    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

     SUPPORTING TOMORROW'S HEALTH PROVIDERS: EXAMINING WORKFORCE PROGRAMS
                      UNDER THE PUBLIC HEALTH SERVICE ACT

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 14, 2017

                                   __________

                               Serial No. 115-57

     [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                     __________

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                        COMMITTEE ON ENERGY AND COMMERCE

                              GREG WALDEN, Oregon
                                     Chairman
    JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
      Vice Chairman                        Ranking Member
    FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
    JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
    TIM MURPHY, Pennsylvania             ELIOT L. ENGEL, New York
    MICHAEL C. BURGESS, Texas            GENE GREEN, Texas
    MARSHA BLACKBURN, Tennessee          DIANA DeGETTE, Colorado
    STEVE SCALISE, Louisiana             MICHAEL F. DOYLE, Pennsylvania
    ROBERT E. LATTA, Ohio                JANICE D. SCHAKOWSKY, Illinois
    CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
    GREGG HARPER, Mississippi            DORIS O. MATSUI, California
    LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
    BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
    PETE OLSON, Texas                    JERRY McNERNEY, California
    DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
    ADAM KINZINGER, Illinois             BEN RAY LUJAN, New Mexico
    H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
    GUS M. BILIRAKIS, Florida            YVETTE D. CLARKE, New York
    BILL JOHNSON, Ohio                   DAVID LOEBSACK, Iowa
    BILLY LONG, Missouri                 KURT SCHRADER, Oregon
    LARRY BUCSHON, Indiana               JOSEPH P. KENNEDY, III,
    BILL FLORES, Texas                       Massachusetts
    SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
    MARKWAYNE MULLIN, Oklahoma           RAUL RUIZ, California
    RICHARD HUDSON, North Carolina       SCOTT H. PETERS, California
    CHRIS COLLINS, New York              DEBBIE DINGELL, Michigan
    KEVIN CRAMER, North Dakota
    TIM WALBERG, Michigan
    MIMI WALTERS, California
    RYAN A. COSTELLO, Pennsylvania
    EARL L. ``BUDDY'' CARTER, Georgia
                             Subcommittee on Health

                           MICHAEL C. BURGESS, Texas
                                     Chairman
    BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
      Vice Chairman                        Ranking Member
    JOE BARTON, Texas                    ELIOT L. ENGEL, New York
    FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
    JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
    TIM MURPHY, Pennsylvania             DORIS O. MATSUI, California
    MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
    CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
    H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
    GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III,
    BILLY LONG, Missouri                     Massachusetts
    LARRY BUCSHON, Indiana               TONY CARDENAS, California
    SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
    MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
    RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex
    CHRIS COLLINS, New York                  officio)
    EARL L. ``BUDDY'' CARTER, Georgia
    GREG WALDEN, Oregon (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................     1
        Prepared statement...........................................     3
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
    Hon. Janice D. Schakowsky, a Representative in Congress from the
      State of Illinois, opening statement...........................     6
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, prepared statement.....................................    61
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, prepared statement........................    62

                                   Witnesses

    Neil S. Calman, MD, FAAFP, President and CEO, Institute for
      Family Health, Chair, Department of Family Medicine and
      Community Health, Icahn School of Medicine at Mount Sinai/Mount
      Sinai Hospital, President, American Association of Teaching
      Health Centers.................................................     8
        Prepared statement...........................................    10
    Adrian Billings, MD, PhD, FAAFP, Chief Medical Officer,
      Preventative Care Health Services, Associate Professor,
      Department of Family and Community Medicine, Texas Tech
      University Health Sciences.....................................    20
        Prepared statement...........................................    22
    Janice A. Knebl, DO, MBA, Dallas Southwest Osteopathic Physicians
      Endowed Chair and Professor in Geriatrics, University of North
      Texas Health Science Center, Medical Director, James L. West
      Presbyterian Special Care Center...............................    32
        Prepared statement...........................................    35
    Juliann G. Sebastian, PhD, RN, Faan, Dean and Professor, College
      of Nursing, University of Nebraska Medical Center..............    45
        Prepared statement...........................................

                               Submitted Material

    Statement of the Council of Academic Family Medicine, submitted
      by Mr. Kennedy.................................................    63
    Statement of the American Medical Association, submitted by Mrs.
      McMorris Rodgers...............................................    66
    Statement of the American Academy of Family Physicians, submitted
      by Mrs. McMorris Rodgers.......................................    67
    Statement of seven medical organizations, submitted by Mrs.
      McMorris Rodgers...............................................    72
    Statement of the Oncology Nursing Society, submitted by Mr. Lance    74
    Statement of the Eldercare Workforce Alliance, submitted by Mr.
      Burgess........................................................    76
    Statement of the Health Professions and Nursing Education
      Coalition, submitted by Mr. Burgess............................    83
    Statement of the Healthcare Leadership Council, submitted by Mr.
      Burgess........................................................    90
    Whitepaper entitled, Cap Flexibility: Putting GME Dollars to
      Work, submitted by Mr. Burgess \1\
    Statement of the National Association for Geriatric Education,
      submitted by Mr. Burgess.......................................    92
    Statement of Congressman Jeff Denham, submitted by Mr. Burgess...    98
    Statement of the American Association of Nurse Anesthetists,
      submitted by Mr. Burgess.......................................    99

    ----------
    \1\ The information can be found at: http://docs.house.gov/
      meetings/if/if14/20170914/106404/hhrg-115-if14-20170914-
      sd007.pdf.

     SUPPORTING TOMORROW'S HEALTH PROVIDERS: EXAMINING WORKFORCE PROGRAMS
                      UNDER THE PUBLIC HEALTH SERVICE ACT

                                  ----------

                          THURSDAY, SEPTEMBER 14, 2017

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:15 a.m., in
    room 2123, Rayburn House Office Building, Hon. Michael Burgess,
    M.D. (chairman of the subcommittee) presiding.
        Present: Representatives Burgess, Guthrie, Murphy,
    Blackburn, McMorris Rodgers, Bilirakis, Brooks, Hudson,
    Collins, Green, Engel, Schakowsky, Butterfield, Matsui,
    Sarbanes, Kennedy, and Eshoo.
        Also Present: Representative Denham.
        Staff Present: Adam Buckalew, Professional Staff Member,
    Health; Paul Edattel, Chief Counsel, Health; Jay Gulshen,
    Legislative Clerk, Health; Edward Kim, Senior Health Policy
    Advisor; Katie McKeogh, Press Assistant; Kristen Shatynski,
    Professional Staff Member, Health; Waverly Gordon, Minority
    Health Counsel; Samantha Satchell, Minority Policy Analyst;
    Andrew Souvall, Minority Director of Communications, Outreach
    and Member Services; and C.J. Young, Minority Press Secretary.

    OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
                  IN CONGRESS FROM THE STATE OF TEXAS

        Mr. Burgess. The hearing will now come to order. The chair
    will recognize himself for 5 minutes for an opening statement.
        Today's hearing provides us with an opportunity to begin
    discussion on how to best address provider shortages in our
    country and how to ensure that today's medical students have
    the skills and resources to succeed in the 21st century. As a
    physician, I have supported programs that improve access to
    care and enhance patient experience, and the programs that we
    are examining today seek to accomplish this goal.
        When looking at the data, our mission is clear. The
    Association of American Medical Colleges estimates by the year
    2030, the United States will have a projected physician
    shortage, anywhere from just over 40,000 to over 100,000
    providers.
        To address this issue, our hearing will focus on four sets
    of unique programs: the National Health Service Corps, Teaching
    Health Center Graduate Medical Education, Physician Workforce
    Programs under Title VII of the Public Health Service Act, and
    Nursing Workforce Programs under Title VIII of the Public
    Health Service Act. Each of these programs seeks to increase
    access to providers in underserved areas and promote the
    training opportunities for medical students and providers to
    maintain their skills.
        For example, programs like the National Health Service
    Corps and the Area Health Education Centers, supported by Title
    VII grants, and Teaching Health Centers, tackle these shortages
    by connecting young providers with underserved communities.
    These programs are essential to addressing the Nation's
    provider shortage by connecting providers to those that are not
    served.
        Additionally, Title VII and Title VIII programs support
    opportunities for continuing medication education for the
    healthcare workforce, which is not only mandatory for many
    providers to keep their licenses, but it is also essential to
    providers as they attempt to keep up with evolving issues and
    treatments. In an age with modern drugs and the 21st Century
    Cures Act supporting future innovation, we must ensure that our
    healthcare workforce is ready for these breakthroughs and
    prepared for future challenges.
        This hearing, however, comes at a precarious time for these
    programs as we seek to reauthorize them and extend their
    funding. For Title VII and Title VIII, both of which have
    expired, yet continue to receive appropriations on a year-by-
    year basis, a commitment by this subcommittee to reauthorize
    these programs would ensure longer-term stability, particularly
    for future generations of providers.
        The National Health Service Corps and the Teaching Health
    Center Graduate Medical Education Program have funding that
    will expire at the end of the fiscal year, and our subcommittee
    is working to ensure these programs will continue to operate
    and serve communities in coming years. As is the case with all
    programs with mandatory funding, finding offsets can be
    challenging, but I am committed, and I know others on the
    committee are committed, to finding a solution and extending
    these programs.
        I want to thank each of our witnesses for being here today
    and providing their unique insights into the problems ahead.
    Dr. Adrian Billings, the Chief Medical Officer of Preventive
    Health Services; Dr. Neil Calman, the President of the American
    Association of Teaching Health Centers; Dr. Janice Knebl of the
    University of North Texas Health Science Center; and Dr.
    Juliann Sebastian, Dean of the College of Nursing at the
    University of Nebraska Medical Center, are each celebrated
    providers and experts in their respective fields, and I look
    forward to hearing from each of them.
        And to prove that we are in an area of glasnost where the
    lion can lie down with the lamb, we have both the University of
    North Texas and Texas Tech University at our witness table
    today, and for that, I am extremely grateful.
        Now, these are not the only programs that support our
    Nation's healthcare workforce, but they are each important and
    deserve our attention. As we move beyond the immediacy, I look
    forward to delving further into this issue and identifying new
    opportunities to support providers as well as communities.
        And I will yield my remaining time to the gentlelady from
    Washington, Mrs. McMorris Rogers.
        [The prepared statement of Mr. Burgess follows:]

