[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]



 
                   INVESTING IN AMERICA'S HEALTHCARE

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              JUNE 4, 2019

                               __________

                           Serial No. 116-40
                           
                           
                           
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                          
                           


      Printed for the use of the Committee on Energy and Commerce

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                            ______                       


             U.S. GOVERNMENT PUBLISHING OFFICE 
40-565 PDF             WASHINGTON : 2021                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
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, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina,     Ranking Member
    Vice Chair                       FRED UPTON, Michigan
DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
    Massachusetts                    SUSAN W. BROOKS, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                                CONTENTS

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     1
    Prepared statement...........................................     3
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     4
    Prepared statement...........................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     8
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................    10
    Prepared statement...........................................    12

                               Witnesses

C. Dean Germano, Chief Executive Officer, Shasta Community Health 
  Center.........................................................    13
    Prepared statement...........................................    16
    Answers to submitted questions...............................   274
Diana Autin, Executive Codirector, SPAN Parent Advocacy Network..    29
    Prepared statement...........................................    31
Aaron J. Kowalski, Ph.D., President and Chief Executive Officer, 
  JDRF...........................................................    46
    Prepared statement...........................................    48
Lisa Cooper, M.D., Bloomberg Distinguished Professor of Medicine, 
  Johns Hopkins Medicine.........................................    53
    Prepared statement...........................................    55
    Answers to submitted questions...............................   276
Thomas R. Barker, Partner, Cochair, Healthcare Practice, Foley 
  Hoag...........................................................   113
    Prepared statement...........................................   115
    Answers to submitted questions...............................   279
Mary-Catherine Bohan, Vice President, Outpatient Services, 
  Rutgers University Behavioral Health Care......................   120
    Prepared statement...........................................   122
    Answers to submitted questions...............................   280
Michael Waldrum, M.D., Chief Executive Officer, Vidant Health....   130
    Prepared statement...........................................   132
Frederic Riccardi, President, Medicare Rights Center.............   134
    Prepared statement...........................................   136
    Answers to submitted questions...............................   282

                           Submitted Material

H.R. 1767, the Excellence in Mental Health and Addiction 
  Treatment Expansion Act........................................   163
H.R. 1943, the Community Health Center and Primary Care Workforce 
  Expansion Act of 2019..........................................   165
H.R. 2328, the Community Health Investment, Modernization, and 
  Excellence Act of 2019.........................................   169
H.R. 2668, the Special Diabetes Program Reauthorization Act of 
  2019...........................................................   172
H.R. 2680, the Special Diabetes Programs for Indians 
  Reauthorization Act of 2019....................................   174
H.R. 2815, the Training the Next Generation of Primary Care 
  Doctors Act of 2019............................................   176
H.R. 2822, the Family-to-Family Reauthorization Act of 2019......   181
H.R. 3022, the Patient Access Protection Act.....................   183
H.R. 3029, the Improving Low Income Access to Prescription Drugs 
  Act of 2019....................................................   185
H.R. 3030, the Patient-Centered Outcomes Research Extension Act 
  of 2019........................................................   190
H.R. 3031, a Bill to amend title XVIII of the Social Security Act   192
H.R. 3039, a Bill to provide for a 5-year extension of funding 
  outreach and assistance for low-income programs................   194
Statement of the American Osteopathic Association, et al., June 
  4, 2019, submitted by Ms. Eshoo................................   198
Letter of June 3, 2019, from the American Federation of State, 
  County and Municipal Employees to Ms. Eshoo and Mr. Burgess, 
  submitted by Ms. Eshoo.........................................   200
Letter of June 3, 2019, from Stacy Chamberlin, Executive 
  Director, Oregon AFSCME Council 75, to Ms. Eshoo and Mr. 
  Burgess, submitted by Ms. Eshoo................................   202
Letter of June 3, 2019, from Susan M. Cleary, President, AFSCME 
  District 1199J, and Joseph Masciandaro, President and Chief 
  Executive Officer, CarePlus NJ, to Ms. Eshoo and Mr. Burgess, 
  submitted by Ms. Eshoo.........................................   204
Letter of June 3, 2019, from Thomas P. Nickels, Executive Vice 
  President, American Hospital Association, to Mr. Engel, 
  submitted by Mr. Engel.........................................   206
Letter of May 6, 2019, from Thomas P. Nickels, Executive Vice 
  President, American Hospital Association, to Ms. Matsui, 
  submitted by Ms. Eshoo.........................................   207
Statement of the Endocrine Society, undated, submitted by Ms. 
  Eshoo..........................................................   209
Letter of May 9, 2019, from Ms. DeGette and Hon. Tom Reed, a 
  Representative in Congress from the State of New York, et al., 
  to Hon. Nancy Pelosi, Speaker of the House, and Hon. Kevin 
  McCarthy, Republican Leader, submitted by Ms. Eshoo \1\
Letter of May 31, 2019, from the Friends of NQF Steering 
  Committee to Hon. Judy Chu, a Representative in Congress from 
  the State of California, et al., submitted by Mr. Engel........   212
Letter of June 4, 2019, from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Mr. Pallone and Mr. Walden, 
  submitted by Ms. Eshoo.........................................   214
Statement of the American Academy of Family Physicians, June 4, 
  2019, submitted by Ms. Eshoo...................................   216
Letter of May 17, 2019, from Ceci Connolly, President and Chief 
  Executive Officer, Alliance of Community Health Plans, to Mr. 
  Pallone, et al., submitted by Ms. Eshoo........................   220
Letter of May 28, 2019, from Kevin Longing, Chief Executive 
  Officer, and Holly Mattix-Kramer, President, National Kidney 
  Foundation, to Hon. Chuck Grassley, Chairman, and Hon. Ron 
  Wyden, Ranking Member, Senate Finance Committee, submitted by 
  Ms. Eshoo......................................................   222
Letter of May 13, 2019, from Friends of PCORI Reauthorization to 
  Mr. Pallone, et al., submitted by Ms. Eshoo....................   225
Statement of the PCORI Board of Governors by Grayson Norquist, 
  Chairperson, June 4, 2019, submitted by Ms. Eshoo..............   232
Statement of the Council of Academic Family Medicine, June 4, 
  2019, submitted by Ms. Eshoo...................................   245
Letter of May 14, 2019, from Richard J. Fiesta, Chair, Leadership 
  Council of Aging Organizations, to Hon. Richard Neal, Chairman, 
  and Hon. Kevin Brady, Ranking Member, House Ways and Means 
  Committee, et al., submitted by Ms. Eshoo......................   248
Statement of the Children's Hospital Association, June 4, 2019, 
  submitted by Ms. Eshoo.........................................   252
Letter of May 13, 2019, from Mr. Engel and Mr. Olson, to Hon. 
  Nancy Pelosi, Speaker of the House, and Hon. Kevin McCarthy, 
  Republican Leader, submitted by Ms. Eshoo......................   253
Statement of America's Essential Hospitals, June 4, 2019, 
  submitted by Ms. Eshoo.........................................   269

----------

\1\ The letter has been retained in committee files and also is 
available at https://docs.house.gov/meetings/IF/IF14/20190604/109583/
HHRG-116-IF14-20190604-SD022.pdf.
Letter of February 6, 2019, from Laura J. Warren, Executive 
  Director, Texas Parent to Parent, to Mr. Burgess, submitted by 
  Mr. Burgess....................................................   271
Family-to-Family Health Information Center letters from Pip 
  Marks, Project Director, Family Voices of California, et al., 
  to Representatives in Congress,bmitted by Ms. Eshoo \2\
Letter of June 4, 2019, from Sister Carol Keehan, President and 
  Chief Executive Officer, Catholic Health Association of the 
  United States, to Ms. Eshoo, submitted by Ms. Eshoo............   273

----------

\2\ The letters have been retained in committee files and also are 
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=109583.


                   INVESTING IN AMERICA'S HEALTHCARE

                              ----------                              


                         TUESDAY, JUNE 4, 2019

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:01 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Engel, Butterfield, 
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas, 
Welch, Ruiz, Dinged, Kuster, Kelly, Barragan, Blunt Rochester, 
Rush, Pallone (ex officio), Burgess (subcommittee ranking 
member), Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, 
Bucshon, Brooks, Carter, Gianforte, and Walden (ex officio).
    Also present: Representatives Schakowsky, Soto, O'Halleran, 
and Rodgers.
    Staff present: Joe Banez, Professional Staff Member; 
Jeffrey C. Carroll, Staff Director; Luis Dominguez, Health 
Fellow; Waverly Gordon, Deputy Chief Counsel; Tiffany 
Guarascio, Deputy Staff Director; Stephen Holland, Health 
Counsel; Zach Kahan, Outreach and Member Service Coordinator; 
Josh Krantz, Policy Analyst; Una Lee, Chief Health Counsel; 
Aisling McDonough, Policy Coordinator; Meghan Mullon, Staff 
Assistant; Samantha Satchell, Professional Staff Member; 
Kimberlee Trzeciak, Chief Health Advisor; Rick Van Buren, 
Health Counsel; C. J. Young, Press Secretary; S. K. Bowen, 
Press Assistant; Jordan Davis, Minority Senior Advisor; 
Margaret Tucker Fogarty, Minority Staff Assistant; Caleb Graff, 
Minority Professional Staff Member, Health; Ryan Long, Minority 
Deputy Staff Director; J. P. Paluskiewicz, Minority Chief 
Counsel, Health; Brannon Rains, Minority Legislative Clerk; and 
Kristen Shatynski, Minority Professional Staff Member, Health.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order. The Chair now recognizes herself for 5 minutes for an 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Welcome to the witnesses. We are delighted to have you here 
and look forward to hearing from you.
    Today, the subcommittee will consider 12 bills to extend 
critical public health programs and invest in Medicaid and 
Medicare services.
    These are programs that Congress has previously authorized, 
but most will expire on September 30th. So Congress has to act 
now to ensure their ongoing benefits.
    We are going to hear testimony about the bipartisan bills 
to extend and invest in the following programs, several that 
were authored by members of this subcommittee. This is a long 
list: Community Health Centers, National Health Service Corps, 
Teaching Health Centers for Graduate Medical Education, the 
Special Diabetes Program and the Special Diabetes Program for 
Indians, Family-to-Family Health Information Centers, the 
Patient-Centered Outcomes Research Institute, State Health 
Insurance Programs, Area Agencies on Aging, Aging and 
Disability Resource Centers, the National Center for Benefits 
and Outreach Enrollment, the National Quality Forum, Certified 
Community Behavioral Health Clinics, Disproportionate Share 
Hospitals, and the Medicare Limited Income NET Program.
    Many of these programs are stuck in a biennial cycle where 
they may expire because of Congress' inaction. Can I just ask 
that the committee be in order? There is a low undertone here. 
I will finish as quickly as possible and then make sure that I 
am not talking when you are.
    So today we are consider reauthorizing these programs for a 
longer time frame, giving them the certainty and the stability 
to conduct long-term planning to better serve patients and the 
American taxpayer.
    I want to highlight a few of these important programs. 
First, we are considering expanding several types of health 
centers that serve our communities in very unique ways.
    The Community Health Center Fund provides funding to nearly 
12,000 health center locations across our country. That takes 
my breath away--12,000 health center locations.
    These health centers provide primary care to one in 13 
Americans, regardless of their ability to pay. Building on the 
Community Health Center model is the Excellence in Mental 
Health and Addiction Treatment Expansion Act, authored by 
Representatives Matsui and Mullin.
    This important bill expands funding for certified community 
behavioral health clinics to 11 more States, and that is very, 
very important.
    As we face a mental healthcare shortage, we have to do more 
to expand access. In my State of California, Californians say 
their community does not have enough mental health providers to 
serve local needs.
    Another center serving the community are the Family-to-
Family Health Information Centers, or the F2F grant program. 
F2Fs assist families with children who have special health 
needs to make informed choices about healthcare.
    F2Fs are staffed by family members who have firsthand 
experience in navigating special needs healthcare services. 
Community Health Centers, Certified Community Behavioral Health 
Clinics, and the F2F Health Information Centers provide unique 
services for the specific populations.
    We are also considering other programs to improve access to 
vital primary care, including the Special Diabetes Program and 
funding for Disproportionate Share Hospitals, which we all know 
goes to hospitals that serve lower-income Americans.
    Other programs conduct needed research to make sure we are 
providing quality care. The Patient-Centered Outcomes Research 
Institute and the National Quality Forum help our Nation's 
clinicians deliver quality care to more people at a lower 
price.
    Finally, we are strengthening Medicare through stronger 
enrollment support and help for low-income beneficiaries. 
Today's hearing is critically important to make sure millions 
of our fellow Americans receive quality healthcare.
    I stand ready to work with every colleague to make sure 
these programs are expanded and extended.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    Today, the subcommittee will consider 12 bills to extend 
critical public health programs and invest in Medicare and 
Medicaid services.
    These are programs that Congress has previously authorized, 
but most will expire on September 30th and Congress must act to 
ensure their ongoing benefits.
    We will hear testimony about the bipartisan bills to extend 
and invest in the following programs, several that were 
authored by members of this subcommittee:
     Community Health Centers;
     National Health Service Corps;
     Teaching Health Centers for Graduate Medical 
Education;
     The Special Diabetes Program and the Special 
Diabetes Program for Indians;
     Family-to-Family Health Information Centers;
     The Patient-Centered Outcomes Research Institute;
     State Health Insurance Programs;
     Area Agencies on Aging;
     Aging and Disability Resource Centers;
     The National Center for Benefits and Outreach 
Enrollment;
     The National Quality Forum;
     Certified Community Behavioral Health Clinics;
     Disproportionate Share Hospitals; and
     The Medicare Limited Income NET Program.
    Many of these programs are stuck in a biennial cycle where 
they may expire because of Congress' inaction. Today, we will 
consider reauthorizing some of these programs for a longer 
timeframe, giving them the certainty and stability to conduct 
long-term planning to better serve patients and the American 
taxpayer.
    I want to highlight a few of these important programs.
    First, we're considering expanding several types of health 
centers that serve our communities in unique ways.
    The Community Health Center Fund provides funding to nearly 
12,000 health center locations across our country. These health 
centers provide primary healthcare to one in 13 Americans, 
regardless of their ability to pay.
    A Community Health Center in my district, the Asian 
Americans for Community Involvement Health Center, provides 
services through a multilingual team of doctors, nurses, and 
patient navigators. This Health Center's team can speak up to 
40 languages to make sure that vulnerable ethnic communities in 
my District are well served.
    Building on the Community Health Center model is the 
Excellence in Mental Health and Addiction Treatment Expansion 
Act, authored by Representatives Matsui and Mullin. This 
important bill expands funding for Certified Community 
Behavioral Health Centers to 11 more States.
    As we face a mental healthcare shortage, we must do more to 
expand access. In my State, half of all Californians say their 
community does not have enough mental health providers to serve 
local needs.
    Another center serving the community are the Family-to-
Family Health Information Centers, or F2F grant program. F2Fs 
assist families with children who have special health needs to 
make informed choices about healthcare. F2Fs are staffed by 
family members who have firsthand experience in navigating 
special needs healthcare services.
    Community Health Centers, Certified Community Behavioral 
Health Centers, and the F2F Health Information Centers provide 
unique services for the specific populations that benefit 
greatly from these programs.
    We're also considering other programs to improve access to 
vital primary care, including the Special Diabetes Program and 
funding for Disproportionate Share Hospitals which goes to 
hospitals that serve lower-income Americans.
    Other programs conduct needed research to make sure we're 
providing quality care. The Patient-Centered Outcomes Research 
Institute and the National Quality Forum help our Nation's 
clinicians deliver quality care to more people at a lower cost.
    Finally, we're strengthening Medicare through stronger 
enrollment support and help for low-income beneficiaries.
    Today's hearing is critically important to make sure 
millions of Americans receive quality healthcare. I stand ready 
to work with my colleagues to make sure these programs are 
extended and expanded.

    Ms. Eshoo. So the Chair now has the pleasure of recognizing 
Dr. Burgess, the ranking member of the Subcommittee on Health, 
for 5 minutes for his opening statement.

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

    Mr. Burgess. I thank you for the recognition, and once 
again today we are considering legislation to reauthorize vital 
public health programs which expire in the coming months.
    So this hearing is timely and, in fact, I am legitimately 
getting worried because that time between now and September 
30th always goes by so fast.
    We are out the month of August, and there are always plenty 
of other competing things that are going on in the House of 
Representatives. So this is great that we are getting down to 
this.
    Community Health Centers, Teaching Health Centers, Special 
Diabetes Programs, Family-to-Family Health Information Centers 
are the bipartisan programs that make a real impact in 
providing access to quality healthcare for Americans.
    The Community Health Center in my district, Health Services 
of North Texas, conducted more than 50,000 patient visits for 
more than 14,000 patients in 2017.
    Community Health Centers are the front lines for caring for 
some of the most vulnerable individuals in our communities, and 
there is bipartisan support for extending this and other public 
health programs.
    Reauthorizing these programs can take a substantial amount 
of time, and I hope that we are able to accomplish these 
reauthorizations prior to the end of the fiscal year.
    I do remain concerned that these bills have funding 
increases but no offsets. Additionally, the language in the 
Community Health Center reauthorization bill does not include 
Hyde protections, which have long been bipartisan and were 
included in the Alexander-Murray Senate companion bill.
    By not including these protections, the majority puts the 
effort to reauthorize these critical programs at risk, and we 
do have to worry about the ability to move them forward if that 
position does not change.
    Again, I hope we can work in a bipartisan manner to get 
these reauthorizations across the finish line in a timely 
manner. In an effort to do so, I introduced H.R. 2700, which 
would use the $5 billion in offsets from the drug pricing bills 
that passed through this subcommittee with unanimous support 
and use that to pay for 1 year of public health extenders.
    While 1 year is not a long enough extension, I thought it 
was important to show our commitment to reauthorizing these 
programs in a fiscally responsible way.
    In fact, every Republican Member of the Energy and Commerce 
Committee is a cosponsor of H.R. 2700.
    The Patient-Centered Outcomes and Research Institute is 
another program up for reauthorization, and I am interested in 
learning today from our witnesses what the return on investment 
has been and what we have learned from the comparative clinical 
effectiveness research.
    Additionally, there are a number of Medicaid deadlines 
looming, the most significant of which is for the mandatory 
cuts to the Disproportionate Share Hospitals.
    The bill before us today, H.R. 3022, entirely eliminates 
the DSH cuts. So OK, I am supportive of delaying DSH for 2 
years or repealing them for 2 years, as Representative Olson 
does in H.R. 3054.
    However, eliminating the cuts entirely would prove a costly 
task and preclude us from making any valuable changes, changes 
that DSH payments desperately need if they are going to have a 
meaningful relationship to the level of uncompensated care that 
is actually being provided at the State level.
    A 2-year delay would provide Congress with ample time to 
revisit DSH and make any changes necessary to improve both the 
efficiency and the effectiveness.
    MACPAC recently recommended three policy changes to improve 
the structure of these DSH allotment reductions, and we should 
take the time to revisit this topic and engage with 
stakeholders to pave a smooth path forward.
    Another Medicaid topic that is absent from today's 
discussion is reauthorizing Medicaid for Puerto Rico and our 
other territories. We must remember that the individuals 
reliant on Medicaid and the territories are American citizens, 
and they are some of the most vulnerable.
    Letting Medicaid funding for these individuals lapse would 
be disappointing and unfair to those living in the territories. 
And let us be clear, finding enough money to adequately fund 
the territories will be much more difficult if we are paying 
for a permanent elimination of the DSH cuts.
    And I do have a letter from the Association of Hospitals of 
Puerto Rico, who dealt with the Medicaid cliff. The coming 
uncertainty it has created over the past decade--this was 
before Hurricane Maria--over the past decade has been a major 
contributing factor to the loss of doctors, specialists, and 
health professionals in the island of Puerto Rico.
    Reauthorizing these public health programs and delaying the 
DSH cuts are important in maintaining access and quality for 
healthcare for Americans.
    I do hope we will be able to work in a way that will ensure 
that we get the legislation to the President's desk prior to 
the end of the fiscal year.
    I remain concerned that the total cost of these bills could 
exceed $50 billion, with no offsets identified to pay for the 
policies.
    So I thank you for having the hearing today, and I will 
yield back the balance of my time.
    [The prepared statement of Mr. Burgess follows:]

             Prepared Statement of Hon. Michael C. Burgess

    Today we are considering legislation to reauthorize vital 
public health programs, which expire in the coming months. 
Community Health Centers, Teaching Health Centers, the Special 
Diabetes Programs, and Family-to-Family Health Information 
Centers are bipartisan programs that make a real impact in 
providing access to quality healthcare for Americans. The 
Community Health Center in my district, Health Services of 
North Texas, conducted more than 50,000 patient visits for more 
than 14 thousand patients in 2017.
    Community Health Centers are on the front lines of caring 
for some of the most vulnerable individuals in our communities, 
and there is bipartisan support for extending this and other 
public health programs. Reauthorizing these programs can take a 
substantial amount of time, and I certainly hope that we will 
be able to accomplish these reauthorizations prior to the end 
of the fiscal year. I do remain concerned, however, that these 
bills have funding increases but include no offsets. 
Additionally, the language in the Community Health Centers 
reauthorization bill does not include Hyde protections, which 
have long been bipartisan and were included in the Alexander-
Murray Senate companion bill. By not including these 
protections, the Majority puts the effort to reauthorize these 
critical programs at risk, and I worry about the ability to 
move them all forward if that position does change.
    Again, I do hope that we can work in a bipartisan manner to 
get these reauthorizations across the finish line in a timely 
manner. In an effort to do so, I introduced H.R. 2700, which 
would use the $5 billion in offsets from the drug pricing bills 
that passed through this committee with unanimous support to 
pay for 1 year of public health extenders. While 1 year is not 
a long extension, I thought it was important to show our 
commitment to reauthorizing these programs in a fiscally 
responsible way. In fact, every Republican Member of the Energy 
and Commerce Committee is a cosponsor of H.R. 2700.
    The Patient-Centered Outcomes Research Institute is another 
program up for reauthorization. I am particularly interested in 
learning from our witnesses what the return on investment has 
been, and what we have learned from comparative clinical 
effectiveness research.
    Additionally, there are a number of Medicaid deadlines 
looming, the most significant of which is for mandatory cuts to 
Disproportionate Share Hospitals. The Majority bill before us 
today, H.R. 3022, entirely eliminates the DSH cuts. I am 
supportive of delaying DSH cuts for 2 years or repealing them 
for 2 years as Rep. Olson does in H.R. 3054. However, 
eliminating the cuts entirely would prove a costly task and 
preclude us from making any valuable changes--changes DSH 
payments desperately need if they are to have a meaningful 
relationship to the level of uncompensated care actually being 
provided at the State level.
    A 2-year delay would provide Congress with ample time to 
revisit DSH and make any changes necessary to improve upon both 
efficiency and effectiveness. MACPAC recently recommended three 
policy changes to improve the structure of these DSH allotment 
reductions, and we should take the time to revisit this topic 
and engage with stakeholders to pave a smooth path forward.
    Another Medicaid topic that is absent from today's 
conversation is reauthorizing Medicaid for Puerto Rico and our 
other territories. We must remember that the individuals 
reliant upon Medicaid in the territories are American citizens, 
and that they are some of the most vulnerable. Letting Medicaid 
funding for these individuals lapse would be disappointing and 
unfair to those living in our territories. And let me be clear, 
finding enough money to adequately fund the territories will be 
much more difficult if we are paying for a permanent 
elimination of the DSH Cuts, etc.
    Reauthorizing the public health programs and delaying DSH 
cuts are important in maintaining access to quality healthcare 
for Americans. I hope that we will be able to work in a 
bipartisan way to ensure that we get legislation to the 
President's desk prior to the end of the fiscal year. I remain 
concerned that the total cost of these bills could exceed $50 
billion and that no offsets have been identified to pay for 
these policies. Additionally, we have another $8-10 billion at 
a minimum, we will have to spend on Medicaid funding for the 
territories. I hope we can work together to resolve these 
issues before the end of September so that we can keep our 
promise to the Americans who rely upon these programs and 
resources.

