, the issue of improving access to 
primary care services, particularly those in rural and 
underserved areas, is an important challenge we must address. 
At our primary care hearing last year, I noted the importance 
of identifying programs with a proven track record of success 
from which we can build upon, as well as the importance of 
taking a closer look at the programs to ensure accountability 
and appropriate stewardship of taxpayer dollars.
    Therefore, I am particularly pleased to welcome Linda Kohn 
with the Government Accountability Office to hear an update on 
the recent work to look at healthcare workforce programs, 
including those which seek to address primary care access and 
workforce challenges.
    GAO's report last fall highlighted how four departments, 
Health and Human Services, Veterans Affairs, Defense, and 
Education, obligated $14.2 billion for healthcare vouchers for 
the healthcare workforce training programs for postsecondary 
training or education for direct care professionals in 2012. 
HHS funds the bulk of these programs, many of which HRSA 
administers. Yet by HRSA's own projections, the demand for 
primary care physicians will grow more rapidly than the 
physician supply, resulting in a projected shortage of 
approximately 20,400 physicians in 2020, a mere 6 years from 
now.
    HRSA's analysis indicated that even with the increased use 
of nurse practitioners, of physician assistants, the primary 
care provider workforce is not prepared to meet the coming 
needs. As of January 1 of this year, HRSA had 6,000 designated 
primary care health professional shortage areas, 6,000. In 
other words, we aren't meeting current demand, much less are we 
preparing for what's coming at us.
    As the Nation faces increasing primary care challenges, 
it's essential that we take an honest assessment of the factors 
driving and exacerbating these challenges. Have we properly 
aligned incentives to encourage individuals to not only pursue 
primary care medicine but practice it and practice it in those 
areas with the greatest and hardest to reach needs? Are 
incentives driving volume or quality? What can we learn from 
patient-centric medical home models, such as Community Care of 
North Carolina?
    As Congress explores ways in which we can better target and 
enhance existing programs to address the workforce challenges 
impacting our Nation's patients, it is critical that we 
understand and examine the root causes and barriers patients 
face in accessing primary care as well as the best metrics for 
judging success. I look forward to hearing from our witnesses 
today about the specific metrics necessary to assess what is 
and is not working to address our Nation's primary care needs.
    It's clear from the projections of current and increasing 
unmet needs that we cannot afford to continue on the current 
course. I look forward to hearing suggestions from our 
witnesses today regarding how we can address primary care 
access and workforce challenges while ensuring accountability 
for programs on behalf of patients and on taxpayers.
    Thank you, Mr. Chairman. I yield.
    Senator Sanders. Thank you very much, Senator Burr.
    Senator Warren.
    Senator Warren. I'd like to just go straight to the 
witnesses. I don't need to do an opening statement. Thank you, 
Mr. Chairman.
    Senator Sanders. Senator Murphy.
    Senator Murphy. I'm good.
    Senator Sanders. You're all witnessing something very 
unusual.
    [Laughter.]
    Senator Burr. But, hopefully, a trend.
    Senator Sanders. Our first witness is Rebecca H. Spitzgo, 
Associate Administrator of HRSA's Bureau of Health Professions. 
She provides national leadership in the development, 
distribution, and retention of a diverse health workforce. From 
2009 through 2013, Ms. Spitzgo was the Associate Administrator 
of HRSA's Bureau of Clinician Recruitment and Service, where 
she oversaw the operations of the National Health Service 
Corps.
    Ms. Spitzgo, thanks very much for being with us.

 STATEMENT OF REBECCA SPITZGO, ASSOCIATE ADMINISTRATOR, BUREAU 
     OF HEALTH PROFESSIONS, HEALTH RESOURCES AND SERVICES 
 ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                         ROCKVILLE, MD

    Ms. Spitzgo. Good morning. Mr. Chairman and members of the 
subcommittee, thank you for the opportunity to testify on 
behalf of the Health Resources and Services Administration.
    My name is Rebecca Spitzgo. I am the Associate 
Administrator for the Bureau of Health Professions in HRSA, 
which is an agency of the Department of Health and Human 
Services. HRSA's mission is to improve health and achieve 
health equity through access to quality services and a skilled 
healthcare workforce. HRSA supports the training of nurses, 
physicians, dentists, and other clinicians and encourages 
providers to work in areas of the country where health 
resources are scarce.
    Across this country in every State, the District of 
Columbia, and Puerto Rico, there is a student or a clinician 
whose future in primary care is being made possible by HRSA's 
workforce programs. HRSA's grant, scholarship, and loan 
repayment programs support the healthcare workforce across the 
entire training continuum from academic training to programs 
that support clinicians currently providing care to individuals 
in underserved rural and urban communities.
    In recent years, Congress and the administration have 
strengthened the primary care workforce by funding additional 
training and educational opportunities, by encouraging 
community-based residencies and teaching hospitals, by 
expanding training for a range of primary care providers, and 
by the historic growth of the National Health Service Corps. To 
date, the Affordable Care Act has supported the training of an 
additional 1,700 primary care providers, including physicians, 
advanced practice nurses, and physician assistants, as well as 
200 behavioral health providers.
    This academic year, the Teaching Health Center Graduate 
Medical Education Program is expanding residency training for 
more than 300 primary care residents and dentists in community-
based settings in 21 States, including HRSA funded health 
centers. For the upcoming academic year, we expect nearly 600 
FTEs will be supported by the Teaching Health Center GME 
Program. In exchange for scholarship and loan repayment, nearly 
8,900 National Health Service Corps clinicians are providing 
care to millions of patients at more than 5,000 National Health 
Service Corps sites in urban, rural, and frontier areas.
    The fiscal year 2015 President's Budget includes a new 
workforce initiative that will help support the residency 
training of approximately 13,000 new physicians by the year 
2024 and grow the number of the National Health Service Corps 
clinicians to an annual field strength of 15,000 in fiscal year 
2015 through 2020. This new investment will increase the supply 
and the distribution of the healthcare workforce, which, when 
coupled with the adoption of new, more efficient models of 
care, will significantly increase access to care.
    This new targeted support for the Graduate Medical 
Education Program will emphasize primary care and will include 
support for residency training in high-need specialties. The 
targeted support for the GME Program will support residency 
training with a strong focus on ambulatory and preventive care 
and the goal of driving higher value healthcare that reduces 
long-term costs.
    In addition, the fiscal year 2015 President's Budget 
includes funding for both rural physician training and for 
inter-professional training, which will increase the capacity 
of the primary healthcare teams to deliver quality, 
coordinated, and efficient care to patients, families, and 
communities.
    Our health workforce programs in HRSA support a wide range 
of primary care disciplines, including behavioral health and 
oral health providers. Roughly one in three National Health 
Service Corps clinicians provide behavioral health services, 
and more than 1,300 provide oral health services. We are 
partnering with the Substance Abuse and the Mental Health 
Services Administration to train and provide placement 
assistance to approximately 3,500 new behavioral health 
professionals and paraprofessionals to meet the needs of young 
people age 16 to 25.
    HRSA's workforce programs also play a critical role in 
supporting a diverse and culturally competent workforce across 
the country. Last year, underrepresented minorities and 
individuals from disadvantaged backgrounds accounted for 
approximately 45 percent of those who completed HRSA's health 
profession training and education programs. And, according to 
self-reporting, more than half of the nearly 1,100 National 
Health Service Corps scholars and residents in the pipeline are 
minorities.
    Taken together, HRSA's workforce programs emphasize the 
training of the next generation of primary care providers, 
strengthens the primary care training and development 
infrastructure, and provides incentives for students and 
healthcare professionals to choose primary care and to practice 
where the Nation needs them most. To meet the health needs of 
Americans, HRSA will continue to make training, recruitment, 
and retention of primary care professionals a priority.
    Thank you again for providing me the opportunity to share 
HRSA's primary care workforce priorities with you today. I am 
pleased to respond to your questions.
    [The prepared statement of Ms. Spitzgo follows:]
                 Prepared Statement of Rebecca Spitzgo
    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to testify today on behalf of the Health Resources and 
Services Administration (HRSA). My name is Rebecca Spitzgo, and I am 
the Associate Administrator of the Bureau of Health Professions in 
HRSA, which is an agency of the Department of Health and Human Services 
(HHS).
    HRSA focuses on improving access to health care services for people 
who are economically, geographically or medically vulnerable. Our 
mission is to improve health and achieve health equity through access 
to quality services and a skilled health care workforce. HRSA's 
programs support the health care workforce across the entire training 
continuum, from academic training to programs that support clinicians 
currently providing care to individuals in underserved and rural 
communities across the United States. HRSA supports the training of 
nurses, physicians, and other clinicians, and encourages providers to 
work in areas of the country where they are needed most.
    In accomplishing our goals, we collaborate with colleagues across 
the Federal Government and with State and local governments, as well as 
a range of other partners in the private sector, including: community-
based organizations, health care providers and academic institutions. 
Together with these key partners, we are working hard to meet the needs 
of the American people and to prepare for changes in the health care 
system to help ensure access to quality, efficient care.
    I have been asked to speak to you today about HRSA's activities 
regarding the primary care workforce and the Nation's needs in this 
area. We appreciate your ongoing interest in HRSA programs and welcome 
the opportunity to discuss them with you, Mr. Chairman, and the 
subcommittee.
  strengthening the primary care workforce through recent investments
    To date, the Affordable Care Act has supported the training of an 
additional 1,700 primary care providers, including physicians, advanced 
practice nurses, and physician assistants, as well as 200 behavioral 
health providers. And, with historic investments from the American 
Reinvestment and Recovery Act of 2009 (ARRA) and the Affordable Care 
Act, the numbers of clinicians in the National Health Service Corps 
have more than doubled from 3,600 in 2008 to nearly 8,900 in 2013. 
National Health Service Corps clinicians, who are located in every 
State, are providing care to approximately 9.3 million medically 
underserved people at more than 5,100 National Health Service Corps 
approved sites in urban, rural, and frontier areas. Approximately 50 
percent of NHSC clinicians serve in HRSA-funded health centers.
    The Affordable Care Act also provided $230 million over 5 years to 
fund the Teaching Health Center Graduate Medical Education (GME) 
program. This funding has expanded residency training for primary care 
residents and dentists in community-based ambulatory patient care 
settings, including HRSA-funded health centers. This program supported 
more than 300 primary care resident full-time equivalents (FTEs) in 21 
States in Academic Year 2013-14. The number of residency programs and 
resident FTEs supported through this program has doubled each academic 
year since 2011, and we expect nearly 600 FTEs to be supported in 
Academic Year 2014-15. There is evidence that physicians who receive 
training in community and underserved settings are more likely to 
practice in such environments.
    HRSA's recent investments in nursing programs promote the supply, 
skills and distribution of qualified nursing personnel needed to 
improve the health of the public. These training programs increase 
nursing education opportunities for individuals from disadvantaged 
backgrounds; improve nurse education, practice and retention while 
increasing quality of care; assist veterans with transition from 
military service to nursing school and civilian nursing careers; 
provide financial support to individuals pursuing an advanced nursing 
education/training; and, provide financial support to schools of 
nursing to increase the number of qualified nurse faculty. And, through 
our scholarship and loan repayment programs, today there are nearly 
1,600 advanced practice nurses in the National Health Service Corps and 
nearly 2,600 nurses in the NURSE Corps working in high-need 
communities.
             building a primary care workforce for tomorrow
    The fiscal year 2015 President's Budget includes a new workforce 
initiative that will help support the residency training of 
approximately 13,000 new physicians by 2024 and grow the number of 
National Health Service Corps Clinicians from 8,900 health care 
providers in 2013 to an annual field strength of 15,000 in fiscal years 
2015-20. This new investment in our health care workforce will increase 
the supply and distribution of the health care workforce, which when 
coupled with the adoption of new, more efficient models of care, will 
significantly increase access to primary care and other specialty 
services.
    This new residency training program, the Targeted Support for GME 
program, will emphasize primary care, but will also include support for 
residency training in high-need specialties. Building on the Teaching 
Health Center GME program, it will focus on supporting residency 
training in ambulatory, preventive care delivered in team-based 
settings.
    The Targeted Support for GME program aims to support residency 
training with a strong focus on ambulatory and preventive care and the 
goal of driving higher value health care that reduces long-term costs. 
In addition, residency programs will be held accountable for training 
residents and retaining them in primary care service in underserved 
areas, as well as providing a broad range of training experiences that 
include team-based care, expanded use of technology, and new, efficient 
models of care.
    The new program includes a $100 million set-aside for children's 
hospitals annually in fiscal year 2015 and fiscal year 2016 to be 
distributed via formula that will continue to support the same types of 
disciplines currently funded through the Children's Hospitals GME 
program. Children's hospitals and current awardees in the Teaching 
Health Center GME program will be eligible to compete for funding 
through the new program. The fiscal year 2015 President's Budget also 
includes appropriations language that would make current Teaching 
Health Center GME balances available until expended and thereby would 
avoid having these funds expire at the end of fiscal year 2015.
    The fiscal year 2015 President's Budget also builds upon the 
historic investments through ARRA and the Affordable Care Act that have 
more than doubled the National Health Service Corps. With more than 85 
percent of Corps clinicians continuing to serve in high-need areas 
after they fulfill their service commitment, the National Health 
Service Corps helps ensure underserved rural and urban communities have 
access to quality health care both today and in the future.
    Other HRSA investments also emphasize the importance of providing 
care in underserved communities. For example, 43 percent of individuals 
who graduated from or completed HRSA-funded health professions training 
and education programs reported working or pursuing further training in 
medically underserved communities one year after graduation or 
completion of their program.
    In addition, the fiscal year 2015 President's Budget includes $10 
million for a new Clinical Training in Interprofessional Practice 
program which will support community-based clinical training in 
interprofessional, team-based care to increase the capacity of primary 
health care teams to deliver quality, coordinated, safe and efficient 
care to patients, families and communities.
    The fiscal year 2015 President's Budget also recognizes the special 
need for primary care providers across rural America. The Budget 
includes $4 million for the Rural Physician Training Grant program to 
provide support for medical schools to recruit and train students 
interested in rural practice and to develop training curriculum that 
focuses on the unique needs of preparing medical students for rural 
practice. These grants will focus on recruiting and training health 
physicians in rural settings with the ultimate goal of increasing the 
number of medical school graduates who practice in rural communities.
                     supporting a diverse workforce
    HRSA's workforce programs also play a critical role in supporting a 
diverse workforce across this country. Underrepresented minorities and 
individuals from disadvantaged backgrounds accounted for approximately 
45 percent of those who completed HRSA's health professions training 
and education programs during the 2012-2013 Academic Year. According to 
self-reporting, more than half of the nearly 1,100 National Health 
Service Corps scholars and residents in the pipeline are minorities. As 
part of their National Health Service Corps commitment, these future 
primary care providers will serve in communities where they are needed 
most to provide culturally competent care.
    And, when we look at specific disciplines, the impact of these 
programs is even more evident--a diversity not yet achieved in the 
national health care workforce. For example, in fiscal year 2013 
African-American physicians represented 17.8 percent of the Corps 
physicians, which exceeds their 6.3 percent representation within the 
national physician workforce, and Hispanic physicians represented 15.7 
percent of the Corps physicians, exceeding their 5.5 percent 
representation in the national physician workforce.
                training for comprehensive primary care
    HRSA's investments in the behavioral health disciplines are also 
significant. National Health Service Corps providers that include 
Health Service Psychologists, Licensed Clinical Social Workers, 
Licensed Professional Counselors, Marriage and Family Therapists, and 
Psychiatric Nurse Specialists have more than tripled since 2008, 
increasing from approximately 700 to 2,440 in 2013. When we add in 
psychiatrists, psychiatric physician assistants, and psychiatric nurse 
practitioners, roughly one of every three clinicians in the National 
Health Service Corps (more than 2,800 out of nearly 8,900 as of 
September 30, 2013) provides behavioral health services.
    HRSA and the Substance Abuse and Mental Health Services 
Administration (SAMHSA) have been partnering to address critical needs 
in behavioral health professionals and paraprofessionals trained to 
address the needs of transition-age youth (ages 16-25). This 
partnership will train and provide placement assistance for 
approximately 1,800 additional behavioral health professionals and 
1,700 behavioral health paraprofessionals. Last week, HRSA and SAMHSA 
issued funding opportunities for this initiative.
    In addition, HRSA funds several programs that support training and 
education for health professionals to improve the integration of oral 
health into primary care. And, in the National Health Service Corps 
approximately 75 percent of the more than 1,300 dentists and dental 
hygienists are working at health centers or health center look-alikes.
    HRSA also is helping to meet the need for new dental providers by 
expanding the dental workforce training and education programs, as well 
as by supporting State development and implementation of innovative 
programs to address dental workforce needs in underserved areas.
                strengthening america's health workforce
    Taken together, HRSA's workforce programs emphasize the training of 
the next generation of primary care providers, strengthening up the 
primary care training and development infrastructure, providing 
incentives for students to choose primary care and to practice where 
the Nation needs them most, and repaying loans for primary care 
providers willing to work in some of the Nation's most underserved 
areas. To meet the health needs of Americans, HRSA will continue to 
make the recruitment, training and retention of primary care 
professionals a priority.
    Thank you again for providing me the opportunity to share HRSA's 
primary care workforce priorities with you today. I am pleased to 
respond to your questions.

    Senator Sanders. Thank you very much for your testimony and 
for the good work that you do. I think you have heard from 
Senator Burr and myself and, I think, from a whole lot of folks 
that we have a crisis in primary healthcare.
    In recent years, we have doubled funding for the community 
health center program. We have tripled funding for the National 
Health Service Corps. Are those investments working?
    Ms. Spitzgo. I would say yes, they are working. We have 
doubled the size of the National Health Service Corps since 
2008, when we had a little over 3,600 clinicians working there. 
Now, we have over 8,900 clinicians working in underserved and 
rural communities.
    We know from talking to our National Health Service Corps 
sites and our community health centers that it's a huge 
recruitment tool for them. They are really able to attract very 
talented providers to come and work in those centers by the use 
of the loan repayment.
    Our scholars, when they finish their training, are highly 
sought after, and everyone says, ``I just wish you had more. 
Bring me all the physicians you can, train all the physicians, 
and I know we can place them.'' I think they have made a 
tremendous difference.
    Senator Sanders. I know that you are not a policymaker. 
You're an administrator. And it seems clear to me that we have 
made progress. More and more young people are now taking 
advantage of the National Health Service Corps, because we have 
more opportunity out there. If you had your druthers, and you 
were sitting up here, and you understood the scope of the 
problem, how much more would we be providing for the National 
Health Service Corps?
    Ms. Spitzgo. I certainly know from our folks and from the 
interest in our programs and from talking to our sites that are 
always actively recruiting for clinicians--it just is a 
continuous process for them--they would like to see us be able 
to support all of the folks who are interested in being a part 
of the program, because it is that huge recruitment 
opportunity. They would love for us to have more scholars that 
are graduating and finishing our program.
    I think as we look at that, the program is very 
prestigious. There is tremendous interest, not only from 
students as they go through school, but tremendous interest 
from the sites that would employ them.
    Senator Sanders. So what you are saying is that you think 
if we increased funding, you would be able to attract more 
young people to get into primary healthcare or dental care. Am 
I hearing that?
    Ms. Spitzgo. Yes. I think there is an interest, yes.
    Senator Sanders. All right. Explain a little bit--maybe we 
have kind of jumped the gun, because I'm not sure that 
everybody knows what the National Health Service Corps is 
about. Go into a little bit of detail--the bottom line here is 
that if I am prepared and agree to work in an underserved area, 
the NHSC is going to repay my debts. But can you go into some 
detail about how that actually works?
    Ms. Spitzgo. Sure. There's actually two main components to 
the National Health Service Corps. First is our loan repayment 
program, which is for fully trained, educated, and licensed 
clinicians who may be coming out of school looking for that job 
and has that educational debt. If they go to work in a health 
professional shortage area and work at one of our approved 
sites, they can qualify for loan repayment. The initial loan 
repayment in a high-need area is $50,000 for a 2-year service 
commitment. So they agree to work in that high-need area for 2 
years.
    Then they do have the opportunity to continue in the 
program. If they have additional qualifying educational debt, 
they can continue to work there until they actually have paid 
off all of their student loans.
    Senator Sanders. So if I graduated school $200,000 in debt, 
how many years am I obliged to work in an underserved area?
    Ms. Spitzgo. To completely pay off your debt, if you have 
$200,000, I'm just going to roughly say I think we're talking 7 
or 8 years with the continuations and continuing to stay in the 
program. But we do prioritize--once you're in the program, we 
fund our continuations first, so you do typically stay if 
you're interested.
    Senator Sanders. And you also have a scholarship program, 
do you not? Say a word about that.
    Ms. Spitzgo. We do. The scholarship program is for students 
who are entering medical school or entering a nurse 
practitioner or physician assistant program to get their 
degree. And for every year of funding they receive for their 
education, they have a 1-year service commitment when they 
complete their degree, with a minimum of a 2-year service 
commitment. So if you only got 1 year of funding, you would 
still have a 2-year service commitment.
    For our physicians, we're talking about typically a 4-year 
service commitment. But they could start in their sophomore 
year. They could start in their junior year. It doesn't have to 
be in their entry year of medical school. And we do assist in 
our scholarship program those who go to our highest-need areas, 
and we do assist with placement and relocation expenses and 
very much, of course, hope that they have a 4-year commitment, 
and by the time that commitment is complete, they'll stay.
    Senator Sanders. But we are not just talking--so everybody 
understands, this is about physicians. We're talking about 
dentists and what other providers?
    Ms. Spitzgo. We're talking physicians--for a scholarship 
program, nurse practitioners, physician assistants, dentists, 
and dental hygienists all qualify.
    Senator Sanders. Thank you very much.
    Senator Burr.
    Senator Burr. Ms. Spitzgo, thank you for being here and 
thank you for the job that is done at HRSA within HHS. Senator 
Sanders pointed to success and used the taxpayer investment as 
an example of the commitment. Let me ask you--what metrics do 
we have in place that you can point to that show the success of 
this program?
    Ms. Spitzgo. I think the metrics we have in place is, one, 
we have an extremely low default rate, less than 1 percent, for 
our loan re-payers. So not only when they get the money to pay 
back their loans, they complete their service commitment.
    We also know that not only do they complete their service 
commitment, but when they've paid all their loans back, they 
stay in underserved and rural areas. After completing the 
program, over 80 percent of the folks continue to work in 
underserved areas after immediately completing the program. And 
we've done a 10-year study that shows that after 10 years, we 
still have 55 percent of those National Health Service Corps 
clinicians still working in underserved and rural areas.
    Senator Burr. Last year, the GAO found that 91 Federal 
programs obligated $14.2 billion toward healthcare workforce 
training programs across four departments, HHS, DOD, VA, and 
the Department of Education. How is HHS working with these 
departments to ensure that these collective efforts are 
coordinated without duplications and reflective of the most up-
to-date workforce projections as provided by HRSA?
    Ms. Spitzgo. We work very closely with our colleagues, 
first starting, I would say, within Health and Human Services 
and, for example, CMS. With some of our Graduate Medical 
Education programs that we fund through HRSA, we work very 
closely and do audits to make sure that CMS funds are not 
funding the same residents that were using HRSA funds.
    We also work with the Indian Health Service in supporting 
tribal communities and their workforce programs to make sure 
that we are complementing each other's efforts. In addition, as 
we work with Education, they have some loan repayment programs 
if you work in underserved areas. So our guidances show very 
much if you have that commitment that you can't be doing the 
National Service Corps and also have a commitment somewhere 
else.
    So we do track with them very closely to make sure that we 
don't have what we call double-dippers and that we're not using 
funds for the same person more than once. We also work with VA 
to look at their programs, to leverage the good work they're 
doing, to see how they are running workforce programs, and to 
see what we can learn from them, as well as to work very 
closely together and not to duplicate.
    Senator Burr. As you know, HRSA oversees the Children's 
Hospital Graduate Medical Education Program, which provides 
training for pediatricians across the country. As you noted in 
your testimony, the President's budget has proposed 
consolidating that funding under a new residency training 
program called Targeted Support for GME.
    Ms. Spitzgo. Yes.
    Senator Burr. This new program will provide funding for the 
Children's Hospital Graduate Medical Education Program until 
2016, at which time children's hospitals will need to compete 
for funding under the new targeted support program. Just this 
week, the bipartisan Children's Hospital Graduate Medical 
Education Reauthorization Act was signed into law, a signal 
from Congress that this program is working well.
    As we work to strengthen our healthcare workforce, do you 
believe that the President's proposed new framework will 
support the pediatric workforce and ensure that we're making 
the appropriate investment in training pediatricians?
    Ms. Spitzgo. Yes. We do think the new program will also be 
able to address that, as well as address the primary care 
residency and the need for those. So the targeted support for 
the Graduate Medical Education Program is very much geared at 
supporting primary care residency as well as other high-need 
residencies where we have a documented shortage.
    The program is also looking to take an innovative approach 
to how we do residency training, and not to just have a payment 
program, but to also have a discretionary program where we can 
really have requirements that we're looking for our grantees to 
meet so that we're using innovative models of care. We're doing 
team-based care. We're utilizing electronic health records in a 
way that really assists to provide a higher quality of care to 
the patients that are being served.
    By having innovative approaches to the way we train our 
residents, we think that will lead to innovative approaches to 
the way we deliver care. Those residents will go out and, 
hopefully, spread that, and all of that will lead to lower 
costs.
    Senator Burr. Ms. Spitzgo, I didn't misinterpret in any way 
what we're doing. We're changing and we're making children's 
hospitals compete, which does not assure us of the investment 
in pediatricians. Am I accurate?
    Ms. Spitzgo. We feel like the structure of the targeted GME 
Program is a community-based setting, and many of the hospitals 
are already operating and run their programs in a community-
based setting. We've also moved the funding from a year-by-year 
discretionary funding to a mandatory funding cycle which will 
bring more assurance that the funding will continue. So there's 
2 years of $100 million that's set aside for the Children's GME 
in 2015 and 2016, and then we think they will be very well-
positioned to compete and also then move into providing some 
innovative models of care as they do residency training.
    Senator Burr. Thank you.
    Senator Sanders. Thank you, Senator Burr.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman. I think we all 
agree that access to primary care is essential for keeping 
people healthy. I want to talk just briefly about a program 
that Massachusetts has to improve the Commonwealth's primary 
care workforce by offering loan repayment programs to help 
doctors with medical school debt.
    The University of Massachusetts Medical School, which is 
ranked by U.S. News and World Report as the fifth best medical 
school in the country for primary care, has a learning contract 
that allows students to waive two-thirds of their tuition in 
exchange for 4 years in primary care or as a specialist in an 
underserved area. Massachusetts also has a State loan repayment 
program grant from the National Health Service Corps that 
provides the commonwealth with Federal funds to match our 
investment in loan repayment programs for those who work in 
underserved communities, including doctors, nurse 
practitioners, and physician assistants.
    I wondered, Ms. Spitzgo, if you could just briefly discuss 
the importance of State programs and, more critically, the role 
that the Federal Government can play to better support those 
programs to help us get more primary care physicians.
    Ms. Spitzgo. Yes. Thank you. You mentioned the National 
Health Service Corps State Loan Repayment Program. I think 
that's an excellent example of one of the programs we've had. 
We've actually done a lot of retooling of that program so that 
it is flexible for the States to really direct it to their 
needs.
    So it is a program where they receive a grant from HRSA, 
and there is a one-to-one matching required. But at that point, 
the State works within the framework of the National Health 
Service Corps Loan Repayment Program, but can really customize 
that program. So they may want to target it to a particular 
area of the State. They may want to target it to all 
disciplines in primary care, or they may want to narrowly focus 
it to just dentists because they really have a shortage.
    So we've really tried to emphasize the value of that. It 
really does give them that flexibility to meet their own needs 
as well as to meet the needs that--maybe through the national 
program they're not getting the number of loan repayments they 
want there. So it can really be a great tool to supplement 
that.
    I think we continue to work with the States. They are our 
partners as well as local governments. HRSA has a wide 
portfolio of programs, but we also can only do so much. We have 
our partners, and we have foundations, and State and local 
governments have an important role as well.
    Senator Warren. I appreciate you pointing that out. Some 
States have worked hard to recognize the shortage in primary 
care and to try to do something about it. But I think it's 
clear that there is still a very big shortage. So we have the 
opportunity at the Federal level to do more to invest in 
programs that permit more creativity and more effectiveness on 
the ground. Thank you.
    I also want to turn to a 2007 study from the International 
Journal of Health Services that found that if the United States 
increased the primary care workforce by 10 physicians per 
100,000 people, we could improve health outcomes and avoid 49 
deaths per year for each one of these groups. This is probably 
because many costly conditions like hypertension and high 
cholesterol are mostly managed by primary care doctors, as was 
confirmed by the Journal of the American Board of Family 
Medicine study earlier this year.
    So it seems obvious that part of our long-term strategy to 
improve outcomes at lower costs in our healthcare system would 
be to increase the number of doctors trained in primary care. 
Now, one promising approach is the Teaching Healthcare Center 
Graduate Medical Education Program, a 5-year initiative 
established by the Affordable Care Act that trains doctors to 
treat complex patients in the community, and it costs only $230 
million. But this program will expire at the end of 2015.
    I wanted to ask you, Ms. Spitzgo, could you speak to the 
return on investment that we get from investing in training a 
primary care resident in a community health center as opposed 
to a traditional residency?
    Ms. Spitzgo. Yes. Thank you. As we look at the Teaching 
Health Center, we feel that program has been extremely 
successful. It's a relatively new program, but we've seen the 
doubling of supporting--the number of slots double each year, 
and it continues to grow. So there is tremendous interest in 
the community in providing residency care at community-based 
settings.
    We feel like as residents train and they provide care in 
community-based settings where the bulk of Americans do receive 
their care, they are very well-trained, and they understand and 
can appreciate the value of primary care and the need for it 
and the challenges that go with the delivery of primary care. 
We are already starting to see some of our graduates that are 
coming out of that very much going into underserved areas as 
well as rural areas and are staying in primary care.
    Senator Warren. That's very good to hear. It's important to 
continue to support traditional residencies, but it's also 
critical that we support new efficient programs like these. And 
I'm committed to making sure that our health centers are fully 
supported and that our training programs don't lose critical 
funding in 2016. Now is the time to invest in our future, and 
this is how we should do it.
    Senator Sanders. Thank you, Senator Warren.
    Senator Murphy.