                 Prepared statement of Hon. Michael C. Burgess

        The Subcommittee will come to order.
        The Chairman will recognize himself for an opening
    statement.
        Today's hearing provides us with an important opportunity
    to begin a discussion on how best to address provider shortages
    in our country and how to ensure that today's medical students
    have the skills and resources to succeed in the 21st century.
    As a physician, I have always supported programs that improve
    access to care and enhance the patient experience, and the
    programs that we are examining today seek to accomplish this
    very goal.
        When looking at the data, our mission is clear. The
    Association of American Medical Colleges estimates that by the
    year 2030, the United States will have a projected physician
    shortage ranging from 40,800 providers to as many as 104,900
    providers.
        To address this looming issue, our hearing will focus on
    four sets of unique programs: the National Health Service
    Corps, Teaching Health Center Graduate Medical Education,
    physician workforce programs under Title VII of the Public
    Health Service Act, and nursing workforce programs under Title
    VIII of the Public Health Service Act. Each of these programs
    seeks to increase access to providers in underserved areas and
    to promote the training opportunities for medical students and
    providers to maintain their skills.
        For example, programs like the National Health Service
    Corps, Area Health Education Centers which are supported by
    Title VII grants, and Teaching Health Centers tackle these
    shortages head on by connecting young providers with
    underserved communities. These programs are essential to
    addressing the nation's provider shortages because they serve
    as driving forces that can connect providers to underserved
    communities and can support the care needs of individuals that
    would otherwise be unavailable without the providers that
    participate in these programs.
        Additionally, programs under Title VII and Title VIII of
    the Public Health Service Act provide an array of opportunities
    to support education in health professional schools. These
    programs range from supporting disadvantaged students to attend
    medical school to supporting fellowships and faculty positions
    so that health professional schools can continue to meet the
    needs of students.
        Title VII and Title VIII also support opportunities for
    continuing medical education for the healthcare workforce,
    which is not only mandatory for many providers to keep their
    licenses, but is also essential to providers as they attempt to
    keep up with evolving issues and treatments. In an age with
    breakthrough drugs and a 21st Century Cures Act that is
    supporting future innovations, we must ensure that our
    healthcare workforce is ready for these breakthroughs and is
    prepared for future challenges in delivering care.
        This hearing, however, comes at a precarious time for these
    programs as we attempt to reauthorize them and extend their
    funding. For Title VII and Title VIII which have both expired
    yet continue to receive appropriations on a year by year basis,
    a commitment by this Subcommittee to reauthorize these programs
    would ensure longer-term stability and offer future generations
    of providers with opportunities to grow and serve our
    communities.
        And for the National Health Service Corps and the Teaching
    Health Center Graduate Medical Education program which have
    funding that will expire at the end of the fiscal year, our
    Subcommittee is hard at work ensuring that these programs will
    continue to operate and serve communities in the coming years.
    As is the case with all programs with mandatory funding,
    finding offsets can be challenging, but I am committed to
    finding a solution and to extending these programs.
        I would like to thank each of our witnesses for being here
    today and providing their insights on the problems ahead. Dr.
    Adrian Billings, the Chief Medical Office of Preventive Care
    Health Services, Dr. Neil Calman, the President of the American
    Association of Teaching Health Centers, Dr. Janice Knebl, from
    the University of North Texas Health Science Center, and Dr.
    Juliann Sebastian, the Dean of the College of Nursing at the
    University of Nebraska Medical Center, are each celebrated
    providers and experts in their respective fields, and I look
    forward to hearing from them.
        These are not the only programs that support our nation's
    healthcare workforce, but they are each important and deserve
    our immediate attention. And as we move beyond the immediacy, I
    look forward to delving further into this issue and identifying
    new opportunities to support providers and underserved
    communities.

        Mrs. McMorris Rodgers. Thank you, Mr. Chairman.
        It is estimated that we could have a nationwide doctor
    shortage of 23,000 by 2025, and the physician population ratio
    in rural communities, like mine in eastern Washington, is
    especially stark. That is why it is so important that we
    reauthorize the Teaching Health Center Graduate Medical
    Education Program. This program specifically trains residents
    in specialties with the largest shortages, such as family
    medicine and psychiatry. And when compared with traditional
    Medicare GME residents, the Teaching Health Center residents
    are more likely to practice primary care, remain in underserved
    areas, and work in rural communities.
        My legislation, H.R. 3394, aims to not only reauthorize
    this critical workforce program, but expand it to ensure
    communities have access to primary care doctors and dentists
    they desperately need.
        I want to thank the committee for holding this hearing, and
    also my colleagues, like Representative Denham, who helped this
    effort.
        Thank you, Chairman.
        Mr. Burgess. The chair thanks the gentlelady.
        The chair now recognizes the subcommittee ranking member,
    Mr. Green of Houston, for 5 minutes for an opening statement.

       OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
                    CONGRESS FROM THE STATE OF TEXAS

        Mr. Green. Thank you, Mr. Chairman.
        I want to thank our witnesses there, and not only our
    Texans because we don't have to have an interpreter to talk to
    each other. But I also want to welcome our witness from the
    University of Nebraska Medical Center. I have a little tie
    there with my daughter and her husband, doctors there, but more
    importantly, I have two grandchildren that live in Omaha. So
    thank you for being here.
        Today we are examining the National Health Service Corps
    Program; the Teaching Health Center Graduate Medical Education
    Program; H.R. 3728, Educating Medical Professionals and
    Optimizing Workforce Efficiency and Readiness, the EMPOWER Act
    of 2017; H.R. 959, the Title VIII Nursing Workforce
    Reauthorization Act of 2017.
        The National Health Service Corps program provides
    financial support to health professional students and primary
    care providers who commit to provide service in medically
    underserved communities. The NHSC program is comprised of four
    separate programs.
        First, the NHSC Scholarship Program, which provides
    scholarships to healthcare professional students who agree to
    serve in underserved communities upon the completion of their
    education and training.
        The NHSC Loan Repayment Program, which provides loan
    repayment assistance to primary care providers in exchange for
    service in a health professional shortage area.
        The NHSC Students to Service Loan Repayment Program, which
    provides assistance to the medical and dental students in their
    last year of school in exchange for a commitment to primary
    healthcare in a health professional shortage area for 3 years.
        And finally, the State Loan Repayment Program, which is a
    Federal-State partnership grant program that provides loan
    repayment to clinicians who practice in a health professional
    shortage area in that state.
        Together, the program supports a critical workforce in
    areas that are much in need. The Teaching Health Center
    Graduate Medical Education Program was established under the
    Affordable Care Act of 2010 to encourage increased training of
    primary care and medical and dental residents in community-
    based settings, such as federally qualified health centers or
    rural health clinics. It must be reauthorized before the end of
    the month or it may go away altogether.
        Title VII of the Public Health Service Act established the
    Federal Healthcare Workforce Development Grant programs
    administered by HRSA that have long enjoyed bipartisan support
    in Congress. Colleagues on this committee have legislation to
    reauthorize Title VII. I am pleased to support this
    legislation.
        Finally, we are examining Title VIII of the Public Health
    Service Act, which established Federal nursing workforce
    development grant programs administered by HRSA. The programs
    focus on nursing education, practice, recruitment, and
    retention. Nurses play a vital role in our healthcare
    workforce, and this program is essential to the success of
    delivery of care.
        I also want to mention the Health Centers Fund, which
    provides substantial funding to federally qualified health
    centers or community health centers, which are on the front
    line of our healthcare safety net, providing primary care to
    millions of Americans. The Health Centers Fund runs out at the
    end of the month. This funding cliff threatens their ability to
    provide care our constituents depend on, and I cannot stress
    the importance of extending this funding enough.
        Thank you again to our witnesses. I look forward to their
    testimony.
        And I would yield the remainder of my time to my colleague
    from California, Congresswoman Matsui.
        Ms. Matsui. Thank you very much for yielding me time, and I
    thank the witnesses for being here today.
        As we move forward to improve our healthcare system,
    bolstering our workforce is a critical piece to the puzzle. I
    am pleased that we are holding this hearing today to discuss
    the reauthorization of multiple important healthcare workforce
    programs, including the Geriatric Workforce Program in Title
    VII that I worked on with Representative Schakowsky, the Title
    VIII Nursing Workplace Program, that I worked with on with
    Representative David Joyce, the National Health Service Corps,
    and the Teaching Health Centers.
        It is estimated by 2030 over 3 million trained healthcare
    workers will be needed just to maintain the current needs of
    our Nation's seniors. My geriatrics workforce bill with
    Congresswoman Schakowsky, included in the Title VII bill we are
    discussing today, will help meet that need by investing in our
    geriatric workforce and incentivizing the creation of training
    programs in underserved communities.
        Our Nation's aging population will especially increase the
    demand on our nursing workforce, and a reauthorization of Title
    VIII would ensure that critical nursing education programs can
    continue.
        Investments in our healthcare workforce are investments in
    the long-term prosperity of our healthcare ecosystem. And I do
    appreciate the committee's attention to these issues, and I
    yield back the balance of my time.
        Mr. Green. I yield back my time.
        Mr. Burgess. The chair thanks the gentleman. The gentleman
    yields back.
        Not seeing the chairman of the full committee here, is
    there a member on the Republican side who would seek the
    chairman's time. Seeing none, is there a member on the
    Democratic side who would seek the ranking member's time?
        For what purpose does the gentlelady from Illinois seek
    recognition? You are recognized 5 minutes for an opening
    statement.

           OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A
         REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

        Ms. Schakowsky. Thank you.
        I am so pleased we are here today to consider these
    critical health workforce bills. I would like to thank the
    distinguished panel for their work in support of these
    programs. I am pleased to cosponsor H.R. 3728, the EMPOWER Act,
    to reauthorize the healthcare workplace development grant
    programs, which we are considering today.
        Additionally, as a co-chair of the Seniors Task Force, I
    was delighted to introduce H.R. 3713, the bipartisan Geriatric
    Workforce and Caregiver Enhancement Act, with Representative
    Matsui. This bill works to fully achieve the goals of this
    hearing, supporting tomorrow's health providers.
        Our Nation is facing a severe and mounting shortage of
    healthcare professionals to meet the needs of older Americans.
    This growing need is reflected in Illinois. By 2030, it is
    estimated that the older adult population will increase to 3.6
    million and represent almost a quarter, 24 percent, of the
    Illinois population.
        The reauthorization of the Geriatrics Workforce Enhancement
    Program and the Geriatric Academic Career Awards are critical
    in addressing this shortage. In Chicago, Rush University
    Medical Center is one of the outstanding health and education
    institutions to receive a grant from the Health Resources and
    Service Administration, HRSA, and have a geriatric workforce
    enhancement program. At Rush, providers are trained to better
    care for older adults.
        We must continue to support this vital work. I look forward
    to working with my colleagues on this committee to advance this
    important bill.
        Thank you. And I now yield to Congressman Kennedy.
        Mr. Kennedy. Thank you to my colleague from Illinois, and
    many thanks to all the witnesses today. Thank you to the
    chairman and the ranking member for calling this important
    hearing.
        By bringing the expertise of all of the witnesses and their
    experiences to Washington today, you are helping us strengthen
    the future of our community healthcare system, including
    Teaching Health Centers and the National Health Service Corps.
    Thank you for your commitment and thank you for your work.
        A few weeks ago, I visited a community behavioral health
    center in a town in my district that has been devastated by the
    opioid epidemic. A staffer there told me that she volunteers
    pro bono to ride with the local police department to the homes
    of every single person who had overdosed, the following day
    after their episode, to offer compassion, support, and any care
    that they and their family need. They have been to hundreds of
    homes. And not once have they ever been turned away.
        In our medically underserved and most vulnerable
    communities there will always be the need for more providers.
    And there always be providers willing to work long, hard hours,
    underpaid, to care for their neighbors and to fill the gaps in
    the hopes that our government at some point catches up. By
    investing in these workforce programs, we can inspire a new
    generation of health practitioners who are trained for the
    communities where they will work and serve and live in for
    years.
        Instead of once again asking our local leaders to bear the
    burden of our inaction, we should address the healthcare
    shortage today, starting with these bills, extending the
    community health centers, and reauthorizing CHIP.
        Thank you. And, Mr. Chairman, I would ask to submit for the
    record the following letter from the Council of Academic Family
    Medicine. I yield back.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. Does the gentleman yield back?
        Mr. Kennedy. Yes, I yield back.
        Mr. Burgess. The chair wishes to note the presence of our
    colleague, Mr. Denham from California, not a member of the
    committee, but certainly has been a valuable Member in
    providing expertise and emphasis on some of the bills that we
    are considering today.
        That concludes opening statements. The chair would remind
    members that pursuant to committee rules, all members' opening
    statements will be made part of the record.
        We do want to thank our witnesses for being here today and
    taking time to testify before the subcommittee. Each witness
    will have the opportunity to give an opening statement,
    followed by questions from members.
        Today, we will hear from Dr. Neil Calman, Chief Medical
    Officer, Preventive Health Care Services; Dr. Adrian Billings,
    President of the American Medical Association of Teaching
    Health Centers; Dr. Janice Knebl, Dallas Southwest Osteopathic
    Physicians Endowed Chair and Professor in Geriatrics at the
    University of North Texas Health Science Center; and Dr.
    Juliann G. Sebastian, Dean and Professor, College of Nursing,
    the University of Nebraska Medical Center.
        We appreciate your being here today.
        And, Dr. Calman, you are now recognized for 5 minutes to
    give an opening statement.

      STATEMENTS OF NEIL S. CALMAN, MD, FAAFP, PRESIDENT AND CEO,
       INSTITUTE FOR FAMILY HEALTH, CHAIR, DEPARTMENT OF FAMILY
      MEDICINE AND COMMUNITY HEALTH, ICAHN SCHOOL OF MEDICINE AT
         MOUNT SINAI/MOUNT SINAI HOSPITAL, PRESIDENT, AMERICAN
     ASSOCIATION OF TEACHING HEALTH CENTERS; ADRIAN BILLINGS, MD,
      PHD, FAAFP, CHIEF MEDICAL OFFICER, PREVENTATIVE CARE HEALTH
        SERVICES, ASSOCIATE PROFESSOR, DEPARTMENT OF FAMILY AND
      COMMUNITY MEDICINE, TEXAS TECH UNIVERSITY HEALTH SCIENCES;
        JANICE A. KNEBL, DO, MBA, DALLAS SOUTHWEST OSTEOPATHIC
         PHYSICIANS ENDOWED CHAIR AND PROFESSOR IN GERIATRICS,
       UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER, MEDICAL
     DIRECTOR, JAMES L. WEST PRESBYTERIAN SPECIAL CARE CENTER; AND
       JULIANN G. SEBASTIAN, PHD, RN, FAAN, DEAN AND PROFESSOR,
       COLLEGE OF NURSING, UNIVERSITY OF NEBRASKA MEDICAL CENTER

                      STATEMENT OF NEIL S. CALMAN

        Dr. Calman. Thank you, Chairman Burgess, Ranking Members
    Green, and distinguished members of the subcommittee. Thank you
    for inviting me to speak to you about the THCGME, or Teaching
    Health Center Graduate Medical Education Program.
        I am a family physician in practice for 40 years in the
    South Bronx and the Lower East Side of Manhattan. I am
    President and CEO of the Institute for Family Health, a
    nonprofit network of 31 federally qualified community health
    centers, and three family medicine residency programs.
        In 2012, we began participating in the new THCGME Program
    to expand resident training into two severely underserved rural
    New York communities, and also in Harlem and the South Bronx.
        As President of the American Association of Teaching Health
    Centers, and on behalf of the 57 teaching health centers, I
    implore you to reauthorize the THCGME Program before it expires
    on September 30, and to do so for a minimum of 3 years. It is a
    unique and critically important initiative aimed at ending the
    primary care physician shortage which plagues our county.
        The shortage of primary care in the U.S. creates an
    underemphasis on basic preventive healthcare, the delayed
    detection and treatment of serious disease, and the overuse of
    emergency care and acute hospitalization for many preventable
    conditions. All of this has driven our healthcare costs to
    unsustainable levels. Sixty million Americans lack access to a
    primary care doctor, and by 2020, the U.S. may face a deficit
    of 20,000 primary care doctors.
        The THC programs are accountable for every dollar of
    funding, and they produce results. Eighty-two percent of
    teaching health center graduates remain in primary care,
    compared to 23 percent of other graduates. Twice as many
    practice in underserved communities, 4 times as many in rural
    areas, and 16 times as many in federally qualified health
    centers.
        Congresswoman Cathy McMorris Rodgers is very familiar with
    the THC program in Spokane and has been a champion for
    increasing our health workforce in medically underserved areas,
    especially in rural America. We are so grateful to her for
    introducing bipartisan legislation to reauthorize the program
    sustainably for 3 years and to fund expansion to help satisfy
    the pent-up demand throughout the country for new teaching
    health centers.
        We appreciate that Congresswoman Tsongas and 67 other
    Members of Congress cosponsored this legislation, including
    Congressman Jeff Denham, who not only cosponsored it, but also
    introduced his own legislation that would appropriate even more
    funds for expansion.
        Traditional graduate medical education occurs almost
    exclusively within hospitals, but primary care takes place in
    the community and doctors officers and in community health
    centers. To get more doctors in primary care, especially in the
    areas most in need, teaching health centers move training into
    the community where residents and their faculty do over 600,000
    patient visits each year.
        Primary care providers are the first place a person goes to
    find out if their cough is from common cold or from pneumonia,
    whether their headache is from stress, an impending stroke, or
    a brain tumor. They learn to identify and treat anxiety and
    depression. And they learn to treat pain, while minimizing a
    patient's risk of developing opioid dependence.
        Primary care saves lives and saves money, and the Teaching
    Health Center Graduate Medical Education Program helps solve
    our primary care crisis. However, it is 2 weeks away from
    extinction. We need it reauthorized now and at the level
    recommended in the HRSA-funded study published last year of
    $157,000 per resident per year. We need a 3-year authorization
    at $116.5 million per year so that centers will not terminate
    their training programs and continue recruiting new residents.
        When our center extends an offer to a resident, we make a
    commitment to them for 3 years. A 2-year Federal funding
    commitment is insufficient to stabilize our programs.
        In addition, we have had grossly inadequate funding for the
    past 2 years, as low as $95,000 per resident. As a result, some
    centers were forced to stop recruiting. In my program at the
    Institute, the decrease in funding from the initial level of
    $150,000 per resident per year created a loss of $2 million a
    year and forced us to reduce our Harlem residency from 36 to 18
    doctors.
        The McMorris Rodgers-Tsongas legislation funds $157,000 in
    training costs per resident for all 732 current residents and
    additional funds for up to 10 new programs. This will add
    another 120 primary care residents.
        In closing, I want to stress that the health of all
    Americans requires that the other programs that you will hear
    about today are also funded timely and adequately: the National
    Health Service Corps, which provides doctors who serve in our
    Nation's community health centers, the community health centers
    themselves that provide care to 24 million Americans, and Title
    VII and Title VIII, which support training in the critical
    disciplines of medicine, nursing, dentistry, and others.
        Thank you for giving me the opportunity to testify this
    morning.
        [The prepared statement of Dr. Calman follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. The chair thanks the gentleman.
        The chair observes that there is a vote on, on the floor,
    and we are going to need to take a recess in order to allow
    members to vote. Unfortunately, this is a fairly long series,
    so I can't tell you the exact timing, but the committee will
    reconvene after the series of votes concludes on the floor.
        The committee stands in recess.
        [Recess.]
        Mr. Burgess. We had heard testimony from Dr. Calman. I
    believe we are prepared to hear testimony from Dr. Billings.
        Dr. Billings, you are recognized for 5 minutes, please.