    Ms. Eshoo. The gentleman yields back.
    We do plan to have a hearing on the issue of Medicaid in 
Puerto Rico, Dr. Burgess. And before I move on to Mr. Pallone, 
I want to point out that we have some very special guests here 
this morning with us, and you see them with the bright blue 
ribbons on them.
    They are representing foster children from across our 
country. So welcome to each one of you. We are thrilled that 
you are here.
    [Applause.]
    Ms. Eshoo. And as a former foster mom, an extra special 
welcome.
    Now, I have the privilege of recognizing the chairman of 
the full committee, Mr. Pallone, for 5 minutes for his opening 
statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Madam Chair.
    Today we are examining 12 pieces of legislation that make 
critical investments in programs supporting Medicare, Medicaid, 
public health and our Nation's health workforce.
    It is critical that we come to bipartisan agreement on 
these bills because, without congressional action, many of 
these programs will expire on September 30th.
    On our first panel we will discuss several public health 
initiatives, including three programs that play an essential 
role in America's health workforce, and these are the Community 
Health Center Fund, the National Health Service Corps, and the 
Teaching Health Center Graduate Medical Education Program.
    A strong health workforce is the foundation of a strong 
health system. It is essential that we continue to invest in 
these programs that are working to train providers and place 
them in communities where they are needed the most.
    And today, nearly 12,000 Community Health Centers provide 
essential care to millions of patients across the country. I am 
grateful to my colleagues, Representatives Clyburn and 
O'Halleran, for their leadership in providing robust funding 
for both Community Health Centers and the National Health 
Service Corps, which offers loan forgiveness to health 
professionals who commit to provide service in medically 
underserved areas.
    I would also like to thank Representative Ruiz for his 
leadership on legislation to reauthorize the Teaching Health 
Center Program, which trains primary care residents in 
community-based settings such as Community Health Centers.
    I am also proud to be a long-time advocate for the Family-
to-Family Health Information Center Program and strongly 
support Representative Sherrill's legislation to reauthorize 
it.
    This program helps families of children with special 
healthcare needs get the information and support needed to 
provide the best care possible for their children.
    On our second panel will examine proposals related to the 
Medicare and Medicaid programs. We will discuss a proposal led 
by Representative Engel that would permanently eliminate the 
cuts to hospital funding that Congress has been forced to delay 
over and over again every year.
    Medicaid Disproportionate Share Hospital funds, or DSH 
funds, provide critical financial support to hospitals that 
care for some of the most vulnerable.
    Without action by Congress, DSH funding will be cut by $4 
billion in October of this year. These cuts will place an 
incredible strain on hospitals that are already struggling to 
provide care to children with complex medical needs, low-income 
Americans, and rural communities, and I commend Representative 
Engel for his efforts to permanently eliminate these harmful 
cuts.
    We will also get an update on a demonstration in Medicaid 
to increase access to comprehensive mental health and substance 
use disorder treatments through certified community behavioral 
health clinics.
    Every day, 130 people in the U.S. die from an opioid 
overdose. As our country continues to struggle through this 
terrible epidemic, clinics in the States participating in this 
demonstration have had remarkable success at improving access 
to care, including 24-hour crisis care, and I thank 
Representatives Matsui and Mullin for their work to extend and 
expand this important program.
    So I just want you to know I am committed to working with 
all of my colleagues to advance all these important programs 
before the September 30th deadline.
    It is also my hope that we can find a way to provide 
longer-term extensions so that those who operate or receive 
services from these programs have greater certainty.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today we are examining 12 pieces of legislation that make 
critical investments in programs supporting Medicare, Medicaid, 
public health, and our Nation's health workforce. It's critical 
that we come to bipartisan agreement on these bills because 
without Congressional action many of these programs will expire 
on September 30th.
    On our first panel, we'll discuss several public health 
initiatives including three programs that play an essential 
role in America's health workforce; these are the Community 
Health Center Fund, the National Health Service Corps, and the 
Teaching Health Center Graduate Medical Education program.
    A strong health workforce is the foundation of a strong 
health system. It's essential that we continue to invest in 
these programs that are working to train providers and place 
them in communities where they're needed the most.
    Today, nearly 12,000 Community Health Centers provide 
essential care to millions of patients across the country. I'm 
grateful to my colleagues Representatives Clyburn and 
O'Halleran for their leadership in providing robust funding for 
both Community Health Centers and the National Health Service 
Corps, which offers loan forgiveness to health professionals 
who commit to provide service in medically underserved areas.
    I would also like to thank Representative Ruiz for his 
leadership on legislation to reauthorize the Teaching Health 
Center program, which trains primary care residents in 
community-based settings such as Community Health Centers.
    I'm also proud to be a longtime advocate for the Family-to-
Family Health Information Center program and strongly support 
Representative Sherrill's legislation to reauthorize it. This 
program helps families of children with special healthcare 
needs get the information and support needed to provide the 
best care possible for their children.
    On our second panel, we'll examine proposals related to the 
Medicare and Medicaid programs. We'll discuss a proposal led by 
Representative Engel that would permanently eliminate the cuts 
to hospital funding that Congress has been forced to delay year 
after year. Medicaid Disproportionate Share Hospital funds, or 
DSH (DISH) funds, provide critical financial support to 
hospitals that care for some of our most vulnerable.
    Without action by Congress, DSH funding will be cut by $4 
billion in October of this year. These cuts will place an 
incredible strain on hospitals that are already struggling to 
provide care to children with complex medical needs, low-income 
Americans, and rural communities. I commend Representative 
Engel for his efforts to permanently eliminate these harmful 
cuts.
    We'll also get an update on a demonstration in Medicaid to 
increase access to comprehensive mental health and substance 
use disorder treatment through certified community behavioral 
health clinics. Every day, 130 people in the United States die 
from an opioid overdose. As our country continues to struggle 
through this terrible epidemic, clinics in the States 
participating in the demonstration have had remarkable success 
at improving access to care, including 24-hour crisis care. I 
thank Representatives Matsui and Mullin for their work to 
extend and expand this important program.
    I'm committed to working with all of my colleagues to 
advance all of these important programs before the September 
30th deadline. It is also my hope that we can find a way to 
provide longer-term extensions so that those who operate or 
receive services from these programs have greater certainty.
    Thank you to all of the witnesses for being here today.

    Mr. Pallone. And now I would like to yield the remainder of 
my time to Congressman O'Halleran. Oh, down there.
    Mr. O'Halleran. Thank you, Chairman Pallone, Ranking Member 
Walden, Congresswoman Eshoo, and Ranking Member Burgess for 
allowing me to join the subcommittee hearing this morning on 
two very important pieces of legislation I am proud to have 
introduced.
    First, the Community Health Investment Modernization and 
Excellence Act would reauthorize and provide moderate increases 
in funding for Community Health Centers, the National Health 
Service Corps, over a period of 5 years.
    These services are vital for rural and medically 
underserved areas including the 1st District of Arizona where 
18 federally funded health community organizations provide care 
for nearly 200,000 patients.
    Second, the Special Diabetes Program for Indians is an 
incredibly important program and has been successful in 
lowering rates of diabetes across Indian country.
    I have seen firsthand how these communities have long been 
disproportionately impacted by diabetes. Prior to the inception 
of this program, the prevalence of this disease was increasing 
among the American Indian and Alaska Native communities.
    A lot of it is because of food also, not just exercise, but 
the fact that these are food deserts, for the most part, and 
50, 100 miles round trip to get to food at all.
    Unfortunately, rates of diabetes in these populations 
remain higher than any other group. We have more work to do. It 
is my hope that as we move forward that we realize that these 
programs are vital to Native Americans across our country.
    And I yield back.
    Ms. Eshoo. The gentleman yields back.
    I would like to recognize a former Member of Congress 
that's here with us today and was a member of the Energy and 
Commerce Committee, Phil Gingrey--I am sorry. I wanted to 
pronounce it right. Dr. Phil, that's right. Another Dr. Phil. 
Welcome. It is great to see you.
    [Applause.]
    Ms. Eshoo. OK. Now I would like to introduce the first 
panel of witnesses for today's hearing.
    Mr. Walden. Madam Chair?
    Ms. Eshoo. Yes. Oh, I am sorry. The gentleman from Oregon, 
the ranking member of the full committee. I am sorry. I 
apologize.
    Mr. Walden. Thank you. We will move on. Not a problem at 
all.
    Ms. Eshoo. I apologize. You have 5 minutes.
    Mr. Walden. Not 6?
    Ms. Eshoo. Five wonderful minutes.
    Mr. Walden. I have one----
    Ms. Eshoo. Five and a half. How is that?
    Mr. Walden. OK. I will try----
    Ms. Eshoo. For my blunder.
    Mr. Walden [continuing]. To knock this out faster than 
that.
    Ms. Eshoo. Yes.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Good morning. Good morning to our panelists and 
everybody here.
    This is a really important day and marks an important step 
for the committee's work to examine legislation that really 
strengthens our healthcare safety net by extending these 
critical programs.
    These programs, which have long enjoyed, and I think you 
have heard this this morning, strong bipartisan support, 
include Community Health Centers, Teaching Health Centers, the 
National Health Service Corps, Special Diabetes Programs, and 
more.
    Each program plays a very significant role in our Nation's 
safety net for millions of Americans, especially the medically 
underserved who face barriers to accessing care.
    In my own district in Oregon, we have 12 Community Health 
Centers. They serve 240,000 people through 63 different 
locations. So we need to work together to both strengthen this 
program and the others that we are examining today.
    In the last Congress, I helped lead the effort to provide 
record funding for our Community Health Centers and reauthorize 
and fund these other programs.
    We did it in a bipartisan way, and we got it into law. We 
are also reviewing legislation that extends the Patient-
Centered Outcomes Research Institute, the Excellence in Mental 
Health Demonstration Program, and legislation repeals part of 
the Affordable Care Act's requirement that DSH hospitals suffer 
these payment cuts.
    I want to raise a couple of concerns at the beginning for 
my colleagues as we begin this reauthorization process. I am 
concerned that the language in the Teaching Health Center 
reauthorization bill may have some unintended consequences for 
the program and the legislation reauthorizing the Community 
Health Centers does not include the Hyde language, as we have 
discussed previously, which Congress has consistently supported 
and renewed annually on a bipartisan basis multiple times and 
for decades.
    In addition, I am concerned most of the bills we are 
reviewing significantly increase the authorization levels but 
don't identify pay-fors to keep the promise of higher funding 
levels.
    And while we are the authorizing committee--I understand 
that--we also know it is a bit of a false promise to set a high 
reauthorization level without also doing the heavy lift to 
figure out how to pay the bill, because we are going to get 
called upon to do that.
    A significant concern is H.R. 3022, the bill to eliminate 
DSH cuts, giving hospitals relief from the cuts that were 
called for under the Affordable Care Act.
    Let me be clear. Republicans have never supported the DSH 
cuts and worked successfully to prevent them. But we should not 
surrender completely our ability to reform and modernize the 
program to ensure that funding is actually directed to those 
that it was intended to be used for.
    In fact, in March of this year, MACPAC's own report states, 
and I quote, ``The commission has long held that DSH payments 
should be better targeted to hospitals that serve a high share 
of Medicaid-enrolled and low-income uninsured patients and have 
higher levels of uncompensated care consistent with the 
original statutory intent of the law establishing DSH 
payments,'' closed quote.
    In other words, we should make sure the law is working as 
intended.
    I am pleased to see the bipartisan commitment to continuing 
to fund the Excellence in Mental Health Demonstration. As one 
of the eight States to be awarded funding, Oregon has seen 
significant and positive results that truly helped my State's 
residents.
    In fact, recently I met with providers at a certified 
community behavioral health clinic in southern Oregon that's 
involved in this demonstration. The initial findings show they 
are achieving great results in the community. So count me as a 
fan.
    The demonstrations are created to determine if new programs 
actually work, and we need to get the results of this 
demonstration before we dramatically expand it, as the 
legislation we are viewing today would do by adding 11 States 
to the program.
    My legislation, H.R. 3074, the Continuing Access to Mental 
and Behavioral Health Care Act, would extend funding for the 
original eight States for an additional 2 years so we can 
complete the demonstration project and get the data that 
taxpayers really deserve.
    I am disappointed, Madam Chair, that the committee did not 
include in this hearing H.R. 2700, the Lowering Prescription 
Drug Costs and Extending Community Health Centers and Other 
Public Health Priorities Act.
    Republicans are serious about our commitment to responsibly 
extend these critical public health programs with bipartisan 
offsets, and I am not sure why our legislation was excluded 
from the discussions today.
    We, obviously, will work together as we have to avoid 
unnecessary shutdown of these programs in September when their 
authorizations expire.
    So we look forward to working with you and others on the 
committee. I look forward to hearing from our witnesses today.
    And thank you, Madam Chair, and I yield back. I would say 
as a footnote I know several of us have the other hearing 
upstairs we have to get back and forth to.
    But thank you for being here, and thanks for the great work 
you and the people represented in this room do for our citizens 
back home.
    I yield back.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    Today marks an important step forward in this committee's 
work to examine legislation that strengthens our healthcare 
safety net by extending critical public health programs.
    These programs, which have long enjoyed strong bipartisan 
support, include Community Health Centers, Teaching Health 
Centers, the National Health Service Corps, and the Special 
Diabetes Programs. Each program plays a significant role in our 
Nation's safety net for millions of Americans, especially the 
medically underserved who face barriers to care. In my rural 
district in Oregon, we have 12 Community Health Centers that 
serve more than 240,000 Oregonians across 63 delivery sites, so 
we need to work together to strengthen this program and the 
others we are examining today. I led the effort in the last 
Congress to provide record funding for America's Community 
Health Centers--and we did it in a bipartisan effort.
    We are also reviewing legislation that extends the Patient-
Centered Outcomes Research Institute, the Excellence in Mental 
Health Demonstration Program, and legislation that repeals the 
part of Obamacare that requires cuts to Disproportionate Share 
Hospital (DSH) payments.
    I want to raise a couple of concerns for my colleagues as 
we begin this reauthorization process. I am concerned that 
language in the Teaching Health Center reauthorization bill may 
have some unintended consequences for the program, and the 
legislation reauthorizing the Community Health Centers does not 
include Hyde language, which Congress has consistently 
supported and renewed annually on a bipartisan basis, multiple 
times, for decades.
    In addition, I'm concerned that most of the bills we are 
reviewing significantly increased the authorized funding 
levels, but don't identify pay-fors to keep the promise of 
higher funding levels. And while we are the authorizing 
committee, we all know it's a false promise to set a high 
reauthorization level without doing the heavy lift of figuring 
out how to pay the bill.
    Of significant concern is H.R. 3022, the Democratic bill to 
eliminate the DSH cuts--giving hospitals relief from cuts 
established under Obamacare. Let me be clear, Republicans have 
never supported the DSH cuts and worked successfully to prevent 
them, but we should not surrender our ability to reform and 
modernize the program to ensure that funding is directed to 
those that need it.
    In March of this year, MACPAC report's own report points 
out, and I quote: ``The Commission has long held that DSH 
payments should be better targeted to hospitals that serve a 
high share of Medicaid-enrolled and low-income uninsured 
patients and have higher levels of uncompensated care, 
consistent with the original statutory intent of the law 
establishing DSH payments.'' We should make sure the law is 
working as intended.
    I am pleased to see the bipartisan commitment to continue 
funding for the Excellence in Mental Health Demonstration. As 
one of the eight States to be awarded funding, Oregon has seen 
significant, positive results that have truly helped 
Oregonians. I recently met providers at a certified community 
behavioral health clinic in southern Oregon that is involved in 
this demonstration. The initial findings show they're achieving 
good results in the community.
    So, count me as a fan. But demonstrations are created to 
determine if new programs actually work. We need to get the 
results of this demonstration before we dramatically expand it, 
as the legislation we're reviewing today would do by adding 11 
States to the program.
    My legislation, H.R. 3074, the Continuing Access to Mental 
and Behavioral Health Care Act, would extend funding for the 
original eight States for an additional 2 years so we can 
complete the demonstration project and get the data taxpayers 
deserve, rather than prejudge the outcome.
    I'm disappointed that the committee did not include in this 
hearing H.R. 2700, the Lowering Prescription Drug Costs and 
Extending Community Health Centers and Other Public Health 
Priorities Act. Republicans are serious about our commitment to 
responsibly extend these critical public health programs with 
bipartisan offsets. I'm not sure why our legislation was 
excluded from the discussion today. We need to work together to 
avoid an unnecessary shutdown of these programs in September 
when their authorizations expire.

    Ms. Eshoo. The gentleman yields back.
    Now I would like to introduce the first panel of witnesses 
for today's hearing. Mr. Dean Germano, chief executive officer 
of the Shasta Community Health Center. Welcome and thank you. 
Ms. Diana--is it Autin? Autin. She's the executive codirector 
of SPAN, S-P-A-N, Parent Advocacy Network. Welcome, and thank 
you to you.
    Dr. Aaron Kowalski, president and chief executive officer 
of JDRF--marvelous organization that has chapters all over the 
country, and they come on a regular basis to my Palo Alto 
district offices. I am sure they do to every Member's office 
here. Dr. Lisa Cooper, professor of medicine, Johns Hopkins 
University School of Medicine--welcome to you, and thank you.
    Just a quick word about the lights. First it is green. When 
it turns yellow, you have 1 minute, and red you stop. So it is 
only as complicated as that, and I know that you will adhere to 
it.
    So now I would like to recognize Mr. Germano for 5 minutes 
for your testimony. If you would like to summarize what you 
have written and submit it to us and do something other than 
what you submitted to us, you are all welcome to do that.
    You are recognized, Mr. Germano. Thank you again.

STATEMENTS OF C. DEAN GERMANO, CHIEF EXECUTIVE OFFICER, SHASTA 
  COMMUNITY HEALTH CENTER; DIANA AUTIN, EXECUTIVE CODIRECTOR, 
    SPAN PARENT ADVOCACY NETWORK; AARON J. KOWALSKI, Ph.D., 
 PRESIDENT AND CHIEF EXECUTIVE OFFICER, JDRF; AND LISA COOPER, 
  M.D., BLOOMBERG DISTINGUISHED PROFESSOR OF MEDICINE, JOHNS 
                        HOPKINS MEDICINE

                  STATEMENT OF C. DEAN GERMANO

    Mr. Germano. Chairwoman Eshoo, Ranking Member Burgess, 
distinguished members of the subcommittee, thank you for 
inviting me to testify about the Teaching Health Center 
Graduate Medical Education, Community Health Centers, and the 
National Health Service Corps Programs.
    I strongly encourage you to provide increased and stable 
funding for all three programs before they expire on September 
30th. The success of these critical programs is at risk when 
funding for any one of them is jeopardized.
    Shasta Community Health Center is based in Redding, 
California, in a predominantly rural and medically underserved 
region. Federally qualified health center since 1996, we care 
for over 40,000 patients annually.
    Since 2014, we have been one of 56 teaching health centers, 
graduating eight residents, and we have employed 25 National 
Health Service Corps loan repayment recipients since 2000.
    Our eight THCGME graduates--of the eight, five work 
primarily in underserved populations in Redding and similar 
communities. Even using these programs my health center is four 
to five primary care physicians short and it can take up to 12 
to 18 months to recruit a physician.
    So growing our own through the THCGME program is a survival 
imperative. In 2018, Congress reauthorized the THC program 
through this September at a more sustainable level of $150,000 
per resident.
    Responding to the primary care physician shortage is 
incredibly timely because by 2030 we will need more than 
120,000 physicians to meet this country's demands.
    I am very grateful that Representatives Ruiz and McMorris 
Rodgers have introduced bipartisan legislation, H.R. 2815, to 
extend the THC program for 5 years.
    We know that hospital-based training produces physicians 
whose skills and experiences don't always match the primary 
care needs of the community and who rarely choose to practice 
in rural or underserved areas.
    By contrast, the THC model uses ambulatory health centers 
in underserved communities for training and the data proves 
that these graduates are three times more likely to practice in 
such settings after their residencies.
    H.R. 2815 will help THCs restore some resident slots that 
were authorized by HRSA but not filled during the years of 
uncertainty and it would fund a very modest increase in 
resident allocation to help offset inflation.
    Lastly, H.R. 2815 expands the program to meet pent-up 
demand. HRSA last approved a new THC in 2014 and many potential 
sponsors of such centers have expressed interest in becoming a 
teaching health center.
    Our health center depends on the Section 330 grants which 
allow health centers to expand their facilities, open new 
sites, and to meet unmet needs in areas with limited access to 
care.
    Section 330 grants leverage other funders because they 
confer status of high-quality healthcare provider. Broad 
bipartisan support for health centers has sustained 1,400 
community health center organizations, caring for over 28 
million patients and more than 11,000 rural, urban, and 
frontier communities nationally.
    The September 30th expiration date threatens the very 
existence of the health center program. Over the last several 
years, Shasta and CHCs across this Nation have experienced 
serious uncertainty due to funding disruptions.
    Our doors are open to everyone regardless of ability to 
pay. Services are offered on a sliding fee scale basis and we 
locate sites in medically underserved communities.
    However, recent funding lapses threaten the notion of 
continuous access. We are grateful that Representatives 
O'Halleran and Stefanik introduced H.R. 2328 to provide 5 years 
of stable funding for the CHC fund including $200 million in 
annual growth and $15 million in annual growth for the National 
Service Corps.
    Likewise, H.R. 1943, introduced by Representative Clyburn, 
provides 5 years of funding with 10 percent annual growth, an 
addition of $4.6 billion for health center capital funding, 
which would further--and would further expand the Corps.
    Shasta has benefitted greatly by the Corps. Over 50 years 
the Corps has effectively placed more than 50,000 people in the 
highest areas of need in our country so they can provide 
primary medical, dental, and/or mental and behavioral health 
services in underserved communities with more than 10,000 
placements last year alone.
    Our clinicians have come to Shasta with staggering student 
debt, enter the National Health Service Corps loan repayment 
program, and through their service many are debt free in just a 
matter of years.
    Thankfully, Congress has extended the Corps through 
September and we are very concerned that another expiration of 
funding would cause great damage to the program.
    Additionally, currently funding only allows for awards of 
40 percent of loan repayment applicants and a mere 10 percent 
of scholarships.
    H.R. 2328 and 1943 would fund even more applicants for 
loans and awards and thus substantially increase access. As CEO 
of the community health center, a teaching health center, on 
behalf of all National Health Service Corps recipients, I urge 
Congress to provide increased and stable funding for these 
programs before they expire on September 30th.
    Thank you.
    [The prepared statement of Mr. Germano follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    

      
    Ms. Castor [presiding]. Thank you.
    Ms. Autin, you are recognized for 5 minutes.