                      Statement of Senator Murphy

    Senator Murphy. Thank you very much, Mr. Chairman.
    Thank you, Ms. Spitzgo, for being here. I just want to 
associate myself for 2 seconds with the remarks of Senator 
Warren. We have one of these community health center residency 
programs in Connecticut, run actually by a former Congressman 
from Connecticut, Jim Maloney, in Danbury.
    It has worked enormously well, and he points out regularly 
to me and others that the data suggest that a physician trained 
in a community health center is 300 percent more likely to stay 
in an underserved area than someone who is trained in a 
traditional residency program. That is not, just as Senator 
Warren said, to create an advertisement for divesting in 
traditional residency programs. But you get a really good 
return on your investment in community health centers.
    Ms. Spitzgo, I sort of wanted to talk about the problem 
rather than the treatment at the beginning. I had the chance a 
couple of years ago to sit down with a group of University of 
Connecticut medical students who were in their first year. 
Maybe there were 15 students around the table, and I asked 
them, ``How many of you are considering going into primary 
care?'' One of the fifteen raised their hand, and, of course, 
that's a stunning number given that it wasn't so long ago that 
half of the kids graduating from medical school would go into 
primary care.
    I asked them what was the reason. And, clearly, the first 
reason was this subject of most of our discussion today, that 
they just didn't believe they were going to get paid at a level 
that would allow them to pay back their loans. But they also 
talked about the fact that there was a sense that there was 
much less prestige involved in going into primary care than 
there was going into other specialties, and they wanted to be 
on the cutting edge of medicine, and they were better off to go 
into cardiology or orthopedics or neurosurgery.
    Can you just talk a little bit about why we have a shortage 
in primary care? And is it simply a matter of reimbursement 
levels, or are there other things that we should be considering 
doing or the profession should be considering doing to, I 
guess, create that level of attraction that used to be there 
for primary care?
    Ms. Spitzgo. I think we have many factors that are driving 
those decisions. I do believe it starts in the education. It 
starts with understanding, I think, and valuing primary care 
and valuing preventive care and the difference that it can make 
overall in our healthcare systems. It also comes, I think, from 
the experiences that our students are able to have as they're 
going through school and the exposure that they can get to 
working in an underserved area, working in a rural area, 
mentoring with a primary care physician who may share those 
experiences and those challenges.
    I think the other part of that goes to where are innovative 
approaches and our new ways of delivering care? Where does it 
feel like there's the ability to have some creativity and to 
think about doing it differently, which is where I think our 
new residency program really wants to go. We want to drive some 
innovation.
    This isn't just seeing a patient every 10 minutes. This is 
about really being able to provide the level of care and the 
interaction and working as a team and really looking at new 
things and new challenges and population health. How do you 
work all of that into your practice and bring that? And I think 
that's very exciting, and that's the message we need to get to 
our students to start having them think differently and 
appreciate, I think, the value of delivering primary care.
    Senator Murphy. To the extent that reimbursement is an 
issue, as you know, the ACA made a pretty significant 
investment in raising Medicaid rates for primary care 
physicians. We've seen a remarkable transformation in 
Connecticut. I'll just give you the quick statistics.
    From 2012 to 2013, we went from 235 APRNs practicing in the 
Medicaid arena to 578. We went from 1,300 physicians to 2,400 
physicians. We went from 25 PAs to 236 PAs. Clearly, that tells 
us that if you pay physicians in the Medicaid program and you 
pay practitioners in the Medicaid program close to what it 
actually costs them to do the work, they're going to start 
taking Medicaid clients, many of which are in the underserved 
areas.
    How important do you think it is that we maintain these 
rates? The ACA only picks up the tab from a Federal perspective 
for the first 2 years. How important is it for underserved 
areas and Medicaid populations, in particular, to keep these 
Medicaid rates for primary care pegged at the Medicare number 
going forward?
    Ms. Spitzgo. I think we do hear regularly, obviously, 
reimbursement rates can help us drive change and really drive 
innovation in the healthcare delivery. As we look at our sister 
agency, CMS, and their innovation models that they are 
currently funding and testing out, many of them include 
workforce and looking at rates and really looking at what will 
drive those changes. So I think as we continue, having the data 
that you just shared with us and looking at those outcomes and 
what the difference has made as we've made adjustments will 
very much help to pave the path forward, hopefully, on what is 
a workable solution.
    Senator Murphy. Thank you, Mr. Chairman.
    Senator Sanders. Ms. Spitzgo, thank you so much for your 
testimony.
    Now we'll bring up our second panel. We have a great panel, 
and I want to thank all of the panelists for being here. We 
think that at 11 o'clock--although around here, one is never 
100 percent positive--there will be a vote. So people will 
disappear and the chair will rotate a little bit. But we will 
try to get back--I will get back, for sure, to continue the 
discussion.
    Our first panelist is Stan Brock. Mr. Brock is the founder 
and president of the nonprofit healthcare organization, Remote 
Area Medical, called RAM, based in Rockford, TN. He has a very 
diverse resume.
    He worked as a cowboy in the Amazon and later hosted the 
television wildlife series, Wild Kingdom. After organizing 
volunteers to deliver medical care in remote villages around 
the world, he saw the great need here in the United States and 
founded RAM, which has held over 700 free healthcare 
expeditions since 1985.
    Mr. Brock, thank you for your work and thank you for being 
here this morning.

  STATEMENT OF STAN BROCK, FOUNDER AND PRESIDENT, REMOTE AREA 
                     MEDICAL, ROCKFORD, TN

    Mr. Brock. Thank you, Mr. Chairman and distinguished 
members of the committee. Welcome to America, number 37 in the 
World Health Organization's country rankings. I am a voice for 
more than half a million patients that Remote Area Medical, 
RAM, has treated free of charge in 723 mobile medical clinics 
during the last 28 years.
    I know what it is like to be poor and without help. I am 
one voice of the millions of people who are not a part of our 
healthcare system. They have been left behind and forgotten. I 
speak for them today.
    I came from a place where there was no doctor, living with 
the Wapishana Indians in the upper Amazon. Their only recourse 
when faced with catastrophic injury or sickness was a tribal 
witch doctor. But at least they had that. Some of the sick that 
we see here in the United States have nowhere to turn. That is 
why I created Remote Area Medical.
    When I suffered a serious injury, one of the Indians said, 
``The nearest doctor is 26 days on foot from here.'' I felt 
then what so many in our Nation feel today when they need a 
doctor and cannot get care. For millions of Americans, they 
might as well be 26 days on foot from the nearest doctor. In 
fact, one of our patients recently walked 15 miles because he 
was desperate for medical attention.
    Healthcare in America is a privilege of the well-to-do and 
the well-insured. That leaves about 50 million people flat out 
of luck. These families live in fear of injury and sickness 
with no insurance or not enough of it. The predicament of these 
millions of marginalized Americans raises questions of 
morality, injustice, and education.
    Poor education begets poor health. Poverty feeds on poor 
nutrition which creates obesity, diabetes, heart disease, and 
cancer. The vicious cycle lies in wait for each child enslaved 
in poverty as they pass from beneath the security of State and 
Federal programs into the barren wastes of adulthood. Many, 
nursing mouthfuls of decayed and abscessed teeth or suffering 
from fading vision, will inevitably join the long lines of 
desperate patients at a RAM free clinic.
    I have looked into the distraught faces of Americans 
imprisoned by poverty, from child to grandparents, all 
generations lining up by the hundreds in places as diverse as 
Los Angeles or a fairground in the mountains of southwest 
Virginia. I have seen our elderly in makeshift wheelchairs, 
people clutching precious numbered scraps of paper, their RAM 
free clinic ticket to relief from unnecessary agonizing pain 
and sickness. They cannot afford healthcare.
    This leads some of our American families, with their 
children, to sleep in tents and cars, often for over 24 hours, 
waiting for a RAM event to open its door. Blindfolded, you can 
stick a pin on a map of America and wherever it lands, you will 
find hundreds, if not thousands, of sick hurting people in need 
of care that they cannot obtain.
    Our people are living in sickness and pain and in need of 
basic medical attention. At RAM clinics, dental care is the 
greatest demand with vision services a close second. Eighty-
five million Americans do not have dental insurance, and half 
of those can't afford to pay for a dentist without it.
    What are they to do? Hospital emergency rooms don't do 
dentistry and they don't make glasses. In most cases, Medicaid 
does not cover dentistry or vision for adults, and finding a 
Medicaid practitioner to provide treatment can be a real 
challenge.
    RAM is not a solution to the American healthcare crisis. We 
need to be in places like Haiti, not Tennessee and California. 
RAM bridges the gap for those suffering needlessly in our 
system. A RAM event is logistically strained at 1,200 patients 
a day, and we are forced to turn away hundreds and sometimes 
thousands of sick people.
    Our healthcare system has failed our people because they 
either do not have access or they cannot afford it. As a result 
of the great need of those who are sick or injured, we have 
reached out to legislators for help. In 1995, RAM asked the 
State of Tennessee to change the law to allow out-of-State 
licensed practitioners to provide free care to underserved 
patients in Tennessee. This highly successful program attracts 
60 percent or more of the medical volunteers at RAM events from 
out of State. A total of 12 States have now adopted the 
Tennessee model, but this process has taken 20 years.
    Doctors are still calling me to say that it is easier to 
volunteer their services in places like Guatemala than it is 
here in the United States. I have two pictures here that I'd 
just like to hold up. Is this 1936 picture of a depression-era 
mother in California any more revealing than this 2012 picture 
of a thousand Americans holding up their hands appealing for 
healthcare before daybreak at a RAM free medical event in 
Bristol, TN? Where have we gone wrong in the last 76 years that 
separates these iconic images?
    Thank you.
    [The prepared statement of Mr. Brock follows:]
                    Prepared Statement of Stan Brock
    Welcome to America--No. 37 in the World Health Organization's 
country rankings! I am a voice for more than half a million patients 
that REMOTE AREA MEDICAL (RAM) has treated free of charge in 723 
mobile medical clinics during the last 28 years. I know what it is like 
to be poor and without help. I am one voice of the millions of people 
who are not a part of our healthcare system. They have been left behind 
and forgotten. I speak for them today.
    I came from a place where there was no doctor, living with the 
Wapishana Indians in the upper Amazon. Their only recourse, when faced 
with catastrophic injury or sickness was a tribal witch doctor. But at 
least they had that. Some of the sick that we see here in the United 
States have nowhere to turn. That is why I created RAM. When I 
suffered a serious injury, one of the Indians said, ``The nearest 
doctor is 26 days on foot from here.'' I felt then what so many in our 
Nation feel today, when they need a doctor and cannot get care. For 
millions of Americans, they might as well be 26 days on foot from the 
nearest doctor. In fact, one of our patients recently walked 15 miles 
because he was desperate for medical attention. Health care in America 
is a privilege of the well-to-do and the well-insured; that leaves 
about 50 million people flat out of luck. These families live in fear 
of injury and sickness with no insurance or not enough of it.
    The predicament of these millions of marginalized Americans raises 
questions of morality, injustice and education. Poor education begets 
poor health. Poverty feeds on poor nutrition which creates obesity, 
diabetes, heart disease and cancer. The vicious cycle lies in wait for 
each child enslaved in poverty as they pass from beneath the security 
of State and Federal programs into the barren wastes of adulthood. 
Many, nursing mouthfuls of decayed and abscessed teeth or suffering 
from fading vision, will inevitably join the long lines of desperate 
patients at a RAM free clinic. I have looked into the distraught faces 
of Americans imprisoned by poverty, from child to grandparents, all 
generations lining up by the hundreds in places as diverse as Los 
Angeles, or a fairground in the mountains of southwest Virginia. I have 
seen our elderly in makeshift wheelchairs, people clutching precious 
numbered scraps of paper, their RAM free clinic ticket to relief from 
unnecessary agonizing pain and sickness. They cannot afford healthcare. 
This leads some of our American families, with their children, to sleep 
in tents and cars, often for over 24 hours, waiting for a RAM event to 
open its door. Blindfolded, you can stick a pin on a map of America and 
wherever it lands, you will find hundreds, if not thousands of sick 
hurting people in need of care that they cannot obtain.
    Our people are living in sickness and pain and in need of basic 
medical attention. At RAM clinics, dental care is the greatest demand 
with vision services a close second. Eighty-five million Americans do 
not have dental insurance and half of those can't afford to pay for a 
dentist without it. What are they to do? Hospital emergency rooms don't 
do dentistry and they don't make glasses. In most cases, Medicaid does 
not cover dentistry or vision for adults, and finding a Medicaid 
practitioner to provide treatment can be a real challenge. RAM is not 
a solution to the American healthcare crisis. We need to be in places 
like Haiti, not Tennessee and California. RAM bridges the gap for 
those suffering needlessly in our system. A RAM event is logistically 
strained at 1,200 patients a day and we are forced to turn away 
hundreds and sometimes thousands of sick people.
    Our healthcare system has failed our people because they either do 
not have access or they cannot afford it. As a result of the great need 
of those who are sick or injured, we have reached out to legislators 
for help. In 1995, RAM asked the State of Tennessee to change the law 
to allow out-of-state licensed practitioners to provide free care to 
underserved patients in Tennessee. This highly successful program 
attracts 60 percent or more of the medical volunteers at RAM events 
from out-of-state. A total of 12 States have now adopted the Tennessee 
model, but this process has taken 20 years. Doctors are still calling 
me to say that it is easier to volunteer their services in places like 
Guatemala than it is here in the United States! Is this 1936 picture of 
a depression-era mother in California any more revealing than this 2012 
picture of a thousand Americans holding up their hands appealing for 
health care before daybreak at a RAM free medical event in Bristol, 
TN? Where have we gone wrong, in the last 76 years that separates these 
iconic images?

    Senator Sanders. Thank you very much.
    Our second witness is Dr. Gary Wiltz. He is a board 
certified internist and currently serves as CEO of Teche Action 
Clinic, a network of community health centers based in 
Franklin, LA, that serves six parishes in southwest Louisiana. 
He is also the current Chairman of the Board of the National 
Association of Community Health Centers, which represents more 
than 1,200 health center organizations nationwide.
    Thank you so much for being with us, Dr. Wiltz.

STATEMENT OF GARY WILTZ, M.D., EXECUTIVE DIRECTOR AND CLINICAL 
          DIRECTOR, TECHE ACTION CLINIC, FRANKLIN, LA

    Dr. Wiltz. Good morning, and thank you, Chairman Sanders, 
Ranking Member Burr, and Senator Murphy and Senator Warren. 
Thank you for that kind introduction, so I won't repeat that. 
Just one more fact about NACHC--we represent all of the 
Nation's community health centers, and we are serving some 22 
million people nationwide in nearly 9,000 rural and urban 
settings.
    I want to talk to the subcommittee today--and thank you for 
focusing on this issue--about the critical issue of primary 
care access. I'd like to focus my remarks on the tremendous 
strides that we've made in community health centers in 
providing access to primary care to millions of people in this 
country. And at the same time, I want to highlight a looming 
funding crisis that threatens the program's very existence.
    Last year, Teche Clinic provided care to more than 18,000 
underserved Louisianans, 97 percent of whom are low-income. 
Nearly half of our patients are uninsured, and a third are 
covered by Medicaid. These are patients that I know very well. 
You see, I began my service at Teche Action Clinic in 1982 as a 
National Health Service Corps scholar, and some 32 years later, 
I'm still there seeing patients every day.
    It is from that perspective that I want to speak about what 
access to care really means. Access is a term that's being 
frequently used in our healthcare dialog and discussion, but 
there's little agreement on what it really means. To those of 
us who serve on the front lines of healthcare delivery, access 
is more than just having an insurance card. It is more than 
getting care in an emergency room.
    Access is having a place to go for regular, reliable, high-
quality preventive and primary care. By its very design, the 
locally controlled nonprofit health center model breaks down 
the barriers to healthcare access, including those created by 
geography and income.
    Health centers are also economic engines in some of the 
most economically depressed communities in the Nation. At our 
health center in Franklin, we're one of the largest employers 
in the community. We provide over 150 good-paying jobs, all 
above minimum wage.
    Not only do health centers deliver effective care, but, 
nationally, we save the health system $24 billion by keeping 
patients out of costly healthcare settings such as emergency 
departments. At our health center, we're open 6 days a week, 7 
a.m. to 7 p.m. We have demonstrated a decrease in inappropriate 
emergency room usage by 40 percent.
    Just recently, an uninsured man--as Senator Warren alluded 
to earlier--an uninsured man came to our center on a Saturday 
evening at 6 o'clock after he knocked off from work, suffering 
from headaches due to uncontrolled hypertension. We were able 
to diagnose and treat his problem that evening, saving him from 
having to stay in an emergency room for hours and a costly $800 
bill. More importantly, he was able to return to work the next 
day without missing that day's pay.
    Despite the history of strong bipartisan support from 
Congress, many communities in need still lack primary 
healthcare access. Even in communities with a health center, 
significant unmet need remains. A recent report from NACHC and 
the Robert Graham Center found that as many as 62 million 
Americans lack regular access to primary care. So, clearly, our 
work continues and is not done.
    Yet without deliberate congressional action, both health 
centers and primary care workforce programs--unless we get this 
remedied, they're going to face a threat to their very 
existence. Next year, the mandatory Health Center Fund, which 
currently accounts for more than half of all health centers' 
dollars, will end unless it is reauthorized. At that point, 
health centers face a 70 percent reduction in grant funding, 
leading to significant cuts to operations and elimination of 
healthcare access in some of the Nation's most vulnerable 
communities, even as demand for our care continues to grow.
    I mentioned earlier that we are soon to open two more new 
community health centers and two new sites. If these cuts come 
into effect, not only will we not be able to open those two new 
sites, but it would force me--and I'm CEO of these community 
health centers--to lay off over 10 percent of my staff. And, 
most importantly, 3,000 of our current patients would go 
without services.
    In addition to health centers, the National Health Service 
Corps, of which I am a proud alumni, and the Teaching Health 
Center programs also face a funding cliff. The Corps is a vital 
program that provides scholarships and loan repayments to 
providers who commit to serving in underserved areas, as I have 
done for my entire career.
    The Teaching Health Center program is an innovative effort, 
as alluded to earlier, to grow the supply of primary care 
providers trained in community-based settings. I know my 
colleagues on the panel will speak more about these workforce 
programs, but let me just say this. The funding cliff that 
faces these programs threatens the stability and sustainability 
of our healthcare system.
    Failing to fix this cliff would send the country in the 
wrong direction by reducing primary care capacity and sending 
costs spiraling. We strongly urge Congress to address this 
problem this year so that access to care in our communities can 
become a reality for years to come. I look forward to your 
questions.
    [The prepared statement of Dr. Wiltz follows:]
                 Prepared Statement of Gary Wiltz, M.D.
    Chairman Sanders, Ranking Member Burr and members of the 
subcommittee, thank you for the opportunity to join you today to 
discuss such an important--and urgent--topic: the persistent and 
growing need for access to primary care in communities across this 
country. My name is Gary Wiltz. I am a board-certified internist and 
currently serve as chief executive officer of Teche Action Clinics, a 
network of soon-to-be 10 community health centers serving six parishes 
in southwest Louisiana whose home base is in Franklin, LA.
    I also currently serve as chairman of the board of the National 
Association of Community Health Centers (NACHC), which represents the 
more than 1,200 Health Center organizations nationwide. Health centers 
currently provide care in more than 9,000 rural and urban underserved 
communities and serve some 22 million patients, which is a direct 
result of broad, bipartisan support for the Health Center Program in 
Congress. This support, which extends back decades and has been 
embraced by presidential administrations of both parties, has led to 
continued and expanded investment in our model of care. On behalf of 
all of America's community health centers, I want to thank you, Mr. 
Chairman and each member of the subcommittee and Congress for your 
unwavering focus on this issue. The reason I am here to talk with you 
today is to discuss the positive impact and tremendous strides 
Community Health Centers have made in providing access to primary care 
services to millions of vulnerable Americans throughout the country as 
well as highlight a looming funding crisis that threatens the very 
existence of the Health Center Program.
    I came to Teche Action Clinic in 1982 as a National Health Service 
Corps (NHSC) Scholar with a 3-year service commitment, and 32 years 
later I am still there, serving patients every day. It is from that 
perspective that I want to speak to the subcommittee today about the 
notion of access to care. ``Access'' is a term that gets used 
frequently in our national health care discussion, but with varying 
interpretations of its meaning. For some, access means merely having 
health insurance coverage. Others have suggested that a local emergency 
room constitutes sufficient access. To those of us who serve on the 
``front lines'' of health care delivery, access is more than just 
having an insurance card. It is more than getting care in an emergency 
room. Access is having a place to go for regular, reliable, high-
quality preventive and primary care.
    Teche Action Clinic is just such a place. In 2013, we provided 
access to care to more than 18,000 underserved Louisianans, more than 
97 percent of who are low-income. Nearly half of our patients are 
uninsured and nearly a third are covered by Medicaid. We provide not 
only primary medical care but also oral health, behavioral health, 
onsite pharmacy, lab, WIC, nutrition counseling, diabetes education, 
chronic disease management and enabling services including 
transportation, translation and enrollment services. Like all health 
centers, our doors are open to everyone regardless of ability to pay. 
We are a Joint Commission certified Patient-Centered Medical Home, 
meaning our care is delivered in a coordinated manner by an 
interdisciplinary team with a focus on increasing safety, improving 
health and reducing costs.
    Community Health Centers like the one where I serve are locally 
controlled, non-profit entities. By its very design, the health center 
model breaks down barriers to health care access, including those 
created by geography and income. Health centers are also economic 
engines in some of the most economically depressed communities in the 
Nation. In 2009 alone, Health Centers generated $20 billion in economic 
impact and were responsible for nearly 200,000 jobs. My health center 
is one of the largest employers in our community providing over 150 
good paying jobs, all above minimum wage.
    Community health centers not only deliver effective care, but we 
have a demonstrated track record that shows that we're a smart 
investment of public funds. Nationally, we save the entire health 
system approximately $24 billion annually by keeping patients out of 
costlier health care settings, such as emergency departments. At our 
Franklin site we are open 6 days a week 12 hours a day 7:30 a.m. to 
7:30 p.m., and we have been able to decrease inappropriate ER visits in 
my community by over 40 percent. Just recently, one of my patients, who 
is employed but uninsured, came to the health center on a Saturday 
evening after he got off work at 6 p.m. He was suffering from a severe 
headache due to dangerously high blood pressure. We were able to get 
him in, diagnose the problem and treat him that evening, which saved 
him from waiting for hours to be seen at an emergency room and paying 
over $800.00. Our ability to see him and provide him with services when 
he needed care also allowed him to go to work the next day.
    In addition to providing the right care at the right time at the 
right price, Health Centers have established an impressive record of 
delivering high-quality care to our patients. Research has shown that 
Health Centers provide equal or better care compared to other primary 
care providers, all while serving communities with more chronic illness 
and socioeconomic complexity. Health center patients receive more 
preventive services, such as immunizations, health education, 
mammograms, pap smears, and other screenings, than patients seen in 
other settings.
    Unfortunately, many of the residents in my State, both the 
uninsured and insured, are unable to access critical primary and 
preventative care services because they just can't afford it or do not 
have access to a health center or other primary care providers. Clearly 
our work is not done. Despite the strong bipartisan support and the 
history of investment in our capacity, many communities in need still 
lack a Health Center or any other form of basic primary care. Even in 
communities with a Health Center, demand often far exceeds supply and 
significant unmet need remains due to limited resources. Many Health 
Centers struggle to recruit and retain a primary care workforce that is 
prepared to address the challenges of providing care to the medically 
underserved.
    A recent report issued by NACHC and the Robert Graham Center for 
Policy Studies indicates that as many as 62 million Americans lack 
regular access to primary care. Access barriers such as geography, 
income, and insurance status--and the provider shortages that 
exacerbate them--lead to poorer health outcomes and increased costs for 
taxpayers. Yet at the very time that this need for expanded access is 
most necessary, without deliberate congressional action both Health 
Centers and vital primary care workforce programs face a threat to 
their very existence. I want to focus the remainder of my testimony on 
this issue--which we have taken to calling the Primary Care Cliff--and 
the urgency of addressing it as soon as possible.
    The Health Center grant, which supports the operations of the more 
than 1,200 federally funded health center organizations nationwide, is 
financed through a mix of annual discretionary appropriations and 
mandatory funding appropriated through the Health Centers Fund. In the 
coming fiscal year, if the health centers program were to maintain 
discretionary funding at current levels and to fully utilize the last 
remaining year of funding in the mandatory health center fund, we would 
build the capacity to serve as many as 11 million new patients.
    In fiscal year 2016, however, Health Centers face a funding cliff: 
the mandatory funding, which currently accounts for more than half of 
all health center dollars, will end unless it is reauthorized. With 
only discretionary funding at current levels, Health Centers would see 
up to 70 percent reductions in grant funding, leading to significant 
cuts to operations and reduction or elimination of health care access 
in some of the Nation's most vulnerable communities. This would occur 
just as the demand for the type of care Health Centers provide is 
growing. I mentioned earlier that my center is soon to be 10 sites as 
we will be opening two new sites in a high-need parish in the next 2 
months. If these cuts are to come to fruition, not only would I be 
unable to open these two new sites, I would be forced to close two 
additional sites, lay off over 10 percent of my staff and more 
importantly over 3,000 of my current patients would no longer have 
access to primary care services in Franklin.
    In addition to Health Centers, the National Health Service Corps 
and Teaching Health Center programs also face looming funding cliffs. 
The National Health Service Corps is a vital program that provides 
scholarships and loan repayment to providers that commit to serving in 
underserved areas, as I have done for my entire professional career. 
The Teaching Health Center program is an innovative effort focused on 
growing the supply of primary care providers trained in community-based 
settings.
    I know my colleagues on the panel will be speaking in more depth 
about these workforce development programs, but let me just say this: 
taken together, the funding cliff that faces these three programs 
threatens the stability and sustainability of our health care system. 
Failing to fix this cliff would send the country in the wrong direction 
by reducing primary care capacity and sending costs spiraling upward. 
There is no way we can absorb a 70 percent cut. Instead it will force 
Health Centers to close sites and lay off workers, meaning a major 
reduction critical access for the patients and communities we serve.
    We strongly urge Congress to address this problem this year--so 
that health centers and our current and future clinicians can plan for 
the future knowing that access to care in our communities can be a 
reality for years to come. I know each of us, as well as the 
organizations we partner with and represent, is eager to work with you 
to address this problem. Thank you for your time and I look forward to 
your questions.