                      STATEMENT OF ADRIAN BILLINGS

        Dr. Billings. Thank you, Chairman.
        Chairman Burgess, Ranking Member Green, and members of the
    subcommittee, my name is Dr. Adrian Billings, and I am a full
    spectrum family medicine physician with Presidio County Health
    Services, a federally qualified health center practicing in
    rural Alpine, Texas. I am here today as a board member of the
    Association of Clinicians for the Underserved, which was
    founded by National Health Services Corps alumni over 20 years
    ago. The mission of the ACU is to improve the recruitment and
    retention of primary care providers in underserved communities,
    and the Corps is a critical component of that effort.
        I am also a fellow with the American Academy of Family
    Physicians, an organization that strongly supports the National
    Health Service Corps program. The Corps was created 45 years
    ago in a bipartisan manner, and since then, has proven to be a
    very effective program placing healthcare providers in our
    Nation's most medically underserved areas. As an alumnus of the
    National Health Service Corps scholarship program, I am honored
    to be here to describe the significance of this program upon
    medical students, healthcare professionals, and underserved
    communities.
        In 1999, as a first-year medical student, I
    enthusiastically submitted an application for the National
    Health Service Corps scholarship program, knowing that it would
    allow me to accomplish my dream of practicing family medicine
    on the Texas-Mexico border without the burden of school loans
    that may have forced me down a different path. After completing
    my family medicine residency and surgical obstetrics
    fellowship, I moved to Alpine to fulfill my Corps scholarship
    commitment. I fulfilled my 4-year commitment in the private
    practice option, as there was little in the way of healthcare
    infrastructure at the time. When I arrived in Alpine in 2007, I
    was one of only three family doctors in a 12,000 square mile
    area serving a total population of 25,000 patients in the vast
    Big Bend region. In those first 4 years of practice, I was on
    call 24 hours a day, 7 days a week. My work, although rewarding
    in many ways, was exhausting.
        I was able to graduate medical school debt free because of
    the National Health Service Corps. And I have chosen to stay
    because of the sense of calling I still feel to be practicing
    along the Texas-Mexico border. But our community needed more
    healthcare access, and so did I. So I made the decision to
    merge my private practice with a federally qualified health
    center in the neighboring community, Presidio County Health
    Services.
        Once we were part of PCHS, the practice received both
    Federal funding and malpractice coverage that enabled me to
    recruit family physician partners to share the load. Access was
    increased, and my working schedule became far more manageable.
    Thanks to Texas Tech University Health Science Center, I have
    hosted 300 medical students and residents, four of whom have
    returned to practice in the Big Bend region, which now has
    seven practicing family physicians up from three when I first
    arrived.
        I am pleased to report that my story is not rare among
    Corps alumni. A majority of Corps providers continue to
    practice in a shortage area 10 years after completing their
    service obligation, just as I have.
        In the last year, the Corps has placed more than 10,000
    providers, serving more than 11 million people.Despite this
    level of service, it would still require around 20,000 more
    providers to meet today's existing need of our Nation's 15,000
    designated shortage areas.
        While I could talk about the impact the Corps has had on me
    and my community all day long with you, I want to be sure to
    highlight the importance of preserving the program and the
    urgency of doing so. Without immediate action from this
    subcommittee, funding for the Corps will expire in 2 weeks.
    This potential lapse in funding will cause an immediate and
    severe impact in underserved areas across the country such as
    my own.
        No new awards or continuations will be made after October
    1, effectively eliminating the need for the next generation of
    Corps clinicians and jeopardizing access to healthcare services
    for millions of people, including my patients. The Corps will
    continue to function, but only administratively, not
    programatically. I can assure you as an alumnus that the Corps
    is one of the most effective programs this country has to
    enable clinicians like me to choose primary care and to serve
    in underserved communities.
        I truly believe that, based on the merits of the program,
    the Corps can withstand any kind of debate that focuses on
    value, impact, and long-term savings. We know that access to
    primary care saves lives and saves money. And the Corps is
    designed to increase access to primary care services where we
    need it most.
        I want to thank the subcommittee for the longstanding
    bipartisan support consistently shown for the Corps, and I
    appreciate the opportunity to testify before you today on
    behalf of the Corps, ACU, AASP, and most importantly, the
    millions of patients living in underserved communities who rely
    on healthcare services provided by Corps clinicians. Thank you.
        [The prepared statement of Dr. Billings follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. The chair thanks the gentleman for his
    testimony.
        Dr. Knebl, you are recognized for 5 minutes, please.

                      STATEMENT OF JANICE A. KNEBL

        Dr. Knebl. Thank you, Chairman.
        Dr. Burgess, Ranking Member Green, and distinguished
    members of the subcommittee, thank you for the opportunity to
    appear before you today and discuss the workforce programs
    under the Public Health Service Act on behalf of the Eldercare
    Workforce, which is a group of 31 national organizations
    representing consumers, family caregivers, healthcare
    professionals, that includes direct care workers joined
    together to address the immediate and future need for more
    expert health professionals to care for all of as we age.
        I am also very pleased to be joined by colleagues from
    across the country who work tirelessly to improve the health of
    our Nation's population.
        Today, I am here to discuss the Title VII Geriatrics Health
    Professions programs, which are focused on enhancing the
    ability of America's healthcare workforce to provide high-
    quality care for older adults. These Title VII funds support 44
    geriatric workforce enhancement programs we call GWEPs, and we
    are GWEPsters, which trained almost 19,000 emerging health
    workers or trainees in over 45 professions and disciplines from
    2015 to 2016 academic year.
        Collectively, the GWEPs are leveraging the skills of
    geriatric health professionals already in short supply across
    different professions to educate other members of the
    workforce, caregivers, and direct healthcare workers. Many of
    our trainees had little or no exposure to geriatric principles
    before our programs.
        I would like to tell you a story about how GWEP changes the
    lives in my home State of Texas, where the current population
    of older adults is 5.9 million and growing, so I have constant
    job opportunities in Texas. I am at the University of North
    Texas Health Science Center, located in Fort Worth, Texas,
    where I am faculty and I am a practicing geriatrician. Our GWEP
    is called the Workforce Enhancement and Healthy Aging and
    Independent Living, or the WE HAIL program.
        Since January of 2016, we have offered rural communities
    free programs focused on Alzheimer's disease education to
    almost 500 older adults and their family caregivers. Caregiving
    for someone with Alzheimer's disease is extremely stressful and
    unpredictable. I can speak to this, not only professionally,
    but personally as both my grandmothers and my mother now is
    afflicted with Alzheimer's disease. So we really need to try
    and reduce that stress and help them with problem-solving
    skills so that they can continue to keep their loved ones at
    home where they would like to have them.
        We have also had training for our physical therapy students
    and medical students in trying to teach older adults about
    falls prevention, which, as you know, can be very serious
    consequences for them. They participated in an evidence-based
    program called A Matter of Balance that is lay leader training.
    The students in turn then go out and do falls preventions
    workshop in senior centers. And we have basically gone to about
    14 of them, touching almost 300 older Texans.
        Across health professions training there is a paucity of
    content focused specifically on ensuring the healthcare
    workforce of tomorrow has the skills and competence to care for
    all of us as we age. Our GWEP is filling that role in Texas and
    the gap because we have trained, to date, almost 2,000 students
    to be our future doctors, nurses, social workers, pharmacists,
    physical therapists, dieticians, and physician's assistants,
    and we have them working as inner professional team training.
        We are also working with primary care practices, healthcare
    systems, and the aging network social services by training
    inner professional teams of current practicing professionals to
    try and help them with patient-centered primary care for older
    adults and looking into the new integrated delivery systems. In
    fact, we have six more training teams that are going to start
    Friday, tomorrow, at our university.
        This year, WE HAIL has received innovation awards from the
    National Association for the Area Agencies on Aging and the
    American Public Health Association. And we believe this
    demonstrates the widespread recognition for the need for high
    quality integrated and collaborative geriatrics training for
    health professions. There are 43 other GWEPs across the United
    States, and they are trying to improve this current and future
    care. But the need for the programs will be greater.
        As you know, by 2030, we are going to have 20 percent of
    our population over the age of 65, that will be about 70
    million people, and we already have about 19 million caregivers
    trying to help older adults. And our GWEPs, we are definitely a
    community of learners and collaborators. We love to share our
    ideas. We have a national GWEP network, the National
    Association of Geriatric Education and the John A. Hartford
    Foundation GWEP Coordinating Center out of the American
    Geriatric Society.
        I know that, like us, my colleagues at the other GWEPs are
    leveraging their GWEP funding to create lasting change on how
    they deliver care at their institutions and in their
    communities, and we are learning from each other about what
    works and what may not. We may be a small workforce, but we are
    mighty, and we are tireless advocates on behalf of improving
    the care for older adults.
        This funding offers each of us a platform for making that
    possible, for demonstrating how attention to core geriatric
    principles can improve the care we all provide. In just 1 year,
    according to the Health Resource Service Administration, we
    have collectively trained almost 19,000 trainees in over 45
    professions and disciplines. About 11 percent of our trainees
    come from disadvantaged backgrounds or underrepresented
    minorities in their chosen health professions, and we have
    partnered with almost 400 healthcare delivery sites to provide
    the trainees with that clinical training experiences in
    geriatrics. Thanks to our work, over 100,000 faculty and
    practicing professionals have experienced nearly 1,200
    continuing education programs. No surprise to someone who has
    worked in the field of geriatrics, about 75 percent of our GWEP
    graduates receive training in medically underserved
    communities, and upon completion of the training, are actually
    going to go back and serve in those communities.
        I am very grateful and encouraged by the hard work that
    this committee has done on the reauthorization of these
    programs. I am especially grateful to Representative Jan
    Schakowsky for her leadership in introducing the Geriatrics
    Workforce and Caregiver Enhancement Act legislation that would
    increase funding for the only Federal geriatrics program and
    reestablish the Geriatric Academic Career Award, which was a
    previously funded program for developing clinician educators
    that ensures that the geriatric academic workforce will be
    prepared to train our future geriatric workforce needs.
        So, Mr. Chairman, Dr. Burgess, Ranking Member Green, and
    distinguished members of the subcommittee, addressing the elder
    care workforce crisis and the other vital health professions
    programs under the Public Health Service Act is an opportunity
    we cannot afford to ignore. We appreciate the hard work the
    committee has undergone to reauthorize all the important health
    professions program. I thank you so much for this opportunity
    today, and I look forward to your questions.
        [The prepared statement of Dr. Knebl follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Doctor.
        Dr. Sebastian, you are recognized for 5 minutes, please.