                    STATEMENT OF DIANA AUTIN

    Ms. Autin. Good morning, Chairman Eshoo, Mr. Ranking 
Member, members of the subcommittee. I am Diana Autin, 
executive codirector of the SPAN Parent Advocacy Network, home 
of New Jersey's Family-to-Family Health Information Center, or 
F2F.
    Today, I represent both SPAN and Family Voices, a national 
organization of and for families whose children and youth have 
special healthcare needs, which also provides support to the 
Nation's F2Fs.
    I am here today to support H.R. 2822, the Family-to-Family 
Reauthorization Act, which will extend funding for F2Fs for an 
additional 5 years at the current funding level of $6 million a 
year.
    F2Fs help families with special healthcare needs navigate 
healthcare and other systems advocate effectively for their 
children and work as partners with providers.
    Children and youth with special healthcare needs include 
those with autism, epilepsy, traumatic brain injury, cancer, 
schizophrenia, asthma, diabetes, or any other condition that 
requires healthcare services beyond that required by children 
generally.
    Throughout the U.S. there are about 14 million children 
with special healthcare needs, 19 percent of all children under 
18 and more than one in five families with children.
    Families struggle to find the right primary and specialty 
care providers to treat their children and to pay for their 
care. Even with insurance, out-of-pocket costs can be very high 
with copayments and other costs that insurance may not cover at 
all.
    It is difficult to navigate through the worlds of public 
and private insurance and other sources of care and financing 
that all have different eligibility criteria.
    Children may miss getting needed services because their 
families are unaware of or don't know how to access or afford 
them. That's where F2Fs come in.
    We are staffed by parents of children with special 
healthcare needs. Beyond their training, our staff have 
expertise and empathy, learn through personal experience.
    We reach out to underserved communities and provide our 
services in a culturally and linguistically appropriate manner. 
We provide one-to-one assistance like helping a family appeal 
denial of coverage for needed services, get insurance coverage 
or find appropriate pediatric specialty care.
    For example, in New Jersey, a father called our F2F about 
his 13-year-old son with Downs Syndrome, autism, major 
behavioral challenges. He was struggling to afford prescribed 
medications which were making his son's behavior worse and 
making him gain weight.
    Our F2F staff connected him to a nearby federally qualified 
health center and helped him develop a behavior support plan 
for school and access additional services.
    Within 6 months, his son was weaned off the medications and 
had lost 30 pounds, and his overall health and behavior had 
improved.
    Some families face more than the usual challenges. Military 
families must relocate often, needing to find new providers, 
reapply for Medicaid, and negotiate for services in a new 
district.
    In New Jersey, we help these families by embedding staff at 
and working closely with Joint Base McGuire-Dix-Lakehurst.
    Special challenges also arise for families who aren't 
proficient in English or who come from diverse cultural 
backgrounds or urban low-income families who may need to take 
multiple busses to get to services, and for rural families who 
must travel long distances to get specialized care. Sometimes 
one parent may even have to relocate.
    Families in the territories and Native American and Alaska 
Native families face linguistic and cultural barriers and the 
complications of remote locations, often compounded by extreme 
poverty.
    That's why we were so pleased when last year Congress 
expanded the F2F program to serve these families. There is now 
one F2F in each State, five territories, and three Tribal 
organizations as well as DC.
    Each receives $96,750 a year. Despite our modest budgets, 
we provided information, training, and/or assistance to nearly 
1 million families in 2018.
    F2Fs provide a great value for taxpayers. We help families 
get the care and services their children need to survive and 
thrive and to avoid medical bankruptcy and we assist providers 
and policy makers to better serve children and youth with 
special healthcare needs.
    Our efforts result in higher quality, more cost effective 
care and better outcomes.
    The bill before you today would extend the F2F program for 
an additional 5 years, longer than ever before. Although 
modest, the F2F grant provides a foundation upon which other 
funding and activities can build.
    Status as a Federal grantee provides credibility that makes 
it easier to secure additional funds and partners. However, 
those other funding sources--government agencies, foundations 
and individual donors, and community partner organizations 
don't want to invest time or money in an entity that might not 
survive for more than a year.
    Greater stability of F2F funding would be extremely 
valuable to our effectiveness. Since its creation over a decade 
ago by Senator Charles Grassley and the late Senator Ted 
Kennedy, the F2F program has enjoyed strong bipartisan support.
    We thank Representatives Sherrill and Upton for continuing 
this bipartisan commitment to F2Fs so we can help families 
secure timely, high quality, and family-centered care for their 
children and youth.
    On behalf of Family Voices and SPAN and as a parent myself, 
I thank the subcommittee for the opportunity to testify about 
the value of Family-to-Family Health Information Centers, and I 
am happy to answer any questions.
    Thank you.
    [The prepared statement of Ms. Autin follows:]
    
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    Ms. Castor. Thank you very much.
    Dr. Kowalski, you are recognized for 5 minutes.

             STATEMENT OF AARON J. KOWALSKI, Ph.D.

    Dr. Kowalski. Ranking Member Burgess and members of the 
subcommittee, thank you for giving me the opportunity to 
testify before you today.
    In 1977, my brother--my younger brother, Steven, was 
diagnosed with type 1 diabetes, or T1D, at the age of 3. In 
1984, I too was diagnosed with T1D when I was 13 years old.
    Because of that, I went on to get my doctorate in 
microbiology and molecular genetics, and then focused my career 
on the fight to cure this terrible disease and to help other 
people with diabetes stay healthy until then.
    I've worked at JDRF, the world's largest charitable funder 
of type 1 diabetes research for 15 years, and just 8 weeks ago 
I became its president and CEO.
    I am here today with a simple message from our community. 
The Special Diabetes Program is making a tremendous difference 
in our lives and our hopes for the future.
    We need you to continue to give it robust support. There is 
so much momentum that we can't afford to lose. We are grateful 
for the leadership of this committee on both sides of the aisle 
over the years and the broad bipartisan support in Congress for 
this Special Diabetes Program, or SDP.
    By supporting the SDP, you have been the catalyst that has 
fundamentally changed diabetes management, diabetes care, and 
have brought us even closer to cures for diabetes.
    In addition, lives are being transformed by the Special 
Diabetes Program for Indians, or SDPI, which funds prevention 
and treatment programs for those in American Indian and Alaska 
Native communities that are particularly affected by type 2 
diabetes.
    Approximately 30 million Americans have type 1 or type 2 
diabetes and about a third of the Medicare budget is spent on 
people with diabetes.
    Thanks to the funding provided by Congress, we have seen 
major progress in type 1 diabetes research that has led 
directly to improvements in the health and quality of life for 
people with diabetes and significantly reduced the risk for the 
terrible and costly complications of the disease.
    This includes the first FDA-approved artificial pancreas, 
or AP system, which came on the market several years earlier 
than expected, thanks to research supported by SDP.
    AP systems drive significantly better glucose levels, which 
reduce the risk for these terrible complications. For those who 
do have complications, we've seen incredible advances in drugs 
that preserve and even improve vision who have diabetic eye 
disease, and other drugs that are being tested as we speak for 
those who are at risk for diabetic kidney disease.
    And this is just the start. The SDP is currently funding 
multidisciplinary and path-breaking research to understand the 
causes of type 1 diabetes and how it can be cured.
    While the SDP research funding moves us closer to cures and 
improves the quality of care for those with type 1 diabetes, 
the SDP eye program that is run by the Indian Health Service 
has played a critical role in tackling type 2 diabetes among 
American Indians and Alaska Natives, a population that is 
disproportionately suffering from the disease.
    These communities have a diabetes prevalence rate 
approximately 2 times the national average and the death rate 
1.8 times higher than the general U.S. population due to 
diabetes.
    Thanks to the SDPI, which funds evidence-based diabetes 
treatment and prevention programs that help over 700,000 people 
in 35 States, there have been marked improvements in average 
blood sugar levels and reductions in the incidence of 
cardiovascular eye and kidney disease.
    As you can see, SDP and SDPI programs are making a real 
difference in the lives of people with type 1 and type 2 
diabetes. That's why JDRF strongly supports House Bills 2668 
and 2680, introduced by Representatives DeGette, Reed, 
O'Halleran, and Mullin that will raise the amount of funding to 
$200 million a year for SDP and SDPI and fund them for 5 years.
    All of us at JDRF are grateful that 378 representatives, 
including nearly all of the members on this subcommittee and 
the full committee signed a letter to leadership, led by 
Representatives DeGette and Reed, that recognizes the important 
contributions of this program--these programs, and calls for 
the program's renewal.
    We look forward to working with this broad group to get 
these bills passed and continue diabetes research advances and 
care.
    Thank you, and I would be happy to take any questions.
    [The prepared statement of Dr. Kowalski follows:]
    
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    Ms. Eshoo [presiding]. Dr. Cooper, you are recognized for 5 
minutes for your testimony.
    Put your microphone on.

                 STATEMENT OF LISA COOPER, M.D.

    Dr. Cooper. Good morning, Chairwoman Eshoo.
    Ms. Eshoo. We want to hear every word. We want to hear 
every word of your testimony.
    Dr. Cooper. Thank you. Ranking Member Burgess and 
distinguished members of the subcommittee, thank you for 
inviting me to participate in today's hearing.
    I am Dr. Lisa Cooper, a professor at the Johns Hopkins 
Schools of Medicine, Nursing, and Public Health, where I have 
served as faculty for 25 years.
    As a board-certified general internist, I treat adult 
patients with a range of illnesses and unique healthcare needs. 
As a health services researcher, I have devoted my career to 
improving quality and addressing disparities in the U.S. 
healthcare system.
    Over the past 9 years, my colleagues and I at the Johns 
Hopkins Center for Health Equity, along with our health system 
and community partners, have completed three NIH-funded 
clinical trials improving hypertension control in African-
American communities.
    And now, with the support of PCORI, I am leading a new 
trial called Rich Life, launched in 2016 with 30 primary care 
practices in Maryland and Pennsylvania.
    Rich Life investigates whether system improvements and 
team-based care models can reduce disparities and 
cardiovascular risk factors, including hypertension, diabetes, 
and depression.
    This study will help clinic directors and primary care 
doctors choose how to care for people who have high blood 
pressure and could be extremely impactful in communities that 
have high rates of this condition and limited access to care.
    Throughout my experience as a practicing clinician and 
researcher, one theme is clear. Too often, patients do not have 
enough accessible or relevant information to make informed 
decisions about their care and too often we, as clinicians, 
must make decisions about our patients without knowing which 
option would best fit their unique needs and circumstances.
    For all the advances we have made with new innovative 
clinical research, we sometimes still lack the information we 
need to help our patients make the best choices for themselves. 
That is why the Patient-Centered Outcomes Research Institute, 
or PCORI, is so important.
    PCORI is the leading funder of comparative effectiveness 
research, which is research that compares how well different 
treatments and care approaches work so patients and doctors 
have the information they need to make decisions that are right 
for them.
    PCORI's research is unique and complementary to research 
funded or conducted by the NIH, which focuses on discovery, the 
AHRQ, which focuses on health services research, and FDA, which 
focuses on reviewing drugs, devices, and other products for 
safety and efficacy.
    Patient-centered outcomes research is comparative 
effectiveness research that focuses not only on clinical 
outcomes but also on the needs, preferences, and outcomes most 
important to patients and those who care for them.
    This research is helping patients choose the treatments 
best for them and focuses on many of the most pressing health 
concerns our country faces today such as heart disease, cancer, 
diabetes, and opioid dependence.
    PCORI is the only research funder that ensures that 
everyone has a seat at the table who has a stake in healthcare 
improvement.
    As a researcher who has received funding from both the NIH 
and PCORI, I have seen firsthand the values and differences of 
both institutions and what they both bring to the table.
    To date, PCORI has funded more than 600 studies that 
address high-priority conditions, new and emerging approaches 
to care, as well as ways to improve doctor-patient 
communication and, importantly, PCORI funds the dissemination 
of research findings as well as implementation of actionable 
results.
    For example, PCORI funded a study that found that a simple 
decision aid can help people who go to the ER with chest pain 
better understand their risk of having a heart attack and 
therefore decrease unnecessary hospitalizations for testing.
    Over 5 years this could benefit 9.4 million Americans and 
save $4.8 billion nationwide. Another example is a study in 
Washington State clinics that implemented an initiative focused 
on more cautious prescribing of opioid drugs, which led to 
reductions in high dose opioid prescribing while preserving 
patient pain control.
    In both these examples, using a patient-centered approach 
not only improved health outcomes and patient quality of life, 
it also reduced utilization.
    Simply put, results from PCORI-funded research are 
actionable, impactful, and have the potential to improve health 
outcomes for patients across the country and that is why it has 
strong support from more than 170 healthcare organizations.
    But there is still much more to be done. Ensuring that 
PCORI has long-term and consistent funding is vital to their 
research funding mission. It also provides the stability that 
researchers need to conduct this work in training and support 
for the next generation of researchers.
    In closing, our healthcare system requires solutions that 
are both evidence based and patient centered to improve are and 
reduce healthcare spending. PCORI is uniquely set up to meet 
this challenge.
    Therefore, I urge Congress to renew its investment in 
patient-centered outcomes research and enact a 10-year 
reauthorization of PCORI's charge and funding before it 
expires.
    Thank you for your time and I look forward to our 
discussion.
    [The prepared statement of Dr. Cooper follows:]
    
