[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.
                              ----------                              


             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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