                   STATEMENT OF JULIANN G. SEBASTIAN

        Ms. Sebastian. Good afternoon. My name is Juliann
    Sebastian, and I serve as the chair of the board for the
    American Association of Colleges of Nursing. I want to
    sincerely thank Chairman Burgess and Ranking Member Green for
    holding this important hearing, and for the opportunity to
    testify today on behalf of H.R. 959, the Title VIII Nursing
    Workforce Reauthorization Act of 2017.
        I would also like to extend my gratitude to two members on
    this subcommittee, Representatives Doris Matsui and Kathy
    Castor, who introduced this legislation with their bipartisan
    colleagues, Representatives David Joyce, Tulsi Gabbard, Rodney
    Davis, Suzanne Bonamici, and Patrick Meehan.
        I also wish to thank House Energy and Commerce Committee
    members who have cosponsored this legislation, Representatives
    Anna Eshoo and Eliot Engel.
        AACN represents 810 baccalaureate and graduate schools of
    nursing across all 50 states and the District of Columbia. Our
    membership extends to over half a million individuals,
    including 19,000 full-time faculty members, more than 497,000
    nursing students, and the deans who lead these institutions.
        AACN, along with 50 other national nursing organizations,
    fully supports the reauthorization of these programs. This bill
    is a necessary step toward ensuring that not only direct
    recipients continue to benefit from Title VIII, but that
    patients and communities across the country are afforded high-
    quality nursing care through a workforce that is highly
    educated, innovative, and diverse.
        At my school, Title VIII funding has provided vital
    learning and career opportunities for nursing students in each
    of our academic programs. As an example, Title VIII funding has
    allowed us to expand rural emergency and acute care courses for
    nurse practitioner students planning to work in critical access
    hospitals.
        Nebraska has a large number of critical access hospitals,
    64 in total. Many rely on nurse practitioners for important
    clinical care needs. Because nurse practitioners at critical
    access hospitals must be able to meet health needs across the
    gamut, from primary care, to urgent and emergency care, and
    critical care, our faculty are committed to finding ways to
    help students learn to meet the health needs across this full
    continuum.
        Our advanced rural hospital care program was initiated with
    Title VIII funds. So far, 34 nurse practitioners have completed
    courses that will help them meet needs in critical access
    hospitals, and another 14 nurse practitioner students are in
    process. Faculty also recently received Title VIII funding
    through the advanced nursing education workforce program that
    will expand the number of family nurse practitioner and
    psychiatric mental health nurse practitioners able to practice
    in rural and underserved areas.
        This grant allows us to support both students and the
    preceptors by using telehealth, which, as you know, is an
    increasingly important part of care in rural areas. The
    majority of the counties in our State are rural, so it is
    important to us to educate undergraduate and graduate students
    in this way. Mine is only one of hundreds of examples of how
    Title VIII dollars yield an invaluable return on investment.
        I would like to highlight a couple more stories. At
    Vanderbilt University School of Nursing in Nashville,
    Tennessee, Title VIII funding has been used to support nurse
    managed health clinics, which not only provide clinical
    training, but provide primary care services to over 900
    patients a year. Ninety percent of the individuals served by
    Vanderbilt's nurse managed clinic live below 200 percent of the
    Federal poverty line. From 2012 to 2016, the clinic improved
    blood pressure control in patients with hypertension from 18 to
    61 percent.
        Another example, at Western Carolina University School of
    Nursing, a recently graduated student received financial
    assistance through the Nursing Workforce Diversity Program,
    which aims to increase the number of individuals
    underrepresented in the profession of nursing. She was an honor
    student and has taken a position as a registered nurse in a
    rural community hospital in the western part of the state.
        I hope these several examples show how Title VIII is a
    critical pipeline for students, faculty, institutions, and the
    patients they serve.
        I thank the subcommittee members for this opportunity to
    share the tremendous impact of Title VIII programs and how its
    recipients' careers have and will continue to improve our
    Nation's health. I applaud the subcommittee for bringing H.R.
    959 to this hearing, as it is a necessary legislative step to
    modernize the programs and support America's patients, their
    families, and the communities in which they live. Thank you.
        [The prepared statement of Ms. Sebastian follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Guthrie [presiding]. Thank you.
        I thank the witnesses for their testimony, and we will now
    move to questions, the first portion of the Q&A. And I will
    begin the questioning and recognize myself for 5 minutes for
    that.
        For Dr. Calman, I like the approach that the Teaching
    Health Centers program helps local providers like community
    health centers grow their own workforce. Can you explain how
    this residency program boosts staff ranks at rural and
    community health centers over the long term?
        Ms. Calman. I am sorry, could you repeat the last sentence?
        Mr. Guthrie. Oh, could you explain how this residency
    program boosts the staff ranks at rural and community health
    centers over the long term?
        Dr. Calman. Sure. The program is really geared towards
    taking medical students and bringing them into programs in
    rural and underserved areas. And when they train in those
    areas, they have a much higher probability of staying in those
    areas. So if you think about bringing people who might normally
    train in a regular big hospital in the city, but now moving
    them out into the community for their 3 years, they develop
    relationships in those communities. It is a different style of
    practice to practice in a small rural community. You learn
    different skills, you learn to be more self-reliant, as Dr.
    Billings explained. You get a sense of self-reliance that
    allows you to go out into places where there are not a lot of
    doctors and not a lot of specialists. And so, we are creating
    that pipeline for people so that you can go into these
    communities and serve.
        Mr. Guthrie. Thank you.
        Dr. Knebl, in your testimony, you mentioned that a majority
    of geriatrics workforce graduates who receive this training
    announce commitments to further pursue training or in a
    practice in medically underserved communities. In your
    experience, how do these programs specifically help medically
    underserved communities?
        Dr. Knebl. So as we were talking about, number one, it is
    underserved, but through these programs, because they are
    interprofessional, we are training members of the whole
    healthcare team to go out. And so those trainees that will go
    out to those areas, obviously, will all then have more
    knowledge and skills. And I know that a lot of our trainees are
    going to these areas because we partner with our county
    hospital, John Peter Smith Hospital, which has one of the
    largest family medicine residencies in the whole country. And
    so they actually track where their residents are going.
        And so to have the enhanced training in geriatric care,
    where a lot of the older adults are actually living, if you
    look at the data as to rural communities, and so to get, then,
    those trainees back out there, along with, then, the other
    members of the healthcare team, nursing, physical therapy,
    pharmacy, PAs, et cetera, we believe that is going to help
    enhance that, and then the care ultimately for the older
    adults.
        Mr. Guthrie. OK. Good. This is for you, but I will also let
    Dr. Sebastian go first, and then anybody else can add to this.
    But many of the Title VII and VIII programs has curriculum
    development and continuing education components. How do your
    programs help the health professions workforce quickly adapt to
    the Nation's most pressing healthcare concerns? So how are the
    continuing education components of these programs addressing
    you in emerging public health issues? So Dr. Sebastian?
        Ms. Sebastian. The Title VIII funds are the ones I will
    speak to initially. And those funds, we are unable to secure
    those funds unless we propose programs that, in fact, are
    nimble and highly responsive to local healthcare concerns and
    to national health priorities. So the curricular enhancements
    and the curricular changes that are put in place as a result of
    these funds are inherently focused on contemporary issues, such
    as mental health concerns, education, and more primary care
    providers for rural and underserved areas, incorporation of
    telehealth, which I mentioned was one example in our local
    school, as well as the opioid crisis and more specific kinds of
    contemporary health issues.
        Mr. Guthrie. OK. Thank you.
        Dr. Knebl?
        Dr. Knebl. Yes. I will just add to that, that what we have
    tried to do out of the GWEPs, my personal GWEP, the WE HAIL
    program, we actually did a community needs assessment in
    collaboration with our health systems in our community. And we
    heard from them what the major issues were. And that then gave
    us the focus for the CME programs for the healthcare
    practitioners.
        So the areas that came up, just to share with you, is
    Alzheimer's disease, falls and fall prevention, medication
    management for older adults because of the challenges they can
    have, health literacy so that the healthcare workforce can
    speak in a way to that older adult and their family so they
    understand what they need to do, and chronic disease
    management. So we took what the community felt were the issues,
    and that is how we developed the curriculum that now we are
    disseminating, not only locally, but also throughout Texas and
    in many rural communities.
        Mr. Guthrie. Well, thank you very much. My time has just
    expired. So I will yield back, and I will recognize the ranking
    member, Mr. Green of Texas, for 5 minutes for questions.
        Mr. Green. Thank you, Mr. Chairman.
        Dr. Billings, I want to thank you for joining us, and the
    whole panel today. And I know we talked earlier about the
    National Health Service coordinated issue with community-based
    clinics. Dr. Billings, can you explain how the National Health
    Service Corps helps community health centers like the Presidio
    County Health service recruit providers?
        Dr. Billings. The National Health Service Corps is a vital
    workforce pipeline to community health centers throughout the
    country and our territories. Approximately 5,000 providers
    every year fulfill their loan repayment and/or scholarship
    repayment within a community health center. Without the
    National Health Service Corps, community health centers
    undoubtedly would close down because they would not have
    providers to take care of the patients.
        Mr. Green. I have a very urban district in Houston and our
    FQHCs are so valuable in our area, it is a safety net. By the
    way, this committee actually proposed, and we passed finally,
    to give volunteer doctors in FQHCs tort claims protections. So
    a doctor maybe wants to cut half their practice, they can still
    work and treat people.
        Could you explain what a failure of Congress to extend the
    National Health Service Corps would mean to community health
    centers like yours?
        Dr. Billings. That would be in 2 weeks when we go off the
    cliff, if we go off the cliff, there will be an immediate
    cessation of loan repayment beginning October, November. That
    is the first round of loan repairs. So there will be an
    immediate and drastic effect on taking care of patients and the
    patients that need the access to care the most.
        Mr. Green. Thank you.
        Dr. Sebastian, the numbers I have heard, according to the
    Health Resources and Service Administration, we are expected to
    experience a nursing shortage of approximately 150,000 people,
    2030. I understand that one cause for this is shortage of
    sponsors in nursing schools due to the limited supply of
    nursing faculty. Would you elaborate on the challenges
    attracting students and professionals into the nursing faculty
    workforce?
        Ms. Sebastian. Yes. Nursing faculty, one of the challenges
    that we experience is the competition in terms of wages with
    the clinical practice arena. So that is often a big challenge
    in terms of recruiting nursing faculty. We are working very
    hard and, actually, with the support of the Nurse Faculty Loan
    Program, to attract more students into faculty roles. And that
    particular component of Title VIII has been very helpful to
    attract students who then can, in fact, look towards some
    relief from their loans as a result of the provisions of the
    Nurse Faculty Loan Program.
        Mr. Green. Some numbers we see is that graduations in
    baccalaureate programs in nursing, U.S. nursing schools turned
    away 64,000 qualified applicants from baccalaureate or graduate
    studies in 2016 due to the insufficient number of faculty,
    clinical sites, classroom space, clinical preceptors, and
    budget constraints. Most nursing schools responding to the
    survey pointed that the faculty shortage is the reason for not
    accepting all of these qualified applicants.
        How does Title VIII programs help increase the supply of
    nursing faculty and the number of students accepted in nursing
    programs?
        Ms. Sebastian. Well, a prime example is the Nurse Faculty
    Loan Program, and as you pointed out, all of those factors
    influence our ability to hire faculty, not just the salary
    issue. Salaries have actually improved in some components of
    the nursing faculty ranks, but also issues related to budget,
    inability to provide additional clinical site placements. So I
    would say that the Nurse Faculty Loan Program is one huge
    example.
        But the other opportunities that are provided by the