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    Ms. Eshoo. Thank you, Dr. Cooper.
    We have now concluded the opening statements of our 
witnesses. Our thanks to each one of you. We will now move to 
Members' questions. Each will have 5 minutes to question the 
witnesses, and I will start by recognize myself for 5 minutes.
    Mr. Germano, in your testimony you mentioned a grow your 
own--grow your own strategy of training healthcare providers to 
address the primary care shortage, and we have that shortage in 
the country, and primary care physicians are the gateway to the 
entire healthcare system.
    Can you tell us briefly how that strategy has actually 
worked? How has it benefited the community?
    Mr. Germano. Well, our data through HRSA--the teaching 
health center information--really shows that we have three 
times the success rate of training and keeping our residents in 
our communities compared to other models of training.
    So the data is pretty clear. It is----
    Ms. Eshoo. But what makes it so?
    Mr. Germano. Well, I think a big part of it is----
    Ms. Eshoo. They love your community? I mean, what is it 
that keeps them glued there?
    Mr. Germano. Well, I think part of it is that they see the 
mission. They're connected to the mission. Many of them come 
from those communities or communities like it.
    They have a heart for what we do and we really support them 
in their training and they have become confident in working 
with underserved populations, and they get connected rooted 
into our communities.
    Ms. Eshoo. In California, thanks to the ACA, we've reduced 
our uninsured rate down to 6.8 percent, which is incredible 
when you think of the most populous State with the most diverse 
population, which is not the easiest to insure. That's down 
from 16 percent before the ACA was passed.
    These are--these are large increases in healthcare 
coverage. So if someone really doesn't know that much about 
Community Health Centers and what they do, how would you 
respond to them and say this is why we are needed?
    Mr. Germano. Well, we had that success in California. Our 
rates up in Shasta are higher than that. They were almost 25 
percent before and now they're down to almost 6 and now have 
climbed back to 10 percent again.
    We also have the situation of people with major medical and 
other costly front-end plans that make it difficult to afford 
primary care.
    Our goal is primary prevention. We need a solid system. Any 
system in the world that has success in terms of caring for 
their populations and keeping a lid on costs really have strong 
primary care systems and that's what the Community Health 
Centers represent is a very strong primary care preventive 
health system.
    That is the--I think that is the key for every community 
across America and we have 84 million Americans that don't have 
the benefit of a community health center to do that for them.
    Ms. Eshoo. Even though we have how many, 12,000 in the 
country?
    Mr. Germano. Fourteen thousand.
    Ms. Eshoo. Fourteen thousand. My staff wasn't right. Oh, my 
goodness. Mortal sin.
    Dr. Cooper, in the studies that are done, can you just 
briefly describe how those studies develop legs and walk into a 
patient's life?
    Studies are always important for what they reveal. But then 
how do they become real in people's lives?
    Dr. Cooper. So I think what I would say is the way they 
become real in people's lives is that actually their patients 
involved in the design of these studies so they're actually 
involved from the very inception. Patients contribute----
    Ms. Eshoo. But the larger population, though.
    Dr. Cooper. So you mean afterwards? After the research is 
done? I think this is a critical piece is that once we have 
results of the work, for example, if we know that there is a 
tool that helps patients to make decisions about whether or not 
to stay in the hospital for chest pain is actually getting that 
information out to doctors and patients so that when they're at 
the point of making that decision they are aware of the 
existence of that tool.
    Ms. Eshoo. So have you measured this? I mean, just does 
that--that as an example, patients with--that go to the 
emergency room, they think they are having a heart attack--your 
study says you should do A, F, and Z, what is the outcome?
    Dr. Cooper. So that is not--that is not my study. That is 
another study that was funded by PCORI where, basically once 
people used the tool they were able to determine whether or not 
they felt comfortable going home.
    Ms. Eshoo. Well, how do you do that? Do you go through 
insurers?
    Dr. Cooper. So what we do----
    Ms. Eshoo. Do people line up at a clinic----
    Dr. Cooper. Right.
    Ms. Eshoo [continuing]. To get the piece of paper that 
explains it?
    Dr. Cooper. Right.
    Ms. Eshoo. Tell us how it works.
    Dr. Cooper. Yes. So the--I think the process varies 
depending on where you are, right. So one of the reasons we 
have a lot of people involved in PCORI research is that we talk 
to insurers, we talk to front line providers, we talk to staff, 
and we talk to patients and families, and we find out what 
works in a particular system.
    And so one size doesn't fit all. So we may learn from a 
particular health system that they have community health 
workers who are the ones who work with patients and who show 
them how to use the tool, and----
    Ms. Eshoo. I think I know how it works. I want everyone 
else to hear it.
    Dr. Cooper. Right. But, you know, in another health 
system----
    Ms. Eshoo. Always know the answer to your own question, 
right?
    Dr. Cooper. Right. In another system it might be something 
different where they have pharmacists who are the ones who 
actually help people to work through their questions and 
their----
    Ms. Eshoo. Well, my time is expired, and I thank the 
witnesses. The Chair now recognizes Dr. Burgess for his 5 
minutes to question.
    Mr. Burgess. Thank you for the recognition, and I want to 
first start off by answering Mr. Germano's question that you 
asked of him--how, when you grow your own, how does that work 
and for at least in the physician space--I can't speak to other 
healthcare providers, but from a physician space we tend to 
settle where we train, and this is something we have--I have 
studied this question for years and the Texas Medical 
Association has done an extensive research on this. Not so much 
where someone goes to medical school but where they do their 
training.
    You typically marry during those years and, as a 
consequence, your spouse has a big say in where you spend your 
practice life. You become familiar and comfortable with the 
doctors to whom you refer or you know who to watch out for in 
the community.
    So that information is very helpful to the young physician 
just starting out, trying to build a practice.
    So when you gave that answer, I was reminded of all the 
work the AMA has done on this and it is--it is a significant 
body of work.
    It became really apparent to me after Hurricane Katrina and 
visiting with doctors down in the Louisiana-Mississippi gulf 
coast and the Dallas-Ft. Worth area where I am from was guilty 
of stealing a lot of physicians from that area at that time and 
quite successfully.
    But one of the best predictors as to whether or not someone 
was going to stay in the--in the area around New Orleans was if 
their spouse was from there--not if they were from there but if 
their spouse was from there. That is a very--that can be a very 
powerful anchor. And, again, we do tend to marry during our 
training years and that is, I think, part of the answer there.
    Now, of course, Dr. Gingrey being in the audience, and I am 
reminded of the night we heard--we marked up the--well, it 
wasn't really the Affordable Care Act.
    It was what went over to the Senate. But it came back and 
it was entirely different. I remember his insightful questions 
on the comparative effectiveness research that night.
    Dr. Cooper, just so everyone understands, you get a direct 
appropriation under the Affordable Care Act of $150 million a 
year. Is that correct?
    Dr. Cooper. So my understanding is that the funding is set 
through a separate funding stream for PCORI--that there is a 
PCORI fund that is funded through a variety of different 
sources.
    Mr. Burgess. Right. There is a trust fund. There is a 
charge for every insurance policy that is sold as well as there 
is a transfer from the Medicare trust fund, which makes up an 
aggregate of dollars that you have to spend.
    Do we have anything that would give us sort of a return on 
investment guide for the Patient-Centered Outcomes and Research 
Initiative?
    Dr. Cooper. So we have a number of different studies that 
have shown that different approaches, when incorporating 
patients' preferences into decision making, that actually we do 
reduce utilization and could really save significant amounts of 
money.
    So the example I gave you----
    Mr. Burgess. But let me interrupt you for a second. Who 
would save significant amounts of money? Do we know? Do we have 
a good sense of--we have spent, I think last year, $630 million 
on PCORI. What's the return on investment for that?
    Dr. Cooper. So I would get back to you with the help of the 
PCORI staff on that because PCORI actually doesn't fund cost 
effectiveness research. It wasn't--that wasn't part of----
    Mr. Burgess. Comparative effective, just not cost 
effective.
    Dr. Cooper. Yes.
    Mr. Burgess. And I get that. And, you know, your specialty 
through the American Board of Internal Medicine several years 
ago came up with the Choosing Wisely program. Is that something 
you have looked at through PCORI, sort of look at those studies 
that we know we all do as physicians but the return on 
investment is not that great?
    And I think it was the--again, your specialty society which 
said maybe we ought to think about what we are ordering.
    Dr. Cooper. Absolutely. I know of one study that was funded 
by PCORI that specifically looked at monitoring of glucose 
levels in patients who are on oral treatment for diabetes and 
showed that actually doing glucose monitoring at home really 
didn't contribute anything important to the patient's health.
    And so the study actually suggested that people on oral 
hypoglycemics do not need to engage in glucose monitoring. And 
so that kind of an outcome really shows that you can save money 
by eliminating all of those----
    Mr. Burgess. I am just going to interrupt you for a second. 
My time is running out. Of course, it might affect your 
decision as to whether nor not to have that piece of coconut 
cream pie that's in the refrigerator.
    But on the chest pain study that you did with the chest 
pain tool, is there any way that you can assess--look, I am an 
OB/GYN doctor. I practice defensive medicine.
    So I will tell you from my days in the ER, chest pain--I 
mean, it is a problematic situation for the doc on the front 
line and you're always worried you're going to send someone out 
who then ends up having the big one in the parking lot and 
dies.
    So is there a way you have dealt with the liability 
question?
    Dr. Cooper. What I would say is that there is a clinical 
algorithm that was used with that tool, which included some 
risk prediction, and that people who answered questions in a 
certain way on that tool were able to be sent home safely.
    And, in fact, those people who went home had lower uses of 
utilization and didn't have any worse complications. And so an 
estimation is that that would save considerable amounts of 
money if people were able to feel comfortable, both doctors and 
patients, based on a thorough assessment of the patient's 
profile that it was safe for them to go home.
    Mr. Burgess. I will follow up with you about that in 
writing because it is--it is an important concept. I will yield 
back.
    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes the chairman of the full 
committee, Mr. Pallone, for 5 minutes for questions.
    Mr. Pallone. Thank you, Madam Chair.
    I first wanted to ask the question of Mr. Germano. When the 
Community Health Center Fund was created in 2010 under the ACA, 
it was originally authorized to boost funding to Community 
Health Centers for 5 years and we have reauthorized it twice in 
the 4 years since for periods of 2 years each time.
    Since we first passed the Community Health Center Fund, 
we've seen growth based on a record of success. Health centers 
have grown from serving 19.5 million patients and providing 
almost 77 million patient visits in 2010 to serving 27.2 
million patients and 110 million patient visits in 2017.
    For today's hearing, Chairwoman Eshoo has noticed two bills 
that both reauthorize Community Health Centers and the National 
Health Service Corps for 5 years as well as the 5-year 
extension of the Teaching Health Center Graduate Medical 
Education Program.
    And I strongly believe that all these programs are very 
worthy of a long-term extension to bring stability to centers 
like your own that are providing community-based residency 
training and essential services to those who need it.
    So, Mr. Germano, if I could ask you, can you tell us about 
the impact a long-term extension of funding would have on your 
health centers' ability to provide care to patients, manage a 
budget, recruit and retain members of the healthcare work force 
and can you compare that to the challenges that your health 
center would face with a short-term extension?
    Mr. Germano. Thank you for that question, Congressman.
    The running of a Community Health Center tied to your 
community is a complex venture. Most of the things we do to 
impact our community are long-term orientation.
    Think about building a new site, for example. I say it 
takes 4 to 5 years from thought to finish if you have all the 
means. When you--when you're working on short term 
appropriations it has a paralysing effect on your ability to 
plan ahead and make those kinds of investments. It really does.
    2018, when we went through the 2-year--the fiscal cliff 
piece--I know of health centers that created layoffs. They did 
freezes of staff. They withdrew contracts for clinicians that 
they needed because they couldn't--they didn't know they 
could--they didn't have the confidence they could commit to 
meeting those obligations.
    It really has a paralysing effect on the ability to think 
forward and plan. It has that same effect on your board of 
directors and it also sends a message to your community about 
how stable are you really if the rug can be pulled out from 
under you so easily, from their perspective.
    So the long-term is really about planning and doing things 
efficiently and correctly. Short term is--it makes it very 
difficult to think ahead and make those kinds of commitments.
    Mr. Pallone. Thank you. I appreciate that. And I would add 
too--I have to go to the next question---but, you know, a lot 
of these are very small, too, and I think when you talk about 
small Community Health Centers, which many are including in my 
district--it is even worse, I think.
    But anyway, let me--I have to go to Ms. Autin, and my 
question is about New Jersey's experience with Family-to-
Family. I want to acknowledge that New Jersey has for a long 
time been a leader in the Family-to-Family program, which 
connects families of children and youth with special needs to 
the healthcare resources they need and I am glad my colleague 
from New Jersey, Representative Mikie Sherrill, has taken a 
leadership role introducing the bill to reauthorize this vital 
program.
    So let me just ask you, can you talk about your 
organization's long history in New Jersey and how that helps 
you provide technical assistance to other States, the 
territories, and Tribes that have sought to implement and 
improve their own programs, if you will.
    Ms. Autin. So SPAN actually has been around for over 30 
years and we were one of the very first F2Fs that was selected 
out of the legislation that was--came from Senator Grassley and 
Senator Kennedy.
    So that's been--you know, being one of the first F2Fs that 
got started that gave us the opportunity to really learn on the 
ground and then be able to share that information with other 
F2Fs.
    We also had the opportunity to do that because along with 
the two people from National Family Voices including Norah 
Wells, the executive director of Family Voices, I am one of the 
codirectors of the national center that provides technical 
assistance to the F2Fs, and one of the ways in which we do that 
is by providing peer-to-peer support.
    And so we connect F2Fs that have knowledge and expertise in 
one area to other F2Fs. Because we are in such a diverse State, 
because we've been around so long, because we have many other 
programs that can supplement and support our F2F and because of 
our really very positive relationship with our State Department 
of Health Title 5 program, I think we have a lot of lessons 
learned that we've been able to share with other F2Fs around 
the country and hosted them when they came to visit us for 
different issues around cultural responsiveness, et cetera. 
So----
    Mr. Pallone. All right. Thanks so much. Thank you.
    Thank you, Madam Chair.
    Ms. Eshoo. The gentleman yield back.
    I now would--let us see, who is--who is next?
    Oh, Mr. Upton. A pleasure to recognize former chairman of 
the full committee Mr. Upton of Michigan.
    Mr. Upton. Well, thank you, Madam Chair, and I appreciate 
the hearing. I know that we all do. And before I get to my 
questions I wanted to take this opportunity just for a moment 
to draw my colleagues' attention to a bill that I am 
cosponsoring, which I think is an excellent complement to the 
programs being discussed today.
    H.R. 2075, which is the School-Based Health Centers 
Reauthorization Act of 2019, this is a bill that I strongly 
believe in. I have talked to many of my schools back home in 
Michigan. I look forward to working with the chair and the 
ranking member to advance this bill in the coming months.
    It is bipartisan and it really does make a difference in a 
meaningful way. I guess I will start off with Dr. Kowalski. In 
your testimony you told us about the critical diabetes 
management--how critical that diabetes management is and the 
role that SDP has played in bringing innovative new 
technologies to the market.
    I have been involved with this issue for a long time and 
have seen wonderful advancements as I watch folks who started 
early with JDRF 20 some years ago and are still--I mean, 
technology changes are amazing and really lifesaving.
    How do these technologies prevent the complications from 
diabetes in terms of lowering health costs as we look to 
reauthorize this money?
    Dr. Kowalski. Sure, and thank you for your leadership. I 
was just up at UM talking about a center that we are working on 
with the team there.
    And both type 1 and type 2 diabetes complications are 
caused by high blood sugar, and high blood sugar has a 
nefarious effect of driving changes in your body that affect 
your eyes, your kidneys, your heart, and your limbs.
    The incredible advances that have happened in terms of the 
ability to monitor blood sugar, for example, SDP helped support 
the advancement of continuous glucose monitors.
    I use a continuous glucose monitor. I have not poked my 
finger in over 5 months. It is absolutely incredible, and we 
are seeing those advances be applied in type 1 and type 2 
people to lower A1C measures, which is the measure of blood 
glucose levels.
    Mr. Upton. Let me just interrupt you for a second. I 
don't--so one of the manufacturers is, what, Dextrom, right? So 
if they moved Dextrom----
    Dr. Kowalski. Dexcom.
    Mr. Upton [continuing]. Monitor that so that they've got a 
new system now without having to poke and test that, literally, 
every day?
    Dr. Kowalski. Yes. They do, as does another company, Abbott 
Diabetes, and from a JDRF perspective, we think competition is 
good. We want more options out there, and what we are seeing is 
competition driving more access, better glucose levels, less 
risk for complications.
    Mr. Upton. Thank you.
    Ms. Autin, H.R. 2822--it is a bill that I have cosponsored 
along with Ms. Sherrill, reauthorizes the F2F program for 5 
more years. You talked a little about it--remarks about why 
this is so important and I know more than just New Jersey--my 
colleague is not--can you elaborate why it is--why this is an 
important issue for us to move forward?
    Ms. Autin. Thank you for that wonderful question, and it is 
important for all of the F2Fs. For one thing, it is very 
difficult to do planning, you know, as an organization when you 
don't know whether or not you're going to be around for more 
than another year.
    I talked about partners and other funders. I mean, in our 
organization that F2F funding, you know, brings in lots more 
money to do that work and many other F2Fs the same thing is 
true. They want to know that there is going to be stability in 
that organization before they put their money there.
    I think one of the most important things, though, is that 
we all are staffed by families of children with special 
healthcare needs.
    Mr. Upton. And that is important.
    Ms. Autin. That is so important. It is important because we 
are the people who know what the systems are like and how to 
really navigate them on the ground. But, of course, we also 
have children that have special healthcare needs.
    And so we--it is even more important that we have stability 
of employment, stability of health insurance, being able to 
know and project that we are going to be able to have a job and 
keep our children covered under that same health insurance plan 
where we have already found the 10 specialists that are all 
covered by our, you know, health maintenance organization.
    And, you know, I have had to have this experience multiple 
years where I have had to tell staff, I can't promise you that 
there is going to be a job here in the next six--you know, 
after 6 months from now, and then those families have to make 
that very difficult decision to possibly leave a job that they 
love and that they are really great at and go someplace else 
where they have more stability, and that means we have more 
turnover.
    That means we lose great staff and then that means there 
are more costs that are associated with trying to reach out to, 
you know, somebody else to come and fill that position.
    So the--you know, having the 5 years of funding is going to 
be one of the most important improvements in the F2F 
reauthorization that we have ever had.
    Mr. Upton. I look forward to working with everybody to get 
that done. Yield back. Thank you.
    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes Ms. Matsui of California, who is 
the sponsor of H.R. 1767, for 5 minutes of questioning.
    Ms. Matsui. Thank you very much, Madam Chair, and I really 
appreciate all of you being here today and I would like to 
extend a special welcome to Mr. Germano from my home State of 
California.
    Now, I appreciate your sharing with the committee how long-
term sustainable healthcare funding is essential to supporting 
primary care and preventive services in Shasta and across 
California.
    And as you may know, in 2014 I helped author the Excellence 
in Mental Health law that established certified community 
behavior health centers--CCBHCs--in eight States across the 
country.
    Earlier this year I introduced H.R. 1767, a bill to expand 
Excellence's CCBHC's Medicaid demonstration with my colleague, 
Representative Markwayne Mullin from Oklahoma.
    Now, in the Medicaid demonstration program we also know how 
important it is to have mental and physical health a holistic 
way of doing things. So we encourage partnerships in 
coordination with certified community behavior health centers 
and Community Health Centers.
    And I would like to get a better sense of how CHCs address 
serious mental and addiction disorders, specifically, the level 
of access that patients with schizophrenia and opioid use 
disorders have to intensive community-based services in Shasta 
and the surrounding counties.
    I know in my district in Sacramento are seven federally 
funded health center organizations and 36 clinical delivery 
sites create a safety net infrastructure that provides primary 
and behavior healthcare needs in Sacramento.
    Mr. Germano, what kind of partnerships has the Shasta 
Community Health Center forged with community mental health 
providers in your service area?
    Mr. Germano. Thank you for that question, and certainly, in 
rural areas of California and across this country the mental 
health gap is huge, and that is true also in our community.
    Our health center has two--played two major parts in this. 
One, we have created an integrated behavioral health component 
which really integrates the behavioralist, typically LCSWs--
licensed clinical social workers--as well as marriage and 
family therapists within our primary care practice as team 
members with our primary care doctors and nurse practitioners 
and PAs so those warm hand-offs can happen.
    That's important, and some screening can be done more 
effectively. We also employ psychiatrists on our staff--because 
our county and our systems in California are mostly county-
based for the seriously mentally ill, have really struggled in 
trying to keep that--those services going.
    So we have in fact gone off and hired psychiatrists and we 
work with the county as well because of in-patient services, 
and then there are advocacy groups, NAMI and others, that we 
work very closely with. We cannot do what we do effectively in 
underserved communities without an effective mental health 
delivery system.
    Ms. Matsui. Right.
    Mr. Germano. And it takes all those pieces, and it does 
take a village to provide those kinds of services. And I am 
happy to say we've been working hard at it on the addiction 
side. We have moved very heavily into medically assisted 
therapies now.
    We have--we have redirected our resources into creating 
what we call MAT services. We are--right now we have 200 
patients on medically assisted therapies and we are growing 
that program to try to meet that need--the opioid abuse issues 
in our communities, and we are really pleased with the results 
so far.
    Ms. Matsui. Well, that is wonderful. With the Excellence 
Act with the certified community behavioral health centers we 
have a Federal definition. So it is just like we had to 
federally qualify health centers.
    So, in a sense, they, working together, can really have an 
effect on the community. I will have to say that my cosponsor, 
Markwayne Mullin, is not here today because of floods in his 
district.
    But he has worked with many public safety groups in order 
to provide that type of service so that they feel very good 
because they don't have to waste hours and hours taking these 
people to ERs or trying to figure this out.
    So anything that we can do, particularly in rural areas, I 
know will help the people there who don't have ready access to 
behavior health needs.
    So anyway, I thank you very much and I yield back.
    Ms. Eshoo. I thank the gentlewoman. She yields back.
    I now would like to recognize the gentleman from Virginia, 
Mr. Griffith, for 5 minutes for his questions.
     Mr. Griffith. Thank you very much, Madam Chair. I do 
appreciate it. I appreciate our witnesses being here.
    What I like about having hearings like this is we learn a 
lot. This is not my field of expertise, although I have about 
30 or 31 Community Health Centers in my district.
    It is a fairly large district. Probably have needs for a 
few more, in all fairness, but I do appreciate what you all do.
    And I am now going to yield to Dr. Burgess.
    Mr. Burgess. I thank my friend from Virginia for yield.
    Mr. Germano, let me--let me ask you. In your testimony you 
talked about the--expanding or you mentioned that expanding the 
types of providers that would be eligible to participate in the 
National Health Service Corps is a zero-sum game. Can you--can 
you further elaborate why this is?
    Mr. Germano. Yes. As I stated in my testimony, only about 
40 percent of current applicants actually get a loan repayment 
acknowledged. You know, they participate. They can go forward, 
and only 10 percent of scholars.
    So if the fund isn't significantly increased--significant--
adding more players to that field will just water down that 
benefit and I don't think it serves any of our purposes.
    I happen to support the allied health professions who are 
looking to take advantage of this. But we need to greatly 
increase the scope of the National Service Corps--their 
dollars--in order to do that. It really is a zero-sum game 
right now.
    Mr. Burgess. And Dr. Kowalski, if I could just ask you--
obviously, your organization of which you are now president--so 
congratulations on the ascendency to that lofty position, or my 
condolences, one of the two--so can you tell us how JDRF 