    Senator Sanders. Dr. Wiltz, thank you very much.
    If you will forgive me, Senator Murphy has to leave, and he 
wanted to introduce Dr. Flinter. So I'm going to kind of jump 
over and we'll go to Dr. Flinter.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman, for your 
courtesy. I'm just pleased to have my good friend, Margaret 
Flinter, here with us today. She's the senior vice president 
and clinical director of Community Health Center, Inc. It's the 
largest FQHC in Connecticut, serving about 130,000 patients in 
13 practice settings.
    But her expertise here today is really about all the great 
work that she's done to develop a model of formal postgraduate 
residency training programs for new nurse practitioners that 
are committed to practice as primary care providers, 
particularly in community health centers. This model now has 15 
sites all around the country. For this committee's purposes, 
there are sites in Massachusetts, Pennsylvania, South Carolina, 
and Washington State.
    She's a great friend, but also a real expert in the field 
of primary care, and I'm delighted to have her join us this 
morning.
    Senator Sanders. Dr. Flinter, can you live up to all of 
that?
    Ms. Flinter. I don't know what else I can say.
    Senator Murphy. And I would just add that she is 
testifying, despite the fact that she has been up 2 nights in a 
row watching the UConn Huskies win two national championships.
    [Laughter.]
    Ms. Flinter. Go Huskies. And they did a great job.
    Senator Sanders. Dr. Flinter.

STATEMENT OF MARGARET FLINTER, APRN, Ph.D., c-FNP, FAAN, FAANP 
 SENIOR VICE PRESIDENT AND CLINICAL DIRECTOR, COMMUNITY HEALTH 
                  CENTER, INC., MIDDLETOWN, CT

    Ms. Flinter. Thank you so much, Senator Murphy. Good 
morning, Chairman Sanders and Senator Burr and Senator Warren 
as well. We are so pleased to have the honor to testify before 
you today.
    Primary care has been the defining focus of my entire 
career, from the time I started as a young public health nurse 
in rural Connecticut and Georgia and then as a family nurse 
practitioner primary care provider and a leader at the 
Community Health Center. I came there in 1980, newly graduated, 
ink barely dry on my diploma from the Yale School of Nursing, 
because the National Health Service Corps had the good sense to 
assign me to what was then a storefront clinic on Main Street, 
USA, in Middletown, CT.
    It was my great good fortune to find a band of deeply 
committed visionary community organizers and clinicians who are 
as committed to community health and primary care as I was. And 
as Senator Murphy has said, from those humble beginnings, we 
care for 130,000 patients--medicine, dentistry, behavioral 
health--in community health centers, but also in our school-
based health centers around the State, which numbers nearly 
200.
    Today I want to address three questions that are the focus 
of so much of my work and I know on your minds. Who wants to be 
a primary care provider? Second, how do we attract these 
providers to the areas that need them most, both rural and 
urban? And, third, how do we retain them once they're there?
    First, the workforce shortage issue. You are hearing and 
will hear compelling testimony from my colleagues. I'll tell 
you in advance that I've read their testimony, and I support 
their recommendations, and, in particular, the Teaching Health 
Center reauthorization, which recognizes, as I do, that it's 
both about training to the complexity of the care we deliver in 
primary care and in health centers, but it's also about 
training to a model of care that is patient-centered and data-
driven that focuses on quality and delivering care where people 
live and work.
    You will hear many statements about why there is a shortage 
of primary care physicians. But I'm going to ask you to step 
back and ask not just why don't more physicians choose primary 
care, but who else wants to be a primary care provider, and how 
do we support them in that choice.
    My response is that nurse practitioners still 
overwhelmingly choose primary care as their specialty. Eighty 
percent of nurse practitioners specialize in a primary care 
specialty, and 70 percent are in primary care today. We can 
attract them and support them and assure their successful 
transition to the role of a primary care provider by giving 
them the opportunity for formal postgraduate residency training 
programs in community health centers. In 2007, I and my 
colleagues at the health center launched the country's first 
program after many years of recognizing the need for such a 
program.
    GME legislation has been so successful in preparing 
physicians, but it has never included nurse practitioner 
residency training. We can't afford to lose new NPs from 
community health centers, where the first year of practice can 
rightly be described as one of shock and awe, or deter them 
from coming to our setting simply because we haven't done the 
work required to facilitate a successful transition from 
brilliant education to practice.
    We are now in our seventh year. Our applicants come from 
all over the country. Twenty-seven of our twenty-eight 
graduates are practicing as primary care providers all across 
America. Fifteen other health centers have started programs 
like ours, and 14 more residency programs will come online in 
2014. It now extends beyond the community health centers to 
include nurse-managed health centers and even large health 
systems such as, Senator Burr, the Carolina healthcare system 
in your home State where we've had the pleasure of meeting such 
wonderful leaders.
    We've come together. We've created a national nurse 
practitioner residency training consortium to set standards and 
to work for a sustainable stream of funding, such as that 
that's available to physicians. And we will seek a legislative 
commitment based on the fact that in 2010, Congress authorized 
grants of up to $600,000 a year to implement NP residency 
training programs in community health centers. But the 
authorization expires this year, and no grants were ever 
awarded because the program was never funded. We ask that it be 
done and reauthorized and funded for 5 years.
    My second question: How do we recruit providers to 
underserved areas, both rural and urban? And I will simply 
state what others have said: ``Expand the National Health 
Service Corps.'' It worked for me in 1978. It worked for 40 of 
my 200 clinicians on my staff, who at one time in their career 
were National Health Service Corps, and that cuts across all 
the disciplines.
    And, finally, I want to answer the question: How do we 
retain the best and the brightest? We do it by not making 
coming to practice in a community health center a choice 
between a stimulating career in practice and research and 
training and being involved in leadership, but rather we can 
make our health centers the locus of those activities.
    That's what the Weitzman Institute at the Community Health 
Center does, whether it's through our Project ECHO model of 
connecting primary care providers to specialists around the 
country to focus on the most pressing and difficult issues in 
primary care, things like the management of chronic pain, 
dealing with opioid and heroin addiction, managing HIV and 
hepatitis C, and primary care. We can create these kinds of 
innovations. We can use technology. We can have our research 
within the health centers. And we can truly improve the health 
and the healthcare of all Americans.
    I thank you very much for the opportunity to be here today.
    [The prepared statement of Ms. Flinter follows:]
Prepared Statement of Margaret Flinter, APRN, Ph.D., c-FNP, FAAN, FAANP
    Good morning, Chairman Sanders, Senator Burr, and distinguished 
members of the Subcommittee on Primary Health and Aging. It is an honor 
to speak to you today on the issues of healthcare access and workforce 
challenges across the United States.
    Thank you, too, Senator Murphy for your kind introduction, and for 
all of your efforts to ensure access to high-quality health care for 
all Americans, first as our State Representative in Connecticut, then 
as a Congressman, and now as a U.S. Senator.
    I am Margaret Flinter of the Community Health Center of 
Connecticut, and primary care has been the defining focus of my career, 
first as a young public health nurse in rural Connecticut and rural 
Georgia, then as a family nurse practitioner, primary care provider, 
and executive leader of one of the country's finest community health 
centers. I came to the Community Health Center, Inc. in 1980, newly 
graduated from the Yale School of Nursing as a family nurse 
practitioner and ready to begin my ``service obligation'' as a National 
Health Service Corps scholar. It was my great good fortune that the 
NHSC assigned me to what was then a small storefront on Main Street in 
Middletown, CT, where I found a small band of visionary and passionate 
community organizers and clinicians, like founder and CEO Mark 
Masselli, and family physician Dr. Carl Lecce, all of whom shared my 
own vision and passion for primary care and community health.
    We put our shoulders to the wheel in building a remarkable 
community health center first in Middletown, but over time and in 
response to requests from community leaders in cities all over 
Connecticut, we developed community health centers in 12 cities across 
our State. Through our W.Y.A. or ``Wherever You Are'' philosophy of 
going where the need is, we have also pioneered the expansion of 
statewide, school-based health centers and primary care services in 
homeless shelters. Today, our Community Health Center has over 130,000 
active patients throughout the State. We are known for our clinical 
excellence but also for our commitment to innovation in addressing 
complex issues in primary care; for our formal research; and for 
training the next generation of qualified health care providers.
    Today I want to address three questions that are the focus of much 
of my work and your area of interest today. First: who wants to be a 
primary care provider? And what must we do, now, to support those who 
make the affirmative commitment to become primary care providers? 
Second: how do we entice those providers to practice in underserved 
areas, both rural and urban, to care for our most vulnerable 
populations? Third, and just as important: how do we retain these 
talented, brilliant, and committed individuals in community health 
centers over the long haul? In answering these questions, I will speak 
to what we can and are doing, ``in the field,'' and also, how you are, 
and can, help us continue to do so.
    First, let me address the workforce issue, and particularly the 
shortage of primary care providers. You are hearing compelling 
testimony today from my colleagues on this subject, and in particular, 
the need and strategies for attracting, training, and retaining more 
physicians in primary care. I support their recommendations and 
testimony. I am particularly supportive of the Teaching Health Center 
reauthorization and program, which recognizes, as I will emphasize in 
my testimony, that we must train the next generation not only to the 
clinical complexity of primary care in community health centers, but to 
our model of care--and that is best accomplished by FQHC-based 
residency training. You are well familiar with the many challenges that 
contribute to the shortage of primary care physicians--the low 
percentage of medical school graduates who choose primary care vs. 
specialties, the salary discrepancies between primary care and 
specialties, the burden of debt, and the deep frustration with primary 
care practice of the past few decades, which I believe we are fully 
capable of reversing--and I will speak to strategies to address that 
shortly.
    But I want to step back. Instead of asking only why more physicians 
don't choose primary care, why not ask this broader question: Who else 
wants to be a primary care provider, and how can we support them in 
that choice and ensure that they will stick with it--particularly in 
the complex setting of community health centers?
    My response is that nurse practitioners still overwhelmingly choose 
primary care as their preferred specialty, and we can attract, support, 
and assure their successful transition to the role of primary care 
provider in community health centers and other complex settings by 
giving them the opportunity for formal, post-graduate residency 
training programs in federally qualified health centers and nurse-
managed health clinics.
    In 2007, I and my colleagues at CHC, Inc. launched the country's 
first formal post-graduate residency training program for new nurse 
practitioners who aspire to practice careers as primary care providers 
in community health centers. We did this after many years of observing 
the very difficult transition of brilliantly educated and fiercely 
committed new NPs as novice primary care providers in the very busy, 
immensely complicated settings of community health centers. The need 
and call for residency training for new NPs had been written about, 
talked about, and studied for years but the brick wall of GME 
legislative language failed to include NP residency training and 
impeded its development. We cannot afford to lose new NPs in community 
health centers--or deter them from coming to our setting--simply 
because we have not done the work required to facilitate their 
successful transition from university to practice.
    We decided that someone had to build the model for NP residency 
training, and so we did. This NP Residency Training Program is full-
time for 12 months. It is very intensive training that addresses the 
clinical complexity of health problems suffered by often uninsured, 
low-income health center patients, and trains these NPs to a model of 
high performance primary care--team-based, and integrated with 
behavioral health; person-focused but also driven by actionable data to 
achieve better and better outcomes.
    We are now in our 7th year and have expanded to eight residents per 
year. Our applicants come from all over the country--we have had 
applicants from all but two States--and I can tell you that 27 of our 
28 graduates to date are practicing as primary care providers in 
community health centers and safety net settings all across America, 
from Louisiana to Iowa, as well as in Illinois, Massachusetts, 
California and Washington State.
    From the time we started and in response to our first published 
article on the model, we have been asked by others to help them develop 
NP residency training programs. Today there are 15 NP residency 
training programs for primary care NPs across the country, and 14 more 
that will come on line in 2014. They include community health centers, 
nurse-managed health clinics, and the Veterans Administration's Five 
Centers of Excellence in Primary Care Education--plus the Jesse Brown 
VA Medical Center in Chicago. We have over 60 organizational members 
nationwide, with six participating facilities in Massachusetts alone--
in Belmont, Boston, Cambridge, Charlestown, Leominster and Worcester; 
another NP residency training site has been established at the Fay 
Whitney School at the University of Wyoming in Laramie; and now even 
large health/hospital systems such as the Carolinas Healthcare System 
in Senator Burr's home State--with six NP residency training sites--are 
joining this national movement.
    To advance the model of NP residencies, I and my colleagues created 
the National Nurse Practitioner Residency Training Consortium, which 
has brought together the leaders of the movement to advance the 
development of NP residency training nationwide. Our goal is to set and 
maintain appropriate standards for these residencies and work for a 
sustainable stream of Federal funding similar to that available for 
physicians and dentists under GME. In short, we seek a legislative 
commitment to NP residencies, and we believe we are almost there. In 
2010, Congress gave the Secretary of HHS the ability to award grants of 
up to $600,000 a year to eligible health centers seeking to implement 
NP residency training programs. However, that authorization expires 
this year and no grants have ever been awarded because the program was 
authorized but never funded. It is our request that, this year, the 
previously enacted provision be reauthorized and funded for another 5 
years, because this program is absolutely critical to address the 
looming primary care workforce shortage we face over at least the next 
10 years. While our consortium is growing due to the tremendous need in 
our communities, many of the existing participants advise that they may 
be unable to continue the training without the provision of Federal 
funds moving forward. For example, the nationally renowned Penobscot 
Community Health Center in Bangor, ME, just advised me that although 
they will maintain the program next year, it will be cut by two-thirds. 
They implemented the program and spread information concerning NP 
residencies within the State but unfortunately say they will be 
educating at reduced capacity, compared to what they could have done, 
due to lack of funding.
    My second question asked how we can recruit providers to 
underserved areas, both rural and urban. The National Health Service 
Corps, originally and brilliantly championed by Senator Warren G. 
Magnuson of Washington State, has stood the test of time as an 
effective, efficient, and elegant way to meet multiple critical needs: 
the need of the new clinician to obtain financial support; the need of 
the newly graduated clinician to obtain help with loan repayment; and 
the dire need of communities to acquire primary care providers. Since 
1972, the Corps has done just this. I know this first hand. When I made 
the decision, after several years as a public health nurse, to attend 
graduate school at Yale, the financial challenge was daunting. In 1978, 
I was fortunate that the NHSC accepted me as a NHSC scholar, and I 
gratefully committed myself to a future period of obligated service. 
Why wouldn't I? All I wanted--as I have seen with subsequent 
generations of NHSC scholars and loan forgiveness recipients--was a 
chance to practice, as a primary care provider, with people and in a 
community that needed my care.
    In preparing for today's testimony, it occurred to me that I really 
didn't have a firm handle on how many members of my medical, dental, 
and behavioral health staffs had ever been in the NHSC during their 
careers. I posed that question by email to the staff and invited people 
to share the ``where and when'' of their service--but also what it 
meant to them. Time does not permit me to read all 40 of the responses 
I received. These respondents are all ``alums'' of the NHSC and include 
physicians, nurse practitioners (both primary care and psychiatric 
specialist), PAs, Licensed Clinical Social Workers, Licensed Clinical 
Psychologists, Dentists and Dental Hygienists. Perhaps most tellingly, 
while some are currently in their period of obligated service, the 
majority completed their NHSC service many years ago but chose to stay 
and work in primary care. As one NP wrote,

          ``In my experience, the NHSC provided me with the financial 
        support that allowed me to focus my attention directly on the 
        clinical concerns of my patients and connected me with other 
        like-minded clinicians. I remain forever grateful for the 
        opportunity afforded to me by the Corps. For this reason, I 
        would encourage all efforts to increase ongoing support for 
        this wonderful program, and I applaud the NHSC for taking so 
        many steps in recent years to `modernize' their rules, 
        procedures and policies to reflect changing times.''

    Finally, I would like to answer my third question: what do we need 
to do to retain the best and the brightest, the most committed 
clinicians in primary care? For this, we must look to the cutting edge 
innovations and opportunities that create an exciting, stimulating, and 
vibrant career path for clinicians choosing primary care in community 
health centers. We can't have a path that says to practice primary care 
in a community health center, you must forego any thoughts about 
research, teaching, and mastery of complex challenges through on-going 
exposure to the best specialists that academic medical centers might 
offer. Instead, our health centers provide exactly that rich 
environment. I have had the opportunity to see this through the 
creation of our Weitzman Institute, founded in 2005 as the Weitzman 
Center for Innovation in Primary Care, which is an institute with a 
core focus on delivery system research, applying the science of quality 
improvement in primary care, and training. And I have seen how powerful 
a force it is for us at CHC in both attracting--and retaining--our best 
clinicians.
    Finally, I want to speak to overcoming the isolation that can be 
inherent in primary care as we face some of the most vexing problems. 
One example is ``Project ECHO''--an evidence-based, distance learning 
approach developed by Dr. Sanjeev Arora at the University of New Mexico 
and replicated by CHC for FQHCs around the country. Project ECHO-CT. 
connects a team of specialists, by video, with groups of primary care 
providers all over the country. Practitioners in the field present 
their most challenging cases and get expert clinical guidance by 
telemedicine and, in the process, become expert over time themselves. 
Nowhere is this more important than in two critical areas of primary 
care: the diagnosis and management of chronic pain and--sadly, but 
closely related--the management of heroin and opioid addiction. We all 
recognize the danger and precipitous rise in death by opioid overdose, 
both prescription pill and heroin, in our communities. Dealing with 
issues like this--alone and without expert support and guidance--is the 
kind of isolating and frustrating experience that drives people out of 
primary care. Connecting primary care providers with specialists and 
each other to treat and manage these complexities is of enormous value, 
and I would be happy to speak more about this if time permits.
    In summary, I answer my three questions again. Who wants to be a 
primary care provider? Nurse practitioners do, and seek the opportunity 
for further intensive training appropriate to the complex setting of 
community health centers. How can we attract the best, brightest and 
most committed young providers across the medical/dental/behavioral 
health disciplines? By growing the National Health Service Corps. And 
finally, how do we retain these providers? Our responsibility, in the 
field, is to make our health centers not JUST centers of clinical 
excellence, but also the loci of research, training, and the 
advancement of science in primary care.
    We greatly appreciate your leadership and look forward to your 
continued support for these initiatives.

    Senator Sanders. Thank you very much.
    Senator Burr is going to introduce Dr. Dobson.
    Senator Burr. Mr. Chairman, I'm pleased to introduce Dr. 
Allen Dobson, the present CEO of Community Care of North 
Carolina. He's a family physician. He currently serves as the 
vice president of Clinical Practice Development at Carolina's 
Medical Health System in Charlotte, and he is a visiting 
scholar at the Engelberg Center for Healthcare Reform at the 
Brookings Institute here in Washington, DC.
    Let me just say on a personal note that Allen has been 
instrumental in reshaping the delivery of healthcare to the 
most vulnerable in North Carolina and I think nationally. His 
effort to create and to implement community care has been a 
model many have tried to figure out and replicate, if not in 
total, in part.
    Dr. Dobson.

  STATEMENT OF L. ALLEN DOBSON, Jr., M.D., PRESIDENT AND CEO, 
         COMMUNITY CARE OF NORTH CAROLINA, RALEIGH, NC

    Dr. Dobson. Thank you, Chairman Sanders and Senator Burr 
and members of the committee. It is a great pleasure to be with 
you today, and, as Senator Burr said, I'm a family physician. I 
actually started practice 30 years ago in a rural health clinic 
in a small town, and I still live there, despite the number of 
jobs--probably too many.
    Let me just say that building and supporting a strong 
primary care infrastructure must be the top priority in health 
policy today. We believe Community Care is an important model, 
and just let me say that we spent the last 15 years in North 
Carolina building a strong community-based primary care system.
    Ninety percent of our North Carolina primary care workforce 
participates in Medicaid, far better than most States. That's 
private, community health centers, and others. Why? Because we 
started paying better for Medicaid, and Community Care was 
built to provide an infrastructure to support our primary care 
doctors.
    I think the last time I was here, Senator Sanders, I said 
Community Care is a virtual community health center for all 
primary care physicians. It's built on those principles. We 
provide health informatics and care management services in the 
community to enable our primary care doctors to better 
coordinate care and really do true population management in the 
rural communities and urban communities that they serve.
    As a public-private partnership, it's an infrastructure 
that covers all 100 counties. We've achieved one of the lowest 
growth rates of Medicaid spending in the country. We've saved 
the State money by avoiding wasteful spending. In fact, over a 
4-year period, actuaries have said up to a billion dollars.
    Our model is flexible and it serves both urban and rural 
equally well. What does it do? It helps support primary care 
doctors in getting PCMH certified. It works in collaboration 
with the Office of Rural Health, Area Health Education Centers, 
our Community Health Center organizations, the Division of 
Medical Assistance and Public Health. We're the fabric for the 
primary care workforce. All our FQHCs, rural health clinics, 
residency programs, public health departments--all are members 
of Community Care.
    So why is primary care important? Well, it's delivering 
basic preventive care. It's also maximizing that 80 percent of 
care that can be provided at a low-cost setting for our 
population. And it's really coordinating the care of people 
with the most complex diseases and needs. The primary care 
workforce is where that needs to occur.
    The upheaval in healthcare over the last 2 to 3 years has 
actually made things worse, and we all are here to testify 
about the pipeline and the primary care infrastructure. From 
our experience in North Carolina, let me just offer maybe four 
basic thoughts.
    One is we really need to create an effective primary care 
pipeline in medical education. It starts with GME, looking at 
how we can get outcomes, but really focusing on training at the 
site where we know it will make a difference. We know in North 
Carolina if a med student is trained in a North Carolina 
medical school, and, more importantly, if they do their 
training in a North Carolina residency, they're likely to stay. 
The corollary is if they train in a rural area they will most 
likely stay.
    We need to support our community-based AHECs and 
particularly support our Teaching Health Centers. It's a great 
model. Our early results--we have several in North Carolina. 
They are great partners. It's three or four times more likely, 
people who train there will stay and get a job at a community 
health center.
    Physician-led medical homes and medical homes, in general, 
can help control cost and improve outcomes if supported with an 
adequate care management infrastructure and an effective 
population health infrastructure. We've got to do something 
about the 10-minute visit. You can't handle this in a 10-minute 
visit.
    The second thing is that we really need to accelerate 
payment reform supporting primary care. We've talked about it, 
but it's pretty inadequate. We need to create incentives for 
physicians to see and engage patients and handle the most 
complex and high-risk populations. We need to make sure the 
Medicaid rates stay at 100 percent of Medicare.
    We need to help States build the capacity in the rural 
areas and support independent practices. Two-thirds of our 
Medicaid population in North Carolina are served by some 900 
independent practices and FQHCs mostly in rural areas. The care 
management infrastructure we give for the primary care 
providers in North Carolina really helps them manage those 
high-cost patients efficiently.
    We also need to decrease the fragmentation that occurs by 
multiple payers doing it in multiple ways. The Federal 
Government is no exception. We need to support multi-payer 
efforts that align the efforts around the delivery system 
transformation, particularly in primary care, to allow such 
things as the multi-payer advanced primary care demo to be 
continued, because that funding allows the primary care 
workforce to really deliver effectively. So we would ask to 
support that.
    North Carolina has found that if you really support the 
primary care system and residency training in local settings, 
the return on investment is there. It has led to local 
collaboration and care improvement and ultimately improved 
quality and cost control.
    We really need policymakers to help enable our community-
based infrastructures to become strong. That includes not just 
workforce, but health informatics and care management. We think 
we have pieces that will help inform the national dialog, and 
we can achieve long-lasting and widespread reform, but it 
starts with primary care.
    Thank you very much for the opportunity to be here.
    [The prepared statement of Dr. Dobson follows:]
            Prepared Statement of L. Allen Dobson, Jr., M.D.
    Chairman Sanders, Senator Burr and members of the committee, it is 
a great honor to be with you today to discuss health policy issues that 
are critical to our future, both in terms of access to quality 
healthcare and the overall strength of our healthcare system and 
economy.
    My name is Allen Dobson. I am a family physician in North Carolina 
and president and CEO of Community Care of North Carolina (CCNC).
    In North Carolina, as in most of the country, there has been a 
whirlwind of change with new payment structures, new technologies, 
market consolidation, new regulatory requirements, and a new industry 
of healthcare ``consultants'' who tell us they have the latest 
innovation or technology that will fix it all. Despite all of this, 
building and supporting a strong primary care base remains the top 
priority in healthcare policy.
    Over the last 15 years, North Carolina has built a strong, 
community-based primary care system. Over 90 percent of North 
Carolina's primary care workforce participates in CCNC, a Medicaid 
participation rate far higher than most States. This is the result of 
North Carolina paying a somewhat higher rate for reimbursements than 
other States and the support provided to primary care doctors by CCNC. 
This includes health informatics and low-cost care management platforms 
that enable the application of population management across CCNC's 
entire statewide footprint and improve the quality of care delivered.
    This unique public-private infrastructure, which covers all 100 of 
the State's counties, has helped to give North Carolina the lowest 
Medicaid growth rate in the country (see Figures 1 and 2), making it a 
national model for quality improvement and cost control. In an 
independent actuarial study, Community Care was shown to save nearly a 
billion dollars over a 4-year period in our Medicaid program. CCNC's 
system works equally well in rural, underserved and urban areas (See 
Figure 3 for geographic distribution of primary care facilities).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Our model has improved care by building capacity at the provider 
and community level and linking providers together through a statewide 
infrastructure that links providers together. We provide support for 
practices seeking recognition as a Patient Centered Medical Home (PCMH) 
support and other needed help in collaboration with the North Carolina 
Office of Rural Health, North Carolina Area Health Education Centers 
(AHEC), North Carolina Division of Medical Assistance and others.
    We have thrived on innovation, fostering change, and establishing a 
culture of collaboration with all our partners around a common goal, 
improving the care delivered to our most vulnerable citizens.
    Upheaval in the healthcare landscape, however, has accelerated 
rapidly over the last 2-3 years and our doctors are reeling. Our 
primary care medical homes are under stress and this will have a 
significant impact on the future primary care workforce and accesses to 
quality healthcare for our citizens.
    If you are a primary care physician in North Carolina:

     You have probably just bought and implemented an 
electronic medical record and are now figuring out how to meet 
meaningful use requirements. You may be with vendors who have promised 
a Ferrari and delivered a Yugo. Many EHRs still are not capable of 
providing needed reports or communicating with other systems 
effectively.
     Despite buying into technology, doctors are inundated with 
paperwork and clerical tasks often turning physicians into data entry 
clerks. A recent national survey demonstrated doctors spend 22 percent 
of their time on paperwork; that is equivalent to 1 day a week of work.
     You may have been promised enhanced reimbursement for 
becoming an accredited Patient Centered Medical Home and may have 
invested $30,000 to $40,000 and hundreds of staff hours and have yet to 
recoup your investment. Promised payment reforms have been slow to 
come, leaving primary care doctors a volume-based payment system while 
being told they must prove their value before payment changes can be 
considered.
     Physicians now have to decide whether to join (or become) 
an Accountable Care Organization. A recent national survey of emerging 
ACOs put the price tag for startup costs at $4M to $10M. The decision 
of independent physicians to join larger ACOs may be based on money 
rather than performance.
     There is rapid consolidation of our hospital systems, 
leaving independent physicians little choice but to take on salaried 
positions with large health systems. The number of independent 
hospitals has dropped from 142 to 24. From personal communications I 
have had with the North Carolina Medical Society and North Carolina 
Hospital Association, it appears that the number of independent 
cardiology practices in North Carolina has dropped from 196 to 4 in 
just the last 2 years.
     While some notable integrated delivery systems have 
increased healthcare value for purchasers, consolidation also decreases 
competition and may actually decrease local collaboration and 
innovation as the systems becomes more competitive and proprietary.
     There has also been rapid growth in healthcare technology 
platforms that promise to activate patients, provide remote monitoring, 
and control costs. Our State legislators and North Carolina Department 
of Health and Human Services staff are inundated with information from 
vendors promoting the latest app or care management solution and 
promises of savings and return-on-investment. Without a State 
infrastructure or larger reform plan, more fragmentation will occur.
     Unfortunately, this chaos is also having an impact on 
recruiting medical students and residents into primary care. While we 
have increased the number of medical student slots in North Carolina, 
only 19 percent are choosing primary care specialties (See Figure 4).