    advanced nurse education workforce, which is a slightly new
    program this year, help us get more students into graduate
    programs, who then may be interested in the future in faculty
    careers.
        Mr. Green. Thank you. Mr. Chairman, I yield back my time.
        Mr. Burgess [presiding]. The chair thanks the gentleman.
    The gentleman yields back.
        The chair recognizes the gentleman from Florida, Mr.
    Bilirakis, 5 minutes for questioning.
        Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it so
    much, and I thank the panel for their testimony today.
        Dr. Knebl, according to the Alzheimer's Association, more
    than 5 million Americans are living with this disease, with
    projections rising up to 16 million by 2050. How do these
    geriatric workforce programs integrate Alzheimer's disease and
    related dementias education to families and caregivers of older
    adults?
        Dr. Knebl. Well, thank you so much for that question. We
    actually had an opportunity to have a separate addition onto
    our grant funding to actually address the Alzheimer's disease
    and related disorders education. How we are doing it, and I can
    give you that example from our program, is that we actually
    have partnered with the North Central Texas Chapter of the
    Alzheimer's Association, in addition to a dementia-specific
    care center, in terms of delivering certain types of programs
    actually to patients and their caregivers. There are evidence-
    based programs. One is a stress-busting program, one is a REACH
    program where you actually are able to send in a dementia care
    specialist into the home to give the family member respite and
    also education. And so we are doing that collaboration with
    those programs and actually assisting them with some funding to
    expand the reach.
        We then also have our students as part of this so that then
    they can learn from this, and some of our family medicine
    residents are actually getting to get exposure to these
    programs.
        Another thing we are doing is, you know now we have the
    Medicare Annual Wellness Visit, where you have to do screening
    for memory disorders. So what we are doing through our county
    hospital--and many people don't know how we got this to happen
    and I probably shouldn't say it too loud, because maybe they
    will say don't do it. But, basically, what they are doing is we
    have an electronic health record at the county hospital called
    Epic, and some of you may be familiar with that.
        So through the Epic, we are now building platforms within
    it to be able to more adequately assess older adults,
    particularly those with cognitive impairment. We then make
    referrals to the community-based organizations, such as
    Alzheimer's Association. They can now look at the Epic
    platform. We are giving them access so they can see what is
    going on with that patient. They can then follow up. They can
    then reach out to the family to help them, and then they put
    notes in there about what their providing to that patient and
    family that then when the primary care doctor sees the patient
    back in the clinic, we see it. We close the loop between the
    primary care doctor, the referral to the community agency, and
    we make sure that patient and family is getting taken care of.
    So that is something we are doing out of our GWEP that I am
    very excited about.
        Mr. Bilirakis. Can I ask you, when you said the welcome to
    Medicare, which actually my dad, Congressman Bilirakis,
    authored many years ago, so I want to brag about that.
        Dr. Knebl. You should.
        Mr. Bilirakis. He is a wonderful person, and he has done an
    outstanding job over the years. But does that include a mental
    health screening? Is it required? It is required?
        Dr. Knebl. Yes. Well, we are adding in extra tools, because
    this is a geriatric clinic that is out of our county hospital.
    So we are putting mental health for depression screen, we are
    doing fall risk assessments, we are doing basic assessments of
    daily living, instrumental daily living. We are doing all those
    types of assessments as part of this. So there might be a
    patient that is determined to be a fall risk, we will then
    refer them to the senior citizens services, it is called 60 and
    Better, who does the congregant meal programs and actually
    provides the Matter of Balance classes. We would then have that
    person follow up. And again, they would have access to seeing
    the information.
        Mr. Bilirakis. How widespread is that throughout the United
    States, what you are doing?
        Dr. Knebl. It is not. Our hope is, if you are
    reauthorizing, we can now apply to now take this out beyond
    Fort Worth, Texas.
        Mr. Bilirakis. OK. Thank you.
        A question for Dr. Billings. You and your colleagues are
    certainly no strangers to the growing shortage of medical
    professionals across the country. And someone probably has
    touched on this, but in your testimony, you acknowledged the
    National Health Service Corps as an effective, even popular way
    to overcome the recruitment barrier for medical shortage areas.
    What other ways are stakeholders working together to recruit
    and retain medical talent in historically underserved areas,
    and why are they not as successful? And how can they be
    improved?
        Dr. Billings. Sure. Thank you for the question. So through
    the National Health Service Corps, there is a state loan
    repayment component where approximately at least 37 states take
    advantage of Federal money to utilize in for state-specific
    needs that perhaps health professional shortage area scores
    don't go down low enough to fund because of the overwhelming
    need that is out there in the United States.
        Currently, only 10 percent of scholarship applicants are
    able to be funded every year, and only 40 percent of loan
    repayment applicants are currently funded. There is certainly a
    huge need, and there is interest by health students throughout
    the disciplines, and we are not meeting that need for the
    interest that the students have, that want to go into primary
    care. And we want to be able to enable that.
        The other huge need is, of course, we have about 10,000
    field strengths within the National Health Service Corps every
    year. To meet the need of the patients, the health centers, the
    critical access hospitals, the rural health clinics, the Bureau
    of Prisons, Indian Health Service facilities, we need a field
    strength of 28,000 to meet the basic need of today. There is
    just a huge need. There is a lot of work to be done, and it is
    very, very important that we continue to support and enable
    these students that have expressed a desire to go out and serve
    the underserved, that we somehow enable them to realize that
    dream and train them in that setting as well.
        Mr. Bilirakis. OK. Thank you.
        I yield back, Mr. Chairman.
        Mr. Burgess. The gentleman's time has expired.
        The chair recognizes the gentlelady from California, Ms.
    Eshoo, 5 minutes for questions, please.
        Ms. Eshoo. Thank you, Mr. Chairman.
        I want to thank each one of you for what you do, first of
    all. I want to thank you for the passion that you have brought
    into this hearing room. A lot of hearings are very dry, and
    they are always full of important information. But there is no
    doubt in my mind, and I think all of my colleagues, that you
    care so deeply, so passionately about what you do. I think you
    are a blessing to the American people. You really are, and I
    thank you for that.
        I am really privileged to represent Lucile Packard
    Children's Hospital, Stanford University Medical Center, and,
    of course, the school. All of these issues are interwoven into
    my congressional district, as well as a community health center
    in one of--most people don't think that there are poor people
    in Silicon Valley, but there are, there are. There are really
    underserved people that now are being served so much better
    because of the new community health center in East Palo Alto,
    which has always been a poor community.
        So, the extensions of these programs and the Affordable
    Care Act, as well as the Teaching Health Center Graduate
    Medical Education, which was established in the Affordable Care
    Act, are a real source of pride to me in supporting them and in
    the architecture that the ACA had, underappreciated by some,
    unknown by others, but certainly you have highlighted what that
    infrastructure--we talk about infrastructure in the country.
    You have spoken to a magnificent part of the infrastructure of
    our country and how we need to build on that, because there are
    communities that are in need, certainly in rural areas of our
    country and elsewhere. So thank you again.
        I wanted to come back mostly to thank you. I have a flight
    to catch in just a little while, so I will be real quick with
    my questions.
        To Dr. Billings, are there other specialties within primary
    care, dental, and mental health that could benefit from being
    eligible to participate in the Public Health Service Corps?
        Dr. Billings. That is a really great question. And that has
    been a source of debate for many, many years. We know the need
    for meeting comprehensive primary care with the current funding
    level of the National Service Corps is not being met. That is
    evident in the 10,000 field strength that we have. Yet the need
    is for 28,000 participants to meet the basic need of
    comprehensive primary healthcare that we need. We would be more
    than happy to have a conversation once we are meeting in a
    current comprehensive primary care need of expanding that.
        One of my biggest challenges as a boots on the ground
    physician is, when I reach my level of I feel that my patient
    needs to go to a specialist, how do I get them to one? Who is
    accepting Medicaid?
        Ms. Eshoo. I was successful at adding a provision in the
    21st Century Cures Act that designated pediatric mental health
    professionals to be eligible. A little bit of a fight to do
    that, but I prevailed, so that they could participate in the
    Public Health Service Corps. So I appreciate your sharing that
    with me.
        Is the program's current per resident funding level
    appropriate? Who can answer that?
        Dr. Calman. Yes, I guess that is for me. So the Teaching
    Health Center Graduate Medical Education program was originally
    funded, as you said, at a level of $150,000 per resident per
    year. So that was based on a historical analysis of what it
    costs to train a resident.
        What actually ended up happening when it was reauthorized
    was people forgot to take account of the fact that the number
    of programs had been growing, and also the programs had been
    ramping up from just having first-year residents to having
    first, second, and third-year residents. As a result of that,
    the funding was reduced to $95,000 per resident per year, which
    is really only two-thirds of the dollars that are needed to
    support just the resident salaries and the faculty salaries in
    those program. That number is now to up to $116,000.
        And so the program should be happy that they got a little
    bit more money, but not happy about how it happened. How it
    happened was programs dropped out at the lower reimbursement
    level. They couldn't support the residents, they couldn't
    support the faculty. And so we lost a lot of training slots
    through this new program.
        As you said, when you think about a program starting, the
    remarkable thing was there are 57 new programs that developed
    across the country in the short period of time that this
    program's been in existence. All of them geared towards one
    thing: training doctors for underserved rural and urban
    communities. Fifty-seven new programs that just literally grew
    out of nowhere, got accredited, went through the enormous
    accreditation process, and all expecting that the funding would
    be there to continue.
        And so we are really in crisis now and about to lose more
    programs. Two more programs closed just at the beginning of
    this academic year. A critical program in inner city Detroit
    and a program in rural Oklahoma, both lost, programs that had
    been started up through the initial funding but couldn't
    sustain themselves on the inadequate funding that we currently
    get.
        Ms. Eshoo. Well, we obviously need to reauthorize. That is
    absolutely essential, it is critical. But we can't be self-
    congratulatory by simply doing that. I think that you have all
    made the case, the nurses, everything that you are doing at the
    county hospital, that the funding has to be appropriate for it.
        Dr. Calman. Totally.
        Ms. Eshoo. No one sends their kids off to college and says,
    well, I am going to pay for room and board, but I am not paying
    for your tuition. What kind of a deal is that? So we have work
    to do, and I hope the outcome will be worthy of the work that
    you do----
        Dr. Calman. Thank you very much.
        Ms. Eshoo [continuing]. And what you have chosen to do with
    your lives. You really are great Americans. Thank you.
        Dr. Calman. Thank you.
        Ms. Eshoo. God bless you. Thank you.
        Mr. Burgess. The gentlelady's time has expired.
        The chair recognizes the gentlelady from Washington, Mrs.
    McMorris Rodgers, 5 minutes for questions, please.
        Mrs. McMorris Rodgers. Thank you.
        And I agree, I still admire the work that you do, and I
    appreciate your commitment moving forward.
        Just a few questions. Dr. Calman, I wanted you to address,
    and I know this has probably somewhat been addressed in other
    questions, but how would your health center be able to make up
    for the loss in funding for each residency slot if the THCGME
    program is allowed to expire on September 30? If this is even
    financially possible, how would shifting these dollars impact
    core primary care services for your patients?
        Dr. Calman. So it is not really possible. The community
    health centers that are the sponsors of the vast majority of
    the Teaching Health Center slots really don't have excess
    income. And so, what we have really seen is a loss of program
    slots. You really can't sustain the program on inadequate
    funding. We lost 170 positions since the start of this program