collaborates with the National Institute of Health on research 
priorities and particularly as it relates to the Special 
Diabetes Program?
    Dr. Kowalski. Yes, that is a great question. Thank you.
    We work very, very closely with the NIH including with Dr. 
Griffin, who heads up NIDDK, and the program staffs who--staff 
members who focus on various areas. We break up our research 
into curing type 1 diabetes, preventing type 1 diabetes, and 
better treating it, and each of those areas have embedded 
scientists who are experts at JDRF working hand in hand with 
the team at NIH.
    For example, last week, NIH held a meeting where they were 
setting their program priorities and our team participated. So 
there is very close coordination on the research efforts of 
both organizations.
    Mr. Burgess. So tell me this. I spoke to someone yesterday 
on the issue of islet cell transplant. What is the--you talk 
about a cure for type 1 diabetes--what is out there on the 
horizon as far as a cure is concerned?
    Dr. Kowalski. So islet cell transplantation, for those who 
are not familiar, is the harvesting of the cells that make 
insulin from somebody who has passed away prematurely--just 
like an organ transplant but just the cells.
    And what we have seen in that procedure is you can cure 
people with diabetes. I was with one of the founders of that 
procedure and he has people 17 years post-transplant off 
insulin.
    The barriers are the cell source and the immunosuppression 
that is required. So both JDRF and NIH and SDP has really laid 
the foundation here of creating renewable cell sources so that 
we would not require transplant donors, and protecting the 
cells, and we have a variety of amazing programs going on both 
through materials or now with the gene editing CRISPR-Cas 
technology.
    So I am incredibly optimistic. While we are making great 
progress on better treatments, those are band-aids. What we 
need is what we call disease-modifying therapies and I think 
cell therapy is incredibly promising.
    Mr. Griffith. And, Dr. Burgess, if I might jump in real 
quick and reclaim my time----
    Mr. Burgess. Yes, please.
    Mr. Griffith [continuing]. We have some folks working on 
genetically modified pigs who are able to grow some of these 
cells. I think they're doing experiments with it, but they have 
eliminated the alpha-gal syndrome or the alpha-gal protein in 
these pigs and some other things to try to reduce the amount of 
suppression.
    Yield back. Yield back to my friend.
    Mr. Burgess. So there you have it. I knew I was asking that 
question for a reason.
    Mr. Germano, you heard my earlier discussion about the 
liability issues and in Community Health Centers you are under, 
if I recall correctly, a national----
    Mr. Germano. Federal Tort Claims Act?
    Mr. Burgess. Federal Tort Claims Act. So your costs for 
liability insurance are reduced so you're able to expand the 
amount that you're able to offer because you're not spending so 
much on that part of the overhead.
    Is that true in the teaching health centers as well?
    Mr. Germano. Unfortunately, there are gaps. Because of the 
way the FTCA has been interpreted for us, it essentially says 
that as long as the patients are our patients and the services 
are within our scope, it is covered.
    But as you know, as a resident you go in the hospital, 
you're never sure who you're going to run into in the emergency 
room or surgery. So we have to buy alternative insurances to 
cover our residents because of that gap.
    Mr. Burgess. I would like to help you with that.
    Mr. Germano. I would love to have the help.
    Mr. Burgess. All right. We will follow up after committee. 
Thank you.
    Mr. Griffith. And I yield back.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentleman from New York, 
Mr. Engel, for 5 minutes.
    Mr. Engel. Thank you, Madam Chair. I appreciate your 
calling on me.
    Let me say that there are six Community Health Center 
networks in my district. I want to mention them, as they do a 
good job: Bronx Community Health Network, Hudson River Health 
Care, Morris Heights Health Center, Mount Vernon Neighborhood 
Health Center, New York City Health and Hospital Corporation, 
Open Door Family Medical Center, Incorporated.
     Together, they deliver high-quality care to nearly half a 
million of my constituents. Now, I have heard from some of 
these clinics that 2-year reauthorizations can hinder their 
ability to implement innovative care programs and retain 
experienced staff, and to that end I am pleased to cosponsor 
the CHIME Act, a bipartisan measure which would provide 5-year 
reauthorization to increase funding.
    Let me ask Mr. Germano, could you please describe some of 
the consequences of short-term funding measures on a Community 
Health Center's ability to implement care coordination 
programs?
    Mr. Germano. Thank you for that question.
    As was mentioned before, the biggest effect is the 
paralysing effect of not knowing what your future has in store. 
We are making long-term commitments to really change the face 
of delivery in our communities, whether that be the hiring of 
clinicians, whether that be creating of points of access.
    All those things take planning and investment, and when the 
dollars are--can only go out so far, most boards--most 
communities are going to say, we have to put--we have to slow 
down or stop and in some cases we have health centers who ended 
up taking loans to meet payroll. We had others that rescinded 
contracts to providers who were coming because they couldn't 
guarantee they could afford them. It is a very--it really has a 
very destabilizing effect having such a short window like that.
    Mr. Engel. Thank you. I appreciate your testimony.
    Let me also say that when we look at diabetes in my home 
State of New York, there are 2 million New Yorkers who have it. 
It costs the State an estimated $15 billion annually in direct 
medical expenses and, unfortunately, these figures are expected 
to rise as the diabetes epidemic worsens.
    To help turn the tide in this epidemic, Congress created 
the Special Diabetes Program. The program funds cutting-edge 
research into diabetes treatments and technologies, and New 
York research institutions have been awarded $86 million in SDP 
grants.
    Let me ask you, Mr. Kowalski, what are some innovative 
diabetes technologies that have been developed with SDP funds 
and how are they improving diabetes care?
    Dr. Kowalski. Thank you for the question, and first and 
foremost, I think what we've seen, as mentioned earlier, 
continuous glucose monitoring technology has played a pivotal 
role in driving better glucose control.
    More recently, artificial pancreas technologies are coming 
to the market and the SDP program played a pivotal role in 
driving those into the American system much earlier than 
expected and I can tell you that my brother and I use those 
systems very successfully with much better results.
    Ultimately, both in type 1 and type 2 people with diabetes 
these advances forestall the need for--the development of 
diabetes complications and those costly expenses, both SDP and 
SDPI both playing a critical role in slowing and reducing those 
costs.
    Mr. Engel. Thank you very much.
    And Mr. Germano, let me--let me ask you this. The United 
States has a growing shortage of primary care physicians, which 
is estimated to reach 50,000 by the year 2030.
    The shortage disproportionately affects underserved 
communities and the Teaching Health Center program plays a 
vital role in addressing this gap.
    So, Mr. Germano, can you please describe how a 5-year 
reauthorization will help Teaching Health Centers prepare the 
next generation of primary care physicians?
    Mr. Germano. Thank you for that question. The 5-year 
authorization goes to that issue of stability. When we take a 
class in, we are committing to 3 years.
    So when we have 1 or 2 years' worth of funding, it is a 
real leap to guarantee to these young people that we are going 
to continue to support them.
    The health centers that are in underserved communities--
Congressman, sorry--Burgess--Dr. Burgess mentioned that 70 
percent--the data shows 70 percent of those trained in--well, 
in locations where they're trained land within a hundred miles 
of where they are trained.
    So when we are training them in underserved communities we 
greatly increase the opportunity to keep them in our 
communities. Our data shows three times more success than other 
kinds of models.
    So yes, we need teaching health centers in underserved 
communities. We need to keep them there to take care of our 
communities.
    Mr. Engel. Thank you.
    Madam Chair, thank you so much for this. This is really 
important stuff that I know we have both worked on.
    Thank you.
    Ms. Eshoo. I thank the gentleman and he yields back.
    I now would like to recognize the gentleman from Missouri 
who is long on humour and friendship, Congressman Billy Long.
    Mr. Long. Thank you. Appreciate being recognized.
    Mr. Germano, the Teaching Health Center Graduate Medical 
Education Program plays an important role in bringing more 
primary care physicians to rural and underserved areas.
    Shasta Community Health Center participates in this program 
so I am interested in your perspective on this. What are the 
training differences in a teaching health center residency 
versus a traditional hospital residency?
    Mr. Germano. Thank you for that question.
    There is quite a bit of overlap because we have accrediting 
requirements that we have to meet. It doesn't matter where you 
are trained--you have to meet those requirements.
    The difference is that we are looking for medical students, 
fourth year, wanting to get into our residency, for people who 
have a heart and understanding of our community and our 
mission--serving our community.
    We are looking for people with experiences that would 
demonstrate that they will be successful in our environment. We 
then surround them with support and faculty and all the other 
resources we have to make sure they are successful in working 
in our communities.
    We help them root in our communities to the best extent, 
and if they are not staying, we--I have gone out and looked for 
similar communities where their spouse wants to move to and we 
connect them to a health center there.
    So we span the gamut, and I would just finish by saying 
that what we are doing now is we are going now downstream to 
our high schools and saying to our own underserved communities, 
listen, have you thought about a career as a primary care 
doctor.
    And this is how you get in and this is how we are going to 
help you get there, and we are going to get you into medical 
school and we are going to get you into our residency and 
you're going to serve your mother, your dad, your neighbors 
when you're done.
    To me, that is the long term. That is what 5 years of 
commitment does. It gives us that kind of support.
    Mr. Long. How can teaching health centers help alleviate 
the primary care workforce shortages that we are facing?
    Mr. Germano. Well, in H.R. 2815 there is a--in fact, a 
number of the bills--the important thing is we have to grow the 
program. The program is sort of stuck on 56 across the Nation 
with the funding that we have.
    So we need to grow it. In 2815 there is a provision to add 
eight new programs in 2021 and an additional eight in 2023, I 
believe, and it instructs HRSA and then there are other 
expansions of existing programs.
    We have to greatly expand the number of people--of 
residents that we train and that bill allows for, I believe, 
250 more spots of training in our country.
    Mr. Long. And how likely are residents to stay serving in 
the underserved areas after completing their residency at a 
teaching health center?
    Mr. Germano. The data from HRSA shows that it is running 
about--around 60 percent in the communities where they are 
trained. It doesn't mean--and it is something like 82 percent 
stay in primary care.
    And as I mentioned before, if they're not staying in your 
community, they are moving to another underserved community 
where they benefit.
    One of my residents moved to rural Arkansas because that's 
where her hometown was and that is where they needed her, and 
she is helping to deliver babies down there right now. So----
    Mr. Long. Let me--let me ask you another question, kind of 
following up on what my friend, Mr. Engel, was asking.
    You note that over the next decade the United States will 
require nearly 50,000 primary care physicians but the number of 
graduates is now greater than the number of residency slots, 
which I know a lot of Americans would be shocked to find out 
that you can go completely through medical school and not be 
able to get a residency.
    Mr. Germano. It is true.
    Mr. Long. Not be able to become a doctor. What else can we 
do to ensure that graduates can get residency slots and be able 
to practice particularly in rural and underserved areas, which 
will face the deepest impact from these physician shortages?
    Mr. Germano. Well, first and foremost, I think we need to 
create more teaching health centers in underserved communities. 
There are health centers around this country willing to be a 
sponsoring entity and I think we should make a deep investment 
in those health centers.
    And I believe there are other community-based and other 
rural communities that could support a residency teaching 
program. But, for me, if you really want to target underserved 
communities, the Community Health Center environment is where 
the investment should happen.
    I think it can and it should.
    Mr. Long. OK. The National Health Service Corps will play a 
vital role in bringing more primary care physicians to rural 
and underserved areas.
    There are four programs within the NHSC--the scholarship 
program, the loan repayment program, the State loan repayment 
program, and the students to service program.
    However, four of the five programs' placements are within 
the loan repayment program. Could you talk about the role of 
the other three programs that are within NHSC and what we can 
do to enhance the placements within these programs?
    Mr. Germano. Specifically, the scholarship program and the 
State loan repayment program? I want to be clear--is that what 
you're referring to?
    Mr. Long. The--all but the loan--yes, the repayment--the 
State loan repayment program, student to service program, and 
the scholarship program.
    Mr. Germano. Well, I would almost need to get back to you 
with more detail of what we can do.
    Mr. Long. We are out of time anyway so that is a good plan. 
Let us do that. I yield back.
    Ms. Eshoo. The gentleman yields back.
    I now would like to recognize the gentlewoman from Florida 
and thank her for chairing while I ran off to another 
subcommittee upstairs. The gentlewoman from Florida, Ms. 
Castor.
    Ms. Castor. Well, thank you very much, Madam Chair, and 
thank you for organizing this hearing because it is very 
important that the committee examine health initiatives that 
are effectively helping families back home.
    That certainly includes the Special Diabetes Program, 
everything the Family-to-Family Initiative does to ensure 
families with kids with special needs get the care they need. 
Patient-Centered Research is vitally important.
    Thank you for your summary on Teaching Health Centers. I 
hope we can expand them and I want to salute Ms. Matsui for 
working for many years to expand our community behavioral 
health clinics. I think that has a lot of promise for families.
    Probably the most impactful in my Tampa area district will 
be Community Health Centers, and since the adoption of the 
Affordable Care Act with the Community Health Center funding 
that provides grants, I have seen significant expansion.
    It is so important to families in my community. Tampa 
family health centers currently leverages over $9 million in 
Federal investments and serve well over 100,000 of my neighbors 
back home.
    Now, Community Health Centers, they rely on a number of 
funding streams--Medicare and Medicaid reimbursements, some 
private pay. But the grants that come from the Community Health 
Centers fund are critical to expansion.
    Mr. Germano, tell us how health centers across the country 
are using the grants that come from specifically the Community 
Health Center Fund.
    Mr. Germano. Well, our main purpose of the Federal grants 
is really, I think, twofold. One is to make sure that we 
provide effective primary preventive care to our uninsured.
    So every State, depending on how they dealt with the ACA, 
have a different number there.
    Ms. Castor. And isn't that important in States that did not 
expand Medicaid, which, unfortunately, includes the State of 
Florida.
    Mr. Germano. The 330 grant is truly a lifesaver for those 
States because the uninsured rates are much higher. The other 
places that it helps to support the infrastructure delivery of 
those services, not all those other funding sources cover a 
part of what's--of what it costs but it is not the whole thing.
    So we need all those funding sources, including the Federal 
grant. The Federal grant also provides for Federal tort claims. 
People--you know, that's the malpractice coverage that we lean 
on to help make it more affordable for us to deliver services.
    It also allows us to work with our States on prospective 
payment under Medicaid. So Medicaid pays its fair share of what 
it costs to deliver services.
    So the Federal grant is fundamental as a foundational 
building block for what we do.
    Ms. Castor. And a couple of years ago, we were entirely 
frustrated because the Community Health Centers Fund was in 
need of reauthorization. I think you answered Chairman 
Pallone's question about the importance of continuity and on 
the longer term extension.
    I know in my community the 6-month delay in funding for 
Community Health Centers, the National Health Service Corps, 
the Teaching Health Centers, among others, was particularly 
damaging.
    We heard from folks back home that said this funding cliff 
is untenable. They said they had to freeze hiring, including 
physicians, and support personnel. They had to stop all 
construction expansion plans. That is not smart or financially 
wise.
    They had--even reducing the number of patients they saw and 
considered closing existing facilities. So you talked about the 
importance of continuity. But, boy, if--give me a good example 
of how a funding lapse and additional delays affects patients' 
access to care and the workforce that we need to train.
    Mr. Germano. Well, many of our health centers have been--
are at the maximum of their capacity. So the only way to take 
care of more people is to look at expansion. But to expand you 
have to plan. It just doesn't--you just don't pitch a tent and 
start delivering services in many cases.
    So the continuity and being able to plan ahead to do that, 
I mentioned earlier, takes three to 5 years to plan a new site, 
you know, from thought to finish, and you have to have some 
certainty of your funding is going to be there.
    The Teaching Health Centers, as I mentioned, every class is 
a 3-year commitment. You have 1 or 2 years' worth of funding 
and a 3-year commitment, it doesn't serve anybody very well.
    It creates a lot of anxiety, and particularly in part of 
the residents, I might add, wondering if they're going to 
actually finish in the training program they started.
    We did lose one health center during that period. Twenty-
four residents lost their training program. We had to scramble 
and absorb them across the country. Not a good situation.
    Ms. Castor. Well, I agree with you and I--Madam Chair, I 
look forward to the committee marking up these bills with 
robust funding and extension and reauthorization.
    Thank you, and yield back.
    Ms. Eshoo. The gentlewoman yields back.
    A pleasure to recognize the gentleman from Kentucky, Mr. 
Guthrie, for 5 minutes of questions.
    Mr. Guthrie. Thank you, Madam Chair.
    My first question is for Mr. Germano. I am a big supporter 
in Community Health Centers. I think they do a fantastic job.
    We just need to ensure that they are on a successful track 
and they are funded responsibly. One of the things that I have 
been driven by, being on this committee, is all the fantastic 
innovation coming in healthcare.
    Now we can cure--Dr. Francis Collins said we can use the 
``cure'' word for sickle cell anemia. Just all this stuff 
that's coming forward.
    So I just kind of--what innovation do you see Community 
Health Centers doing to be part of the great revolution or 
innovation revolution in healthcare and how they are innovating 
to better serve their communities?
    Mr. Germano. Well, I think a lot of these technologies, 
these advancements, are moving into the ambulatory space. We've 
done--we are doing less and less in the hospitals or at least 
less time, and now it is moving into the outpatient 
environment.
    We have to make sure that the health centers have the 
resources to take advantage of those technologies and those 
therapies. I know that we look at best practices all the time 
in our practice--what can we do, how can we influence, for 
example, our State Medicaid authority to make sure that these 
technologies are somehow added to our scope--are paid for under 
our scope of services.
    We have to make sure that our uninsured aren't left out of 
those advancements, and that's what the 330 program does is 
help us do that.
    We have to stay on top of it. We have patient-centered 
medical homes now. We wrap services around our patients. The 
mental health piece is very important in terms of behavioral 
health. It is not just the technologies; it is actually helping 
people maybe change behaviors to take advantage of these 
things.
    Mr. Guthrie. OK. Thanks. I just have a couple questions.
    So, Dr. Kowalski, thanks for being here today as well. I am 
the ranking member on Oversight and we have been looking at 
insulin pricing and barriers to diabetes care.
    Can you please describe how the diabetes--Special Diabetes 
Program helps--decreases these barriers and is innovating for 
individuals with diabetes?
    Dr. Kowalski. Well, I testified a couple weeks ago on 
insulin pricing and we have an issue in the United States. 
Nobody should die or suffer for lack of insulin. I think what 
we talk about here is we have innovation happening through SDP 
that----
    Mr. Guthrie. The artificial pancreas is something that is 
now available----
    Dr. Kowalski. The artificial pancreas and a variety of more 
coming down the pike when you talk about cures--potential 
cures--and we need to ensure they're accessible.
    So we have been working with Members of Congress and across 
NIH and, of course, with our team to look at policies that 
ensure that the advances that we are seeing that are faster 
than I have ever seen in all my time in science are accessible 
to anybody who will benefit.
    Mr. Guthrie. It is happening at such a rapid, rapid pace, 
isn't it?
    Dr. Kowalski. Absolutely.
    Mr. Guthrie. It is amazing how--and I have two nieces with 
diabetes and so that--I keep a pretty close eye on that as 
well.
    So, Dr. Cooper, can you please just speak to how PCORI-
funded research is taken up in practices and are there any 
long-term measuring tools that PCORI uses to track impact of 
PCORI research?
    Dr. Cooper. Certainly I can do some of that. So I can tell 
you that in the work that I am currently doing the practices 
that we work with are--many of them are Community Health 
Centers and they are eager to test different evidence-based 
approaches in their own settings and to try different ways of 
actually implementing the things that we know from NIH 
discoveries should be used in practice but aren't because often 
those studies aren't done in the real world practices with the 
people who actually have to deliver those services and 
treatments.
    So I think there is a lot of enthusiasm to be engaged in 
PCORI type research and to problem solve with researchers 
around how to get these new discoveries actually implemented 
with the realities of the resources and the staffing that 
exists in the settings.
    Mr. Guthrie. Can you measure the implementation of your 
research? Do you have measures to see how that is moving 
forward?
    Dr. Cooper. So some of the measures we have have to do 
with, first of all, the levels of engagement with different 
stakeholders and what contributions they each make to the 
overall process and how that actually changes the work from its 
inception to when it is complete and then later on looking at 
to what extent the intervention or the program is taken up.
    So we look to see, for example, how many people are 
actually using the intervention that's being tested, how many 
people are being exposed to it, whether it is being used with 
fidelity, so is it being used like--as it was intended or is it 
being adapted and used in a different way.
    And then we look to see to what extent that uptake actually 
leads to the outcomes that we look at.
    Mr. Guthrie. OK. Well, thank you, and my time has expired 
and I will yield back.
    Ms. Eshoo. The gentleman yields back.
    Now I would like to recognize the gentleman from New 
Mexico, Mr. Lujan, for 5 minutes of his questioning.
    Mr. Lujan. Thank you, Madam Chair, and thank you all for 
being here today.
    I want to address a disturbing health trend among Native 
American populations in the United States. Native Americans 
have the highest rates of type 2 diabetes in the United States. 
Native American adults are also 2.4 times as likely as white 
adults to have diabetes, and in 2013 Native American women were 
twice as likely to die from diabetes as white women.
    The reality is that Native Americans are unnecessarily 
dying from diabetes. As we have heard today, the Special 
Diabetes Program and the Special Diabetes Program for Native 
Americans are both extremely successful and have meaningfully 
improved patients' lives.
    For example, since the establishment of SDPI, the 
prevalence of diabetic eye disease and end-stage renal disease 
have been cut in half.
    I believe it is our responsibility to ensure that these 
vital programs have the funding necessary to continue but also 
to expand.
    Mr. Kowalski, in your testimony you highlighted the 
groundbreaking research SDP and SDPI have funded since their 
creation. For Native American communities disproportionately 
affected by type 2 diabetes, how do these programs ensure that 
they receive the access and quality of care that they deserve?
    Dr. Kowalski. Thank you for that question, and I think this 
is a tremendous example of how evidence-based medicine--we have 
had a number of questions about evidence-based medicine, and 
the implementation--can it be cost savings and deliver true 
impact.
    And I think you point out quite rightly that SDPI is 
serving an underserved community who is suffering from a 
disease that is often stigmatized but is highly genetic and 
inherited--type 2 diabetes--and requires significantly more 
resources deployed against it.
    We know that these interventions can make a difference and 
you point out statistics such as the higher than average 
diabetes rates and death rates.
    The prevalence of type 2 diabetes has plateaued since SDPI 
has been implemented. We know that the rates of diabetes 
complications are being reined in and I think this investment 
has been shown to be cost saving.
    The reduction in diabetic kidney disease, which is 
completely covered by CMS, is estimated to be saving over $500 
million since the implementation of this program.
    So I think there is much more to do and I think the 
reauthorization of this program is a hugely important next 
step.
    Mr. Lujan. Well, and that's my follow up is what happens if 
this program is not reauthorized?
    Dr. Kowalski. Well, we know that diabetes is growing, of 
course, in the Native population. But this is across our entire 
country. And if we don't intervene we are going to see 
increasing costs driven by diabetes complications and 
management.
    These interventions work. There is no doubt. This program 
is not just research for research sake. This is implementation 
that is driving better outcomes and saving cost.
    So I think that time is of the essence and we need to get 
this reauthorized as soon as possible.
    Mr. Lujan. Well, I appreciate the emphasis not just on the 
fact that this investment is cost saving, but the second part 
of my question is not just the importance of this 
reauthorization but to expand the service.
    What more can be done to get services in areas where they 
are still needed that they're not getting out there?
    Dr. Kowalski. There is no doubt that here in the United 
States we have a problem on kind of both ends of the spectrum, 
meaning that even people with the best tools still struggle.
    Diabetes is a very hard disease to manage. So when you're 
in an underservedved environment it is tremendously difficult 