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    I believe that policy options that strengthen primary care are the 
most important element to a s successful national healthcare reform 
effort. Primary care is essential for delivering preventive care, 
providing a significant portion of a healthcare needs in a low-cost 
setting and effectively coordinating care of patients with multiple 
chronic diseases.
    Here are three recommendations from our experience in North 
Carolina that may be helpful:

    1. Create an effective primary care pipeline. We need a continuous 
and coordinated medical education strategy with both undergraduate and 
graduate medical education policies that increase the supply off 
primary care doctors in rural areas.
    In North Carolina, as in many parts of the country, there is not 
just a doctor shortage; there is a misdistribution of primary care 
doctors (along with general surgeons and psychiatrists). While the 
focus has been on adding more medical school positions (we have added 
177 slots in the past 2 years), there is likely to be little impact on 
the other end of the pipeline unless we tie GME funding to outcomes. In 
2005, out of 408 medical students in North Carolina, only 21 percent 
went into primary care and just 2 percent went on to practice primary 
care in a rural area. (See Figure 5.)



[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    However, in-state training and community-based GME programs will 
increase the primary care physician supply:

    a. Students who both went to school in North Carolina and completed 
residency in North Carolina, were more likely to practice in North 
Carolina (69 percent vs. 42 percent)
    b. Residents who trained in community-based AHECs were more likely 
to practice in North Carolina compared with those trained in 
conventional GME settings (46 percent vs. 31 percent) and more likely 
to practice primary care (53 percent vs. 31 percent).
    c. We now have two teaching health centers based out of FQHCs in 
North Carolina and a CCNC practice site; we believe this to be an 
effective workforce strategy. Residents trained in an FQHC are 3.4 
times more likely to choose a job in a community health center.
    d. CCNC works with all North Carolina primary care residency 
programs and North Carolina AHEC
    e. CCNC-involved practice are more likely to be involved in 
education.

    We must support and build capacity in primary care in order to 
improve access in rural area as and control costs. The evidence based 
around population health is teaching us that physician-led medical 
homes, supported with care management and effective population health 
strategies and infrastructure can help control costs and improve 
outcomes.
    However, medical homes cannot function under a reimbursement model 
where physicians must see patients every 10-12 minutes. Payment 
structures that incentivize team-based care, population management, 
quality data reporting, and accountable care are a start; but we are 
finding that our independent practices are struggling to participate in 
these new models.
    One of our pediatricians said,

          ``I met with my office manager and my accountant, and we 
        figured out that it costs me $87 an hour to be involved in 
        quality work. I'm not rewarded for it. Doing quality work 
        actually costs me at this point. None of my partners are 
        particularly interested in doing it and they take home more 
        than I do. I do it because it is right and because I see it 
        coming. I also get ulcers when things are not running 
        efficiently and doing quality work has really improved our 
        ability to not let patients fall through the cracks. Some 
        things that used to keep me up at night don't anymore since we 
        have these processes in place. We are delivering better care--
        no doubt.''

    2. Payment reform is needed now and on a larger scale. It should 
focus on incentives that allow primary care doctors--especially those 
in independent practices and FQHCs--to form continuous relationships 
that engage and activate patients to change behaviors and allow 
physicians to manage at risk populations. The Direct Primary Care model 
where some or all primary care services are capitated with a flat fee 
is one example that shows promise.
    3. States need structures to support and build capacity in rural 
areas and for independent practices. In the CCNC program, two-thirds of 
our Medicaid population is cared for in approximately 900 independent 
practices. In fact, despite the consolidation of the last few years, 
over 60 percent of the Medicaid population is still cared for by 
independent physicians and FQHCs, the majority in the rural areas of 
North Carolina. Our independent practices, like FQHCs, take care of a 
complex case mix and are our higher performers in total cost of care, 
hospitalization rates and readmission rates. With the exploding costs 
of ``practice overhead,'' we need lower cost utilities for practices to 
subscribe to that will allow them to participate in value-based care.
    In North Carolina, we have built a statewide informatics 
infrastructure that supports our practices and has enabled our 
practices to identify ED super utilizers, patients who are not getting 
their medications filled, and those with chronic disease who are 
missing needed tests like hemoglobin A1Cs. Our platform also allows 
them to compare their clinical quality data with that of their peers 
and motivates local clinical management entities to improve population 
health.
    We are now working with our partners including FQHCs to knit 
together a statewide health information exchange that will allow 
practices to report quality data and identify populations that need 
more intensive care management and will allow physicians to use 
healthcare resources more efficiently.
                                summary
    In North Carolina, we have found that supporting primary care and 
residency training in local settings has led to local collaboration and 
care improvement--and ultimately improved quality and cost control. We 
look to policymakers to help enable community-based infrastructures 
such as health informatics and care management supporting primary care 
that will further improve population health outcomes. Highly functional 
integrated health systems play an important role, but there will be a 
need for State-based ``utilities'' to support rural and independent 
practices to achieve lasting and widespread reform of our healthcare 
system.
    Thank you for the opportunity to testify before this committee.

    Senator Sanders. Thank you very much, Dr. Dobson.
    Here's what we're going to do. We have a very important 
vote on the floor. That's why some members have disappeared and 
why Senator Burr and I are going to have to disappear. So we're 
going to halt this meeting for a few minutes. We will be up as 
soon as we can. We thank you for your patience.
    [Whereupon, at 11:13 a.m., the committee recessed, to 
reconvene at 11:25 a.m., the same day.]
    Senator Sanders. My apologies again. But here in the 
Senate, there's usually about six things happening 
simultaneously, and that's the way it is.
    We just heard from Dr. Dobson. Senator Burr is going to be 
returning in a minute. And now we'd like to hear from Dr. 
Nichols.
    Dr. Nichols is a Family Medicine Resident at MedStar 
Franklin Square Family Health Center in Baltimore. He 
specializes in family medicine and community health 
epidemiology, focusing on population health management for 
medically complex and disadvantaged patients.
    He has served on the American Academy of Family Physicians 
Commission on the Health of the Public and Science. Dr. Nichols 
is a graduate of the University of Texas School of Public 
Health and Baylor College of Medicine.
    Thanks so much for being with us, Dr. Nichols.

    STATEMENT OF JOSEPH NICHOLS, M.D., MPH, FAMILY MEDICINE 
    RESIDENT, MEDSTAR FRANKLIN SQUARE FAMILY HEALTH CENTER, 
                         BALTIMORE, MD

    Dr. Nichols. Good morning, Chairman Sanders, Senator 
Warren. I want to thank all the Senators present and not 
present today for putting aside lingering NCAA rivalries to sit 
down and talk about this very important issue today. I'm Joseph 
Nichols, and my path to a primary care career began at the age 
of three, when I was diagnosed with acute lymphoblastic 
leukemia, kindling a lifelong interest in medicine as a means 
to help others in need.
    Early on, I entered a pipeline that started at the South 
Texas High School for Health Professions and continued all the 
way through the Premedical Honors College--an 8-year full 
tuition and fees scholarship to the University of Texas Pan 
American and Baylor College of Medicine. So you can imagine how 
excited I was to tell my pediatric oncologist about my plan to 
follow in his footsteps as a doctor for children with cancer.
    To my surprise, this wise subspecialist physician, whose 
life's work saved my life, told me not to subspecialize like 
him, but instead to go where the need was now greatest, as he 
had done at the beginning of his career so many years ago. And 
to him, the need was now greatest for primary care physicians. 
I took his advice seriously.
    Primary care is something everyone needs and deserves, and 
yet it has a constituency of no one. Nobody raises their hand 
and says, ``I have primary care disease.'' A majority of first-
year medical students enter medical school considering careers 
in primary care, but, as Senator Sanders mentioned, about 7 
percent of U.S. medical graduates will go on to practice 
primary care.
    At my school, at Baylor, students gave a variety of reasons 
for following other career paths. But in almost every case, my 
classmates worried about their student loans. Even at the least 
expensive private medical school in the country, many medical 
students abandon plans of becoming primary care doctors because 
of student loan debt. Moreover, most medical students are 
turned off to the prospect of primary care practice early in 
their training.
    Our first intimate experience with primary care usually 
comes in our family medicine clerkships as third-year medical 
students. Most family medicine clerkships expose students to 
dysfunctional and outdated models of primary care delivery, 
often in settings where the fewest resources are available and 
yet where the sickest and poorest patients often seek care 
because they have no other place to go.
    My family medicine clerkship and later experiences with a 
Title VII-funded Care of the Underserved Track at Baylor were 
exceptions that proved the rule, and I'm happy to elaborate on 
why.
    But as medical students, we had abundant opportunities to 
interact with subspecialist physicians who were leading their 
respective fields, but we had almost no opportunities to be 
mentored by primary care physicians providing cutting edge 
care. I was drawn to underserved care because I wanted to 
discover a better way to care for these patients.
    Many of us in the safety net toil day after day trying 
desperately to rescue patients from a rapidly flowing stream of 
suffering, saving them one by one from drowning. Meanwhile, 
what our healthcare system most acutely and keenly lacks is the 
ability to work effectively upstream, addressing the forces 
like poverty, social isolation, and racism that push Americans 
into the river of disability and poor health every day.
    I looked for a family medicine program where I would spend 
most of my days trying to pull patients out of the river, but 
with regular opportunities to venture upstream. At Franklin 
Square, I met patients like Mr. Simms, a loving husband and 
father who used to support his family until he lost his job as 
a result of his diabetes. Unfortunately, with the loss of his 
job, he also lost his health insurance.
    There are other patients in our practice like Mr. Simms, 
including his own son, who already shares many chronic 
illnesses with his father. And although little Regi is 25 years 
younger than Mr. Simms, his disease progression lags behind his 
father's by only 5 years or so.
    Children are supposed to be healthy enough to care for 
their aging parents. If we do not take swift and decisive 
action to grow the primary care workforce, already strained 
safety nets may break, failing from the weight of caring for 
multiple generations of sick patients simultaneously for the 
first time in history.
    More patients surge down the river and become tangled in 
the net every day. We must recognize that my patient, his son, 
and others like them are afflicted primarily by poverty. 
Although poverty often masquerades as chronic diseases like 
diabetes, hypertension, addiction, or depression, we must not 
be distracted by this ruse. We must commit ourselves to moving 
upstream to prevent others from becoming sick, even as we tend 
to the sickness that is already upon us.
    So what then must we do? We must make the total cost of 
medical education more affordable for students committed to 
careers in primary care. Programs like the National Health 
Service Corps Scholarship Programs and loan repayment programs 
are especially critical, accountable, and effective. We must 
identify students likely to enter primary care careers early 
on, as early as high school, and support these students with a 
long-range pipeline leading to primary care practice.
    We must ensure that students receive their first exposure 
to primary care in innovative and effective training sites, 
like revamped academic primary care practices in medical 
schools or Teaching Health Centers. We must support and expand 
the Teaching Health Center program. The most vulnerable and 
most disadvantaged patients continue to fall into the river of 
disability and illness every day.
    Rather than baptizing medical students in the river, let's 
give them a boat. The Teaching Health Center is a boat with a 
motor. Other students deserve to benefit from the excellent 
sort of training opportunities that I had.
    I pray that one day, I'll live to see the day when a former 
patient will share with me her ambition to follow in my 
footsteps. I pray that I will be able to say to her that the 
problem to which I dedicated my life has mostly been fixed. I 
pray that she'll be able to devote her energies to a different 
challenge, to whatever is then the most pressing matter of her 
day.
    Thank you, and be well.
    [The prepared statement of Dr. Nichols follows:]
            Prepared Statement of Joseph Nichols, M.D., MPH
    Good morning Chairman Sanders, Ranking Member Burr, and members of 
the subcommittee. My name is Joseph Nichols, and I am a Family Medicine 
resident at the MedStar Franklin Square Family Health Center in 
Baltimore, MD.
    I'm grateful for the opportunity to share with you today the 
perspective of a young primary care physician anticipating a long 
career of service to the poor and underserved. My testimony today will 
focus on the pipeline that led me to become a primary care physician, 
my view from the front lines of primary care training, and some 
concrete actions that the subcommittee can take right now to grow the 
primary care workforce this country so desperately needs and deserves.
    I was born and raised in Harlingen, TX, a small community on our 
Nation's southernmost border with Mexico. My family's world was upended 
when, at the age of 3, I was diagnosed with acute lymphoblastic 
leukemia. While I would not wish a diagnosis of cancer on anyone, in 
retrospect it led to the best things that have ever happened to me. It 
kindled a lifelong interest in medicine as a means to help others in 
need, and it helps me to identify with the suffering of patients and 
families that I treat. I did fine with my treatment, and I went on to 
enjoy about as normal a childhood as I suspect I could, growing up in 
that unique part of the world.
    Given my lifelong interest in medicine, when the time came, I 
applied to the South Texas High School for Health Professions, a public 
magnet high school which offers students a high quality educational 
experience focused on pursuing careers in health-related fields. ``Med 
High'', as it is affectionately known, results from a novel 
partnership, since 1984, between Baylor College of Medicine and the 
South Texas Independent School District. Med High has been repeatedly 
ranked among the top 100 high schools in the Nation by Newsweek and 
U.S. News & World Report and has demonstrated consistent success in 
producing health care professionals. Three other students in my 
graduating medical school class also shared the stage with me at my 
high school commencement, including our high school salutatorian. Other 
members of my graduating high school class went on to become dentists, 
pharmacists, nurses, public health workers, physician assistants, 
doctoral level researchers, and a variety of other health and 
nonhealth-related professionals as well.
    Until the end of high school, it was my ambition to return to South 
Texas as a pediatric oncologist. I looked for every opportunity to 
follow this dream, and so I applied to the Premedical Honors College, 
what was at the time an 8-year full tuition and fees scholarship 
offered by the University of Texas Pan American and Baylor College of 
Medicine.
    A number of changes have affected the scholarship program and its 
sponsoring institutions since my time there. The Premedical Honors 
College was founded in 1994 as a Hispanic Center of Excellence, with 
Federal dollars from the Division of Disadvantaged Assistance at HRSA. 
The Premedical Honors College soon opened it its doors to students from 
all ethnic backgrounds, losing Federal funding. It was for a time 
supported by funds from both institutions and by a small group of 
generous private foundations. However these private donors eventually 
shifted focus to other worthy endeavors. Meanwhile, the endowments of 
both institutions were hit very hard in the recession. Despite funding 
challenges, both sponsoring institutions remain committed to the 
success of the Premedical Honors College, even as The University of 
Texas Pan American reorganizes itself as the University of Texas Rio 
Grande Valley, in order to better serve the educational needs of 
students from the southernmost region of south Texas, and increasingly, 
Hispanic students from across the Nation.
    When I was admitted to medical school as a high school senior, you 
can imagine how excited I was to tell the pediatric oncologist who 
inspired my career choice. When I shared with him my hope to follow in 
his footsteps as a doctor for children with cancer, he expressed great 
pride for my accomplishments. But to my surprise, he discouraged me 
from this career path. He explained that he entered the field as a 
young resident feeling that the abandonment of children with cancer and 
their families constituted the greatest injustice in medicine of his 
time. I should state that my doctor not only entered into the field 
pediatric oncology; he pioneered it. He led the team that produced the 
first cures for childhood leukemia. By the time I was treated for 
cancer, his work and the work of many others brought survival rates for 
several types of childhood cancer above 90 percent, whereas when he was 
starting his career, many of these diseases had been a death sentence. 
More work on childhood cancer remains to be done, but as his career 
began to wane, he had the satisfaction of seeing other challenges rise 
to prominence.
    This wise physician, whose life's work saved my life, encouraged me 
not to follow in his footsteps, but instead to go where the need was 
now greatest, as he had done at the beginning of his career. To him, 
the need was now greatest for primary care physicians. Moreover, he 
felt that all the compassion and dedication that had been borne into me 
as a cancer survivor would make me exceptionally well suited for this 
equally noble career path.
    I took his advice seriously. It occurred to me that primary care is 
a necessity hiding in plain sight. Primary care is something needed and 
deserved by everyone, and yet it has a constituency of no one. Nobody 
raises her hand and says, ``I have primary care disease.'' This would 
be the field where I would leave my mark.
    The quality and rigor of the advanced placement program at my 
health careers-oriented high school allowed me to complete almost an 
entire year of college coursework as a high school junior and senior. 
So I was fortunately able to finish my undergraduate degree in only 3 
years. I invested my year before starting medical school in studying 
epidemiology at the University of Texas School of Public Health, in 
Houston.
    In public health school, I learned how to think about health in 
terms of populations. I learned, paraphrasing the words of another 
physician champion of social justice, that people live not only in 
bodies, but also in families, neighborhoods, communities and 
populations. The physical and social environments have a profound 
impact not only on our health, but also on our potential for health, 
even at the genetic level. Health is largely a product of where and how 
people live, learn, work, worship, and play. Those of us working 
together in the fields of public health medicine cannot therefore 
meaningfully alter the health or health potential of a person or a 
group without partnering with people beyond the exam room and the 
hospital. And the most effective interventions are those which focus 
not on doing things to people or for people, but rather with people, 
building on their inherent strengths, and working together to build 
healthier environments and practice healthier behaviors.
    So I was excited after my year at public health school to enter 
medical school and begin learning how to go about helping people to 
achieve this thing called health. You can imagine my disappointment 
when I found that we spent almost our entire time talking about 
diseases, when clearly health is so much more than merely the absence 
of disease. Few of my other classmates seemed to notice, or to be 
bothered by this.
    We know that a majority of first year medical students enter 
medical school considering careers in primary care. Unfortunately we 
are also aware that far fewer than the majority of medical school 
graduates will go on to practice primary care. This forces us to 
consider what we're doing, or not doing, to lose students to other 
specialties that may not address the pressing workforce needs of our 
Nation. An important part of medical education is what has been termed 
the ``hidden curriculum''--the inculcation of attitudes and belief 
systems that are distinct from procedural and intellectual knowledge. 
This hidden curriculum contains some of the most noble features of our 
profession, namely compassion, altruism, honesty, and the value of hard 
work. Unfortunately, the hidden curriculum in many medical schools 
turns students away from careers in primary care, due to the 
misperceptions it perpetuates about our specialty, its practitioners 
and our patients.
    You have no doubt heard many other primary care physicians recount 
stories of attending physicians and classmates discouraging their 
choice of specialty. In all honesty, I don't recall being harassed for 
pursuing a career in primary care while at Baylor College of Medicine. 
In fact, a good number of my classmates confided in me that they wished 
they could practice primary care as well. These students gave a variety 
of reasons for following other career paths.
    Some of my classmates said that the breadth and depth of knowledge 
underlying primary care was too vast and difficult to master. Other 
students said they lacked or could not develop the social skills 
necessary to manage long-term relationships with patients in the 
context of these patients' families and communities. But in almost 
every case, my classmates who opted toward subspecialty training and 
away from primary care did so in part because they worried they could 
not afford to repay their student loans as a primary care physician.
    I'm certain that this point has been made to the subcommittee 
before. But to show how extraordinary this part of my story is, allow 
me to tell it another way. Even at the least expensive private medical 
school in the country, many medical students abandon plans of becoming 
primary care doctors because of student loan debt.
    So I applied myself in my clinical years, training in the full 
variety of different types of hospitals available to BCM students, 
including a large inner-city public hospital, a freestanding children's 
hospital, a Catholic hospital, a well-endowed private hospital, and the 
largest Veterans Administration hospital facility. I received excellent 
preparation for providing high-quality primary care to socially 
disadvantaged and medically complex patients at Baylor College of 
Medicine. However I also understand why medical schools struggle in 
producing primary care physicians, especially for the poorest and 
sickest patients where primary care doctors are most desperately needed 
now.
    Most students completing a family medicine clerkship are exposed to 
dysfunctional and antiquated models of primary care delivery, often in 
settings where the fewest resources are available, and yet where the 
sickest patients by necessity seek care. Medical students keenly sense 
the frustration and helplessness, often thinly veiled, of providers 
trapped in inefficient and inadequate systems.
    My family medicine clerkship was an exception that proved the rule. 
Through some advanced planning and extra effort, I arranged to spend my 
month-long family medicine clerkship 2 hours east of Houston, training 
in a 100-year-old rural practice, run by a third-generation primary 
care physician who was an immediate past president of the Texas Academy 
of Family Physicians. This practice cared mostly for sick and elderly 
rural patients who had no other reliable source of primary care 
available in the rural Texas Hill Country, and they did so by building 
a practice perfectly suited to the needs of their patients. Doctors 
there anticipated the need for an electronic medical record in the mid-
1990s, and they were already using their EMR to its full capabilities a 
full 10 years ahead of our more recently determined meaningful use 
deadlines. These physicians served various key roles in the community, 
including school board member, trustee of the local bank, director on 
the board of the local critical access hospital, high school sports 
team physician, radio talk show host, and local county health officer. 
Almost all the characteristics of the patient-centered medical home 
that so many practices are struggling to embrace, even today, were 
already present in this practice, simply because this seemed like the 
right way to do things, and because the doctors working there had the 
capability and commitment to make things better, from one day to the 
next.
    My experiences with an innovative, rural Texas family medicine 
practice stood in stark contrast to those of my colleagues who stayed 
in Houston, placed in dysfunctional urban family medicine clinics, 
where patients were more often than not swept downriver further and 
further each day, despite the most heroic efforts of the providers. 
Even though as medical students we trained in nearly every kind of 
hospital commonly encountered in the healthcare landscape of the United 
States, our outpatient primary care experiences were, by comparison, an 
afterthought. We had every opportunity to interact with many 
subspecialist physicians who were leading their respective fields, but 
we had almost no opportunities to be mentored by primary care 
physicians providing cutting edge care. It was possible for only a 
small motivated minority of students, like myself, to experience the 
sort of advanced model of primary care practice in training that is 
vital for meeting our country's needs.
    Many of us in the so-called safety net toil day after day, trying 
desperately to rescue patients from a rapidly flowing stream of 
suffering, saving them one by one from drowning. Meanwhile, what our 
health care system most keenly lacks is the ability to work effectively 
upstream, addressing the forces like poverty, social isolation, and 
racism that push Americans into the river of disability and poor health 
every day.
    Somehow I survived medical school. I must take a moment to thank 
the then-Dean of Students at BCM. He is a kind and wonderful man who 
was and is incredibly supportive of his students, and of me in 
particular. He went out of his way to encourage each student selecting 
a career in primary care, confiding in us that he (a Harvard educated 
surgeon who had graduated with honors from medical school at Baylor) 
did not feel personally capable of undertaking a career path as 
challenging as primary care. ``You are the real doctors,'' he told me, 
summarizing his admiration for primary care. As wonderful as it was to 
hear the Dean of Students affirm my career choice, it saddens me that 
he shared this message with me privately, and at the end of my third 
year of medical school, after all of my classmates had selected our 
medical specialties, rather than at the very beginning of our training 
and over the course of our difficult first few years.
    I decided to pursue my family medicine training in a residency 
program where I would spend most of my days trying to pull patients out 
of the river, but with regular opportunities to venture upstream. At 
the MedStar Franklin Square Family Health Center, we take primary care 
to our patients. We follow some patients in the nursing home. We 
sometimes go on house calls for patients that cannot make it into the 
office to see us, often bringing along reinforcements from our 
multidisciplinary care management team, including a nurse care 
coordinator, medical and clinical social workers and a pharmacist, 
along with medical and pharmacy students from a variety of schools, 
including Johns Hopkins School of Medicine. In between, my journeys 
upstream have taken me to our local county health department, the 
Maryland State health department, the governing body of the American 
Academy of Family Physicians, the Robert Graham Center, and the U.S. 
Capitol, on more than this one occasion.
    I met patients like Mr. Simms, whose story I'm sharing with you 
today with his permission. Mr. Simms is a loving husband and father, 
who used to support his family working 12 hour shifts 5 or more days a 
week as the manager of a chain restaurant serving 24-hour breakfast. An 
unfortunate combination of eating too much of his restaurant's food, 
not getting enough exercise outside of working such long hours, and a 
genetic predisposition resulted in Mr. Simms developing diabetes in the 
prime of his working years. His disease was advanced by the time it was 
diagnosed, and he needed insulin therapy from the beginning. His long 
and irregular schedule, and the lack of a refrigerator at work where he 
could safely store his insulin, prevented him from giving himself the 
medications he needed to manage his disease.
    He soon lost his job after he developed a serious infection of one 
of his feet, requiring amputation of several toes. This would be the 
first of many surgeries and complications to befall Mr. Simms as a 
result of his diabetes. Unfortunately, with the loss of his job, he 
also lost his health insurance. I met Mr. Simms almost 20 years after 
his diagnosis. He was uninsured and had nearly been bankrupted by his 
medical bills. And like many Americans, he was nearly underwater on his 
mortgage. His wife continued working, and she made just enough money to 
prevent him from being eligible for many of the more common forms of 
public assistance. Mr. Simms worked out a deal with the bank that 
enabled him to keep his house; however he was required to maintain very 
strict limits on his debt, which any further medical bills would upset, 
resulting in the loss of his home.
    Caring for Mr. Simms, and patients like him, I became adept at 
considering the myriad social and economic forces that affect health in 
America. On some rare occasions, I can even use these forces to my 
advantage. For instance, the great majority of medications that I use 
routinely are found on the $4 list of medications available from big-
box store pharmacies. These medicines are tried-and-true, and I take 
two of them myself every morning. It is tempting to believe that this 
is an affordable way of providing patients with good quality medical 
care. Four dollars for a 30-day supply of medicine suddenly becomes 
expensive for patients living on a fixed income who need to fill six or 
more of these prescriptions every month. Meanwhile many essential 
medications remain absent from these lists.
    My patient, Mr. Simms, is a personal hero of mine. Despite multiple 
partial amputations of both feet, prolonged hospitalizations and 
nursing home stays, and the recent loss of an eye to a complication of 
diabetes, he remains cheerful, and he continues to teach our residents 
and our care coordination staff about the needs of patients like him. 
There are already other patients in our practice like Mr. Simms, 
including his own son. Little Regi, as everyone knows him, already 
shares many chronic illnesses with his father. Although Little Regi is 
25 years younger than Mr. Simms, his disease progression lags behind 
his father's by only 5 years or so. The moral of this story: If we do 
not take swift and decisive action to grow the primary care workforce 
and to empower it with the tools it needs to address the upstream 
causes of chronic disease, already strained safety nets may break, 
failing from the weight caring for multiple generations of medically 
complex patients simultaneously, for the first time in history.
    More patients surge down the river and become tangled in the net 
every day. We must recognize that my patient, his son, and others like 
them are afflicted primarily by poverty. Although poverty often 
masquerades as a chronic disease like diabetes, hypertension, 
addiction, or depression, we must not be distracted by this ruse. We 
must commit ourselves to moving upstream to prevent others from 
becoming sick, even as we tend to the sickness that is already upon us.
    So what then must we do?
    First we must shorten the path to medical training. BCM and other 
medical schools have previously successfully experimented with a 3-year 
medical school curriculum, during a time in the past when a shortage of 
physicians was feared. We have the opportunity to refocus medical 
education not on learning everything that one needs to know, but rather 
on learning how to learn. Recognizing that medical school is simply a 
stepping stone into a lifelong process of learning, empower each 
graduate with the tools that she will need to tailor a lifetime of 
learning and practice to meet the needs of her patients.
    Next we must make the total cost of medical education more 
affordable for students committed to careers in primary care. In doing 
so, we must consider the total cost of training, from undergraduate 
education through the duration of residency. Programs like the National 
Health Service Corps Scholarship Programs and Loan Repayment Programs 
are especially critical, linking students and residents to training in 
primary care specifically for the disadvantaged and underserved.
    Next we must identify students likely to enter careers in primary 
care early on, as early as high school, and support these students with 
a long range pipeline approach leading to medical school admission and 
to eventual primary care careers. Invest in novel and effective 
educational programs, such as health professions magnet high schools, 
as key sections of this pipeline. Patch the pipeline along every 
section with extra support and advisement for students from 
disadvantaged backgrounds, helping the students that will be most 
likely to practice and be effective at delivering primary care to 
disadvantaged patients in the future. This investment will pay great 
returns in the future. In the meantime, we need to increase primary 
care production now, so the early experiences of students entering 
medical school in the next few years present a critical opportunity to 
retain trainees in the primary care pipeline.
    Encourage the development and expansion of advanced primary care 
training sites in academic medical centers through grants for research 
and training, especially targeted at the academic primary care 
practices where most students receive their first exposure to primary 
care. Create the same opportunity for medical students early in their 
training to emulate primary care innovators as they have to be 
impressed by subspecialists. While we must continue to advance all 
fields of medicine, in the near future we should focus funding for 
research and training especially on primary care, which has urgent 
catching up to do.
    Support and expand the Teaching Health Center program as a better 
approach to caring for and training with the medically underserved. The 
most vulnerable and most disadvantaged patients continue to fall in the 
river of illness and disability every day. Rather than baptizing 
students in the river, let's give them a boat. The Teaching Health 
Center is a boat with a motor. The students and residents that train in 
Teaching Health Centers will receive the specialized training they need 
to become the primary care physicians that must, in the coming years, 
right the inequities that underlie the majority of the excess 
healthcare costs that we as a nation collectively bear. And while we 
set about growing the primary care workforce we need and deserve, our 
sickest patients will benefit from improved medical care in the mean 
time.
    I want to conclude by saying that my education does not belong to 
me; I did not purchase it or win it. It's rather something with which I 
have been entrusted. Like all medical students, my education was 
heavily subsidized by Federal and State funds, in addition to the 
numerous scholarships which I also received from public and private 
sources. I feel a profound responsibility to use my education and 
skills in service to society, and to pass these skills and knowledge on 
to the next generation of physicians, who will care for myself, my 
family and my neighbors in the future. I want nothing more or less than 
to belong to my community, to dedicate my labors to its health and 
well-being, and for us to care for one another.
    Even though my story may seem exceptional, I am not. While it 
requires a lot of hard work to get where I am today, I also had a 
tremendous amount of help from a great number of people and programs. 
I'm a living example of a well-researched finding that individuals 
coming from socially or educationally disadvantaged backgrounds are 
more likely to pursue careers in primary care. I'm also confident that 
without the ongoing support of a number of unique programs stretching 
back to high school, I would not have been able to achieve admission to 
medical school, and I would not have been able to pursue this goal. 
Other students deserve to benefit from the excellent sort of training 
opportunities that I had, and these sorts of programs show great 
promise for growing the primary care workforce our country needs and 
deserves.
    And I pray I live to see the day when one of my former patients 
will share with me her ambition to follow in my footsteps, helping 
others as I once helped her. I pray that I may have the satisfaction of 
saying that the problem to which I have dedicated my life has been 
vastly improved. I pray that she will devote her energies to a 
different challenge, what is then the most pressing matter of her day.
    Thank you, and be well.