    just a few years ago with the reduction in the funding that
    came with the last inadequate reauthorization. These are 170
    doctors that would have been out practicing in needy
    communities that can't be replaced at this point.
        And so we will continue to lose slots. We will continue to
    see programs close, like the two that I just talked about that
    have just closed, because you can't sustain the funding for
    these programs. These are real costs.
        The difference between this program and regular graduate
    medical education is that we are accountable for every dollar.
    Every dollar goes to either a resident's salary, a faculty
    member's salary, or other program costs that we have to account
    for in every allocation.
        Mrs. McMorris Rodgers. So the legislation H.R. 3394
    provides funding for 3 years at, roughly, $157,000 per resident
    per year. Would you address why this level is so important to
    the teaching health centers like mine in Spokane and across the
    country?
        Dr. Calman. Sure. So in the original authorization of this
    program, there was a demand that the Secretary get an outside
    entity to do a study of the actual cost of residency training,
    and that study revealed that the actual costs were $157,000 per
    resident per year, on average. So if the funding isn't
    reauthorized at that level, we are basically putting the
    program in deficit to start. And you can't really do that.
        And I think we really have to see this as an investment.
    This is an investment, because in every study of primary care,
    the more primary care providers you have in a community, the
    lower the healthcare costs in that community. The more
    specialists you have in a community, the higher the healthcare
    costs in that community. So this is an investment. We are
    investing in the training of primary care people to reduce
    healthcare costs and to be able to provide better care in
    communities that have no doctors at this point or few doctors.
        Mrs. McMorris Rodgers. So building on that just a little
    bit, would you agree that the THCGME program is accomplishing
    the objectives Congress laid out when it was established? And
    how does your association know that this program is actually
    producing physicians that go on to practice in primary care?
        Dr. Calman. So we tract outcomes. This is an outcome-based
    program, like all grant programs. And so we can tell you that
    the percentage of regular graduates that go into primary care
    is normally 23 percent. Eighty-two percent of the Teaching
    Health Center graduates stay in primary care. There are twice
    as many that stay in underserved areas. There are four times as
    many that stay in rural areas, and 18 times as many graduates
    of teaching health center programs go into community health
    centers, federally qualified community health centers, than
    come out of the normal GME program. So we are responsible for
    outcomes.
        And, in fact, in your current legislation, there is a whole
    new set of criteria and outcome measures that must be reported
    from the programs around the country.
        Mrs. McMorris Rodgers. Thank you, Dr. Calman.
        I have several letters of support in favor of H.R. 3394
    that I would like to submit for the record.
        And with that, I yield back.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. The chair thanks the gentlelady. The
    gentlelady yields back.
        The chair recognizes the gentleman from New York, 5 minutes
    for questions, please.
        Mr. Engel. Thank you very much. And I would like to throw
    my lot in with Congresswoman McMorris Rodgers.
        I am glad, Dr. Calman, that you explained about the
    September 30 deadline. And I want to particularly welcome you,
    since----
        Dr. Calman. Thank you.
        Mr. Engel [continuing]. I am a fellow New Yorker. You do
    good work in my home city, and we thank you and your very good
    institution for what it does.
        H.R. 3394, sponsored by Congresswoman McMorris Rodgers,
    would provide a 3-year extension to the teaching health center
    program. I wanted to focus on that.
        I have heard from advocates that an extension of at least 3
    years is critical. So, Dr. Calman, can you explain why the
    program would benefit from a longer term extension?
        Dr. Calman. Sure. When we bring a new resident into our
    program, we commit to them for the full length of their primary
    care training, which is 3 years. So the residents know this.
    And we get questions from applicants. The average program that
    runs a teaching health center gets over a 1,000 applications
    for a handful of positions. The residents that we want----
        Mr. Engel. It is like the House of Representatives.
        Dr. Calman. The residents we want are obviously the best
    and most committed people. They come in and they ask, how do I
    know you are going to be able to complete my training? How do
    you know that you are going have the funds to complete the
    training? Because the teaching health center funds expire in
    very short term. And so it is based on that commitment.
        That commitment is built into the accreditation that we all
    had to get because the ACGME, the accrediting entity, says that
    once we take a resident, we are responsible for the completion
    of their training in our program. And so, we need long-term
    funding in order to provide that security to the program
    applicants and also to the programs.
        Mr. Engel. Well, thank you. And H.R. 3394 also contains
    additional funding for expansion of the program. So let me ask
    you again, Dr. Calman, is there currently demand for new
    teaching health centers and new residency slots in the program?
        Dr. Calman. So there is enormous demand. As I said, our own
    program gets over 1,500 applications for eight positions. So we
    know there is demand for more residency training slots. We also
    know that there is demand for new programs, because as
    president of the American Association of Teaching Health
    Centers, I get these inquiries all of the time. We get calls
    from community health centers saying they really are interested
    in building this sort of pipeline track within their programs
    by starting a training program, because maybe that area of
    their state has had a problem recruiting or a problem
    maintaining an adequate workforce.
        And so all over the country there are places that are
    contemplating starting new training programs. And the only
    thing standing between this and a much larger solution to our
    Nation's primary care crisis is the level of funding and the
    number of programs we can fund, because every program trains
    exclusively in primary care, and according to the new
    legislation that is proposed, would be training people in
    underserved communities.
        Mr. Engel. Thank you. I hope we can pass this bipartisan,
    bicameral bill as soon as possible so that teaching health
    centers can continue to provide much needed care to our
    communities.
        I want to take this opportunity to raise another program
    facing September 30 deadline, and that is community health
    centers. I have heard from community health centers in my
    district concerned about this approaching deadline. And one
    organization I have heard from is HRH Care, which operates two
    centers in my district, but serves about 14,000 of my
    constituents. And here is what they told me: They said that if
    Congress fails to authorize community health centers, in the
    next 2 weeks, centers will be forced to eliminate the Medicaid-
    assisted treatment needed by New Yorkers and others struggling
    with addiction to opioids, and centers will end weekend and
    evening hours, making it much harder for working families to
    get to a doctor. The list goes on.
        So I want to commend the chairman for having today's
    discussion, but obviously, we cannot have it take place in a
    vacuum. Congress must enact a long-term, well-funded extension
    of the community health center program without delay, and the
    health of all of our constituents is at stake.
        So thanks to all the witnesses. Thank you, Dr. Calman.
    Thank you, Mr. Chairman. I yield back.
        Mr. Burgess. The chair thanks the gentleman. The gentleman
    does yield back.
        I recognize myself for questions.
        And, Dr. Calman, let me, just as a point of clarification,
    but for someone who is watching this hearing today, I don't
    want them to get the mistaken impression that you are paying
    your residents $157,000 a year.
        Dr. Calman. Oh, thank you. We wouldn't have any problem
    recruiting.
        Mr. Burgess. That is exactly right. When I was a resident
    at Parkland Hospital, my first year, I think it was well under
    $10,000 that we earned. But that is the total cost of providing
    that educational experience, correct?
        Dr. Calman. Exactly. It pays for the residents' salary, all
    the faculty salaries, all the administration of the program,
    all of the people who are doing recruiting and everything else,
    and substantial faculty, because these programs require
    faculty. Remember that in primary care, you are being trained
    to cross a broad range of areas, and so the faculty have to be
    able to teach people how to do minor surgical techniques, and
    they have to be able to train in OB/GYN, and they have to be
    able to train in train across a broad range of areas.
        So all of those costs are built into the 157. It is a total
    cost of training.
        Mr. Burgess. And I do want to point out that this
    committee, early in the year, passed the Improving Access to
    Maternity Care Act, to expand the ability to place maternity
    healthcare providers in medically underserved areas. It
    actually passed on the floor of the House and is awaiting
    activity over in the Senate.
        There is a recurring theme here that you may encounter
    awaiting activity over in the Senate. I shared Mr. Engel's
    concern that we finish up our work and both houses get the work
    done and get the programs approved.
        Let me just ask Dr. Billings and Dr. Knebl, we have the
    National Health Service Corps that focuses on the distribution
    of primary care providers, and then Title VII and Title VIII
    that we are also talking about this morning. So how do Title
    VII and Title VIII collaborate with the National Health Service
    Corps? What is the coordination between those programs? And,
    Dr. Knebl, let me start with you, and then, Dr. Billings, I
    would like your input.
        Dr. Knebl. So some of the focus, obviously, for us is
    really the geriatric training under the Geriatric Workforce
    Enhancement Programs, and that is to really try to enhance the
    education in geriatrics for primary care, and also for the
    whole primary care health profession team.
        So I would say that I see the inner phase because we are
    very focused on assisting primary care programs to increase the
    geriatric content in education. And everything that we develop
    is to be shared among all types of education programs in the
    area of primary care. And then, as we were talking about
    earlier, the continuing medication education programs for
    people in practice.
        So that we are taking a multipronged approach. We are
    starting in the undergraduate area of education for health
    professions, then into the residency programs, but then also
    when people are in practice.
        So I would say the different products and programs that we
    develop are then applicable and able to be utilized in these
    primary care residency programs.
        Mr. Burgess. Great.
        Dr. Billings.
        Dr. Billings. Healthcare is delivered by a team. It is not
    the physician. It is not a midlevel provider. It is truly a
    team. And the Title VII and Title VIII dovetail very well with
    the National Health Service Corps and with regards to the
    training of the students that are entering into service in the
    National Health Service Corps. The Area Health Education
    Programs that are funded through these programs help to place
    students in underserved areas for their training. So it is just
    vital. We are a team.
        Mr. Burgess. Thank you.
        And, Dr. Sebastian.
        Ms. Sebastian. Yes, I see the National Health Service Corps
    program and Title VIII, particularly, as very complementary. So
    the National Health Service Corps Program provides scholarship
    and loan repayment for students such as nurse practitioner
    students. Close to 90 percent of nurse practitioners actually
    practice in primary care areas, again, as part of a team.
        Title VIII provides some funding to students, but also
    funding for the other costs associated with educating students,
    the cost of placing them in underserved areas, faculty
    supervision, the curricular issues that we want to provide for
    the students--or the curricular opportunities we wish to
    provide for the students.
        So the two programs are in fact very complementary and I
    think work very well side by side.
        Mr. Burgess. Very well. Thank you.
        I want to thank all of you for being here today. And I
    apologize that we had the interruption for votes in the middle
    of the hearing. It is an important hearing, quite clearly.
        But seeing that there are no further members wishing to ask
    questions, once again, we extend our thanks to the witnesses.
        We have received outside feedback from a number of
    organizations on these bills, so I would like to submit
    statements from the following for the record: the Eldercare
    Workforce Alliance, the Health Professions and Nursing
    Education Coalition, the Healthcare Leadership Council, Doctors
    Hospital at Renaissance, the National Association for Geriatric
    Education, and of course, the statement from our colleague who
    was here earlier, Congressman Denham, also, the American
    Association of Nurse Anesthetists.
        Without objection, so ordered, those comments will be part
    of the record.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. Pursuant to committee rules, I remind members
    they have 10 business days to submit additional questions to
    our panel for the record. And I ask the witnesses to submit
    their response to those questions within 10 business days of
    receipt of those questions.
        Without objection then, the subcommittee stands adjourned.
        [Whereupon, at 1:12 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