and the investment in these communities pay huge dividends.
    One-third of the Medicare budget is driven by diabetes 
complications. More investment will reduce cost and, of course, 
this is a human disease. We are talking about costs but these 
are families who are suffering and we need to do better.
    Mr. Lujan. I appreciate your response very much and 
highlighting the importance of reauthorizing this important 
program.
    And with that, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    That is a stunning figure that you just gave, Dr. Kowalski. 
Say it again.
    Dr. Kowalski. One-third of the Medicare budget, and that is 
because Medicare is paying for all end-stage renal disease, and 
when we look at the advances in diabetes care and new kidney 
disease drugs we expect, we could significantly reduce those 
costs.
    Ms. Eshoo. Thank you.
    I now would like to recognize the gentleman from Indiana, 
Dr. Bucshon, 5 minutes for questions.
    Mr. Bucshon. Thank you very much, and thank you all for 
testifying.
    The programs we are discussing today are all very 
important. I think that is pretty clear. And I think we all 
agree they should be funded, the more years the better, for the 
reasons that people have outlined.
    But that said, I have strong concerns about some of the 
bills before us for consideration which do not include the Hyde 
Amendment protections--prolife protections that have been in 
funding bills, preventing government funding for abortions, and 
that has been in place since 1976 and has been supported by 
both parties for decades until about 2016 when many Democrats 
began supporting government funding of abortions.
    It is just an unnecessary partisan discussion injected into 
what is a discussion over critical programs that we need to 
authorize and it makes it difficult for Republicans to be 
supportive of the legislation in their current form.
    I mean, Dr. Burgess introduced H.R. 2700 to reauthorize the 
Community Health Centers and National Health Service Corps, the 
Teaching Health Centers GME, Special Diabetes Program, Family-
to-Family Health Information, centers in sexual risk, 
avoidance, education, and personal responsibility education for 
1 year, and his bill would have used the savings gained from 
the recently passed--at least committee-passed bipartisan drug 
pricing bills to fund that extension, even though it is short, 
it had a pay-for.
    Instead, unfortunately, last week we used the money to fund 
partisan Affordable Care Act provisions, which Republicans 
can't support.
    So I think if we are really serious about preventing these 
program authorizations from expiring, I think we need 
bipartisan legislation--that we need to come to a bipartisan 
agreement on how to pay for these priorities, which we have in 
the past, and I look forward to working with my colleagues on 
both sides of the aisle to advance these critical policies in a 
fiscally responsible way.
    Mr. Germano, in your testimony you talk about the important 
ability to provide dental, mental health, and overall health 
services to the homeless, which is a growing problem in all of 
our districts.
    Additionally, you mention that you use telemedicine 
extensively, and I have a very rural district and am a big 
supporter of telemedicine. It is important.
    Can you talk more about how the Federal funding helps 
support these and other important services that Shasta 
Community Health Centers provide?
    Mr. Germano. Thank you for that question, Congressman.
    Oral health, historically, has been one of the forgotten 
services that are needed in communities of need. Oral health 
disease is the number-one pediatric disease, period, in 
America.
    We made a commitment through Federal 330 dollars a number 
of years ago to build an oral health infrastructure and we have 
actually helped get a school of hygiene open because of our 
association with the junior college and expanding that access 
throughout our community. So a lot of leveraging that went on 
there.
    Telemedicine is a great advancement in a rural community. 
We are--we have consults with--a thousand miles away with 
specialists in major teaching facilities, access that our 
patients would never ever get, really, truthfully, otherwise.
    However, it is expensive. Not so much the technology but 
you're working with major teaching hospitals and what have you. 
So the 330 grant helps to subsidize a lot of that cost to allow 
us to do that and to have our patients be seen effectively.
    Mr. Bucshon. Yes. I mean, I think a lot of things that--I 
was a cardiovascular surgeon before I was in Congress and we do 
overlook dental and oral health and, obviously, we are 
struggling to make sure we have parity in mental health 
services, which I support, obviously.
    And things like telemedicine and other things that I think 
Community Health Centers in rural areas can provide is really 
critically important, and I am hopeful that we can come to an 
agreement on how to make sure that we get all of these programs 
that I mentioned reauthorized hopefully for more than just a 
year or 2 years, but longer, because as I think you outlined, 
this certainty involved in that is really a critical piece to 
this puzzle.
    With that, Madam Chairwoman, I yield back.
    Ms. Eshoo. I thank the good doctor and he yields back.
    Now I would like to recognize the gentleman from Maryland, 
Mr. Sarbanes.
    Mr. Sarbanes. Thanks very much, Madam Chair. Thank you to 
our panel over here.
    So, first of all, I want to thank the chairwoman for 
bringing all these bills before us and having us discuss the 
importance of the reauthorization. These are all critical 
programs and there is a lot of bipartisan support, as you 
gathered, from just the comments of my colleagues today.
    Mr. Germano, I wanted to talk to you a little bit about the 
Community Health Centers. You have given very powerful 
testimony today to why continuing to fund those at robust 
levels and provide those resources is so critical, going 
forward.
    Those health centers, as you know--and maybe you could 
speak to this--serve children and young people significantly. 
So you have a sense of the degree to which that's the case? The 
kind of numbers we are looking at, percentages or anything like 
that?
    Mr. Germano. Across--I can't give you across the country 
but it is substantial. I would say at least 40 percent or more 
in the most----
    Mr. Sarbanes. Yes. I think it is at least 30 and in some 
places it exceeds that in terms of patients that are served by 
health centers who are children under the age of 18.
    And I certainly want to thank my colleagues who have 
introduced H.R. 2328 and H.R. 1943 for maintaining our strong 
commitment to Community Health Centers which support the needs 
of children.
    But it is children's stake in these programs and services 
that has led me to kind of carve out a niche commitment or 
perspective here on the committee and in Congress with respect 
to strengthening school-based health centers because I really 
feel like you have a captive audience.
    You, obviously, have the young people there, and if you can 
deliver services right there on site and do it in a consistent 
way and a comprehensive way, it can make a dramatic difference, 
not just for those individuals--for those students, for their 
families, for the community, for the health of the school, et 
cetera. You can spot issues that may be arising.
    I think having mental health services as a key component--
integral component--of what is delivered by school-based health 
centers is something that we need to examine more deeply.
    Can you speak to--and I know that I think about 50 percent 
of the school-based health centers in the country have some 
linkage to community-based health centers and maybe you could 
talk a little bit to that relationship because through that 
lens you would know of or have a perspective on how important 
it is to deliver those services at the school level because I 
really--I have introduced some legislation that would 
strengthen the support of school-based health centers but I 
have always viewed the Community Health Centers and their 
health as fundamental, kind of foundational to building off of 
that the school-based health response. So if you could speak to 
that, it'd be terrific.
    Mr. Germano. Thank you for that question.
    I think the advantage of school-based health centers--you 
have mentioned it--is they are there. They are there with the 
kids. They are there with the families.
    But in my judgment, they are an island unto themselves 
unless they are connected to a system and that is what the 
health centers are--a system.
    So you are a nurse practitioner in a school, you come 
across kids who may have onset--new onset diabetes or other 
indicators, you need a referral in to the services we provide, 
which would include maybe seeing the pediatrician at my health 
center.
    Maybe needing the diabetic counselor. Maybe helping mom and 
dad with how to plan for their--you know, buying food and those 
kinds of things. Getting them signed up for Medicaid if they're 
eligible.
    So the connection to the network, to the system, is really 
important, I think, in terms of maximizing the value on the 
ground for those services in the schools.
    Mr. Sarbanes. I appreciate that, and, again, I come back to 
this concept that it is a huge lost opportunity if you don't 
site some of these health services in the place where you have 
hundreds, thousands, potentially, of individuals that can take 
advantage of them.
    So resourcing them is important. Examining best practices 
of these school-based health centers--what it means to design a 
comprehensive school-based health center sort of covers the 
waterfront in terms of what you would want to see.
    And then to your point, making sure that the linkages are 
there so that you can, you know, make the right kind of 
referrals, you can step back, get a more holistic view of what 
that individual and their family needs, et cetera, and then 
provide other services as a result.
    So we are going to continue to really lean on this effort 
around school-based health centers but make sure as we do it 
that we are connecting it to the community-based health 
centers, and so keeping them strong, which is what you are here 
to testify about today is, obviously, key.
    And with that, I yield back my time.
    Ms. Eshoo. The gentleman yields back.
    Pleasure to recognize the gentleman from Illinois, Mr. 
Shimkus, for 5 minutes of his questions.
    Mr. Shimkus. Thank you, Madam Chairman.
    I would like to yield my time to Congressman Guthrie of 
Kentucky.
    Mr. Guthrie. OK. Thank you for yielding.
    Dr. Cooper, the PCORI-funded study you are leading is 
comparing two ways to treat high blood pressure. Who will this 
research benefit and how do you envision the outcomes of this 
research changing the way care is delivered?
    Dr. Cooper. Thank you. I think the research will benefit 
several different groups of people.
    So, first of all, it will benefit patients who have high 
blood pressure and who often have other chronic conditions as 
well--because we are studying people who have more than one 
chronic condition--and we are helping them to figure out 
whether working with a team that includes a nurse and a 
community health worker and also access virtually to 
specialists works better than simply going to a clinic where 
they get information in a brochure.
     And so I think if we can show that that works, patients 
will be able to request to work with a nurse community health 
worker team to help them address their issues more 
comprehensively.
    It'll also help clinics and health centers that are trying 
to decide how to staff to take care of patients with certain 
needs--hypertension and other chronic conditions as well as 
social determinants of health, because we are working with 
underserved communities, and it'll help them figure out what 
resources they need, what staffing they need, and also provide 
them with ways to train and monitor that--those programs.
    So that is--I am hoping that that will benefit patients as 
well as health systems and then also help providers to figure 
out what kinds of programs they can refer their patients to 
when they need extra support.
    Mr. Guthrie. OK. Thank you.
    And, Mr. Germano, Community Health Centers program's annual 
funding has more than tripled between fiscal year 2002 and 2018 
due to increases in community health center funds.
    The grants have been used for broad purposes and types of 
grant-supported program activities have expanded and changed 
over time. So since the establishment of the Community Health 
Center Fund in 2011, in general, how have these grant funds 
been used and how have the new investments changed over time?
    Mr. Germano. I think--thank you for that question.
    The biggest increase is in new sites and new services. We 
have seen a tremendous expansion of the Community Health Center 
model across the United States.
    More and more underserved communities have created these 
Community Health Centers. Existing health centers have expanded 
into new communities. Services mentioned earlier--oral health, 
mental health, telemedicine, healthcare for the homeless, HIV 
care--Ryan White.
    So we have really reached out with those dollars and have 
more and more impact. We are now at 28 million Americans who 
are cared for by Community Health Centers. I would like to see 
that doubled. We have 84 million people in America right now 
without a good primary care home and that is what we can 
represent is a good primary care home for them.
    Mr. Guthrie. OK. Thank you.
    That is my questions. If anybody wants my time I will yield 
back.
    Mr. Butterfield [presiding]. The gentleman yields back.
    The gentleman from Oregon, Mr. Schrader, is recognized for 
5 minutes.
    Mr. Schrader. Thank you very much, Mr. Chairman. I 
appreciate it.
    Dr. Cooper, thanks for being here. As one of the original 
sponsors of the bipartisan bill that put PCORI into effect, the 
Comparative Effectiveness Research bill in 2009. So very 
interested in the work that you're doing and trying to bring it 
to fruition and implementation.
    The main goal was to make the healthcare system work a 
little better, centered around the patient, best outcomes. Did 
some initial investment. You have indicated it has been paying 
off. You gave several different examples of, you know, cases 
where you came up with some pretty interesting things that 
you're trying to disseminate out there to the marketplace, to 
different clinics, hospitals, et cetera.
    Things have changed a little bit in the intervening 10 or 
15 years and particularly in the drug space. Things are 
becoming very expensive. Some lifesaving medications--there has 
been the discussion on this panel about value-based 
reimbursement for some of these, you know, medications and what 
have you and the cost of treatment, the copays, et cetera, are 
getting a little more attention for that upper middle class in 
the Affordable Care Act.
    So would you agree that cost of treatment is part of a 
patient's consideration when deciding what--where to go and 
what type of therapy to have?
    Dr. Cooper. I certainly think that cost is part of the 
patient's consideration and people do need to often factor that 
into their decision making around what care or approaches they 
want to take and will be accessible and affordable to them.
    Mr. Schrader. So given that and the problem we have that 
PCORI is expressly prohibited from considering cost 
effectiveness in its mission, should we be thinking about 
tinkering with that a little bit and include the cost of 
treatment as part of an impact so that the patient has the full 
understanding of what they're coming up against, given the fact 
there are so many great treatments out there?
    Dr. Cooper. So I think it is up to you as the lawmakers to 
make that decision. I think that information is important and 
it should be studied somewhere and whether it comes through the 
way that PCORI is funded or authorized or through some other 
mechanism, I am sort of agnostic to that.
    But I think we would all agree that it is important work 
that needs to be done and coordinated with the work that's 
happening at PCORI, either coordinated or done there.
    Mr. Schrader. All right. Thank you. Thank you.
    A little concerned that CMS is not particularly implemented 
or at least from my understanding chosen to really adopt some 
of the great recommendations that are coming out of PCORI.
    Is there a way we should be talking with them or trying to 
get them to perhaps use some of your recommendations a little 
bit more recent or a little more ongoing basis? The outcomes 
are good.
    Dr. Cooper. Right. I definitely would encourage that. I 
think one of the things that PCORI does encourage is 
conversations among researchers and payers and insurers so that 
they are all at the table and they're involved in the design of 
the work and we are answering the questions that are relevant 
to them so that they can use that information in decisions 
about resource use and follow-ups.
    But any other support that we can get in that realm I think 
would be very helpful.
    Mr. Schrader. How about incentivizing CMS? You know, there 
are some great practices--get a chance to use that again. We 
are talking about value-based reimbursement, getting good 
outcomes.
    Dr. Cooper. I think incentivizing patient-centered outcomes 
is important and oftentimes we have been incentivizing, 
typically, clinically and biomedically based outcomes and I 
think it is important to also incentivize health systems that 
pay attention to things that matter to patients and their 
families.
    Mr. Schrader. I think particularly given CMS's clout and 
the influence they have it would be nice to get them behind 
some of these and help disseminate that information.
    Mr. Germano, popular guy here today. We all love CHCs--you 
know, critical to bringing healthcare to a lot of folks that 
can't afford--that have no other access, actually.
    But I am a little concerned that the alignment between some 
of the outcomes that HRSA uses to judge, you know, how the CHCs 
are doing don't align necessarily with the Medicaid outcomes.
    For instance, if you're a health center, child 
immunizations have to be completed by age three. If you're a 
managed care organization, it is age two. You know, would it be 
smart to maybe try and sort of align both the CHC outcomes with 
the Medicaid outcomes too?
    Mr. Germano. Please, can you make that happen?
    [Laughter.]
    Mr. Germano. It does drive my clinicians up the wall 
because we have all these multiple standards and what are we 
held to and what are they held to.
    So to the extent--I mean, I think we are working on it with 
our Medicaid managed care plan or State, not so sure about HRSA 
but trying to get them all aligned to agree as to frequency and 
what the goals are so that we can work towards them.
    It is maddening, in many respects, that we have to do--deal 
with it.
    Mr. Schrader. Thank you. Oregon, I know, is working on 
that, and I yield back, Mr. Chairman.
    Mr. Butterfield. The gentleman yields back.
    The gentlelady from Indiana, Mrs. Brooks, is recognized for 
5 minutes.
    Mrs. Brooks. Thank you, Mr. Chairman.
    I am going to start with you, Mr. Germano, but I have 
several questions for the panel, and thank you all so very much 
for being here.
    Can you further discuss the kind of treatments that 
Community Health Centers are using combatting the opioid 
epidemic?
    Mr. Germano. Thank you for that question.
    Our primary mechanism is to use buprenorphine Suboxone--
medically assisted therapies. We have created clinic systems 
around that. We have about 200 patients now in therapies right 
now. Behavioral health is a big component of that; not just the 
drug, but the behavioral health and the follow-up.
    So we are--we have doubled that program in a year. We are 
probably going to double it again and we are going to add it to 
our maternity services as well.
    Mrs. Brooks. And do you know is that a trend that you are 
seeing with other Community Health Centers?
    Mr. Germano. Very much so. I think we are gaining 
confidence as a system that it works, it is helpful, and if 
done correctly with behavioral health it can be very effective 
for our communities, yes.
    Mrs. Brooks. One of the concerns that I have is the 
workforce shortage, and while we have talked about physician 
shortages, and I appreciate you talking about the issues with 
graduate medical education, I have introduced an Opioid 
Workforce Act because, as I understand, one of our biggest 
concerns in the treatment of opioids is the lack of a trained 
workforce.
    In the teaching Community Health Center model, are there 
any addiction medicine programs for residents that you're aware 
of and is that--Representative Schneider and I from Illinois 
have introduced this Opioid Workforce Act to try to increase 
Medicare-funded residency slots for addiction medicine 
specifically. Are you familiar with any of those types of 
programs?
    Mr. Germano. I am not. But I will say this much. In our own 
residency program, we have made the MAT program a core part of 
their training. So when they are done, they are X waivered and 
they are ready to go when they finish training.
    Mrs. Brooks. That is excellent. Do you know if that is 
something that other Community Health Centers are doing as 
well?
    Mr. Germano. I believe that many of them are doing that. I 
can't say all of them, but I am familiar with several that are.
    Mrs. Brooks. Would additional funded residency programs 
make that more possible or do you think there is a need for any 
specific addiction medicine residencies?
    Mr. Germano. I really can't answer that question. All I can 
say is in the teaching health center world, because our 
communities are suffering from the scourge of opioid abuse, 
they should be training their residents in this field. They 
should give them comfort.
    Mrs. Brooks. And so you'd like to see all--would you like 
to see all the primary care residency programs include your 
medication-assisted treatment training?
    Mr. Germano. I think every community has to decide what is 
a priority. But from what I have seen across this country, I 
would say yes.
    Mrs. Brooks. Dr. Cooper, I would like to ask you about the 
PCORI program relative to opioid and pain management. You 
talked about it a little bit in your written testimony, and I 
am sorry, I had to go to another hearing and missed your 
testimony here. Can you talk a little bit about PCORI-funded 
programs relative to addressing the opioid epidemic?
    Dr. Cooper. Sure. So I did mention the one where there was 
an initiative targeting providers and getting them to decrease 
prescribing of opioids.
    There are other programs looking at team-based models of 
care for opioid addiction, different programs focusing on how 
to monitor medication used for patients, also looking at 
different approaches that combine medication such as Suboxone 
with cognitive and behavioral therapy included.
    So a number of different programs comparing different 
strategies for addressing opioid addiction.
    Mrs. Brooks. Thank you.
    Shifting just for a moment, Dr. Kowalski, congratulations 
on your new role and I have been involved in the Special 
Diabetes Program reauthorization in the past and I know we have 
spent a fair amount of time asking about the funding and so 
forth.
    What are the greatest challenges that are remaining as you 
have taken on this new role and the obstacles? What are kind of 
the biggest obstacles in the disease that concern you the most 
and the greatest challenges that you face, and how can the 
Special Diabetes Program help overcome those?
    Dr. Kowalski. I will echo what we have heard today. The 
lack of clarity on sustained funding is a big obstacle for us 
in diabetes as well. In your home State, we have IU doing some 
of the most innovative work in the immunobiology of type 1 
diabetes, an autoimmune form of the disease.
    TrialNet has played a pivotal role in our understanding of 
potential interventions to slow, prevent, and ultimately, we 
believe, cure the disease.
    The NIH and the SDP play a pivotal role in driving that 
research forward. So a sustainability of funding at a moment 
where we are seeing science exploding, not only in type 1 
diabetes; there is a lot of overlap in other autoimmunity that 
we are working--MS, celiac, rheumatoid arthritis.
    That progress needs to be sustained and we need to keep 
that momentum going.
    Mrs. Brooks. Thank you. Thank you for your work, everyone.
    I yield back.
    Mr. Butterfield. I thank the gentlelady.
    The gentleman from California, Dr. Ruiz, is recognized for 
5 minutes.
    Mr. Ruiz. Thank you, Mr. Chairman.
    First, I would like to thank Congresswoman McMorris Rodgers 
for cointroducing the Training of the Next Generation of 
Primary Care Doctors Act with me.
    This bill will reauthorize the Teacher Health Centers 
Graduate Medical Education Program, which will soon end in 
September 2019 and it will add more primary care doctors in the 
communities that need them the most.
    I know a little bit about this because I grew up in the 
very underserved community of Coachella--farm worker family--
and when I came back after leaving home and coming back as a 
doctor I set to mission to really address the healthcare crisis 
that we have in the area.
    And I did research with some of my students that I was 
mentoring--premed students--and we came up with the Coachella 
Valley Health Care Initiative and Health Care Access Report, 
and we counted that there was one full time equivalent doctor 
per 9,000 residents in large segments of the Coachella Valley.
    And you usually think of Coachella Valley as lush country 
clubs, right. But there are a large portion that still struggle 
to get the care that they need. It is one of the reasons why I 
ran for Congress as well and it is the primary reason why I set 
off to be a doctor.
    The medically appropriate number--recommended number is 1 
to 2,000. So we are 1 to 9,000. To be determined as medically 
underserved it is 1 to 3,500. So we have a lot of work to do 
and the Teaching Health Center Graduate Medical Education 
Program was created under the ACA in the effort to get more 
doctors in medically underserved areas.
    You see, we have a drastic physician shortage crisis 
everywhere in America in terms of absolute numbers. But the 
secondary crisis is that they are maldistributed, leaving large 
portions of our country very medically underserved without 
doctors.
    And as we know, those of us who practice and study this 
that the two largest predictors of where a physician will 
eventually lay roots and practice are where they are from and 
where they last train.
    So I built pipeline programs from the underserved 
communities through my physician--Future Physician Leaders 
Program, getting them from high school, putting them through 
undergrad medical school with the USR School of Medicine and 
then training them in underserved areas, and that is the best 
way that you're going to address the physician shortage crisis 
in the underserved and rural areas.
    So this program works. The Teaching Health Center Graduate 
Medical Education Programs work. In 2017, statistics show that 
82 percent of Teaching Health Center graduates remain in 
primary care compared to 23 percent of traditional GME 
graduates.
    Fifty-five percent of Teaching Health Centers' graduates 
practice in underserved communities, compared to only 26 
percent of traditional GME graduates, and 20 percent of 
Teaching Health Center graduates practice in rural settings 
compared to only 8 percent of traditional GME graduates.
    And I am working in my districts with Borrego Health and 
Neighborhood Health and Clinicas de Salud del Pueblo to really 
address this and bring in more residents into the underserved 
areas.
    So Teaching Health Centers truly take a different approach 
to graduate medical education by placing residents directly in 
the communities most in need of care.
    Dr. Germano, in your testimony you referred to it as ``grow 
your own'' strategy. Could you further explain how Teaching 
Health Centers training experience and outcome is different 
from traditional GMEs?
    Mr. Germano. Thank you both for you commitment to the 
Teaching Health Center Program. And I am not a physician so----
    Mr. Ruiz. I've got 1 minute, so I got too many questions.
    Mr. Germano. But, really, it is about seeding programs in 
underserved communities and rural areas, in particular, have a 
tough time just as----
    Mr. Ruiz. And is different from traditional GMEs how?
    Mr. Germano. In that we identify young people with a 
commitment to serve in our community that come from our 
community and we train them, and that is how we do it.
    Mr. Ruiz. Right. The other problem is that for these 
programs most of them have residencies that require 3 years, 