    Senator Sanders. Thank you, Dr. Nichols.
    Senator Burr.
    Senator Burr. Mr. Chairman, I have the pleasure today to 
introduce Dr. Linda Kohn, Director of GAO's office that has the 
healthcare team where she works on issues related to public 
health, health information, technology, and quality management. 
I want to thank her today for the work that that group has done 
to help us navigate where we should go based upon the 
assessments that they've made.
    And, Linda, GAO does incredible work, work that is 
invaluable to the Congress and, I think, to the American 
people. Would you please convey to your colleagues there how 
grateful we are--especially your team, and to the rest--how 
grateful we are for the work that they do. In many cases, you 
bring reports out that enlighten us on things we didn't know, 
are not always what everybody wants to hear, but are the facts 
that are best used to foundationally fix what's broken. Thank 
you.

  STATEMENT OF LINDA T. KOHN, Ph.D., DIRECTOR OF HEALTH CARE, 
        GOVERNMENT ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Ms. Kohn. Thank you very much for that kind introduction. 
Chairman Sanders, Ranking Member Burr, members of the 
committee, I'm pleased to be here today to discuss our work on 
Federal investments in health workforce training and the 
availability of data related to the supply of and demand for 
healthcare professionals.
    Last fall, we issued a report that identified Federal 
programs that support postsecondary education for direct 
healthcare professionals in fiscal year 2012. Shortly after 
that, we issued another report that examined HRSA's actions to 
project the future supply of healthcare professionals, 
including physicians, physician assistants, and advanced 
practice nurses.
    My statement today is based on those two reports. Together, 
they provide a snapshot of the Federal efforts in ensuring that 
a well-trained and diverse healthcare workforce is available to 
provide care in this Nation.
    Our first report that identified Federal training programs 
is fairly limited in scope. It represents a first cut at trying 
to compile as comprehensive a list as possible for the Federal 
programs that provide support for training of healthcare 
professionals. So we tried to identify the programs, and for 
each one identified, the number of trainees in the program and 
the Federal obligations for 2012.
    As noted before, we found that four departments, HHS, VA, 
DOD, and Education, supported 91 training programs for direct 
healthcare professionals and obligated a total of about $14 
billion in 2012. The largest amount of money went for 
postgraduate residency training for physicians, dentists, and 
others, commonly known as Graduate Med Ed or GME. We identified 
seven programs that totaled about $11 billion or 78 percent of 
the $14 billion total. That was through HHS, mainly Medicare 
and Medicaid, but VA and DOD also supported GME programs.
    So if $14 billion was spent in total, and $11 billion of 
that went to GME, that leaves about $3 billion or 22 percent of 
the pie for all the other 84 programs that we identified. Some 
of those programs provide financial assistance, such as 
scholarships or loans. Others, as we heard, provide financial 
assistance in exchange for a commitment to work in a specific 
facility or location.
    Some of the programs supported primary care, but not all of 
them. Overall, HRSA administered the most programs. But the 
most money went through CMS for GME.
    We identified several challenges in compiling comprehensive 
information about the scope of the programs, and, partially, 
it's because these programs do cross multiple departments and 
multiple agencies within a department. So getting comparable 
information was not always possible for us. For example, we 
identified programs at HHS, VA, and DOD where the number of 
trainees was not available, or maybe we could only get the 
information at an aggregate level. We couldn't break it down at 
a program level.
    The Department of Education has several programs that 
support postsecondary training for various types of students, 
including health professionals. But those programs aren't 
specifically targeted for health professionals. So we weren't 
able to break it down in terms of how many health professionals 
were also included in those programs, even though we know those 
programs are there.
    Our second report focused on HRSA efforts to produce 
workforce projections. HRSA is the agency responsible for 
monitoring the supply and demand for healthcare professionals. 
And we reported in September 2013 that HRSA last published its 
workforce projections in 2008, based on data from 2000.
    Since 2008, HRSA awarded five contracts for studies to 
support updated projections, but had not published any of those 
projections at the time of our work, although four were 
planned. After we issued our report last fall, HRSA published 
the projections for the primary care workforce to 2020.
    We recognize the challenges in producing workforce 
projections, but there is a long lead time for any policy 
changes, such as altering the number or mix of training to 
affect the supply of healthcare professionals. And HRSA has 
also acknowledged the long lead time for any interventions that 
might be possible.
    But together, these two reports aimed to shed some light on 
what might be considered fairly basic information: What is the 
Federal investment in workforce training programs for direct 
healthcare professionals? How many programs are there? How much 
money is being expended? What is known about how many health 
professionals we need? We hope this underlying information 
contributes to your discussions.
    That concludes my prepared remarks, and I'm happy to 
respond to any questions. Thank you.
    [The prepared statement of Ms. Kohn follows:]
               Prepared Statement of Linda T. Kohn, Ph.D.
    HEALTH CARE WORKFORCE--Federal Investments in Training and the 
             Availability of Data for Workforce Projections
                                Summary
                         why gao did this study
    A well-trained and diverse health care workforce is essential for 
providing Americans with access to quality health care services, 
including primary care services. To help ensure a sufficient supply of 
physicians, nurses, dentists, and other direct care health 
professionals for the Nation, the Federal Government has made 
significant investments in health care workforce training through 
various efforts. As Congress considers funding existing or additional 
training programs that would address any potential shortages of health 
care professionals, timely and up-to-date estimates of future supply 
and demand for health care professionals are critical.
    This statement addresses (1) the scope of the Federal Government's 
role in health care workforce training and (2) the availability of data 
related to projecting health care workforce supply and demand. It is 
based on findings from two recent GAO reports. The first report 
identified Federal programs that supported postsecondary training and 
education for direct care health care professionals in fiscal year 
2012, including information about program purpose, funding, and 
targeted health professionals. The second report examined actions HRSA 
has taken to project the future supply of and demand for physicians, 
physician assistants, and advanced practice registered nurses (APRN) 
since publishing its 2008 physician workforce report. These products 
used a variety of methodologies, which are detailed in each report.
                             what gao found
    GAO found that there is substantial Federal funding for health care 
workforce training programs but that obtaining comprehensive 
information about the scope of such programs is challenging. In GAO's 
August 2013 report on the Federal role in health care workforce 
training, GAO found that four Federal departments--the Department of 
Health and Human Services (HHS), the Department of Veterans Affairs 
(VA), the Department of Defense (DOD), and the Department of Education 
(Education)--administered 91 programs that supported postsecondary 
training or education specifically for direct care health professionals 
in fiscal year 2012. All together, the four departments reported 
obligating about $14.2 billion for health care workforce training 
programs in fiscal year 2012, with HHS funding the most programs (69) 
and having the largest percentage of total reported funding (82 
percent). The majority of funding for health care workforce training in 
fiscal year 2012--about $11.1 billion, or 78 percent--was invested in 
seven programs that supported postgraduate residency training for 
physicians, dentists, and certain other health professionals, called 
Graduate Medical Education. The remaining 84 programs administered by 
HHS, VA, DOD, and Education accounted for obligations of about $3.2 
billion and provided varying levels of assistance, ranging from 
participation in short-term continuing education courses to full 
support for tuition and books and a stipend for living expenses. 
Compiling comprehensive information about the scope of Federal support 
for health care workforce training is challenging because multiple 
Federal departments administer such programs, and GAO found that the 
departments did not always have comparable program information.
    Lack of timely, regularly updated data creates challenges for 
projecting health care workforce supply and demand. The Health 
Resources and Services Administration (HRSA)--an agency within HHS--is 
responsible for monitoring the supply of and demand for health care 
professionals. At the time of its September 2013 report, GAO found 
that, since publishing a 2008 report on physician supply and demand, 
HRSA had awarded five contracts to research organizations to update 
national health care workforce projections. However, HRSA had failed to 
publish any new workforce projections. While HRSA created a timeline in 
2012 for publishing a series of new workforce projection reports, the 
agency missed its original goals for publishing them and had to revise 
its publication timeline. HRSA's report on the primary care workforce 
was published in November 2013, more than 3 years after the contractor 
originally delivered its report to HRSA for review.
                                 ______
                                 
    Chairman Sanders, Ranking Member Burr, and members of the 
subcommittee: I am pleased to be here today to discuss our work on 
Federal investments in health care workforce training and the 
availability of data related to projections of supply and demand for 
health care professionals. A well-trained and diverse health care 
workforce is essential for providing Americans with access to quality 
health care services, including primary care services. A number of 
reports published by government, academic, and health professional 
organizations have projected national shortages of some types of health 
care professionals, which could result in patients experiencing delays 
in receiving, or a lack of access to, needed care. To help ensure a 
sufficient supply of physicians, nurses, dentists, and other direct 
care health professionals for the Nation, the Federal Government has 
made significant investments in health care workforce training through 
various efforts.\1\ These efforts include Federal programs that train 
health professionals directly, award grants or make payments to 
institutions training health professionals, and provide financial 
assistance to health professional students through stipends, 
scholarships, loans, or loan reimbursement. In addition, as Congress 
considers policy options to address health care workforce issues--such 
as funding training programs that would address any potential shortages 
of health care professionals--timely and up-to-date estimates of future 
supply and demand for health care professionals are critical. The 
Health Resources and Services Administration (HRSA)--an agency within 
the Department of Health and Human Services (HHS)--is responsible for 
monitoring the supply of and demand for health care professionals.
---------------------------------------------------------------------------
    \1\ For the purposes of this statement, direct care health 
professionals are those who deliver clinical or rehabilitative care to 
patients, such as allopathic and osteopathic physicians, nurses, 
dentists, pharmacists, physician assistants, podiatrists, 
psychologists, and physical or occupational therapists.
---------------------------------------------------------------------------
    This statement addresses (1) the scope of the Federal Government's 
role in health care workforce training and (2) the availability of data 
related to projected health care workforce supply and demand. It is 
based on findings from two recent GAO reports. The first report, Health 
Care Workforce: Federally Funded Training Programs in Fiscal Year 2012, 
identified Federal programs that supported postsecondary training and 
education for direct care health care professionals in fiscal year 
2012, including information about program purpose, funding, and 
targeted health professionals.\2\ The second report, Health Care 
Workforce: HRSA Action Needed to Publish Timely National Supply and 
Demand Projections, examined actions HRA has taken to project the 
future supply of and demand for physicians, physician assistants, and 
advanced practice registered nurses (APRN) since publishing its 2008 
physician workforce report.\3\
---------------------------------------------------------------------------
    \2\ GAO, Health Care Workforce: Federally Funded Training Programs 
in Fiscal Year 2012, GAO-13-709R (Washington, DC.: Aug. 15, 2013).
    \3\ GAO, Health Care Workforce: HRSA Action Needed to Publish 
Timely National Supply and Demand Projections, GAO-13-806 (Washington, 
DC.: Sept. 30, 2013).
---------------------------------------------------------------------------
    Each of the reports cited in this statement provides detailed 
information on our scope and methodology. This statement is based on 
work that was conducted from March 2013 through September 2013 in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.
                               background
    The U.S. health care workforce includes a spectrum of health 
professionals requiring varying levels of postsecondary education and 
training, ranging from diploma programs to graduate degrees and 
postgraduate training.\4\ Some professionals who deliver direct health 
care services to patients require clinical training through a health 
care institution--such as internships, residencies, or fellowships--in 
addition to completing graduate-level educational requirements before 
being eligible for full licensure. These professionals include 
physicians, certain pharmacists, podiatrists, clinical psychologists, 
and dentists seeking a dental specialty.
---------------------------------------------------------------------------
    \4\ Postsecondary education is education or training beyond the 
high school level.
---------------------------------------------------------------------------
    To maintain an adequate health care workforce, the future supply of 
health care professionals must be projected and compared to the 
expected demand for health care services to determine whether there 
will be enough providers to meet the demand. Such projections can 
provide advance warning of shortages or surpluses so that health care 
workforce policies, such as funding for health care training programs, 
can be adjusted accordingly. In its 2008 physician workforce report, 
HRSA noted that due to the long time needed to train physicians and to 
make changes to the medical education infrastructure, policymakers and 
others need to have information on the adequacy of the physician 
workforce at least 10 years in advance.\5\ We have also previously 
reported that producing supply and demand projections on a regular 
basis is important so that estimates can be updated as circumstances 
change.\6\
---------------------------------------------------------------------------
    \5\ Health Resources and Services Administration, The Physician 
Workforce: Projections and Research into Current Issues Affecting 
Supply and Demand (Rockville, Md.: 2008).
    \6\ GAO, Health Professions Education Programs: Action Still Needed 
to Measure Impact, GAO-06-55 (Washington, DC.: Feb. 28, 2006).
---------------------------------------------------------------------------
substantial federal funding for health care workforce training programs 
exists, but obtaining comprehensive information about the scope of such 
                        programs is challenging
    In our August 2013 report, we found that four Federal departments--
HHS, the Department of Veterans Affairs (VA), the Department of Defense 
(DOD), and the Department of Education (Education)--administered 91 
programs that supported postsecondary training or education 
specifically for direct care health professionals in fiscal year 2012. 
All together, the four departments reported obligating about $14.2 
billion for health care workforce training programs in fiscal year 
2012, with HHS funding the most programs (69) and having the largest 
percentage of total reported funding (82 percent).\7\ See table 1 for 
additional details about the number of health care workforce training 
programs administered by HHS, VA, DOD, and Education and the funds the 
departments reported obligating for them in fiscal year 2012.
---------------------------------------------------------------------------
    \7\ GAO asked department and agency officials to provide 
obligations, including those for which expenditures have been made, for 
each program in fiscal year 2012. The term obligation refers to a 
definite commitment by a Federal agency that creates a legal liability 
to make payments immediately or in the future. Agencies incur 
obligations, for example, when they award grants or contracts to 
private entities. An expenditure is the actual spending of money by the 
issuance of checks, disbursement of cash, or electronic transfer of 
funds made to liquidate a Federal obligation. The total reported 
obligations do not include amounts obligated in prior years that were 
expended in fiscal year 2012.

 Table 1.--Health Care Workforce Training Programs Administered by Four
  Federal Departments and Funds Obligated for These Programs in Fiscal
                                Year 2012
------------------------------------------------------------------------
                                  No. of health care
           Department             workforce training      Obligations
                                    programs funded
------------------------------------------------------------------------
Department of Health and Human                   69   $11.7 billion
 Services.
Department of Veterans Affairs..                 12   $1.7 billion
Department of Defense...........                 7*   $0.9 billion
Department of Education.........                  3   $2 million
------------------------------------------------------------------------
Source: GAO summary of Department of Defense (DOD), Department of
  Education (Education), Department of Health and Human Services (HHS),
  and Department of Veterans Affairs (VA) information.
Note: DOD, Education, HHS, and VA obligated a total of about $14.2
  billion for health care workforce training programs in fiscal year
  2012. Amounts listed in this table do not add to $14.2 billion because
  of rounding.
* One of DOD's seven programs represents multiple clinical and
  instructional health professions education programs. For the purposes
  of this statement, we characterized them as a single program because
  DOD could not provide consistent program-level information.

    In total, across all four departments, the majority (78 percent) of 
Federal funding for health care workforce training in fiscal year 
2012--about $11.1 billion--went to seven programs that supported 
postgraduate residency training for physicians, dentists, and certain 
other health professionals, called Graduate Medical Education (GME) 
(see fig. 1). Two programs administered by HHS's Centers for Medicare & 
Medicaid Services (CMS)--Medicare payments to teaching hospitals and 
other entities for Direct Graduate Medical Education (DGME) and 
Medicare payments to teaching hospitals for Indirect Medical Education 
(IME)--accounted for about 66 percent of total reported health care 
workforce training funding.\8\ CMS's Medicaid program also made 
payments to teaching hospitals for GME, and HRSA, another agency within 
HHS, administered two programs that supported GME in settings other 
than teaching hospitals.\9\ VA and DOD also administered GME programs; 
however, the funding information VA provided to us accounted for 
resident salaries and benefits, while the funding information provided 
by DOD accounted for only certain administrative costs to operate its 
GME program.
---------------------------------------------------------------------------
    \8\ For the purposes of this statement, we considered Medicare DGME 
payments and Medicare IME payments to be separate programs. Medicare 
DGME payments cover the teaching costs of training residents, such as 
resident stipends, administrative overhead, and supervisory physician 
salaries. Medicare IME payments support the higher patient care costs 
associated with training residents, such as the ordering of more tests 
and increased use of emerging technologies.
    \9\ Medicaid payments for GME and the two HRSA programs--the 
Children's Hospitals GME Payment program and the Teaching Health Center 
GME Payment program--provided funding for both direct costs of resident 
training, such as resident salaries and benefits, and indirect funding 
to reflect the higher patient care costs associated with resident 
education.



[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    The remaining Federal funding for health care workforce training--
about $3.2 billion--went toward 84 HHS, VA, DOD, and Education programs 
---------------------------------------------------------------------------
that:

     provided financial assistance to direct care health 
professional students and professionals,
     provided or supported instruction or clinical training for 
direct care health professionals, or
     provided a combination of these and other training support 
services.

    Across all 84 non-GME programs, trainees received differing levels 
of assistance, ranging from participation in short-term continuing 
education courses to full support for tuition and books and a stipend 
for living expenses. These 84 programs targeted various types of health 
professionals and eligible individuals. See table 2 for additional 
information about the number of non-GME training programs targeting 
various categories of health care professionals.

    Table 2.--Number of Non-Graduate Medical Education (GME) Training
  Programs That Target Certain Categories of Health Care Professionals
------------------------------------------------------------------------
                                                                 No. of
        Category of health care professionals targeted          training
                                                                programs
------------------------------------------------------------------------
Students, professionals, or faculty in multiple health                47
 professions\1\...............................................
Nurses only...................................................        18
Physicians or physician assistants only.......................         8
Dentists or dental hygienists only............................         6
Behavioral health professionals only..........................         4
Physicians and dentists only..................................         1
                                                               ---------
  Total.......................................................        84
------------------------------------------------------------------------
Source: GAO summary of Department of Defense, Department of Education,
  Department of Health and Human Services, and Department of Veterans
  Affairs information.
Note: We included both programs that solely targeted direct care health
  professionals and programs that targeted direct care health
  professionals among other professionals if the program purpose or
  objectives specifically identified direct care health professionals.
\1\ These programs targeted three or more types of health professionals.

    Compiling comprehensive information about the scope of Federal 
support for health care workforce training is challenging because 
multiple Federal departments administer such programs, and we found 
that the departments did not always have comparable program 
information. For example, at the time of our review, we relied on a 
multitude of sources to identify training programs and program 
information in the absence of a comprehensive listing of such programs. 
In some cases, the level of detail in the information we obtained from 
the four departments varied or data were not available. For example, 
HHS and VA were not able to account for the number of health 
professional trainees supported by certain programs they administer. In 
another example, DOD was unable to provide information about funds 
obligated or the number of trainees supported by each of its multiple 
non-GME clinical training and education programs for military medical 
personnel. Therefore, we reported the number of trainees supported and 
amount of funds obligated at an aggregate level for these DOD programs. 
The funding information reported by DOD also did not include amounts 
for salary and benefits of residents in its GME programs, whereas other 
departments included these amounts in their reported GME funding.
    The scope of our August 2013 review of Federal programs that 
supported postsecondary training and education for direct care health 
care professionals had some limitations. For example, we limited our 
review to programs that specifically targeted postsecondary training 
and education for direct care health care professionals in fiscal year 
2012. There could be additional programs or funding that supported 
health care workforce training that did not specifically target direct 
care health professionals. For instance, in fiscal year 2012, Education 
administered programs--such as the Subsidized and Unsubsidized Stafford 
Loan Programs, the Direct PLUS and Perkins Loan Programs, Pell grants, 
and Federal Work Study--that support postsecondary training or 
education for various types of students, including direct care health 
professionals. However, these programs do not specifically target 
health professionals, and we could not determine the number of direct 
care health professionals supported by these programs or the total 
amount of funds from these programs that supported such training. 
Additionally, there may be other programs that support health care 
workforce training but that did not obligate funds in fiscal year 2012.
     lack of timely, regularly updated data creates challenges for 
           projecting health care workforce supply and demand
    In addition to administering 50 health care workforce training 
programs, HRSA is responsible for monitoring the supply of and demand 
for health care professionals and disseminating workforce data and 
analyses to inform policymakers and the public about workforce needs 
and priorities. The Bureau of Health Professions (BHPr) within HRSA has 
multiple responsibilities related to workforce development, including 
conducting and contracting for studies on the supply of and demand for 
health care professionals. In 2006, we found that HRSA had published 
few national workforce projections despite the importance of such 
assessments to setting health care workforce policy, and we recommended 
that HRSA develop a strategy and establish timeframes to more regularly 
update and publish national workforce projections for the health 
professions.\10\
---------------------------------------------------------------------------
    \10\ GAO-06-55.
---------------------------------------------------------------------------
    At the time of our September 2013 report, we found that HRSA had 
awarded five contracts since 2008 to research organizations to update 
national workforce projections but that HRSA had failed to publish any 
new reports containing projections since those contracts had been 
awarded. While HRSA created a timeline in 2012 for publishing a series 
of new workforce projection reports, the agency missed its original 
goals for publishing these reports and had to revise its timeline for 
publishing them. (See table 3)

  Table 3.--Health Resources and Services Administration's (HRSA) Original and Revised Timelines for Publishing
                      Updated Workforce Supply and Demand Projections, as of September 2013
----------------------------------------------------------------------------------------------------------------
                                                                   Original goal for         Revised goal for
                Report                       Description              publication              publication
----------------------------------------------------------------------------------------------------------------
Primary care.........................  Projects supply of and   No goal date...........  Fall 2013
                                        demand for the primary
                                        care workforce to
                                        2020..
Clinician specialty..................  Projects supply of and   December 2012..........  Summer 2014
                                        demand for physicians,
                                        physician assistants,
                                        and certain advanced
                                        practice registered
                                        nurses\1\ (APRN) to
                                        2025..
Nursing workforce....................  Projects supply of and   September 2013.........  Fall 2014
                                        demand for nurses,
                                        including APRNs, to
                                        2030..
Cross-occupations....................  Projects supply of and   2013...................  2014
                                        demand for more than
                                        20 health professions
                                        to 2030..
----------------------------------------------------------------------------------------------------------------
Source: GAO review of HRSA information.
\1\ Includes nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives.
  Clinical nurse specialists are not included.

    At the time of our September 2013 report, the most recent 
projections from HRSA available to Congress and others to inform health 
care workforce policy decisions--such as distributing physician 
training slots to medical specialties that were projected to experience 
shortages--were from the agency's 2008 report. That report was based on 
data that were, at that time, more than a decade old.
    As of July 2013, HRSA had received some of the contracted reports 
for its review, and others were under development. The first report, 
which included projections for the primary care workforce to 2020, was 
delivered to HRSA in July 2010, but HRSA was still reviewing and 
revising the draft when we released our study in September 2013. We 
recommended that HRSA expedite the review of that report, and the 
agency published its projection in November 2013.\11\
---------------------------------------------------------------------------
    \11\ Health Resources and Services Administration, Projecting the 
Supply and Demand for Primary Care Practitioners through 2020 
(Rockville, Md.: 2013).
---------------------------------------------------------------------------
    Chairman Sanders, Ranking Member Burr, and members of the 
subcommittee, this completes my prepared statement. I would be pleased 
to respond to any questions that you may have.

    Senator Sanders. Dr. Kohn, thank you very much.
    Our next panelist is Dr. Deb Edberg, program director at 
the McGaw Northwestern Family Medicine Residency Program at the 
Erie Family Health Center in Chicago. She is also an Associate 
Professor of Clinical Family and Community Medicine at the 
Northwestern University Feinberg School of Medicine.
    Throughout her career, Dr. Edberg has worked at community 
health centers in the Cook County Health System. She received 
her medical degree from Jefferson Medical College and completed 
her residency training in family medicine at the University of 
Connecticut.
    Thank you very much, Dr. Edberg, for being here.