                     Prepared statement of Hon. Greg Walden

        Today, our country is on the precipice of a health provider
    shortage, impairing our ability to meet the increasing demand
    for services, especially in primary care. Underserved areas,
    like many of the rural counties in eastern Oregon, are acutely
    experiencing this shortage now. That is why it is so important
    that the federal government maintain its long-standing
    investment in the education and training of health
    professionals.
        Today's hearing will examine four health professional
    education and training programs that will prepare current and
    future clinicians to meet the nation's growing health needs and
    increase access to care. We will hear testimony from experts
    who are here to speak about the successes and challenges facing
    the different types of workforce programs under the Public
    Health Service Act.
        Dr. Neil Calman, President and CEO of the Institute for
    Family Health, will speak about the Teaching Health Center
    Graduate Medical Education program, which supports the training
    of residents in primary care.
        Dr. Adrian Billings, Medical Director of Presidio County
    Health Services will share his experience in the National
    Health Service Corps, a program that has been improving
    recruitment and retention of health practitioners in
    underserved areas through scholarships and loan repayments
    since the 1970s.
        Both of these programs face a reauthorization deadline. It
    is my goal to move forward in a bipartisan manner on these
    extenders before the end of the month and ensure they are fully
    and responsibly offset.
        We will also hear from Dr. Janice Knebl, Chair and
    Professor in Geriatrics at the University of North Texas Health
    Science Center about Chairman Burgess's H.R. 3728, EMPOWER Act
    of 2017, which reauthorizes health professions workforce
    programs under Title VII of the Public Health Service Act. This
    reauthorization includes the re-organization of the geriatric
    health professional grant program to reflect changes that the
    Health Resources & Services Administration has pursued to
    improve outcomes for geriatric patients.
        Finally, we will hear from Dr. Juliann Sebastian, Dean of
    University of Nebraska's College of Nursing, about
    Representative Joyce's H.R. 959, the Title VIII Nursing
    Workforce Reauthorization Act of 2017, important legislation
    that reauthorizes critical nursing education workforce
    development programs under Title VIII of the Public Health
    Service Act.
        These are important programs that we rely on, in one way or
    another. I'd like to thank our witnesses for being here with us
    today to give an update on how these programs are performing,
    so we can identify the best path forward in supporting their
    critical services.
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                 Prepared statement of Hon. Frank Pallone, Jr.

        I'm pleased we are holding this hearing to discuss programs
    critical to the success of our health workforce. A strong
    health workforce is the bedrock of a strong health system
    overall. It's essential that we continue to sufficiently invest
    in all our health workforce programs to ensure they are meeting
    the country's needs.
        The National Health Service Corps (NHSC) Program provides
    financial support to health professional students and primary
    care providers who commit to provide service in medically
    underserved areas. The incentives provided by this program help
    place providers in the communities that need them the most.
    However, without congressional action, funding for NHSC will
    expire on September 30, 2017. I strongly support extending
    funding for this program.
        Similar to NHSC, funding for the Teaching Health Center
    Graduate Medical Education (THC GME) Program is also set to
    expire at the end of the fiscal year. Teaching Health Centers
    train primary care medical and dental residents in community
    based settings such as Community Health Centers. THC graduates
    are far more likely to remain in primary care and to practice
    in rural and underserved communities compared to traditional
    GME graduates. Without renewed funding before September 30th
    THC residencies could potentially be interrupted or terminated.
    I strongly support H.R. 3394, introduced by Representative
    McMorris Rodgers (R-WA), which would fund the program for 3
    years at an improved funding level. H.R. 3394 would provide
    THCs the financial stability they need to adequately train a
    class of residents.
        H.R. 3728, the Education Medical Professionals and
    Optimizing Workforce Efficiency and Readiness (EMPOWER) Act of
    2017, introduced by Representatives Burgess (R-TX), Schakowsky
    (D-IL), and Bucshon (R-IN), would reauthorize the programs in
    Title VII of the Public Health Service Act that received
    funding through the FY 2017 Appropriations process. Title VII
    programs provide valuable training to our nation's healthcare
    professionals. I support the reauthorization of these programs
    and thank the bill's sponsors for their work on this issue.
        Finally, H.R. 959, the Title VIII Nursing Workforce
    Reauthorization Act of 2017 would reauthorize the Title VIII
    programs that received funding through the FY 2017
    Appropriations process. Programs in Title VIII of the Public
    Health Service Act improve nursing education, practice,
    recruitment, and retention. A well trained nursing workforce
    benefits all Americans and I strongly support these programs. I
    thank the bill's sponsors, Representatives Joyce (R-OH) and
    Matsui (D-CA), for their bipartisan work on this issue.
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