right. That's one of the minimum years for a family medicine 
residency program. But we have been reauthorizing them for 2 
years. Why is that a problem?
    Mr. Germano. Well, every class you take is a 3-year 
commitment. When you have 2 years' worth of funding, it creates 
a lot of insecurity.
    Mr. Ruiz. Exactly. So this is going to add funding for 5 
years and, hopefully, will start to change that problem.
    The other issue we have is the not only disparities in the 
diversity or lack of diversity in physician workforce but we 
also know that if you train more Latinos and African Americans, 
et cetera, they will go to--more likely to go to Latino and 
African-American communities and they tend to be underserved as 
well.
    So how does this help that?
    Mr. Germano. Well, again, it is that pipeline from our own 
communities, from the faces of our community into the medical--
just like what you are doing down your way.
    We are trying to do that across the country in teaching 
health centers, drawing from our community--our own underserved 
populations, moving them through, looking like the patients 
that, you know, they are going to take care of.
    Mr. Ruiz. And that is not just important in the overall 
idea of diversity is good, but when a patient understands the 
instructions and when the doctor understands the community in 
which they live in, they are better able to tailor the 
therapeutic recommendations and advice so that the patients can 
actually implement them.
    And studies have shown that patients are more compliant, 
especially if they understand through the cultural nuances and 
language--they are more compliant and they have better 
outcomes.
    So it is actually--when you want to measure value of public 
health, having physicians who are similar and can understand 
the life experience of their patients will lead to better 
health.
    Mr. Germano. I agree.
    Mr. Ruiz. I yield my time.
    Mr. Butterfield. The gentleman's time has expired. The 
gentleman yields back.
    The gentleman from Florida, Mr. Bilirakis, is recognized 
for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    Mr. Germano, give Florida's traditionally higher senior and 
veteran populations, maintaining a skilled healthcare workforce 
is critical. It becomes even more of a challenge when student 
debt drives where residents choose to practice.
    Often, it is our rural and traditionally underserved areas 
who suffer, unfortunately. According to HRSA, a family medicine 
resident physicians who train in health center settings are 
nearly three times as likely to practice in underserved 
settings after graduation, when compared to residents who did 
not, underscoring the value of the Teaching Health Center 
Graduate Medical Education Program.
    That is why I recently joined my E&C colleagues introducing 
a fully paid for measure to extend this program--H.R. 2700, the 
Lowering Prescription Drug Costs and Extending Community Health 
Centers and Other Public Health Priorities Act.
    How often--the question is, again, to Mr. Germano--how 
often do medical professionals choose to stay in a medically 
underserved area once Federal funding is no longer available?
    Mr. Germano. Well, that--gosh, it makes it hard, because 
they are making a commitment of their life, right. It is their 
practice and then their family, and they need to have some 
sense of security.
    Mr. Bilirakis. Sure.
    Mr. Germano. When they don't have that, they have choices. 
The marketplace--there are so many opportunities that going to 
an underserved community isn't going to be high on their list 
if they don't feel security.
    So we have to create a secure environment in order to 
attract and keep them.
    Mr. Bilirakis. Yes. How do you propose we do that?
    Mr. Germano. Well, I think stable funding is huge. The 
messaging that comes from that, that you're going to be here 
for the long run, that this is a commitment. We are stable as 
an organization and, obviously, we need them in our 
communities.
    So they are wanted and needed and we can help support them 
in their lives.
    Mr. Bilirakis. OK. Next question. Can you describe how 
Community Health Centers--I am a huge proponent of Community 
Health Centers, as cochair of the caucus--how are they--and 
then also the community clinics--how are they sustained?
    Mr. Germano. We have multiple funding sources. The 330 is 
the building block which we all work from. We have--Medicaid is 
another big piece of it. Medicare is another large piece of it.
    I mentioned the 330 program. We have State resources, 
private--we put it all together. We are not dependent on just 
one but you pull one of those cards out, particularly the 330 
program, and sort of the whole thing falls apart.
    So we pool our resources together to serve the greatest 
broadest scope of services to the biggest number of patients 
that we can reach. So all those--it is a piece of everything, 
including 340(b) and others--other income.
    Mr. Bilirakis. What is your position on veterans having 
access to Community Health Centers and actually the Community 
Health Center would be reimbursed by the VA? And, you know, 
there aren't a lot of--in some rural areas, you know, you don't 
have a lot of access. We don't have VA clinics in some areas, 
VA hospitals.
    What is your position on that and can the Community Health 
Center actually provide for those veterans? Is there room for 
that?
    Mr. Germano. I think--it think that is already happening in 
many places where the--there the Veterans Administration has 
reached out to the Community Health Centers, and I think they 
are limited by capacity issues--going back to workforce again.
    But I think there isn't--other than technical barriers in 
terms of, you know, how payment is made and those kinds of 
things--contracts--I think health centers would readily embrace 
doing more for their veterans.
    Mr. Bilirakis. Yes. And, you know, we would like the 
veteran to have the choice to go.
    Mr. Germano. Absolutely.
    Mr. Bilirakis. Instead of the VA saying, you know, you can 
go into the community, the veteran should have the choice to go 
to the Community Health Center because, again, the care is very 
good.
    Mr. Germano. So we have a healthcare for the homeless 
program and probably a quarter of our homeless are veterans. 
And so we pull them into the system and help them.
    Mr. Bilirakis. Well, thank you very much. Thanks for what 
you do.
    I yield back, Mr. Chairman.
    Mr. Butterfield. The gentleman yields back.
    At this time the Chair recognizes Mr. Gianforte from 
Montana.
    Mr. Gianforte. Thank you, Mr. Chairman. I appreciate you 
having this important hearing. It is imperative that we find 
common ground on these very bipartisan programs so that there 
are no lapses in funding.
    Community Health Centers, National Health Service Corps, 
Teaching Health Centers, and Special Diabetes Program for 
Indians, and the mental health are all incredibly important to 
the State of Montana.
    I fully support these programs and the work they do in our 
State. We need to ensure that they are funded. Robust public 
health programs lead to future savings and better health 
outcomes for all.
    I am concerned, however, by our lack of ability to pay for 
increased funding levels for these programs. We need to ensure 
that we strike a balance between fiscal responsibility and 
guaranteeing that all have access to high-quality primary and 
mental healthcare.
    So I thank the panel for being here today and I want to 
start with a question here for Dr. Kowalski, if I could. In 
your testimony, you mentioned the differences between type 1 
and type 2 diabetes, and that the American Indian and Native 
Alaskan population have a disproportionately higher and are 
affected by type 2 diabetes, in particular.
    Can you elaborate a little bit on the differences between 
type 1 and type 2 and also why the Native American population 
has such a high incidence?
    Dr. Kowalski. Sure. So type 1 diabetes is a form of 
diabetes that is caused by an autoimmune response to the cells 
that make insulin, thus rendering people unable to make insulin 
and requiring replacement.
    Type 2 diabetes is a metabolic disease where the body makes 
insulin but it doesn't work as well. And so why are some 
populations more susceptible?
    That is a huge area of research but we do know it is very 
genetic. Again, earlier I said this is a disease that is 
stigmatized and I think tremendously unfairly because these are 
problems that are inherited and we see in Native populations 
across the globe a higher propensity.
    So this investment in helping people who are underserved 
with type 2 diabetes, namely, in this case, our Native 
populations, pays huge dividends in terms of the quality of 
their lives, their reduction in risk for all of the types of 
damage that high blood sugar causes--eye, kidney, and heart 
disease.
    And we have seen the proof is in the pudding. The return on 
investment on this program has been very, very high.
    Mr. Gianforte. So you would advocate for increased focus on 
type 2 diabetes in Native populations?
    Dr. Kowalski. Both forms of diabetes are under funded by 
Congress. So we believe that both SDP and SDPI are really a tip 
of the iceberg--that there is an unmet need here that is 
significant.
    Mr. Gianforte. OK. Thank you.
    Mr. Germano, unfortunately, Montana has the highest 
incident of suicide in the country. We also have a 
methamphetamine abuse epidemic.
    What role do Community Health Centers play in serving--
ensuring that patients have access to mental health?
    Mr. Germano. Thank you for that question. Community Health 
Centers of today have really embraced what we call integrated 
behavioral health. There is a stigma tied to going to a mental 
health system for some people, and unfortunately so. But 
they'll go to their family doctor--their Community Health 
Center.
    We have embedded behavioral mental health folks in our 
primary care practices. We introduce them to them. We connect 
them to those. We screen for those behaviors--depression, 
anxiety. We connect them to resources. We work together with 
their family doctor, nurse practitioner, PA.
    So it is a huge access point for people who could be, you 
know, subject to, you know, taking their lives, which 
unfortunately is also the case in my region, and that's why we 
have done a lot in this space.
    The addiction piece is another growing element of the 
health centers. We have gotten into the medically assisted 
therapies in a big way and in combination with also our 
behavioral health services because it takes not just the 
therapies but also the mental health support as well.
    Mr. Gianforte. Yes. I recently held a round table on mental 
health and substance abuse, and I was surprised at how 
intertwined these two things are and very hard to diagnose 
between.
    Can you talk about what the Community Health Centers are 
doing, given how closely related mental health and substance 
abuse are?
    Mr. Germano. Well, the first thing is we had to get over 
our own biases and understand, and I think we have, very 
quickly--that there is definitely a behavioral health component 
to a lot of these situations and needs of our patients and 
working collaboratively, like I said, between our primary care 
clinicians and our behavioral health specialists and our 
psychiatrists, in some cases, who think about what's best for 
the patient and their families and their significant others. So 
that's it.
    Mr. Gianforte. OK. I want to thank the panel, and these are 
important programs. We need to make sure they continue.
    With that, I yield back.
    Mr. Butterfield. The gentleman yields back.
    The gentleman from Illinois, Mr. Rush, is recognized for 5 
minutes.
    Mr. Rush. --that are vital to my constituents and, 
importantly, it is absolutely critical, Mr. Chairman, that we 
do not allow the DSH payments to be cut now or in the future. 
The funding--this funding is critical to my county--Cook 
County's level one trauma centers and burn centers and 
emergency preparedness plans for my county, and if these cuts 
were to go into effect, not only these services but all 
healthcare services that serve those folks in need would be 
severely at risk and it would be--this is totally unacceptable 
and I am glad to see this subcommittee taking an aggressive and 
upstanding posture as it relates to coming up with some 
solutions for this pending problem, and I am proud to be a part 
of this subcommittee under the leadership of the chairman.
    I want to take a moment to discuss Community Health 
Centers. You know, Community Health Centers assure that 
healthcare is affordable and accessible for patients in my 
district and around the country. There are eight federally 
funded health centers in my district that serves almost 341,000 
patients each and every year, and in my State 2 out of 10 
patients are unserved, and 6 out of 10 are Medicaid 
beneficiaries. Without Community Health Centers, we would be 
far worse off than we are right now.
    And so I have a question I want to ask Mr. Germano. Mr. 
Germano, I am concerned about pharmaceutical deserts--
pharmaceutical deserts. Does your health center dispense 
prescriptions?
    Mr. Germano. We have--yes, we do. We do quite a bit, 
actually.
    Mr. Rush. All right. There are many drug stores--Walgreen's 
and CVS, CVS particularly--that are closing down in underserved 
communities and putting at risk particularly the elderly who 
depend on these drug stores for their filling of their 
medication--refilling of their medication.
    With these closures, seniors, the poor, those who are risk, 
those who are ill, have to travel many miles in order to get 
their medication, and that is why we--there have been some 
published articles around pharmaceutical--what they call 
pharmaceutical deserts.
    So my question, if given the authority do you believe that 
there is a role that Community Health Centers can play in 
running free-standing pharmacies and would it be helpful if 
there were public-private partnerships between private 
pharmacies and Community Health Centers?
    Mr. Germano. Thank you for that question, Congressman.
    Around me are a number of frontier health centers. They're 
out in communities where the local private pharmacist has 
retired or left, and you're right, there is no pharmacy in 
their community and they have to travel an hour or two, in many 
cases, to the small cities that they can get to.
    It really is a problem with compliance. My health centers 
have worked really hard--my colleagues out there in terms of 
things like mail order pharmacies to try to connect people that 
way.
    There is telepharmacy that is being, you know, developed 
out there that can help as well. We keep stocks of medicines--
certain kinds of medicine--to get people started until we can 
find a more stable source.
    Health centers have pharmacies. Many of them do. Many of 
them run their own. In my case, it is a public-private 
partnership. We have a local pharmacy that actually is embedded 
in my health center. So we work together to deliver that 
service to our patients.
    It really is about compliance and what's in the best 
interest of the patient.
    Mr. Rush. Thank you, Mr. Chairman. I yield back.
    Mr. Butterfield. I thank the gentleman.
    The Chair now recognizes himself for 5 minutes--5 absolute 
minutes.
    Mr. Germano, again, thank you. As the other colleagues have 
said, thank you for being here today.
    Last week, I visited Lincoln Community Health Center in 
Durham, North Carolina, which is formerly Lincoln Hospital, 
which was named for the 16th President of the United States.
    Lincoln is Durham County's main provider and primary 
healthcare for low-income, under insured, and uninsured 
patients.
    The chief medical officer there and his team do remarkable 
work under very difficult circumstances. Seventy percent of the 
patients treated at Lincoln are uninsured or under insured.
    Over 70 percent are living at or below the poverty rate. 
They epitomize the vital work being done in Community Health 
Centers like yours and many others all across the country and I 
underscore why today's hearing is so important.
    Sir, let me ask you. I wanted to talk with you about the 
National Health Service Corps. You mentioned that you have a 
number of them at your health center today.
    I have long championed this program. Last Congress I 
introduced 3862, which is the National Health Service Corps 
Strengthening Act, and this year I led the NHSC Member Funding 
letter to the Appropriations Committee because I know it is a 
critical recruitment and retention program for health centers.
    Like the Rural Group in my district, they have successfully 
used it recruit a number of providers over the years but ran 
into trouble last Congress when we let funding expire, at least 
for a time.
    We were eventually able to get the funding extended but the 
Rural Health Group lost out on an OB/GYN that they were 
recruiting at the time. We must extend this valuable program 
before it expires once again in September.
    You mentioned a bill that I am cosponsoring, H.R. 1943--
that's not the year I was born but it is pretty close--
introduced by my colleague and good friend, Congressman 
Clyburn, that would expand the NHSC.
    Can you tell me what it would mean to the program if we 
were to enact the funding level proposed in that bill, if you 
are familiar with that bill?
    Mr. Germano. Yes, thank you for that question. That bill 
would actually fund every applicant to the program. It would be 
successful--almost every applicant obtaining a contract to 
serve in an underserved community.
    Right now, only about 40 percent do. So that bill--that 
funding bill would allow 100 percent of all applicants to be 
able to be contracted under the National Service Corps and 
serve their communities.
    Mr. Butterfield. Do you support the bill without 
reservation?
    Mr. Germano. Absolutely. Sure.
    Mr. Butterfield. Thank you. I yield back.
    The gentlelady from Illinois, Ms. Schakowsky, is recognized 
for 5 minutes.
    Ms. Schakowsky. Thank you so much, and I am always so 
grateful to be able to waive onto this subcommittee as these 
issues are so important to me.
    By 2032, the United States may face shortages of over 
100,000 physicians. But I actually would argue that we already 
have significant physician shortages today because of the fact 
that healthcare access is not equitable across race, 
socioeconomic status, and geographic location.
    This status quo is unacceptable for our growing aging 
population, for our children, and for all vulnerable 
communities in our country.
    In order to address the shortage and improve healthcare 
access, I am fully supportive of all of the bills that are in 
front of us in this subcommittee today, especially those that 
address inequalities.
    It is clear that we have to reauthorize the National Health 
Service Corps and the Teaching Health Center Graduate Medical 
Education Program for at least 5 years, if not longer, and 
increase funding levels to strengthen our workforce and 
increase access to care.
    On May 17th, Ranking Member Burgess and I introduced H.R. 
2783, the EMPOWER for Health Act--a long acronym--Education 
Medical Professional and Optimizing Workforce Education and 
Readiness Act--that spells EMPOWER.
    And the EMPOWER for Health Act is designed to increase 
access to healthcare in underserved areas and ensure that a 
more diverse healthcare workforce is able to meet the needs of 
our entire population.
    When we pass this bill, we will finally reauthorize 
critical Title 7 funding for--that would ensure people around 
the country have access to skilled physician and medical 
professionals regardless of who they are or where they live.
    Mr. Germano and Dr. Cooper, I wonder if each of you could 
discuss why it is so important that we not only support our 
physicians through the National Health Service Corps and the 
Teaching Health Center Graduate Medical Education Program but 
also ensure that we are building a diverse healthcare workforce 
as the aim of this legislation, the EMPOWER for Health Act. We 
can start with you, please.
    Mr. Germano. Sure. Thank you for that question.
    Debt is a huge issue for medical students. The average debt 
is $240,000 coming out of medical school, and much higher. I 
have had doctors, $300,000, $400,000. My son is a resident. 
He's going to have $400,000 worth of debt by the time he is 
done. It is untenable, and that is a factor in them choosing 
primary care practice as an option in residency because, 
unfortunately, there is a gap between what certain specialties 
make and what primary care clinicians make. So that's a 
problem.
    You can even that gap out with things like the National 
Service Corps. You can take some of that pressure off and help 
them to--make it easier for them to choose what they want to 
do, which is to work in primary care if they could.
    So I think that is a huge issue. And in terms of the 
Teaching Health Centers, we are in the communities that are 
underserved. As was mentioned earlier, we look at pipeline. We 
look at residents--medical students--who have a heart and have 
a connection to our communities--reflect our communities.
    They are the ones who are going to be most effective and 
successful, and that is why we are such big supporters of it.
    Ms. Schakowsky. Thank you.
    Dr. Gordon? Cooper. Dr. Cooper. I am sorry.
    Dr. Cooper. So----
    Ms. Schakowsky. And if you could talk to about how 
diversity then is affected.
    Dr. Cooper. So, you know, one of the areas in which I have 
spent most of my career is better understanding and addressing 
disparities in healthcare, and although there are a lot of 
different factors that contribute to those disparities, one 
significant one is the lack of diversity among health 
professionals. So some of the earlier work that I did actually 
did document that when there was ethnic and racial concordance 
and language concordance between patients and providers that 
patients had better experiences and in some instances actually 
better quality of care as well.
    So we know that it is important, not necessarily that every 
patient has an ethnic or racially concordant provider, but we 
know that ethnic concordance and we know that diversity within 
the health professions actually contributes to better cultural 
competence among all physicians, right, because it changes the 
culture of the profession and it broadens cultural sensitivity 
and knowledge of different social determinants and those 
factors within the profession. So it is critically important.
    And I also think that funding for agencies like PCORI that 
does address the needs of underserved populations and addresses 
disparities and care and health outcomes is an encouragement to 
people from diverse backgrounds who want to pursue careers that 
are focussed on research. But if they feel that the research 
that they're interested in or that will benefit their 
communities is not being supported, that's also a 
discouragement.
    So I think that, you know, all of these programs--the 
funding for training in clinical care as well as in research--
are factors that will help to enhance the diversity of our 
profession.
    Ms. Schakowsky. Thank you so much. I am way over time. I 
yield back. Thank you.
    Ms. Eshoo. The gentlewoman yields back.
    I now would like to recognize the gentleman from Oregon, 
Mr. Walden, for 5 minutes of his questions.
    Mr. Walden. Thank you, Madam Chair, and again, thanks to 
all of you for being here and your testimony and answers to our 
questions.
    Mr. Germano, health centers are oftentimes the only 
provider in our rural areas, and my district is just north of 
you. You're in Redding. I am across the border in Oregon.
    So in addition to isolation and distance, what other 
challenges should we be aware of that you face? I kind of have 
an idea because I spend a lot of time with my health center 
folks.
    But what do you run into? What do you hear from your 
colleagues?
    Mr. Germano. Well, I think that transportation is a big 
problem and particularly sometimes it is tough even getting 
people into our little town of Redding, let alone if they need 
to go to a big teaching center like down in Sacramento or San 
Francisco.
    So we run into that issue quite a lot, and there is also 
smaller groups of, like, for example, for Laotians and others. 
Language can be an issue if it is not common. But there are 
groups that need care, and you have to try to wrap services 
around them that are effective, so interpretation----
    Mr. Walden. What about broadband and telehealth? What do 
you run into there? Do you run into cross-state issues on 
medical licensure?
    Mr. Germano. Yes.
    Mr. Walden. You mentioned it takes 18 months or whatever to 
fill----
    Mr. Germano. Recruit a physician, yes.
    Mr. Walden. I mean, it seems to me--I mean, I run into this 
and you're going across state lines. My district border is 
Washington, California, and Nevada----
    Mr. Germano. Yes.
    Mr. Walden [continuing]. And the rest Oregon, and some of 
this doesn't make sense anymore in today's telehealth world to 
have these----
    Mr. Germano. Artificial barriers.
    Mr. Walden. Thank you.
    Mr. Germano. Yes.
    Mr. Walden. Do you run into that?
    Mr. Germano. Yes, we do. We have to pretty much stay to 
California when it comes to telemedicine for those various 
reasons. Whether it be liability, licensure, our state 
requirements, our Medicaid plan, it really limits us to our own 
region and it is problematic on the borders.
    Mr. Walden. Right.
    Mr. Germano. That is where you--you know, you could have a 
great facility 10 miles north of you and you can't access it 
because you're in another state.
    Mr. Walden. Mm-hmm. Yes, we face that a bit on the east 
side, going up against Boise or you might be--now, the 
veterans--I think Veterans Administration can go nationwide.
    Mr. Germano. Yes, they figured it out. Yes.
    Mr. Walden. And there should be a way we could--it is 
something we ought to--I don't know how we deal with this, your 
state's rights versus whatever. But, you know, come on. You 
might have the expert 10 miles away----
    Mr. Germano. Exactly.
    Mr. Walden [continuing]. And you literally can't access 
them. So and then can you help me and the committee--explain 
the differences between the Teaching Health Center GME program 
and other GME programs.
    Mr. Germano. Very briefly, the graduate medical education 
Medicare CMS program is an entitlement program. They go by a 
whole separate set of rules. They have to follow the same 
accreditation requirements we do under the American Council of 
Graduate Medical Education. But their funding stream is 
hospital based, typically. That is where their funding comes 
from.
    The Teaching Health Center Program is really about--the 
funding runs through the Community Health Centers or the 
consortia of partners, and then we are able to, within the 
scope of those accreditation requirements, tweak their training 
to reflect our reality.
    Mr. Walden. Got it.
    Mr. Germano. For example, we do a lot more in homeless 
healthcare with our residents. Our medically assisted therapies 
is another, you know, core element of what we do, which is 
different than hospital-based training.
    Mr. Walden. Yes, it is really important and I think we've 
got to figure out how to make sure we are staffing up--that you 
are able to staff up. I run into that as well, just the 
recruitment and the retention. What I have also found is if 
they come through one of these programs and practice in that 
area there is a higher likelihood they stay. Is that what you 
run into as well?
    Mr. Germano. Well, the data shows that, you know, and we 
are a living example. I mean, I would like to keep more. I 
would like to keep more of our residents in our community.
    But all of them stay in primary--nearly all of them stay in 
primary care, key one, and two, almost all of them stay in 
working in underserved communities. So that's the other 
benefit. If not ours then their neighbors. So yes, the model 
does work.
    Mr. Walden. Mm-hmm. OK. That's, I think, all I have, Madam 
Chair, at this point. So I yield back.
    Ms. Eshoo. I would like to work with you on this--on the--
you know, on the licensure and all of the complications of not 
being able to go over state lines. It is not defensible anymore 
and there are so many communities that would benefit from our 
fixing that. So let us put that on the to-do list.
    I know that Mrs. McMorris Rodgers is waiting. But we need 
to take the Members and then you will waive on. So I will now 
recognize Mr.--the gentleman from California, Mr. Cardenas, for 
5 minutes of his questions.
    Mr. Cardenas. Thank you very much, Madam Chairwoman, and 
also Ranking Member Burgess for having this important hearing.
    It is great that we are talking about these programs and we 
need to keep focused on the Americans who are all trying to 