  STATEMENT OF DEBORAH EDBERG, M.D., PROGRAM DIRECTOR, McGAW 
  NORTHWESTERN FAMILY MEDICINE RESIDENCY PROGRAM, ERIE FAMILY 
   HEALTH CENTER; ASSISTANT PROFESSOR OF CLINICAL FAMILY AND 
COMMUNITY MEDICINE, NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF 
                     MEDICINE, CHICAGO, IL

    Dr. Edberg. Thank you. Chairman Sanders, Ranking Member 
Burr, Senator Warren, my name is Debbie Edberg, as the chairman 
has said, and I am the program director for the Northwestern 
Family Medicine Residency Program, one of the original 11 
Teaching Health Center residency programs, housed at Erie 
Family Health, which is a 57-year-old federally qualified 
health center serving more than 50,000 patients annually at 12 
locations throughout Chicago and the surrounding suburbs.
    I am here today to talk about the Teaching Health Center 
Graduate Medical Education program and describe the urgent need 
to reauthorize this critical program as soon as possible. On 
behalf of Erie and the American Association of Teaching Health 
Centers, representing the 36 Teaching Health Centers 
nationwide, thank you so much for allowing me to speak at this 
subcommittee hearing.
    The THC program represents a proven and powerful strategy 
to address some of the key challenges confronting our health 
care system. These include ensuring access to care amidst a 
growing shortage of primary care providers and reducing 
persistent health disparities that plague our Nation's 
communities.
    First authorized in 2010, the Teaching Health Center 
program is a 5-year program that directly funds primary care 
residency positions in community-based and ambulatory care 
settings like Erie. It is the only primary care physician and 
dentist residency program managed and directed by community 
health centers themselves.
    Different from traditional GME funding, which funds 
hospitals to train physicians in acute care settings, the 
THCGME funds go directly to community ambulatory care centers. 
This is where we train our residents to address healthcare 
issues such as chronic disease management and prevention of 
serious illness in an outpatient setting before they become 
emergent conditions requiring expensive hospital care. Today, 
36 Teaching Health Centers train more than 300 residents who 
are providing more than 700,000 primary care visits in 
underserved communities nationwide.
    Our 24 residents spend the bulk of their time providing 
comprehensive primary care to patients at our health center in 
Humboldt Park, a low-income, predominately Hispanic community 
on Chicago's west side. Last year alone, our Teaching Health 
Center residents provided care to 7,200 patients through 13,200 
visits. For most of these patients, other options for 
affordable high-quality, community-based primary care were 
extremely limited or nonexistent.
    The THC program has come far in a relatively short period 
of time, growing from 11 to 36 sites and expanding the health 
system's capacity to care for tens of thousands of people 
living in our country's most underserved urban, low-income, and 
rural communities. But there is still much to do. Authorization 
for the Teaching Health Center program expires in 2015, and the 
need for immediate reauthorization has become critical in the 
face of extreme provider shortages and a changing healthcare 
landscape.
    We know that close to 50 million people lack access to 
primary care because of physician shortages in their 
communities. These shortages are projected to reach 91,500 by 
2020, half of which will be in primary care.
    In order to improve health outcomes, reduce disparities, 
and contain costs, there is an urgent need to ensure and expand 
our Nation's capacity to provide high-quality affordable 
primary care. That is what FQHCs do, and we do it well.
    FQHCs or community health centers are a major sector of 
health care, serving 22 million people, or 1 in every 15 
Americans, and this number is rapidly growing. Despite the 
promise and scope of community health centers and the urgent 
need for more primary care providers, we face a significant 
challenge in recruiting the number of qualified primary care 
physicians necessary to meet demand.
    The THC program is the only Graduate Medical Education 
program in the country that provides funding directly to the 
community health center in order to train primary care 
physicians, and we know that many medical students, including 
the best and brightest among them, want this opportunity. In 
2013, Erie received over 872 applications for eight residency 
slots and made a 100 percent match for our top choices of 
residents in the incoming class.
    Engaging and retaining bright and energetic people like 
these into a career in community-based primary care was the 
original promise of the Teaching Health Center program, and 
it's working. Physicians trained in health centers are three 
times more likely to work in a community health center or other 
safety net primary care settings. All eight of our last year's 
graduates from our residency stayed in primary care settings, 
seven remained at community health centers, and five stayed at 
Erie.
    Today, this innovative program stands at a crossroads. Its 
success is in jeopardy without legislation authorizing its 
continuation after 2015. Because of the 3-year term of the 
primary care residency, Teaching Health Centers are already 
feeling the detrimental impact of this potential loss in 
support.
    This year, THC programs will have to decide whether they 
will accept residents who cannot be guaranteed funding for 
their full 3-year residency program or leave valuable primary 
care residency slots vacant. Students are also approaching THC 
residency opportunities with increasing reluctance for fear 
that they will not be able to complete their residency in a 
stable environment.
    To ensure this program continues to thrive, we respectfully 
request your support in working to immediately reauthorize the 
THCGME program through the Senate HELP Committee. On behalf of 
Erie and the American Association of Teaching Health Centers, 
we are extremely grateful to Chairman Sanders for introducing 
Senate bill 1759, which supports this reauthorization.
    We are also thankful to those on this committee who have 
been supportive of this bill, including Senator Casey of 
Pennsylvania and Senator Kay Hagan of North Carolina. Finally, 
I would like to thank our own Senators, Hon. Richard Durbin and 
Mark Kirk, who have supported the mission of Erie for years.
    Once again, on behalf of Erie and the patients we serve, I 
very much appreciate the chance to testify today, and I welcome 
your questions.
    [The prepared statement of Dr. Edberg follows:]
               Prepared Statement of Deborah Edberg, M.D.
    Chairman Sanders, Ranking Member Burr, and distinguished members of 
the subcommittee: My name is Deborah Edberg. I am a family physician 
and program director for one of the original 11 Teaching Health Center 
residency programs, housed at Erie Family Health Center in Chicago. 
Erie is a 57-year-old federally qualified health center (or FQHC) 
serving more than 50,000 patients annually at 12 locations throughout 
Chicago and the surrounding suburbs. Like all of our Nation's 1,200 
FQHCs, our health centers are located in low-income and medically 
underserved communities and provide comprehensive primary care 
regardless of patients' insurance status or ability to pay.
    I am here today to talk about the Teaching Health Center program 
and describe the urgent need to re-authorize this critical program as 
soon as possible. On behalf of Erie and the American Association of 
Teaching Health Centers, representing the 36 Teaching Health Centers 
nationwide, thank you so much for allowing me to speak at this 
subcommittee hearing.
    The Teaching Health Center Graduate Medical Education Program 
represents a proven and powerful strategy to address some of the key 
challenges confronting our health care system. These include ensuring 
access to care amidst a growing shortage of primary care providers and 
reducing persistent health disparities that plague our Nation's 
communities. First authorized in 2010, the Teaching Health Center 
program is a 5-year program that directly funds primary care residency 
positions in community-based and ambulatory care settings like Erie. It 
is the only primary care physician and dentist residency program 
managed and directed by community health centers themselves. Different 
from traditional GME funding which funds hospitals to train physicians 
in acute care settings, the THCGME funds go directly to practicing 
community ambulatory care centers where their clinicians design and 
teach a curriculum that is reflective of the opportunities and 
challenges in caring for medically underserved communities in an 
outpatient setting. This is where we address health care issues such as 
chronic disease management and prevention of serious illness before 
they become emergent conditions requiring expensive hospital care. 
Today, 36 Teaching Health Centers train more than 300 residents who are 
providing more than 700,000 primary care visits in underserved 
communities nationwide.
    Erie is a partner in the Northwestern McGaw Family Medicine 
Residency Program, which brings together Erie, our academic partner 
Northwestern University, and Norwegian American Hospital, the 
disproportionate share hospital in our community. We accepted our first 
class of eight residents in July 2010 and graduated our first class 
last summer.
    Our 24 residents participate in hospital rotations at Norwegian 
American Hospital and specialty rounds at Northwestern Memorial 
Hospital and Lurie Children's Hospital. But they spend the bulk of 
their time providing comprehensive primary care to patients at our 
health center in Humboldt Park, a low-income, predominately Hispanic 
community on Chicago's west side. Last year alone, our Teaching Health 
Center residents provided care to 7,200 patients through 13,200 visits. 
For most of these patients, other options for affordable high quality, 
community-based primary care were extremely limited or non-existent.
    The THC program has come far in a relatively short period of time--
growing from 11 to 36 sites and expanding the health system's capacity 
to care for tens of thousands of people living in our country's most 
underserved urban, low-income and rural communities. But there is still 
much to do. Authorization for the Teaching Health Center program 
expires in 2015 and the need for immediate reauthorization has become 
critical in the face of extreme provider shortages and a changing 
healthcare landscape.
    As was discussed previously in prior hearings, the provider 
shortage in this country is acute and growing. Close to 50 million 
people lack access to primary care because of physician shortages in 
their communities. According to the National Association of American 
Medical Colleges' Center for Workforce Studies, physician shortages are 
projected to reach 91,500 by 2020, half of which will be in primary 
care.
    And with tens of millions of people becoming eligible for health 
care coverage through the Affordable Care Act, a perfect storm is 
brewing. Without enough providers, many of these newly insured 
individuals may remain without care or continue to be relegated to 
emergency rooms. Meanwhile, overloaded Medicaid providers will be 
required to limit the number of patients they see, reduce the services 
they provide, and spend less time with their current patients 
(Zyzanski, et al, 1998). In order to improve health outcomes, reduce 
disparities and contain costs, there is an urgent need to ensure and 
expand our Nation's capacity to provide high-quality affordable primary 
care.
    That is what FQHCs do. And we do it well. FQHCs or community health 
centers are a major sector of health care, serving 22 million people, 
or 1 in every 15 Americans (NACHC, 2013) and this number is rapidly 
growing. Community health centers provide one-quarter of all primary 
care visits for the Nation's low-income population. The White House 
Office of Management and Budget rated community health centers as one 
of the most effective Federal programs (OMB, 2007). And we continue to 
grow into communities where we are needed most.
    Despite the promise and scope of community health centers and the 
urgent need for more primary care providers, we face a significant 
challenge in recruiting the number of qualified primary care physicians 
necessary to meet demand. The Teaching Health Center program is the 
only graduate medical education program in the country that provides 
funding directly to the community health center in order to train 
primary care physicians and we know that many medical students--
including the best and brightest among them--want this opportunity. For 
example, in 2013, Erie received over 872 applications for eight 
residency slots and made a 100 percent match for our top choices of 
residents in the incoming class. Currently we have 2 residents that are 
Pisacano Scholars, meaning that they are among the top medical students 
graduate going into family medicine in the country. We have a resident 
that has been consulting for the World Health Organization and setting 
up community assessments in national and international communities, a 
resident that started and was CEO of a small church-based community 
health center while getting his MBA in medical school and a resident 
that started a sustainable community health center in Bolivia.
    Our newly recruited eight Teaching Health Center residents join our 
current residents as nationally recognized scholars, as well as 
volunteers within domestic and international non-profit organizations, 
advocates, authors, researchers and refugees. Their backgrounds are 
diverse but they share a passion and commitment to working with 
underserved patients in community-based settings.
    Engaging and retaining bright and energetic people like these into 
a career in community-based primary care was the original promise of 
the Teaching Health Center. And it's working. Physicians trained in 
health centers are three times more likely to work in community health 
centers or other safety-net primary care settings. All eight of last 
year's graduates from the Northwestern McGaw Family Medicine Residency 
stayed in primary care settings, seven remained at community health 
centers and five stayed at Erie.
    These talented doctors increase our Nation's capacity to provide 
care in underserved communities. But they are also the leaders of 
tomorrow. In addition to direct experience, the McGaw program provides 
a rigorous academic curriculum that emphasizes leadership in health 
policy, community engagement, and research. The Teaching Health Center 
program invests in students, patients, communities and long-term 
solutions to some of the most critical challenges facing our health 
system and our society.
    Today this innovative program stands at a crossroads. Its success 
is in jeopardy without legislation authorizing its continuation after 
2015. Because of the 3-year term of the primary care residency, 
Teaching Health Centers are already feeling the detrimental impact of 
this potential loss in support.
    This year, for the first time, THC programs will have to decide 
whether they will accept residents who cannot be guaranteed funding for 
their full 3-year residency program or leave valuable primary care 
residency slots vacant. Erie, in particular, relies on support through 
the Teaching Health Center program to fund all 24 of our family 
medicine residency slots in their entirety. Students are also 
approaching THC residency opportunities with increasing reluctance for 
fear that they will not be able to complete their residency in a stable 
environment.
    To ensure this program continues to thrive, we respectfully request 
your support in working to immediately reauthorize the THCGME program 
through the Senate Health, Education, Labor, and Pensions (HELP) 
Committee. On behalf of Erie and the American Association of Teaching 
Health Centers, we are extremely grateful to Chairman Sanders for 
introducing Senate bill 1759, which supports this reauthorization and 
ensures that Teaching Health Centers will continue to guarantee a well-
trained, passionate workforce prepared to meet the needs of underserved 
communities nationwide. We are also thankful to those on this committee 
who have been supportive of this bill including Senator Casey of 
Pennsylvania who is a co-sponsor and a member of this distinguished 
subcommittee and Senator Kay Hagen of North Carolina, who has been 
supportive of our reauthorization efforts for the past year. Finally, I 
would like to thank our own Senators the Honorable(s) Richard Durbin 
and Mark Kirk, who have supported the mission of Erie for years and 
who, I trust, will continue to make the type of high-quality, 
compassionate, and affordable healthcare we provide as an FQHC 
possible.
    Once again, on behalf of Erie, and the patients we serve--I very 
much appreciate the chance to testify today, I welcome your questions, 
and I would be happy to be of assistance to you and the committee in 
the future.
    The author wants to thank Rachel Krause and Dana Kelly for their 
assistance in the preparation of this testimony.

    Senator Sanders. Thank you very much.
    Last, but very much not least, is Dr. James Hotz. Since 
1978, Dr. Hotz has been the clinical services director of 
Albany Area Primary Healthcare, a community health center he 
helped found in south Georgia. He is a graduate of Cornell 
University and the Ohio State University School of Medicine. 
During medical school, he worked in the office of Congressman 
Dr. William Roy who drafted the legislation to create the 
National Health Service Corps legislation.
    He then joined the National Health Service Corps as a 
commissioned officer after completing an internal medicine 
residency at Emory University. He is also on the faculty of the 
Medical College of Georgia and Mercer University School of 
Medicine, served on the Admissions Committee of Mercer, and is 
a former president of the Georgia Association for Primary 
Healthcare. The film, Doc Hollywood, was based off of Dr. 
Hotz's story.
    Dr. Hotz, thanks so much for being with us.

  STATEMENT OF JAMES HOTZ, M.D., CLINICAL SERVICES DIRECTOR, 
              ALBANY AREA PRIMARY CARE, ALBANY, GA

    Dr. Hotz. Thank you very much for that kind introduction. 
Chairman Sanders and Ranking Member Burr, it's a pleasure to be 
here and speak before the members of the committee.
    Thirty-five years ago, I made this decision to go down to 
Albany, GA, and it changed my life. Thirty-six years ago, I 
married a Tar Heel and brought her down to Albany with me. So I 
have a lot of affection for the State of North Carolina.
    My job is to really tell you the view from the trenches and 
what it's like. You've heard a lot of the national statistics 
about what happened and what things are like. But let me tell 
you what happened when I came to work in Congress 40 years ago 
with Congressman Roy, who was a physician from Kansas, and 
Congressman Paul Rogers. They were drafting very innovative 
legislation back then, expanding public funding for residency 
programs in family medicine, PA programs, community health 
centers. But their crown jewel was the National Health Service 
Corps.
    Yes, Roy and Rogers worked together, and their legislation 
was called by the DC pundits the Happy Trails legislation. 
Those of you who are as old as I am remember Roy Rogers, the 
singing cowboy, and his theme song was Happy Trails. What has 
happened to these happy trails? They brought millions of 
physicians to communities where they could take care of and 
provide primary access for people throughout the country.
    But you wanted a view from the trenches. Let me tell you 
what it's like down in Albany, GA. Three million people have 
received primary care service visits from our community health 
center, two-thirds of them through National Health Service 
Corps people. I am here to speak about the National Health 
Service Corps.
    While I worked for the Congressman, I worked on a piece 
that added dentists and scholarship people to the National 
Health Service Corps. And I asked for advice from Congressman 
Roy, and he said, ``Join the Corps and let us know how it 
works.'' I'm telling you, there's never been a program that 
works this well.
    The National Health Service Corps has been our foot in the 
door for recruiting. How do you recruit people from Washington, 
DC, or from Atlanta to come down to the swamps of southwest 
Georgia? It's through the Corps.
    We have 52 clinicians that now help take care of our 34,000 
patients we see. Eighty percent fall below poverty. We have the 
largest rural HIV program in the country--see 1,000 people. 
Twenty-four of these people were recruited through the National 
Health Service Corps. We have 286 years of experience with 
these folks, or 24.2 years for our average tenure of stay. 
Those are metrics, Senator Burr, that I think are very 
important from the field.
    Unfortunately, the demand for Corps clinicians and loan 
forgiveness greatly outstrips our current supply. Last year, we 
had six people apply to try to get loan forgiveness. Only three 
could get it. We have three spots that are open in our center 
right now that we can't fill because we don't have that 
available. We just don't have enough slots.
    We currently have five slots open. We've never had slots 
open in our center. It's the most difficult recruiting we've 
faced. Why is it difficult? A lot of people have talked about 
the fact that we're not training enough primary care 
clinicians. I chair our State's AHEC primary care work group, 
and I have extensive written testimony that I've submitted that 
tells you that people aren't going into primary care.
    But I'm going to give you a view from the trenches. You 
wanted to know about debt. I have four kids who have gone 
through this, all of whom during medical school have rotated at 
our health center, all of whom have decided to go into primary 
care, and their debt is not $145,000. These are kids that had 
no debt going into medical school. They lived in low-cost 
cities in Georgia--Macon and Augusta--and their debts are 
$227,000, $224,000, $313,000, and one who's in his third year 
of medical school is at $189,000--$1.15 million in debt.
    Every one of these kids rotated at our center. All of them 
wanted to go into primary care. But my oldest, who's now 
starting to do these debt payments--and I've submitted what 
that looks like, a screen shot of his loans--he either pays off 
at $4,000 a month in 10 years, or he pays off until he's 57 
years old. He said, ``Dad, I don't know if I can afford to stay 
where I am.'' He works at a community hospital in Rome, GA, 
taking care of poor people, and I am very proud of him.
    But the future of the National Health Service Corps, this 
very important program that's going to put people out there, is 
in jeopardy. In fiscal year 2015, it goes away unless you 
people do something about it. And time is of the essence. I can 
tell you in my 40 years of experience, there's never been a 
program that puts primary care clinicians in underserved areas 
like the National Health Service Corps. It is the crown jewel.
    But don't take my word for it. We have 50 organizations 
that have signed a letter that says this is an important thing 
to do, and I don't think there's 50 organizations that agree to 
anything like this. This is the best program out there, and 
everybody agrees with it. But this funding will expire unless 
you do something about it. We need a long-term solution to this 
problem.
    I would like to say it's a pleasure to come before this 
committee and talk about this issue. But the solution is not in 
academic medicine. The medical schools are not going to solve 
the problem. As I learned 40 years ago from Dr. Roy, the 
solution is really in your hands. You're the ones who are going 
to fix this problem, as you did 40 years ago.
    So will that happy trail to primary healthcare continue? 
The answer is going to be if you guys do it.
    Thank you very much. I'll be glad to answer any questions.
    [The prepared statement of Dr. Hotz follows:]
                 Prepared Statement of James Hotz, M.D.
    Hello Chairman Sanders, Ranking Member Burr, and members of the 
subcommittee. Thank you for this opportunity to speak to you today 
about a program that is near and dear to my heart, the National Health 
Service Corps (NHSC). My name is Dr. Jim Hotz, and I am the Clinical 
Services Director for Albany Area Primary Health Care (AAPHC) in 
Albany, GA, an organization I helped found 35 years ago. Over these 
past 35 years, I have helped start and have been on the board of a 
variety of different organizations that have been attempting to provide 
a high quality medical home for the underserved of the Nation. I have 
helped to start a community health center system, a regional AHEC, a 
family practice residency program, a regional planning agency, a 
regional rural HIV program, and a regional cancer control coalition. I 
have been chairman of a regional hospital board, an AHEC, a State 
primary care association and a statewide primary care workgroup and 
have been on the clinical faculty of two medical schools and a family 
practice residency program. All of these organizations are attempting 
to cope with the challenge of supporting local health care systems 
within the context of a diminishing supply of primary care clinicians. 
Unfortunately none of these local programs can solve what is a national 
workforce policy crisis. These experiences have made me realize how 
crucial it is to have this hearing on ``Addressing Primary Care Access 
and Workforce Challenges: Voices from the Field.'' It is my belief that 
the NHSC is the single most effective policy innovation this country 
has ever developed to address the primary care workforce challenge. I 
am here today on behalf of the Association of Clinicians for the 
Underserved (ACU), which was founded by NHSC alumni over 15 years ago. 
The mission of the ACU is to insure the NHSC will continue to be an 
effective solution to the access needs of the medically underserved of 
this Nation.
    Medical school creates an apprenticeship learning environment where 
the student often has a life changing experience while working under 
the supervision of the inspirational master clinician. Exactly 40 years 
ago I had the direction of my life changed by Dr. William Roy. Health 
reform was a major issue in Washington at that time and I wanted to 
become involved. I asked my curriculum advisor at Ohio State if he 
could help me construct an experience in DC that would satisfy my 
community science requirement and allow me to use vacation time to work 
as a legislative aid in Congress. I told him I wanted to be where ``the 
action was'' in health reform and he told me I needed to ride the 
``Happy Trail.'' I didn't know what that meant, except that it was a 
song sung by Roy Rogers. However, in Congress at the time were 
Congressman Dr. William Roy of Kansas and Congressman Paul Rogers of 
Florida--``Roy'' and ``Rogers.'' They had become the architects of the 
most dynamic health reform legislation since Medicare and Medicaid. 
Local DC pundits jokingly called it the ``Happy Trails Legislation.'' 
Being a physician, Dr. Roy could offer clinical rotations for students 
to learn health policy and earn medical school credit and in return he 
got cheap source of labor. A group of us worked with Dr. Brian Biles 
who was Dr. Roy's chief of staff to craft legislation on a menu of 
programs that were to serve as the infrastructure for health reform. 
The master blue print was put forth in ``Building a National Health-
Care System'' by the Committee for Economic Development (CED) in April 
1973. This 105-page document was created by over 100 men who 
represented Fortune 500 companies, academic institutions or major 
foundations and felt the urgent need to address ``the health care bill 
that increased sharply--between 1965 and 1972 national health 
expenditures rose from $39 billion to $83 billion, or from 5.9 to 7.6 
per cent of GNP,'' and ``Per capital annual expenditures rose from $78 
to $394.''
    Dr. Roy, in an amazingly productive 4-year tenure, worked with 
Cong. Rogers to put into place an infrastructure to manage an 
effective, efficient health system based on the recommendations of 
these members of the CED who were in fact successful managers of 
effective and efficient business systems. Dr. Roy introduced the HMO 
act of 1972 that revolutionized health care financing and made 
prepayment legal and placed a premium on keeping people healthy. Yes, 
the HMO was delivered by a Kansas Obstetrician! Roy and Rogers 
collaborated to preserve and promote the community health centers 
program through a major restructuring and reauthorization bill in 1973. 
But the program Dr. Roy and Cong. Rogers were most proud of was the 
National Health Services Corps. They realized health care could only be 
effective and efficient if primary care was available in all 
communities. They saw the infant National Health Services Corps as the 
solution to the primary care distribution problem in this country. 
During a blizzard on December 31, 1970 and minutes before the midnight 
deadline, President Richard Nixon signed Public Law 91-623 the 
``Emergency Health Personal Act of 1970.'' In his award winning book 
``The Dance of Legislation,'' Eric Redman describes how the NHSC was 
born through the heroic efforts of Senator Warren Magnuson of 
Washington. But what isn't covered in the book is that Dr. Roy with 
Cong. Rogers adopted this infant legislation and allowed it to grow 
through a series of amendments over the next 4 years. These amendments 
helped shape the NHSC into the most effective program ever devised to 
distribute primary area clinicians to underserved communities. I helped 
work on the National Health Services Manpower Act (H.R. 14357) that 
added the scholarship component to the NHSC and greatly expanded the 
size and diversity of the field strength of the Corps. The vision of 
Dr. Roy was ``any physician who practices--in an area designated to 
have a shortage--the Secretary shall pay in full the principle and 
interest of any outstanding educational loan.'' Now medical school 
could be affordable not only to the wealthy but even the inner city or 
poor farm kid could finance his dream of a medical education.
    After using up all my vacation and elective time I returned to Ohio 
State intending to eventually go back to work in DC. Dr. Roy decided to 
run for Senate in the fall of 1974 but got beaten by Bob Dole in a very 
bitter campaign by less than 5,000 votes. I called and offered my 
condolences and asked for advice on my career. Dr. Roy said ``join the 
NHSC and make a difference before you come back here!'' I followed his 
advice and convinced Jim Bingle, my brother-in-law, to volunteer with 
me into the Commissioned Corps of the NHSC in 1978. I had lived with 
Jim during medical school and figured if he was dumb enough to live 
with me he probably was dumb enough to join the NHSC and make $32,500 
which was the starting salary back then. Through Cong. Roger's 
continuing efforts, the ``Happy Trails'' legislation flourished under 
President Carter and community health centers and the NHSC grew 
rapidly. Unfortunately with this rapid growth was some pain and the 
NHSC was having trouble finding a match for the two of us. I was 
finishing my Internal Medicine training at Emory in Atlanta and one of 
my instructors Dr. Neil Shulman offered to help place me in Georgia. He 
arranged a meeting with Dr. Jim Alley, director of Public Health in 
Georgia and an appointee while Jimmy Carter was Governor of Georgia. 
Dr. Alley arranged for Bingle and me to be assigned to Georgia to help 
develop a community health center in areas of greatest need. We were 
given several options for communities to serve and preferred Athens 
which was near Atlanta but were tricked into visiting several very poor 
counties in south Georgia that had no doctors. Dr. Shulman wrote a 
humorous account of this adventure that was made into the movie ``Doc 
Hollywood.''
    We initially worked at a Health System Agency in Albany, GA and 
with community groups wrote a grant and to develop a community health 
center program that became Albany Area Primary Health Care (AAPHC). Dr. 
Bingle and I remained in the Commissioner Corps for 6 years after which 
he left to return to Ohio and do a fellowship in cardiology. I stayed 
on and for the first 10 years of AAPHC every one of our recruits were 
from the NHSC and most were obligated scholars. Our success in those 
early years were a byproduct of the legislation of Dr. Roy and Cong. 
Rogers--the NHSC, Community Health Centers, and the Health System 
Agency--the Happy Trails Legislation indeed created a happy trail of 
access for the underserved of south Georgia.
    During the past 35 years, AAPHC has had over 3 million patient 
visits in one of the poorest and most rural areas in the State. It is 
estimated that over 2 million of these primary care encounters were 
delivered by a clinician recruited through the NHSC. AAPHC now has 
offices at 14 different sites in seven counties and last year had 
33,267 users of our health care system. Over 75 percent of our patients 
are an ethnic minority, 80 percent live in poverty and 25 percent have 
no health insurance. We provide services from ``womb to tomb''--
Obstetrics to Geriatrics; from ``head to toe''--Dentistry to Podiatry; 
and everything in between with Pediatrics, Internal Medicine, and 
Family Medicine and last year had 136,287 clinical visits.
    The NHSC has been an invaluable ``foot in the door'' for our 
primary care recruiting. The swamps of southwest Georgia are not a 
natural attraction for the medical professional of today. But once 
clinicians join our group they receive deep professional satisfaction 
from the practice environment we provide. Out of a total of 52 clinical 
providers currently employed by AAPHC, 24 have been recruited or 
retained using the NHSC. Currently we have 16 physicians, 2 dentists, 5 
PAs and 1 Certified Nurse Midwife who were recruited or retained 
through the NHSC. Our overall clinical retention rate is 9 years and 
for our 24 NHSC awardees this tenure is:

     i. 1-10 years = 13 clinicians;
     ii. 11-20 years = 7 clinicians; and
    iii. 20+ years = 4 clinicians.

    The NHSC has led to 286 years of service with an average tenure of 
24.2 years.
    Although the NHSC field strength has expanded to nearly 8,900 in 
2013, the demand has greatly outstripped the supply and last year the 
NHSC received twice as many applications as it had resources to fill. 
Of those applications six came from AAPHC. Where once our recruiting 
was facilitated by the NHSC, we have not been able to secure loan 
forgiveness and have lost three recruits in the past year who said they 
would have come if the loan forgiveness was available. We have not been 
able to recruit a scholar since 2011 and are down to three scholars 
fulfilling an obligation and four clinicians who are currently enrolled 
in loan forgiveness.
    Shelley Spires who has been in charge of recruiting at AAPHC for 
the past 13 years says the past couple years have been the most 
difficult she has experienced. For over a decade we had no vacant 
positions and we currently have five. Several of these positions have 
been vacant for over a year. This is now my 36th year of recruiting for 
AAPHC and I completely agree with Shelley.
    There are a number of reasons recruiting is so challenging. First 
and foremost is the overall shortage of primary care physicians being 
produced by the GME system of the United States. I chair the Georgia 
statewide AHEC Primary Care Work Group and since 2008 we have been 
conducting a summit and producing a detailed analysis of the problem 
and offering a series of recommendations to our State. The following is 
a brief review of the workforce problems we discovered:

     An American Journal of Medicine article (2008) predicted 
the GME ``funnel'' caused by the Balanced Budget Act of 1997 which 
capped Medicare funding for GME. The article forecast a rapid expansion 
of our total medical school enrollment from 18,560 in 2005 (2,800 DOs 
and 15,760 MDs) to 25,136 in 2012 (5,227 DOs and 19,909 MDs), but there 
would be no expansion of PGY1 slots. There were 24,269 such slots in 
2005 and projected to be the same in 2012. Where once we imported 5,709 
U.S. and foreign International Medical Graduates (IMGs) to fill open 
slots, by 2012 there weren't even slots available for 867 U.S. medical 
school graduates. This prediction has largely held true and less and 
less of these graduates have gone into primary care.

          This article also predicted a primary care shortage 
        of 45,800 by 2025.

     A Journal of the American Medical Association article 
(2008) showed that even in the three major residency programs producing 
primary care, many were not staying in primary care:

          Family Medicine: 3,018 and 95 percent Primary Care = 
        2,867.
          Internal Medicine: 8,550 and 45 percent General IM; 
        Of General IM, 50 percent loss to hospitalist (NEJM 11/27/08) = 
        1,967.
          Pediatric Medicine: 2,645 and 61 percent Primary Care 
        = 1,967.

          Net Yearly Primary care production = 6,447.

     The Robert Graham Center in Annals of Family Medicine 
(2012) predicted a shortage of 52,000 primary care physicians in 2025 
taking into account the ACA and change in residency production.
     The Association of American Medical Colleges predicts a 
shortage of 91,500 doctors by 2020 and in a report from this 
subcommittee last year 1/29/2013 you stated, ``According to the Health 
Resources and Services Administration, we need 16,000 primary care 
practitioners to meet the need that exists today.''

    AAPHC is now recruiting from a pool of primary care physicians that 
is shrinking at a time when demand is dramatically increasing. To make 
the situation even worse, we are recruiting physicians who are 
experiencing a substantial increase in educational debt. Many are 
either selling out to the highest bidder like well-funded hospitalist 
programs, doing fellowships specializing in higher paying fields like 
cardiology or oncology that often pay three to four times what primary 
care does or they are signing up with programs that offer significant 
loan relief programs. Once the NHSC was the premier program for debt 
relief but now it cannot meet even 50 percent of the current demand. 
The maximum amount of loan relief was recently cut from $155,000 for 5 
years continuous service to now a max of $100,000 for 5 years. For 
programs with HPSA scores of less than 14 the amount was reduced to 
$30,000 for 2 years. This reduction comes in the face of medical school 
debt that now often exceeds $250,000 for recent grads. The vision of 
Dr. Roy of the NHSC being a vehicle for relief of all medical school 
debt for practice in an underserved area is becoming a greater 
challenge given current NHSC resources.
    How big is the problem and how big is the fix? In a 2008 NEJM 
article, the average debt was $145,000 for public medical schools and 
$180,000 for private school. However the total debt for all medical 
students was estimated to be $2 billion--the amount we paid in 1 month 
for ``cash for clunkers.'' In a 5/28/2011 New York Times article, Bach 
and Kocher estimated, ``we could make medical school free for roughly 
$2.5 billion.'' They recommended a payback for students choosing to 
specialize but none for those going into primary care.
    For those who want a view from the trenches, I asked my four 
children to share their debt experience with this committee. All four 
were HOPE scholars at the University of Georgia and had zero debt at 
the time of graduation. All four were provided with health and auto 
insurance by me. They all lived on frugal budgets during medical school 
in the low cost cities of Macon and Augusta, GA. They went either to 
Mercer, a private school that receives State support, or to the State 
school, the Medical College of Georgia (MCG). My oldest, George, is now 
an internist working with Floyd Memorial, the community hospital in 
Rome, GA. My second son, Jim, is in Internal Medicine Residency at 
Indiana University and will be a chief resident next year, planning a 
career in primary care. My daughter, Mary, is in her first year of a 
primary care Internal Medicine program at the University of South 
Carolina--Greenville. My youngest son Steve is in his second year of 
medical school at Mercer University in Macon.
    Here is the debt they face:

     George--Mercer University School of Medicine 2005-9

          Current debt: $227,329.55.
          Interest: 2.1 to 7.65 percent.
          Minimum payment of: $1,536.58.
          Loan Payoff Date: 3/7/37!
          He is currently trying to make payments of $3,886.09 
        to pay off in 10 years. He selected Rome to be near his wife's 
        family and to be able to work in a community like Albany. 
        Unfortunately his area has no HPSA score above 14 and the 
        hospital can only afford minimal debt relief. He likes his 
        practice and does traditional office and hospital internal 
        medicine, but admits once he starts a family he may need to 
        reconsider his options. Currently he is my only child who is 
        paying off his debt but he has communicated many times to his 
        sister and brothers the reality of the debt crunch when it 
        becomes payback time!

     Jim--Medical College of Georgia 2007-11 (the lowest cost 
school in the State)

          Current debt: $224,446.
          Interest: 6.8 to 7.9 percent.

     Mary--Mercer University School of Medicine 2009-13

          Current debt: $313,009.
          Interest: 6.8 to 7.9 percent.

     Steve--Mercer University School of Medicine 2011-present

          Current debt: $189,236.
          Interest: 6.8 to 7.9 percent.

     Total debt of children = $1,154,620.

    Our Primary Care Workgroup in Georgia discovered that one way the 
medical schools financed their expansion was by increasing tuition. 
This had the unfortunate result of dramatically increasing medical 
school debt which had the unintended consequence of reducing the 
likelihood these students would choose a lower paying career in primary 
care. An article in Academic Medicine January 2013 explored the 
question, ``Can Medical Students Afford to Choose Primary Care?'' The 
conclusion was that ``Graduates pursuing primary care with higher debt 
levels ($250,000 to $300,000) need to consider additional strategies to 
support repayment--use of Federal loan forgiveness.)

    Medical School Tuition in Georgia 2005-2012:

    Emory--38,000 to 45,000; increase of 25.0 percent.
    MCG--10,850 to 24,726; increase of 108.6 percent.
    Mercer--30,220 to 41,457; increase of 37.0 percent.
    Morehouse--24,000 to 36,903; increase of 53.8 percent.
    PCOM (DO started 2008)--33,587 to 40,812; increase of 21.0 percent.

    AAPHC physicians like myself are on the clinical faculty at Mercer 
and MCG and each of my children either did 4-year rural continuity 
tracts at our practice or took multiple electives here. They each say 
these rotations helped convince them to select careers in primary care 
internal medicine and they expressed an interest in the NHSC and 
working at a community health center but wonder if the NHSC program 
will be a viable option for them when they graduate and if they will be 
able to afford to stay in primary care
    Today the NHSC places roughly 8,900 clinicians across the country. 
These placements are for doctors, dentists, dental hygienists, nurse 
practitioners, physician assistants, certified nurse midwives and a 
variety of mental health provider types. In fact, the largest group of 
providers is in mental health today, comprising 28 percent of the total 
field strength. These 8,900 providers provide care to nearly 10 million 
people across the country.
    There are three main parts of the NHSC, including the Scholarship 
program, the Loan Repayment program and the recent Students to Service 
program that helps fourth year medical students choose primary care by 
paying off their debt in exchange for service. However, the largest 
part of the NHSC is the Loan Repayment program, and this is what most 
people think of when they speak of the Corps. The Loan Repayment 
Program pays off a portion of student debt for every year of service in 
a Federal shortage area. These are not Federal employees. Each 
placement is an employee of the site itself, which uses the NHSC Loan 
Repayment program as a recruitment tool--but it is more than that. It 
really is a way the Federal Government leverages local resources. While 
it isn't a required match of Federal funds, each site pays their 
employee much more than the $25,000 or $15,000 they receive in Federal 
loan repayment. So in essence, the Federal Government is only picking 
up a small slice of their compensation and getting all the benefits to 
boot. Being able to place a primary care clinician in an underserved 
area for $25,000 or less per year is an incredible deal for the Federal 
Government for sure.
                     current status of nshc funding
    Starting in 1974, funding for the NHSC had been through regular, 
annual appropriations. This changed under the American Recovery and 
Reinvestment Act (ARRA) and the Affordable Care Act (ACA). Both of 
these laws provided new mandatory funding for the program that was 
intended to better address the shortages across our country. However, 
recognizing this infusion, in fiscal year 2011 Congress dramatically 
decreased the appropriation, and then in fiscal year 2012 eliminated it 
altogether. The program now relies completely on this mandatory funding 
stream for 100 percent of its operations.
    And the ACA funding ends in fiscal year 2016, meaning the program 
is completely defunded unless Congress chooses to either extend the 
mandatory funding, or once again provides funding through the annual 
appropriations process. I understand that neither of these routes will 
be easy to navigate. Our country faces record debt levels and there are 
nearly continuous negotiations on Federal spending levels.
    However, I really believe that based on the merits of the program, 
the NHSC can withstand any kind of debate that focuses on value, 
impact, and long-term savings.
    Access to primary care saves lives and saves money, and the NHSC is 
designed to increase access where we need it most.
    Last month the President proposed one way to address the funding 
issues facing the NHSC. His proposal expanded the program in fiscal 
year 2015 with a combination of annual appropriations and the creation 
of a new mandatory trust fund. Then for the following 5 years, the 
program would be funded at $710 million per year through fiscal year 
2020.
    I would say there are positive and negative things about this 
proposal, but we applaud the President for putting it on the table. 
Just raising the issue, starting the debate about the future of this 
program is important, and we are very appreciative.
    But the challenge is now in your hands. Is the NHSC a valuable 
program? Based on my 40 years of experience, I would say most 
definitely. Is the program threatened? Clearly. How should you fund it, 
and what funding level would achieve the goals of the program? That is 
up to you to decide. But I would urge you to do it sooner rather than 
later. The debt levels are exploding, primary care shortages are 
increasing and recruitment and retention in underserved areas is 
getting harder and harder.
                               conclusion
    It is amazing how fast these last 40 years have passed. Dr. Roy 
returned to practice medicine in Kansas, ran for office twice and lost, 
and has been a regular columnist for the Topeka Capital-Journal. 
Congressman Rogers went on to decades of distinguished service in 
Congress and died just a couple years ago. Their ``Happy Trails'' 
legislation has made an extraordinary contribution to increase health 
care access in this country. It has provided the path for my career and 
been a source for primary care over 3 million visits at AAPHC. Will it 
provide a trail for my children and other future primary care 
clinicians? Without the NHSC, what will be the solution? Neil Shulman 
and I along with one of my patients Vic Miller wrote a sequel book and 
screenplay to ``Doc Hollywood.'' In this book, ``Where Remedies Lie'', 
we describe what happens to ``Doc Hollywood'' as he confronts the 
challenges of providing primary care access to a rural region in the 
Deep South whose citizens are poor and black. His ``Remedy'' was a 
``Happy Trail'' of the NHSC and the community health center program.
    In a PBS interview in 1996, Dr. Roy stated how proud he was of his 
legislative legacy, but especially of the NHSC. ``I'd worked hard on 
the National Health Services Corps to get physicians into rural and 
underserved areas,'' he told the reporter. Since its birth in 1970 over 
45,000 primary care clinicians have used its help to go to underserved 
communities. It is one of the ``crown jewels'' of public health policy 
and may face extinction in 2016 if you do not act.
    I just want to say thank you to the subcommittee for holding this 
hearing, discussing the importance of the Federal programs aimed at 
increasing access to primary care, and most of all, raising the profile 
of the National Health Service Corps. Dr. Roy 40 years ago inspired me 
to follow the ``Happy Trail'' that has led to a fulfilling career at 
AAPHC. The National Health Services Corps has been part of my life for 
40+ years, and I can assure you it is the most effective program this 
country has ever devised to distribute primary care clinicians to the 
underserved communities. You are now the ones who must keep the ``Happy 
Trail'' open for the citizens you serve. I would be glad to answer any 
questions you may have.
                                 ______
                                 
                               APPENDIX 1

           Current Loan Statement for one of the Hotz children. All loans are medical school-related.
----------------------------------------------------------------------------------------------------------------
                                                                        Current     Current                Late
              Select               Disbursement      Type of Loan      Principal   Interest  Outstanding   Fees
                                       Date                             Balance      Rate      Interest     Due
----------------------------------------------------------------------------------------------------------------
.................................    08/22/2005  Direct Subsidized       7,930.28     2.10        12.77     0.00
                                                  Stafford Loan.
.................................    08/05/2006  Direct Subsidized       8,393.59     6.55        42.17     0.00
                                                  Stafford Loan.
.................................    07/14/2007  Direct Subsidized       8,393.62     6.55        42.17     0.00
                                                  Stafford Loan.
.................................    07/08/2008  Direct Subsidized       8,393.53     6.55        42.17     0.00
                                                  Stafford Loan.
.................................    08/22/2005  Direct Unsubsidized    36,488.55     2.10        58.78     0.00
                                                  Stafford Loan.
.................................    08/05/2006  Direct Unsubsidized    42,880.78     6.55     3,356.31     0.00
                                                  Stafford Loan.
.................................    07/14/2007  Direct Unsubsidized    44,372.65     6.55     3,326.07     0.00
                                                  Stafford Loan.
.................................    07/08/2008  Direct Unsubsidized    39,435.76     6.55     2,535.03     0.00
                                                  Stafford Loan.
.................................    05/10/2007  Direct Student Plus     6,302.78     7.65     1,378.76     0.00
                                                  Loan.
.................................    07/25/2007  Direct Student Plus    10,129.83     7.65     2,100.46     0.00
                                                  Loan.
.................................    07/25/2008  Direct Student Plus     1,496.53     7.65       216.96     0.00
                                                  Loan.
----------------------------------------------------------------------------------------------------------------

                             Lower Payment
                            Online Services

    Forms
    Mortgage Verification
    Go Paperless
                            Account Summary
    Principal Balance: 214,217.90
    Last Payment: 3,886.09
    Received On: 03/07/14
    Next Payment: 02/07/15
    Total Due: 1,057.77
    Final Payment: 03/07/37
    Account Status: Repayment

    Senator Sanders. Senator Warren has to leave in a few 
minutes.
    Senator Warren, why don't you begin?
    Senator Warren. Mr. Chairman, I think I'm not even going to 
have time for my questions. But I'm going to do this. I want to 
say three things. I have questions around student loans and the 
current difficulties that this puts on anyone, but, 
particularly, on those who are going into primary care, where 
their pay is, on average, going to be about half that of people 
going into specialties. So I'm going to submit questions for 
the record around student loans.
    The second thing I'm going to submit questions for the 
record around is why we're not doing better on integrating 
nurse practitioners and physician assistants. We know that if 
we fully use nurse practitioners and physician assistants, we 
could cut the impact of the shortage of primary care physicians 
by as much as two-thirds. So I'll have some questions for the 
record about that.
    But the third thing I want to say is thank you to all of 
you for being here. You are committed. You are out there. You 
are on the front lines. You are training the next generation. 
You are making it happen. You come to us and you remind us that 
we know what the problem is. We just all say the same things. 
We get what is wrong.
    We see innovative solutions. We see effective solutions. We 
can see what needs to be done. It is now up to Congress to put 
the resources into it so that these programs can be fully 
implemented, so they can be fully funded, so we can have the 
right regulations in place for you to do your jobs for the 
American people.
    I appreciate your being here. But I really see this as the 
pressure being back on us to do what we ought to be doing here 
in Congress to support you and your work. Thank you. Thank you 
for being here.
    Thank you, Mr. Chairman. I'm sorry that I have to leave.
    Senator Sanders. Thank you very much, Senator Warren.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Hotz, your best quality is your decision as to who you 
married and where she was from. Let me say that.
    [Laughter.]
    But I say to you, as I say to the rest of you, thank you 
for the work you do in the trenches. More importantly, thank 
you for your willingness to come up here and share with us 
information that is vital to the decisions we've got before us.
    Dr. Kohn, prior to GAO conducting its review of the 
federally supported healthcare workforce programs last year, 
was there a comprehensive list of all the federally funded 
healthcare workforce training programs in the country?
    Ms. Kohn. We didn't find one. We didn't find one, and we 
did try. To get our work, we had to check the budget. We had to 
check departmental budgets and budget justifications. We had to 
look at prior publications, published articles. We went to all 
the different agency websites.
    We checked a compendium that wasn't complete as a 
compendium of Federal programs. That didn't quite get us where 
we needed to go. So in the end, we ultimately had to go to 
every department, every agency, and do program by program by 
program to get the information that we published.
    Senator Burr. Mr. Chairman, let me just take a personal 
moment, if I could. One, we've got two GAO reports, and we've 
got this line of witnesses up here. And this is what really 
irks me. Here we had the Assistant Director of HRSA here. But 
your testimony wasn't important enough for her to stay. And 
this is a person on the front line of it.
    I think, we've got to stress with these agencies that this 
is not just for us. It's for the folks that are implementing 
the programs that we set up, and it's important not that their 
staff be here, because they're the ones that drive their staff.
    It's important that they be here to hear your stories, to 
hear the nuances that exist, because in a lot of cases, we're 
trying to thread a needle, trying to determine 30-year-old 
programs and their effectiveness and the resounding need to 
continue it, trying to look at all the healthcare dollars that 
we spend in workforce programs and figure out what doesn't 
work. What can we do away with, and can we double down on 
something else that everybody agrees does work?
    We might hear that from you, but if the people that 
implement the programs don't hear it firsthand, we're not going 
to be as effective. We may thread half the needle, but not all 
of it.
    Let me ask you, Dr. Dobson, because the chairman, I know, 
is going to be patient with me up to the end of my 5 minutes. I 
think you've got some interesting perspectives from the 
standpoint of North Carolina. How does the CCNC model address 
primary care access, and what could other States learn from 
Community Care and the experiences we've gone through?
    Dr. Dobson. I think the No. 1 thing is that we bring people 
together at the very local level and say this is a shared 
responsibility to take care of your citizens in your community. 
You have groups of primary care doctors. You have public health 
departments. You have these resources. It's really around 
coordinating the care. Community Care comes in and provides the 
support to knit it together in an effective manner.
    I think one of the issues around workforce and getting 
people to do primary care is this--it is the money, but it's 
also the prestige. I think CCNC has helped people say, ``Well, 
primary care is important in North Carolina.''
    Senator Burr. You've got a Medicaid beneficiary that walks 
in the door and doesn't have a medical home. You're creating a 
medical home for them by a primary care doc. Who else is at the 
table?
    Dr. Dobson. Besides the primary care doc? The hospital, the 
community health center, social services, public health, 
everybody who works in that community, and understanding that 
every community is different. In a rural area, or in my town, 
the health delivery system is our clinic and the local 
drugstore. That's what we have. It's very different than 
Charlotte or urban areas. So you have to work with what you 
have.
    Senator Burr. But you bring the full consortium of 
disciplines, medical disciplines, to the table to assess what's 
the best course to follow.
    Dr. Dobson. And the flexibility to say it is a function of 
what the healthcare system has to provide. So what do we do if 
we don't have a community health center in our community? We 
work with the rural practices there, and they get extra 
support, because we could not do it without them.
    Senator Burr. Mr. Chairman, let me just say that--because I 
was involved very early on with Allen on this quest that has 
turned into what I think is an unbelievable success for our 
State--the participants--when I say participants, the medical 
professionals--weren't driven by how much money they were 
getting out of this. The model was set up where everybody at 
the table focused on a patient's healthcare--was focused on 
outcome.
    And I think this is something we lose when we talk about 
policy and we talk about how you structurally put it. If we're 
not focused on outcome, then we've made a huge mistake, because 
at the end of the day, the metrics ought to carry through all 
the way from a standpoint of not only how we do it and is that 
successful, but did we change the health outcome of the 
individual?
    Because I think we all know if we can't take individuals 
that are sick and get them well quick and keep them well, if we 
can't take those with chronic illness and put them on a 
maintenance program that eliminates the hospital visits or the 
ER visits, then there's not enough money in healthcare, period, 
no matter how much we all collectively might put in, to handle 
people that are not making the right decisions based upon good 
medical counsel.
    So CCNC has done that. I think others realize the successes 
in their markets and how similar they are. That just happens to 
be our market.
    I thank the chair.
    Senator Sanders. Thank you very much, Senator Burr.
    I'm going to pick up from where Senator Warren left off by 
suggesting that as a Nation, we spend a lot of money on 
healthcare. We really do. We spend almost twice as much as do 
the people of any other country, and yet we heard from Mr. 
Brock that all over America, you have people who are desperate, 
who are spending their nights in a car to try to get their 
teeth pulled and so forth.
    Let me ask you this. In terms of money, if we address the 
crisis of primary healthcare--we heard that we need some 50,000 
new primary care physicians by 2025. That's going to be an 
expensive proposition. But here's my question. Do we save 
money, or do we waste money by investing in primary care? Is 
this, in fact, a good investment, or should we see it as just 
another expenditure?
    Why don't we just start with you, Dr. Hotz? Is this a good 
investment?
    Dr. Hotz. There's a number of studies that have been done 
on that. The American College of Physicians, the internists, 
looked at that, and there's a substantial saving in primary 
healthcare. You can actually look at the cost of healthcare 
driven by the number of primary care physicians per 100,000 
population, and there's a lot of us who really invest in this.
    It's interesting--we mentioned a lot about the National 
Health Service Corps. I'm here representing the Association of 
Clinicians for the Underserved, which is made up of old Corps 
docs who believe in what we're doing, because we know we make a 
difference. The data is overwhelming. There's white paper that 
the ACP put out that goes chapter and verse----
    Senator Sanders. Are you making a difference financially?
    Dr. Hotz. Do we make a difference financially?
    Senator Sanders. Yes. Are we saving money by investing in 
primary care?
    Dr. Hotz. Yes. Healthcare is less--if you look at the 
proportion of the number of primary care docs in health systems 
of care--pick a nation. It's always cheaper. The more primary 
care docs, the better the ratio. The data is overwhelming. It's 
the only way you bend the curve. And look at what people are 
investing in. The ACOs and the people who are trying to bend 
the cost curve--it's primary care.
    Senator Sanders. Dr. Edberg, let's just go right down the 
line, please. The question is: Is it cost-effective for America 
to invest in primary care?
    Dr. Edberg. If I could, I'll share a quick story I heard 
from my chairman of family medicine, who told me about a friend 
of hers who was a 65-year-old man who had been complaining of 
chest pain and went straight to the cardiologist. He had the 
EKG, the stress test, and ended up with a cardiac 
catheterization--all normal.
    He mentioned to her, ``You know, my chest is still 
hurting.'' And because she was a family doctor and knew him 
well, she said, ``Do you not play the bass at church?'' And he 
said he did, and she said, ``I think you need to get a stand 
for your bass.'' It was the pain that was just from the bass 
resting against his chest.
    I think we can obviously see the tens of thousands of 
dollars that were wasted in the workup when he could have just 
gone to his primary care physician.
    Senator Sanders. Thank you.
    Dr. Kohn.
    Ms. Kohn. GAO's work didn't examine that issue. But we do 
know from the listing that we have--didn't focus on primary 
care, but we know there's at least 23 or 24 programs that do 
explicitly talk about primary care, even though we know there's 
more programs than just the ones that explicitly say it. We 
know there's more programs doing primary care. So I think by 
having the list, there's the potential to be able to start 
looking at specific programs and start being able to answer 
those questions.
    Senator Sanders. Dr. Flinter.
    Ms. Flinter. Yes. We absolutely save money by investing in 
primary care.
    Senator Burr, I thought you might have been alluding to 
something a little different in your question about who's there 
around the table. So I just want to speak to that element. It's 
really a team in primary care these days, and we did not really 
get a chance to talk about how important the advancement of the 
model of primary care that we have today is, with the full 
integration of our behavioral health specialists with our 
primary care providers and the nutritionists, the diabetes 
educators, sometimes the chiropractors and other people, to 
make sure that we're delivering the right care to the right 
people at the right level and at the right cost.
    And in this we have metrics. I know how important that is 
to everyone. I look at the community health centers and the 
Uniform Data Set, this UDS report. You can see for all of us, 
individually as organizations, collectively as a system of 
primary care, how well we are doing at things that we know 
directly reduce cost.
    Every 1 percent reduction in the hemoglobin A1C of a 
diabetic is associated with a reduction in cost, and you can 
look and see, individually or collectively, how well we're 
doing with that. And that has to be as much our passion as 
reducing suffering, because in this case, reducing suffering 
and reducing dollars goes hand in hand, and that's really the 
path we want to be on.
    Senator Sanders. Dr. Nichols.
    Dr. Nichols. Senator Sanders, in response to your question, 
yes, absolutely. Starting with some very profound research that 
was done by the late Barbara Starfield at the Johns Hopkins 
School of Public Health and the work that has continued at the 
American Academy of Family Physicians, Robert Graham Center, 
has consistently shown that primary care is, in fact, an 
excellent investment for our Nation's health.
    Many of these studies have been cited in your reports on 
primary care. However, if there are any members of the Senate 
whose memory requires a refresher, I'd be happy to forward 
those studies to them.
    Senator Sanders. Thank you.
    Dr. Dobson.
    Dr. Dobson. Yes, absolutely, the return on investment is 
large. In the aggregate, it's a long-term investment. But there 
are short-term savings that can be had. And I do apologize, but 
I probably didn't answer the question that Senator Burr asked, 
that we do create teams in the community that deal with need. 
It's primary care. It's creating teams around patients.
    The biggest short-term investment for the GAO and others is 
on the complex patients. How do you take care of them? We've 
got some very interesting work around--when you ask the primary 
care doctors what they need to take care of the really 
complex--I need care management, I need people, I need 
psychiatrists, I need a team around this patient.
    We've gotten down to saying if we can identify which 
patients coming out of the hospital need a home visit within 24 
hours, and if three home visits prevent a re-admission--but we 
change the trajectory of that patient's care for 365 days, 
which means that's your return on investment. And we're getting 
more data to be able to say how many people need to get back to 
their primary care place of care within 5 days, within 7 days, 
to really make a difference.
    That's where your money will come to support the long-term 
investment, and we need to do more research around it. But 
that's--absolutely, there's a return on it.
    Senator Sanders. Dr. Wiltz.
    Dr. Wiltz. Community health centers serve 15 percent of 
Medicaid recipients at 1 percent of the cost. We save the 
system $24 billion. We have a model that works. It's proven. 
The triple aim of quality, cost, and outcomes--we've had study 
after study that shows this.
    We exist in a medical neighborhood, so the hospitals, all 
of the elements that you talked about--we're a part of that 
whole. We're not saying we're the panacea, that we can solve 
all the problems. But I do think, and we've proven in our 
history, that we are a big part of the solution.
    Senator Sanders. Mr. Brock.
    Mr. Brock. We're talking about a loss of productivity here 
among these people. The age group of the people that we see is 
predominantly between the age of 29 and 64. We're only seeing 2 
percent or 3 percent children at these events. So we're 
talking, really, about the workforce.
    All of them, although they may be there primarily for 
dental care and vision care, are really there in great need of 
basic medical care as well and, particularly, I might, add 
mental health problems. We could hold one of these RAM programs 
every day of the year and see a thousand people, without a 
doubt. So it's an incredible loss of productivity.
    Senator Sanders. Thank you. That's a very good point. I 
went way over my time.
    Senator Burr.
    Senator Burr. Mr. Chairman, I'm done except to say thank 
you once again to all of our witnesses today. This has been 
invaluable from a standpoint of the information you've supplied 
to us.
    Thank you, Mr. Chairman.
    Senator Sanders. Thank you very much.
    Let me ask you this. If there was an understanding here in 
Congress of what you all just said, that investing in primary 
healthcare not only keeps people healthier but saves money, and 
if somebody said, ``You know what? We need 50,000 or 60,000 new 
primary care physicians by the year 2025'' and looked at it 
almost from a military perspective--we've got a mission, and 
we've got to accomplish that mission--how do we do it?
    Now, I think we've heard a lot of good ideas today, and I 
would throw out that maybe someone wants to comment,

          ``Are we going to do that when kids are graduating 
        school $250,000 in debt? Are we going to do that if we 
        don't have a stronger National Health Service Corps? 
        Are we going to do that if we do not have something the 
        equivalent of a community health center in every 
        neighborhood in the United States of America?''

    How do we do that?
    If you were sitting up there making that decision--let me 
start with you, Dr. Wiltz.
    Dr. Wiltz. I think I mentioned this before, but you have to 
get them when they're stem cells. You have to get a kid when 
they are undifferentiated and they're still open to the 
possibilities, not a rotation in their third year of medical 
school. They have to be exposed in junior high and high school 
and be a part of the community and have that experience of 
working in a team.
    Senator Sanders. So if we say to young people in elementary 
school and high school and college,

          ``You're going to be able to go to medical school 
        regardless of your income, but we need a commitment 
        from you of X number of years to serve in underserved 
        areas.''

Do you think that would be a significant step forward?
    Dr. Wiltz. I think all the numbers bear it out. If you're 
only able to fund one out of every seven applicants for the 
scholarship, that tells you the need is there. I have 10 nurse 
practitioners that are on the loan repayment program, and we 
still have others that are trying to apply for it.
    So the willingness--the American people will serve, if we 
make the venue possible and fund it. And the access issue with 
community health centers--the new applications point to--that 
people are continuously applying. HRSA could tell you that 
they're only funding about a third, if not less, of all the 
applications that we're getting. So the need is still there.
    Senator Sanders. This is despite a huge expansion of the 
program.
    Dr. Wiltz. That's correct. The need is still there.
    Senator Sanders. Other thoughts?
    Dr. Hotz.
    Dr. Hotz. We describe it as four rights. You've got to get 
the right students in. There are plenty of students like Dr. 
Nichols that are applying. I was on the medical school 
admissions--get them in, make certain we have the medical 
schools and the other training programs getting the right 
people in.
    They have to have the right debt. My belief is that we 
ought to forgive all the debt for anybody who want to go to 
underserved areas, as long as they stay there. Ms. Spitzgo 
talked about the ability to take that debt and get them there--
very important.
    You have to have the right training programs at the right 
size. Right now, we only train 24,000 people per year, even 
though our medical school is going to graduate more. We have to 
go up probably 5,000, and it ought to be in primary care, and 
it ought to be in Teaching Health Centers.
    Those are the things that we have to do. And then we have 
to treat them right in medical school. All of my kids have done 
continuity tracks out in rural areas and working at health 
centers, at the education health centers.
    Those are the four rights. Get the right student in, the 
right debt, leverage them when they are most vulnerable, when 
they're stem cells, get them into the right medical schools, 
and you can--and the University of Alabama has a program, and 
75 percent of their people go out and do family medicine, 
because the State of Alabama pays for people to go into family 
medicine in rural areas. And then make certain that you get the 
right size--and when you expand GME, make certain that you 
expand it in primary care.
    Senator Sanders. Dr. Nichols.
    Dr. Nichols. Thank you, Senator Sanders. I want to make the 
point that those future family physicians of 2025 are this very 
year in their freshman year of high school. The clock is 
ticking, and the onus is on us within the next 3 years to start 
identifying some of these students and offer them an entry way 
into this pipeline.
    There are many Senators on this committee, Senator Burr 
included, who have a lot of experience with pipelines, perhaps 
pipelines of a different sort. But the pipeline we're talking 
about here today is a pipeline that carries even more valuable 
cargo. Instead of oil, we're talking about primary care docs.
    But the principle is very much the same and should be 
familiar to any of them. The pipeline has to start at the right 
place, you've got to plug all the leaks along the way, keep 
greedy private interests from siphoning off the cargo along the 
way, and get the pipeline to where it needs to go. It needs to 
start in high school. It needs to run all the way through to an 
eventual primary care practice in the places where we need 
them.
    We need to keep hospitals from siphoning them off as 
subspecialist physicians. And we need to pay them, the point 
being that I think we're a lot more valuable than oil. In fact, 
I'm worth my--I think I'm easily worth my weight in oil.
    Actually, my weight in oil--I did the math this morning. 
It's $55. I think if we can all agree that a primary care doc 
is worth about $55--all the time and energy we spend talking 
about oil pipelines. Maybe we should spend a little bit more 
time talking about the primary care pipeline.
    Senator Sanders. Dr. Flinter.
    Ms. Flinter. No surprise. I'm going to take an opportunity 
to speak directly to nurse practitioners as primary care 
providers. Ten thousand new nurse practitioners enter the 
workforce every year, and, trust me, those specialists and 
hospital systems are beginning to go after them, just like 
they've gone after the primary care doc. That's why we need to 
create opportunities for nurse practitioners who have a passion 
to combine everything that is nursing with everything that is 
medicine and primary care and practice in our community health 
centers and in other underserved settings.
    When we sort of did the back of the envelope math on 
whether we could authorize these nurse practitioner residency 
training programs, 15 health centers could produce 100 nurse 
practitioners who have already completed their doctor of 
nursing practice or their master's program. Over 5 years, 
that's 500 people, each with a minimum panel of 1,000 patients. 
That's 5,000 people. It's a math problem as well as an issue of 
opportunity and ability.
    But we can do it. It's really a matter of committing 
ourselves to this course, building the infrastructure, and that 
infrastructure stays. It doesn't disappear at the end of a year 
or two. Thank you.
    Senator Sanders. Dr. Dobson.
    Dr. Dobson. I'd add to the comments--let me share a 
conversation we had with some students and residents in North 
Carolina. When asked, ``What would you like to do when you get 
done?'' And they thought, ``Well, my only choice is to either 
work at the health system or search out some other 
alternative.'' And they said, ``But, gosh, if I could be a 
small business and be a primary care doctor in a small town, I 
might actually do that.''
    The problem is we don't have an infrastructure to support 
those choices. So the question is we've got to get the right 
people in. We really need to train them where they're going to 
practice and in the style they're going to practice. It's 
important if you want somebody to practice in a rural area, 
they need to understand what it's like. Training them in a big 
city is not going to get them in a small practice.
    They need to exit without debt or with less debt, and then 
we need to even give them a life of significance in their 
communities where they're supported and feel part of something, 
because it's--trust me, I still live in a town of 1,000, and I 
know how healthcare goes, because I go to the grocery store and 
it takes me an hour, because I get stopped on every aisle with 
people.
    Senator Sanders. Try being a Senator going to the grocery 
store.
    [Laughter.]
    Dr. Dobson. Exactly, Senator. I think there are a lot of 
opportunities to really make significant strides in health 
policy. And, remember, in my testimony, I said a significant 
number of the patients are still cared for by small, 
independent practices. They're small businesses in the 
community.
    We've tried to create a virtual community health center, 
including our health centers, to support these small rural 
practices. They're extremely significant and important in our 
rural areas. I think we can crack this nut, and the return on 
investment is there. We have to save the money and keep putting 
it upstream.
    Senator Sanders. Thank you.
    Mr. Brock.
    Mr. Brock. It's a question of opportunity, and just because 
boys and girls maybe come from a minority group or an 
underprivileged group, that doesn't mean they're not bright and 
that they couldn't meet these academic standards. In my case, I 
came from an underprivileged home back there in England. But I 
was a fairly bright kid, I think, and I knew--I was told that 
there was an opportunity to go to one of Britain's finest 
schools if only I could pass the examination to get there.
    I worked hard at the books, and I took that examination, 
and I went to one of the finest schools in Britain totally 
free, with books paid for, everything paid for. I could have 
gone all the way to university and all the way to become a 
doctor at no cost. I'd like to see some kind of a program for 
these underprivileged kids here. I didn't take advantage of 
mine because I ran off to Brazil to become a cowboy. But I 
could have become a doctor, and it would not have cost me a 
nickel.
    Senator Sanders. The point that you raise--and I think Dr. 
Hotz also raised it and others--it's not a radical idea that 
we're talking about. I mean, in many countries around the 
world, people graduate medical school with, amazingly enough, 
no debt whatsoever, because those nations feel that it is in 
the country's best interest to have doctors.
    Maybe people can comment on this--my understanding is that 
if the U.S. military wants a doctor, what they will say to you 
is, ``Young man, young woman, congratulations. We're going to 
send you to medical school, and in payment, you're going to 
give us 5, 7 years of your life.''
    Dr. Hotz, is that true?
    Dr. Hotz. Yes. We had an expression back when we were 
working on this. We called it ``Give me five.'' Give us 5 
years, and you're debt free, and that's what the military does.
    Senator Sanders. And it works.
    Dr. Hotz. It works.
    Senator Sanders. Yes, Dr. Nichols.
    Dr. Nichols. I'm actually an example of the sort of program 
that Mr. Brock is describing. The program I alluded to, the 
Premedical Honors College, since 1994, has been a really 
innovative partnership between Baylor College of Medicine and 
the University of Texas Pan American, which is soon to be 
renamed the University of Texas Rio Grande Valley, being 
reorganized to better serve Hispanic students from the poorest 
areas of Texas and Hispanic students all over the country, in 
fact, now coming to this school.
    But the need was for primary care physicians, particularly, 
that could provide culturally sensitive care to patients on the 
border with the United States and Mexico. Since 1994, 297 
students have matriculated into the Premedical Honors College.
    As of June 2013, 206 have successfully completed their 
undergraduate components, getting bachelor of science degrees 
from UTPA; 181 graduates have entered a Texas medical school, 
145 at Baylor College of Medicine, but some at other schools as 
well; 124 students have earned their M.D. degrees, including 
myself; and 51 of us have completed our advanced training and 
are now in practice, 24 of those 51 in south Texas, and that's 
without any particular requirements, just feeling an obligation 
to come back and practice.
    The majority of the rest of them that are not practicing in 
south Texas are practicing in underserved areas in San Antonio 
and other Hispanic enclaves of underserved and the urban areas 
of Texas. Thirty-seven students are currently enrolled at 
Baylor, and 42 are currently enrolled at UTPA, so the pipeline 
continues. Despite the loss of Federal funding years ago, the 
pipeline continues.
    Senator Sanders. Let me just conclude, first of all, 
thanking all of you, personally, for the work you are doing. As 
we have heard many times this morning, you're in the trenches. 
You are saving people's lives. You are working in an area that 
gives hope to people in your community who, I suspect, if you 
were not there, would not know what to do. You have also given 
us this morning a whole lot of good ideas about where we have 
got to go.
    But let me conclude in a hopeful way. I think we know where 
we have got to go, and I think virtually all of you have raised 
those issues about where we need to go. So our job now is to 
pick up that ball and run with it, and let's see if we can 
transform our healthcare system and put a much greater focus on 
primary care.
    Thank you all very much for being here this morning. The 
meeting is adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                     Community Health Center, Inc.,
                                       Middletown, CT 06457
                                                      May 18, 2014.
Hon. Elizabeth Warren,
SH-317 Hart Senate Office,
U.S. Senate,
Washington, DC. 20510.

    Dear Senator Warren: Thank you for the honor of testifying before 
you and the Senate HELP Committee's Primary Care and Aging Subcommittee 
on April 9, 2014. It is my pleasure to respond here to the question you 
posed to us at the end of the hearing.
    In your remarks, you said,

          ``Not every medical incident requires a doctor to get the job 
        done. Last November, the Health Resources and Services 
        Administration released a report estimating that the projected 
        primary care shortage could be cut by more than two thirds if 
        nurse practitioners and physician assistants were fully 
        integrated into the primary care delivery system. It's 
        important to think creatively about ways to fully mobilize this 
        workforce. For example, the VA defines its own scope of 
        practice for nurse practitioners and physician assistants, 
        without regard to which State the facility is located in. And 
        the government authorized support for nurse practitioner 
        residency programs--including those in Massachusetts--but 
        Congress never funded the initiative. All medical professionals 
        have a role to play in meeting the increasing demand for health 
        care in this country, and all of them should have the chance to 
        practice up to the level of their training.''

    Your question was then:

          ``What steps can Congress take to help ensure that our health 
        care system uses the full range of providers to reach the 
        highest number of patients, in the most efficient way 
        possible?''

    Let me answer your question by addressing three different areas: 
(1) the importance of nurse practitioners and physician assistants as 
full primary care providers in the U.S. health care system, and the 
steps we can take to support and ensure their choice of primary care as 
the focus of their primary care careers; (2) the critical importance of 
the primary care team in ensuring outstanding clinical care and 
increasing the capacity of each and every primary care provider to 
manage far more patients in a way that is both clinically effective and 
satisfying to patients and providers alike; and (3) the steps that 
Congress can take to help ensure use of the full range of providers to 
reach the highest number of patients in the most efficient way 
possible.
    First, let me address the importance of NPs and PAs as primary care 
providers. You are correct when you say that, ``not every medical 
incident requires a doctor to get the job done.'' We have nearly a half 
century of experience and research since Dr. Loretta Ford first 
developed the expanded role of nursing and created a new role, that of 
nurse practitioner, established for nurses prepared at the graduate 
level, who can provide a full range of preventive, acute, and chronic 
care to individuals and families. The scope of this new nursing role 
was broadened to include diagnoses, treatment, and management of health 
problems. Over the decades, as the education, training, and 
certification of NPs has advanced, NPs have become central and critical 
to the U.S. primary health care system. The American Academy of Nurse 
Practitioners (AANPs) estimates that one-fifth of all primary care 
services in the United States are delivered by an NP in settings that 
range from private practice to community health centers; from nurse-
managed health centers to retail clinics; from schools to correctional 
facilities; and beyond. Unlike physician residents in medicine, the 
majority of NPs still choose a primary care focus for their practice 
careers, although they are also well-represented in non-primary care 
specialties, such as acute care. I am very appreciative of the efforts 
of the Federal Government over many years to support and increase the 
capacity of our Nation's universities to develop our fine system for 
educating nurse practitioners and preparing them for practice in all 
areas.
    We have ample evidence to document the quality, safety and 
acceptability of care provided by NPs in primary care. In my decades of 
practice and leadership as an NP, I have seen the slow but steady 
progress over time in our State scope of practice laws that have 
gradually, but far too slowly, moved in the direction of independent 
practice by NPs. Today, 19 States allow fully independent NP practice 
while the remainder have some combination of requirements for 
collaboration or supervision in certain domains of practice.
    As you are so well aware, though, we must focus not just on the 
provision of medical ``incident care'' such as one might find in the 
NP-run retail clinics--with their excellent track records of providing 
a well-defined list of services and treatments for episodic/acute 
ailments in convenient, accessible locations. In addition, we must also 
attend to the far more complex role of NPs as primary care providers 
who take responsibility and are accountable for the ongoing care and 
treatment of an entire panel of patients. This is particularly true in 
our Nation's safety net of community health centers, where nearly 20 
million individuals are enrolled to receive comprehensive primary 
health care.
    As the primary care provider shortage looms, we have to ensure that 
we can attract the best, brightest, and most committed potential 
primary care providers--physicians, NPs, and PAs--into this role. As I 
stated during my testimony, we are doing this at a time when primary 
care has never been more exciting--or more challenging. The complexity 
of patient clinical co-morbidities, the need to provide what was 
formerly considered specialty level care in primary care in 
collaboration with specialists, the range of treatment options, the 
advances in research and technology, and the redesign of primary care 
practice--combined with the need for every PCP to manage larger panels 
of patients than ever before--can be overwhelming to those who are new 
to practice. These factors combine to demand that we create 
postgraduate residency training opportunities for those new NPs who 
aspire to this role. We simply have to ask, ``who wants to be a primary 
care provider?'' and ensure that we have done everything in our power 
structurally, and in terms of the transition from their excellent 
education to practice, to support them. That's why we at CHC, Inc. in 
Connecticut created the country's first formal postgraduate NP 
residency training program, and why so many other FQHCs around the 
country are following suit. We are very happy to see that several 
institutions are developing similar programs for PAs, and some are 
combining their postgraduate residency training programs in what are 
called ``Advanced Practice Clinician'' residencies, which are inclusive 
of both NPs and PAs. It is clear, based on our 7 years of experience in 
designing and hosting NP residency training programs, that new NPs who 
aspire to practice careers as primary care providers, in the 
challenging setting of FQHCs, want, need, and deserve this opportunity 
for further training and the mastery, confidence, competence, and 
potential for leadership in practice that come with such additional 
training.
    The second area I would like to address is the potential for 
primary care teams to significantly increase their capacity to manage 
larger panels of patients and thus reduce the ``shortage'' of primary 
care providers in a different way. I am the national co-director of a 
Robert Wood Johnson-funded project called, ``PCT-LEAP'' for ``Primary 
Care Teams: Learning from Effective Ambulatory Practices''. I am a co-
director of this RWJF project, along with Dr. Ed Wagner of the McColl 
Institute at Group Health in Seattle, and Dr. Tom Bodenheimer of the 
Center for Excellence in Primary Care at the University of California 
at San Francisco. On May 15, 2014, I had the pleasure of hosting Dr. 
Wagner and Dr. Bodenheimer at the Community Health Center, Inc.'s Ninth 
Annual Weitzman Symposium on Innovation in Community Health and Primary 
Care. We reviewed the evidence from the PCT-LEAP project and other 
projects studying ``exemplary'' primary care practices around the 
country. It is exceedingly important when we think about the primary 
care team as well as the primary care provider--when we think about 
expanding the role of medical assistants, redefining the role of the 
primary care nurse, integrating behavioral health clinicians into the 
team, adding pharmacists whether directly or by electronic 
consultation, adding health coaching as a skill for all members of the 
team, and supporting the entire team with timely, actionable data on 
care and gaps in care--that we are creating a new day in primary care, 
where patients maintain their satisfying and healing relationship with 
their own MD, NP, or PA as their primary care provider, but also know 
and are well-cared for by a high performance team of individuals 
committed to their best healthcare and health. As Dr. Wagner said, 
``the future of primary care is already here; it's just not evenly 
distributed.'' His comment illustrates the point that while we have 
identified many practices that have now achieved the goal of 
constituting a high performance primary care team, our next challenge 
is to disseminate the knowledge and tools to expand these teams across 
the country.
    Finally, I would like to answer your question about how Congress 
can support these efforts. You noted that Congress in 2010 authorized 
Section 5316 of the Affordable Care Act, a provision that would provide 
residency training for new nurse practitioners in community health 
centers and nurse-managed health clinics across the Nation. However, 
Congress never funded this initiative. I would therefore ask you to 
support the reauthorization and funding of section 5316 in the amount 
of $75 million through fiscal year 2019, as currently included in S. 
2229, the ``Expanding Primary Care and Workforce Act,'' introduced by 
Senator Sanders on April 9, 2014. Properly funding section 5316 would 
establish a demonstration project with 20 to 25 sites nationwide, where 
a minimum of three nurse practitioners would be trained as residents at 
each site, each year, for 3 years. Each site would be funded up to 
$600,000 per year. The Sanders bill would also reauthorize and create a 
mandatory appropriation for the National Health Service Corps (NHSC) of 
$4.9 billion through fiscal year 2020; appropriate $10 million for the 
National Health Care Workforce Commission; reauthorize the Nurse 
Faculty Loan Program through fiscal year 2019; reauthorize the Primary 
Care Residency Expansion Program through fiscal year 2019; and 
reauthorize the Area Health Education Centers (AHECs) through fiscal 
year 2019.
    Second, I would ask your support for reauthorization and funding of 
the Teaching Health Center Graduate Medical Education (THCGME) program, 
along with the expansion of that program to include residency training 
for new NPs and other health care professionals, so that FQHCs can 
innovate and develop residency training programs not only for 
physicians but also for other professionals such as NPs and PAs. 
Reauthorization of the THCGME program is funded at $800 million in S. 
2229, though use of the funds is not expanded to include NPs or PAs; 
unfortunately, the bill as drafted supports only training of physician 
residents. That should be changed.
    Third, I would ask your continued support for the community health 
center program in general. The Sanders bill, S. 2229, also creates a 
mandatory appropriation for FQHCs of $25 billion through fiscal year 
2020.
    Fourth, I would suggest that Congress focus on those primary care 
settings that have already developed highly innovative models of high 
performance primary care and have systematically developed the 
infrastructure, training, and tools to help other practices achieve the 
same goals. In my organization, we have developed a rigorous approach 
to dissemination, training, and on-going support for other highly 
motivated practices, whether they seek to implement NP residency 
training; to transform from provider-centric to team-based primary 
care; to develop new data systems to support care; or to tackle the 
highest complexity issues we see in primary care, such as managing 
chronic pain and addiction.
    We at CHC, Inc. in Connecticut are ready and able to work with 
others, and we have the structure in place through the adoption of the 
Project ECHO (Extension for Community Health Outcomes) telemedicine 
model first developed in New Mexico to help primary care providers 
manage Hepatitis C in primary care with the support of specialists. At 
CHC, Inc., we have adopted, refined, and grown the Project ECHO model 
and now help organizations across the country and the world improve 
their primary care practices through this case-based, distance learning 
opportunity that provides support over time to primary care practices 
tackling ambitious goals of transformation and improvement. I would 
urge Congress to consider the establishment of one or more national 
training centers to fulfill exactly this urgently needed role using our 
model.
    Thank you for this opportunity to respond to your question, and for 
your commitment to good health and health care for everyone.
            Sincerely,
         Margaret Flinter, APRN, Ph.D., c-FNP, FAAN, FAANP,
                       Senior Vice President and Clinical Director,
                                      Community Health Center, Inc.
Response by Joseph S. Nichols, M.D., MPH to Questions of Senator Warren
    The research is mixed on how student debt factors into the decision 
to pursue a medical career in primary care. Primary care doctors make, 
on average, a little more than 50 percent of what a specialist makes, 
so the burden of debt certainly weighs heavily on them. Medical 
students graduate with an average of about $170,000 in student loan 
debt. That's a lot, but debt at graduation tells only half the story. 
According to the American Association of Medical Colleges, a doctor who 
started off with $175,000 in debt can end up repaying more than 
$300,000 once interest is factored in. The interest rate is not set at 
the cost to the government. Instead, it is set at a level that is 
projected to produce billions of dollars in profits. A recent GAO 
report estimated that the Federal Government will bring in $66 billion 
off the loans it made between 2007 and 2012.

    Question. Recognizing that these are estimates, and of course 
estimates can change, what are your thoughts about the U.S. government 
turning a profit on student loan interest rates at a time when Federal 
policy should be making it as easy as possible for medical students to 
choose careers in primary care?
    Answer. Thank you, Senator Warren, for the question and for your 
leadership on this issue.
    Almost no one can afford the cost of a medical school education. 
This is because, in addition to the high sticker price, there are 
numerous intangible costs to medical education that are subsidized by 
Federal and State Governments. Therefore, every medical student 
graduates with a significant amount of debt, whether or not this debt 
can be added up in the form of student loans. However, the message 
medical students receive from the Federal Government upon graduation is 
that our educational loan debt is the debt that is of most interest to 
our society.
    The contract between medical school graduates and society must be 
rewritten in a way that challenges our doctors to begin their careers 
with service in the places where they are most needed. If broader 
opportunities existed, many medical school graduates would gladly 
exchange their financial debt for a social debt, repaid not with 
monthly payment amounts that only inflated sub-specialist wages can 
support, but with service to the sickest patients in the areas of the 
country experiencing the most need.
    The Federal Government currently profits tremendously off of the 
interest charged to our student loan debt. However this profit is 
shortsighted when measured in dollars and cents, considering the huge 
opportunity cost of the health needs that could be met if this monetary 
debt was effectively transformed into a social debt repaid through 
service.
    Clearly, this situation calls for expansion of current, time tested 
and effective loan repayment programs incentivizing service as a 
primary care provider to medically underserved areas. Future expansions 
of these programs should aim to entirely eliminate the debt faced by 
physicians who commit their careers in service of the greatest needs of 
our society.
      Response by James Hotz, M.D. to Questions of Senator Warren
    The research is mixed on how student debt factors into the decision 
to pursue a medical career in primary care. Primary care doctors make, 
on average, a little more than 50 percent of what a specialist makes, 
so the burden of debt certainly weighs heavily on them. Medical 
students graduate with an average of about $170,000 in student loan 
debt. That's a lot, but debt at graduation tells only half the story. 
According to the American Association of Medical Colleges, a doctor who 
started off with $175,000 in debt can end up repaying more than 
$300,000 once interest is factored in. The interest rate is not set at 
the cost to the government. Instead, it is set at a level that is 
projected to produce billions of dollars in profits. A recent GAO 
report estimated that the Federal Government will bring in $66 billion 
off the loans it made between 2007 and 2012.

    Question. Recognizing that these are estimates, and of course 
estimates can change, what are your thoughts about the U.S. government 
turning a profit on student loan interest rates at a time when Federal 
policy should be making it as easy as possible for medical students to 
choose careers in primary care?
    Answer. Senator Warren, I appreciate your recognition of the 
negative impact that student loan interest rates have on medical 
students selecting careers in primary care. At a time when our Nation 
needs an additional 52,000 primary care physicians to satisfy the 
demands of 2025, it makes no sense to have a Federal loan program that 
increased the cost of student loans by $66 billion from 2007 to 2012! 
Instead of recruiting the additional 5,000 primary care physicians we 
need each year; the current loan structure is creating a marketplace 
that drives physicians out of primary care practice. In a thought 
provoking New York Times letter on May 28, 2011 Peter Bach and Robert 
Kocher propose, ``Why Medical School Should Be Free.'' They point out 
that ``for roughly $2.5 billion per year--we can make medical school 
free.'' Their suggestion is to keep medical school free for those 
electing primary care and to have those going in higher paying 
specialties pay back the cost of their education. This would be one 
option.
    A more moderate proposal would be to expand the National Health 
Service Corps loan forgiveness program to forgive the loans of all 
primary care practitioners going to areas of greatest need in this 
country. Another option would be to restructure the current student 
loan interest and repayment mechanisms to incentivize primary care. A 
menu of options could run from lower interest for those selecting 
primary care to no interest and some principal reduction for those 
selecting primary care in the most underserved areas. With a $66 
billion profit generated in the 5 years up to 2012 there seems to be 
room in the Federal student loan program for revisions that would 
create economic incentives to distribute the primary care workforce to 
areas of greatest need in this country. I am optimistic that Congress 
can find ways to restructure the current Federal loan program to better 
meet not only the primary care needs but also the larger workforce 
needs of the people you serve.
    In keeping with the ``Voices from the Field'' theme of the hearing 
I would like to show the pressure the current Federal loan program 
places on someone I know well who is trying to start a career in 
primary care. My oldest son, George, resisted the temptation of higher 
paying specialty opportunities after completing an internal medicine 
residency. He took a job with a regional hospital in Rome, GA and 
joined a primary care practice that has its doors open to all in the 
community. His income is less than half what a specialist would make 
but this was his calling and his wife supported the decision and all 
started out smoothly. He was making four times his salary as a 
resident, Rome was near his wife's home, they bought a small house, 
they were used to living on a tight budget, and then they started 
paying his medical school loans! They elected an amount slightly under 
their monthly mortgage payment and after paying $1,650.49 a month from 
10/2012 to 4/2013 they were shocked to see they had made 7 payments 
totaling $11,553.43 and ALL went to interest! The principal had not 
been reduced at all, and unlike the home mortgage none of this was 
deductible. George and his wife took a hard look at their financial 
situation. Until then the loan was just an abstract threat, but now 
reality has set in. They had to make some hard decisions--to tighten 
the budget more and pay off a larger amount each month or else this 
debt monkey would be on their back for 25 more years--or George could 
decide to go back into a higher paying specialty. Fortunately for the 
people of Rome, they decided to stay, cut down more on spending and 
increased their payments to $3,886.09 a month so they would be out of 
debt in 10 years. That first payment was made on 3/7/14 and $893.04 
went to principal and $2,993.05 to interest.
    Before 2006, George was able to get part of his Stafford Loan at 
2.1 percent. After 2007 until his graduation in 2008, the interest 
rates skyrocketed to 6.55 and 7.65 percent. My youngest son, Steve, is 
in medical school now and his rates are also in the same range--from 
6.8 to 7.9 percent. For Steve and most of his classmates these loans 
are significant only when a family member, friend or a physician 
faculty member tells them of the grim reality of debt, high interest 
and the pain of repayment. That is when this debt storm starts raining 
down on the dreams of a career in primary care. Unfortunately there has 
also been a relentless increase in medical school tuition to pay for 
expanding class sizes resulting in substantially larger medical school 
debt at a time in which the interest rates have risen to painfully high 
levels. It is clear what the future primary care ``Voices from the 
Field'' are saying, ``Help!''
    Senator Warren and subcommittee members the time for action is now. 
The first step in ``Addressing Primary Access and Workforce 
Challenges'' is in addressing the excessive burden of medical school 
debt and interest. This can happen in a number of ways, including a 
reduction of interest rates, a reduction in tuition costs or full loan 
repayment. Each of these can be achieved by strategic use of the 
National Health Service Corps program, and I'd be happy to work with 
you to make that a reality.
    Thank you Senator Warren for this opportunity to answer your timely 
and insightful question and I hope my comments will be of help. I am 
here on behalf of the Association of Clinicians for the Underserved and 
you can feel free to contact me or the Association if there are any 
further questions or if we can be of any service in the future.

    [Whereupon, at 12:20 p.m., the hearing was adjourned.]

                                   [all]