make sure that they get better service.
    According to the nonpartisan Kaiser Family Foundation, 
those who visit health centers are far more likely to be low 
income and working poor, by the way, with more than half 
falling below the poverty line and are far more likely to come 
from a community of color.
    Health centers are also far more likely to serve patients 
that speak only--other than English, for example, when compared 
to other primary care settings. These are the primary care 
providers that these communities have come to rely on and where 
many families have received life-saving care we need to make 
sure that these centers actually are able to continue to serve.
    Again, I just want to point out that far too often when 
people think of people getting care where there is little to no 
fee to the actual end user that it is somebody who is not 
working for a living.
    I want to make it very clear that I know that in my 
district I have many, many working poor individuals who fit the 
results that the Kaiser Family Foundation research has exposed.
    Mr. Germano--in my district we would call you Germano--I am 
sorry if I am saying it wrong--so can you talk about some of 
the outreach activities that Community Health Centers are able 
to do to reach these communities?
    Mr. Germano. Our health centers in our region and across 
our State and our Nation really is about outreach. We have a 
number of our staff who that is their job is to reach 
populations, people who won't normally connect with us whatever 
the situation.
    So we work with churches. We work with social services 
agencies. We work with our police departments, law enforcement. 
They come in contact with folks or families or situations--
social services agencies.
    So our goal is to make sure that we are connected to all 
these other resources and that we welcome everybody into our 
medical home.
    Mr. Cardenas. OK. Where would these communities go if they 
no longer had access to services provided by Community Health 
Centers?
    Mr. Germano. You know, I shudder to think. The default is 
the emergency room, right, and----
    Mr. Cardenas. Or no care at all?
    Mr. Germano. Pardon me?
    Mr. Cardenas. Or no care at all.
    Mr. Germano. Or they--right. They defer until it becomes a 
critical issue, and that would be horrible for everybody.
    Mr. Cardenas. I just had an unfortunate reality conveyed to 
me by a young woman who was explaining to me the horrors of her 
family's experience in this country when it came to healthcare.
    She had two parents that were working poor. They had to 
rely on facilities like this to get their care. Her little 
brother was born with congenital conditions that they never 
could figure out exactly what it was, and he passed away.
    And later on, her father became very, very ill--the father 
of this little boy--and he, apparently passed away as well. So 
two tragedies in one family.
    And the actual tragedy to her little brother was actually a 
factor in why her father passed away way, way too young, 
because his exact words to her that she conveyed to me when she 
said, ``Dad, you're really sick. You need to go to the 
doctor,'' and this is pre-Affordable Care Act, because I asked 
the question--I said, but the Affordable Care Act.
    She said my father passed away a month before the 
Affordable Care Act kicked in. He said, ``I am sick and tired 
of seeing all these bills. I can't afford it.''
    So your--the facilities that we are talking about today are 
the facilities that will actually help individuals get access 
to healthcare and, secondly, not be afraid--not be afraid of 
the financial burdens at least--at least to see a doctor. At 
least to find out am I going to die or am I going to be OK.
    Mr. Germano. You know, even today we see some of our 
uninsured patients come in with late onset diseases and you ask 
them, we've been here--we've been--why--they have reasons, and 
we don't fully understand it.
    But it is up to us to get the message out that this--you 
can come here and you will see a doctor or a nurse practitioner 
or PA. We will help you to get medications. Anything we can do 
within our four walls we will try to do for you. It gets 
tougher once you get outside of our four walls. But we can do a 
lot within our four walls.
    Mr. Cardenas. And what area of California do you serve?
    Mr. Germano. Up in Redding, California.
    Mr. Cardenas. Do you know a Dr. Lupercio? Have you ever met 
him? He works in a hospital. I was curious if you have come 
across each other.
    Mr. Germano. I don't think so.
    Mr. Cardenas. Pulmonary specialist, born in Mexico, got 
educated here. Serving the community. Amazing human being.
    Mr. Germano. I will have to meet him.
    Mr. Cardenas. Thank you, Madam Chair. I am sorry. I went 
over my time. Thank you so much.
    Ms. Eshoo. I am a nice chair. I let people go over and 
finish their thoughts.
    But we are winding down. Now, I would like to recognize the 
gentlewoman from New Hampshire, Ms. Annie Kuster of the famous 
Kuster family in her home state.
    Ms. Kuster. Thank you, Chairman Eshoo, and thank you for 
this hearing and for all you for your patience today.
    Many of the programs that we are talking about today are 
critical in my home state of New Hampshire where we are in the 
midst of a major opioid epidemic. 2017 we had 424 drug overdose 
deaths involving opioids and many of the programs that we are 
discussing are critical to combatting this epidemic.
    I want to give a particular shout out to our Community 
Health Centers serving some of the most vulnerable populations 
in our rural state. They have been instrumental in providing 
comprehensive care to those who need it, particularly, after 
Medicaid expansion under the Affordable Care Act.
    And programs like PCORI have funded incredible research at 
Dartmouth Medical School in my district, studying treatment for 
pregnant women with opioid use disorder.
    So I also appreciate that this collection of bills address 
the workforce issues that we have been seeing. We are trying to 
encourage young people getting into career in technical 
education in our high schools, to get an LNA coming out of high 
school and then go to our community colleges and then go to our 
4-year colleges and working their way up in the healthcare 
credentials.
    I want to start, Mr. Germano--you spoke of the difficulties 
in recruiting and retaining primary care physicians to 
underserved areas, and I am hoping that you could speak 
particularly with the Community Health Center model and the 
workforce that stands up the Community Health Centers are 
especially equipped to handle many of the public health 
challenges we face, and if you could elaborate on how these 
programs will make a difference for these workforce issues.
    We have an unemployment rate of 2.4 percent, which is the 
envy of many of my colleagues. But it creates tremendous 
challenges in rural communities.
    Mr. Germano. Definitely. The health centers more and more 
across this country have become, in my judgement, the de factor 
public health department now. They are the ones touching the 
lives of great swaths of our community.
    No disrespect to public health. They have gone into more 
the monitoring and surveillance and those kinds of very 
necessary things. So the primary care networks--the Community 
Health Centers have been the face of immunizations and sort of 
other surveillance and interventions.
    So yes, we play a critical role as a safety net. That is 
our job. That is what we should--one of our jobs--that should 
be one of the things we do. Workforce with the lower--I mean, 
it is a great thing we are seeing our unemployment rates drop 
but it creates some real challenges in terms of recruitment and 
retention.
    Can we stay competitive, and not just about the doctors and 
the nurse practitioners but all our front line staff and what 
have you. So we are constantly chasing our tail, making sure 
that we are remaining competitive to keep our employees and 
sustain them.
    So, again, ongoing sustainable funding is really critical 
in us to predict what we can afford.
    Ms. Kuster. Great. Thank you, and thank you for appearing 
on behalf of the Community Health Centers, a great asset to our 
community.
    Dr. Cooper, I am going to turn to you about the PCORI 
funding--that we have researchers at Dartmouth College 
examining the outcomes of prenatal care for women receiving 
medication-assisted treatment and the research is integral to 
understanding how to--prenatal, postpartum, how to support moms 
to have healthy babies. Could you discuss how a gap in 
appropriations will impact projects like these and the need for 
predictable and consistent funding?
    And just while you are at it, in your opinion are there any 
other entity sources--NIH or the Agency for Health Care 
Research and Quality--that would be able to fill the gap or is 
this research that wouldn't continue?
    Dr. Cooper. I think a gap in funding from PCORI would 
significantly threaten a project such as the one you described 
for a number of reasons.
    One of them is that oftentimes when we do have results from 
such a project and they are positive results the promise that 
they hold is that we could then spread them to other settings 
or disseminate them more widely.
    But without ongoing support from an institute like PCORI 
the ability to package the materials that have been developed 
and to use the learnings from that research to spread to other 
settings or to disseminate it would be limited significantly.
    Additionally, you would have researchers who are conducting 
patient-centered outcomes research who may leave the field 
because of that uncertainty and either go back into clinical 
practice or do administrative work or something else.
    They might also pursue research that is not patient-
centered outcomes research and I don't think NIH and AHRQ would 
fill that gap completely. I think that there are some 
institutes at NIH that support similar work.
    For the most part, they don't support the level of 
stakeholder engagement that PCORI does. It takes a long time to 
build partnerships with patient advocacy groups, family 
members, health insurers, health system leaders to conduct the 
research that ends up being very practical and sustainable over 
time, and we don't get that kind of funding.
    Ms. Kuster. My time is up. I apologize. I would like to 
yield back. But thank you. Thank you.
    Ms. Eshoo. The gentlewoman yields back.
    I now would like to recognize the gentlewoman from 
Illinois, Ms. Kelly, for 5 minutes of questioning.
    Ms. Kelly. Thank you, Madam Chair and Ranking Member, and 
thank you for your testimonies this morning.
    I have heard from patients and providers that PCORI's 
approach to incorporating patients into research process makes 
the results more meaningful to people who will actually use it.
    Dr. Cooper, you mentioned PCORI's unique governance 
structure with the emphasis on patient input and engagement. 
For the last couple of years I have been very involved with 
legislation dealing with maternal mortality, and while no one 
knows exactly what happens and why there are the healthcare 
disparities--I mean, some things we can guess--do you see PCORI 
being helpful or instrumental in dealing with that healthcare 
disparity? Because there is a great one in this country.
    Dr. Cooper. Most certainly I do see a strong potential for 
PCORI to contribute to research in the area of disparities in 
maternal mortality, one reason being that often women who come 
from underserved communities and African-American women in 
particular and American-Indian women who have higher rates of 
either maternal mortality or infant mortality are not 
represented in a lot of studies. So their perspective isn't 
given.
    And so at PCORI they would have the opportunity to 
contribute to the research questions that would be answered and 
to contribute to the way that research should be conducted and 
the way the results should be shared with other patients and 
family members who would need the information in their decision 
making around their care.
    Ms. Kelly. I know in these we had OB/GYNs in and I know in 
the State of Washington, Native American women died 8 times the 
rate of white women, and in my State of Illinois black women 
die 6 to 1 times rate, which is bigger than the national 
average.
    And then you have been here a long time, so is there 
anything we haven't asked you that you want us to know about 
PCORI?
    Dr. Cooper. I think the only thing I would say is that I 
was so excited when PCORI was funded because it is the kind of 
work that I thought was needed for a long time--that we have a 
lot of wonderful discoveries and therapies and drugs but they 
just weren't getting out to the people who need them, and 
people weren't able to make sense of a lot of the information 
that was coming at them.
    And what PCORI allows us to do is actually to compare a lot 
of these different developments and discoveries and actually 
learn more about how each one of them works and applies to 
different people because they don't all work the same for 
everyone and it is really important to get everyone's 
perspective and to tailor those treatments and the appropriate 
concerns that people have and to the appropriate needs and 
resources within the context where they get healthcare.
    Ms. Kelly. Thank you very much, and I will yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Now I will recognize the gentlewoman from California, Ms. 
Barragan, for 5 minutes of questioning.
    Ms. Barragan. Thank you. I wanted to first thank the panel 
for being here. There is so much to cover in so little time. 
But before I do that, I wanted just to quickly talk about 
something that's going to happen on the second panel. I want to 
just spend a moment to discuss the Medicare limited income 
newly eligible transition program.
    This demonstration program which began in 2010 provides 
temporary Part D prescription drug coverage for low-income 
Medicare beneficiaries not already in the Medicare drug plan.
    This program has been incredibly successful in the past 10 
years, saving $300 million and making sure beneficiaries get 
access to medication.
    I was proud to introduce the Improving Low-Income Access to 
Prescription Drugs with my colleagues, Congressmen Olson, 
Marchant, and Lewis, that would make the LI NET program 
permanent.
    Far too many individuals across America already struggle to 
afford their prescription drugs. By making the LI NET program 
permanent, we can continue to provide transitional prescription 
drug coverage for those with low incomes.
    I look forward to advancing our work to help all Americans 
get the medications they need.
    Now, talking a little bit about Community Health Centers, 
this past week in my district I held a round table with 
Community Health Centers and other healthcare providers in my 
district, and in my district we work very closely with the 
Harbor Community Clinic in San Pedro.
    And I know there is already been a lot of discussion about 
what Community Health Centers do and I also know some of this 
has been covered earlier.
    But I think it is really critically important. Mr. Germano, 
if you could just tell us what the impact would be on 
communities of color if the fund is not reauthorized.
    Mr. Germano. Health centers are very centered in 
communities of color around the country. They really are. They 
have a huge presence, and not enough, in my judgment.
    And if funding becomes destabilized then I think you start 
losing those investments that have already been made and it 
prevents further investments in those communities because you 
can't plan ahead. It is that certainty again.
    Ms. Barragan. So we've recently seen an outbreak of the 
measles----
    Mr. Germano. Yes.
    Ms. Barragan [continuing]. And Community Health Centers 
provides, as you mentioned, immunizations. Would that be at 
risk if this was not funded?
    Mr. Germano. It goes back to that public health safety net 
role again. We had that situation in my own community where we 
became ground zero for detection as we had a couple cases in 
our community, and public health rallied around us to be that 
face of prevention in our community.
    Yes, it would be--it would be a loss across this country 
and a danger.
    Ms. Barragan. Thank you. My district is California's 44th. 
It is south L.A., it is Compton, it is Watts, it is the Port of 
L.A. It is a majority minority district. It is about almost 90 
percent Latino/African American, and we have the highest 
diabetes rate than any other congressional district in the 
State of California.
    It is also very personal. My mother has diabetes. Family 
members have type 1. And so Mr. Kowalski, what would be the 
impact on communities of color if this program were no longer 
funded--the Special Diabetes Program?
    Dr. Kowalski. So the Special Diabetes Program has delivered 
on a number of advances that will help anybody with diabetes. 
But, of course, in underserved communities you have a much 
higher incidence and prevalence rates.
    We have tremendous momentum on many fronts via treatment, 
preventative therapies, and ultimately cures for diabetes, and 
it would be a tremendous shame to see us lose that momentum and 
what we would be doing is costing individuals time in their 
lives, literally, and ultimately our system millions and 
millions of dollars.
    So I urge the Members, as you know, that this program is 
paying dividends and it will help all communities who are 
impacted by diabetes.
    Ms. Barragan. All right. Thank you.
    Dr. Cooper, I want to thank you for your work on the issue 
of racial health disparities. It was in 1999 when I was working 
at the NAACP that this issue became one near and dear to me.
    Can you tell me how the Patient-Centered Outcomes Research 
Extension Act of 2019 plays a role in helping address racial 
health disparities?
    Dr. Cooper. Yes, I would be happy to do that. One of 
PCORI's main focus areas is addressing disparities. So they 
also focus on several special populations which include racial 
and ethnic minorities, persons with low socioeconomic status as 
well as people who have many disabilities.
    So I think because they have a special portfolio focused on 
addressing disparities a lot of that work actually does address 
issues that are critical to those communities and those 
populations.
    For example, you might have a new drug or therapy for 
diabetes. But what we might not understand is how acceptable is 
that treatment to people who will have low income or people who 
live in an ethnic minority community. Are there stigmas around 
certain kinds of therapies? What about the costs associated 
with getting those things or any other barriers to managing 
their condition that might get in the way of them benefiting 
from those therapies, and PCORI has the ability to address a 
lot of those with their research portfolio.
    Ms. Eshoo. Does the gentlewoman yield? The gentlewoman 
yields.
    I now would like to recognize the gentlewoman from 
Delaware, Ms. Blunt Rochester, for 5 minutes of questions.
    Ms. Blunt Rochester. Thank you, Madam Chair, for the 
recognition and for turning the committee's attention to the 
critical public health programs that must be reauthorized this 
fall.
    Just yesterday I introduced legislation to reauthorize 
another program set to expire in September--the Personal 
Responsibility Education Program, or PREP--and I look forward 
to working with my colleagues on the committee to ensure that 
this and other public health programs are reauthorized before 
the September deadline.
    Delaware has three federally qualified Community Health 
Centers, serve approximately 50,000 patients across the State 
each year. So in Delaware that's one in 19 Delawareans.
    And I support both H.R. 1943--the Community Health Center 
and Primary Care Workforce Expansion Act--and H.R. 2328--the 
Community Health Investment Modernization and Excellence--CHIME 
Act, because Community Health Centers need long-term sustained 
funding. I think that is a message that we have heard loud and 
clear here today.
    Delaware has seen the impacts of this firsthand because 
Westside Family Health Center became the first Community Health 
Center in the country to lose a location because of unstable 
Federal funding, a closure that impacted about 2,800 patients 
who were disproportionately low income.
    So I want to just kind of turn to the issue of planning--
short-term planning but, specifically, on the impact of 
recruiting and retaining particularly primary care physicians.
    And I know, Mr. Germano, you talked about this. In 
Delaware, it has a huge impact. It is estimated that we have 
just 815 primary care physicians in Delaware, down 5.4 percent 
since 2013.
    And so I just wanted to ask you, you talked a little bit 
about the impact but and you said--you talked about the fact 
that wherever a person is trained they might tend to stay.
    So if you could just reiterate that, and also just briefly 
talk about suggestions that you would have to incentivize 
people to continue to stay and work in those underserved 
communities.
    Mr. Germano. Thank you for those questions. The data shows 
overall, I had mentioned, that 70 percent of residents stay 
within 100 miles of where they have trained, and the Teaching 
Health Centers go even further. We had more success because we 
have looked or providers who meet our mission, who are 
interested in our mission, and are many times tied to our 
communities in other ways, so have roots or will develop roots 
there.
    So I think absolutely critical. That is the pipeline 
bringing them into our system and then getting them through and 
then helping them stay.
    So I think those are--those are the big ones. Those are the 
issues.
    Ms. Blunt Rochester. No, that's helpful. That's helpful.
    I am going to shift very quickly to Dr. Cooper. You talked 
about PCORI and, you know, one of the reasons why what you 
shared is so vital is because of the issue of health 
disparities and I was hoping that you could spend a little bit 
of time on that, the impact of addressing health disparities.
    In Delaware, we have the Nemours child health system and 
health corps that are key stakeholders in receiving these funds 
and doing exciting work. But particularly as it relates to 
trust in clinical trials and how you get people to actually 
participate for their own--the connection to the healthcare 
system.
    Dr. Cooper. Thank you. Yes, so I will just mention briefly, 
I actually had a project that was funded that engaged with the 
Westside Health Center in Delaware many years ago.
    It was not funded by PCORI. It was funded by AHRQ, and we 
were able to successfully engage health centers and African-
American patients in a project that compared two different 
approaches to treating depression.
    The difference between that project and my PCORI-funded 
work is that I did not have the benefit of the full year of 
planning to engage all the appropriate stakeholders and to get 
their input into the program.
    And so when that project ended, even though we showed 
successful results, it wasn't actually sustained. But now, with 
the kind of funding that PCORI offers, there is actually a full 
year devoted to planning and to stakeholder engagement so that 
everyone sort of on board with the plan gives input to it and a 
lot of discussion takes place about how this program will be 
sustained if it is shown to be successful.
    Ms. Blunt Rochester. Excellent. Thank you for sharing that.
    Just one last point. Delaware had the sixth highest rate of 
overdose deaths in 2017, and so we know that the opioid crisis 
is having a huge impact, and one of our health centers, La Red, 
actually has focused on this.
    So I will submit some questions for the record surrounding 
the opioid addiction crisis as well. So thank you and I yield 
back.
    Ms. Eshoo. The gentlewoman yields back.
    Now it is a pleasure to recognize the gentleman from 
Georgia, Mr. Carter, and followed by the patient gentlewoman 
from Washington State, Ms. McMorris Rodgers.
    So first, the gentleman from Georgia.
    Mr. Carter. Thank you, Madam Chair. I thank all of you for 
being here. I know it is been a long day and you're almost 
there, so hang in there, OK?
    Certainly important things we are talking about. There is 
no question about that. Mr. Germano, I wanted to ask you, do 
you happen to know how many health profession shortage areas 
there are in this country? Any idea?
    Mr. Germano. I don't, but there are a lot.
    Mr. Carter. There is a lot. Most of them in rural areas, I 
would assume, as opposed to urban. But I suspect we'd be 
surprised to find them in urban areas as well.
    Mr. Germano. I think there are quite a few in urban areas 
as well.
    Mr. Carter. Right. Right. Earlier, we--earlier one of my 
colleagues asked you about dental health and that is certainly 
important.
    First of all, again, I am from Georgia, and remember there 
are two Georgias. There is Atlanta, and there is everywhere 
else, and it is true. And I represent south Georgia. We got a 
lot of rural areas in south Georgia, a lot of healthcare needs.
    Accessibility to healthcare is a big concern of ours and a 
big challenge and particularly oral healthcare as well, and I 
was just wondering if you could reiterate what you said earlier 
about oral healthcare and how important it is, particularly in 
our most needy areas like that.
    Mr. Germano. Well, know that oral health disease is not 
just a cosmetic thing. It has the underlayment of causes other 
problems. Women who are pregnant with oral health disease could 
have bad outcomes with their babies, for example.
    We know that we can prevent a lot of this. It is not just 
having a dental office. We have embedded dental hygienists in 
our pediatric practices now where they are going in after the--
after the visit, in many cases, and they are doing a little 
education and they are painting the teeth of children so to try 
to prevent, you know, cavities and other problems and educating 
as well.
    Oral health disease--number-one pediatric disease in 
America is oral health disease.
    Mr. Carter. Right.
    Mr. Germano. And it is preventable. That's the thing. A lot 
of oral health disease is preventable.
    Mr. Carter. You know, we talk a lot about making sure we 
have--with good reason making sure we have doctors in 
underserved areas. But there are other healthcare professionals 
that we need to concentrate on also such as dentists.
    Mr. Germano. Yes.
    Mr. Carter. Any others that you can think of that really 
propose a glaring void there--healthcare professionals that we 
just----
    Mr. Germano. Well, I would love to see the role of the 
pharmacists be more----
    Mr. Carter. Thank you very much. Oh, did I mention that I 
am currently the only pharmacist serving in Congress?
    Ms. Eshoo. That was a good answer.
    Mr. Carter. It was a good answer.
    [Laughter.]
    Mr. Germano. I do think there is a role for--the problem is 
in the FQHC world, pharmacists are not recognized as billable 
providers; hence, it makes it difficult to put it together.
    But it makes total sense. My clinicians clamour for that--
you know, that kind of direct clinical pharmacy involvement, 
not just on the retail side but on the clinical side. It would 
make a world of difference.
    Mr. Carter. Right. Thank you for that.
    Let me switch now to a problem that, unfortunately, we are 
a leader of in the State of Georgia and that is maternal 
mortality. And, you know, it is--it is embarrassing for me to 
say that and whereas I do question sometimes how we arrive at 
some of these figures because I want to make sure we are 
comparing apples to apples when we talk about maternal 
mortality. But we cannot deny the fact that it is a problem and 
particularly in the State of Georgia.
    And I am just wondering, you know, one of the challenges 
that we face, as I mentioned before, is just a lack of 
providers, and what--you mentioned earlier, and you are spot on 
because, when I served in the Georgia State Legislature, one of 
the things that we discovered was that most of the physicians--
as Dr. Burgess pointed out as well--most of the physicians stay 
where they practice--where they do their residency--and we 
learned that in Georgia.
    That is why we increased the number of residencies in our 
State in order to try to attract physicians and try to get them 
to stay.
    But any ideas on what we can do aside from that to increase 
the number of providers, particularly in the--in the rural 
areas and particularly in the way of OB/GYNs where we need this 
for--to address the situation of maternal mortality?
    Mr. Germano. Well, most OB/GYN training programs are in big 
cities, so that you are running against it right away in terms 
of attracting OB/GYNs to rural communities. So that is tough.
    But what we can do is to work with, like, our nurse 
practitioners.
    Mr. Carter. There you go.
    Mr. Germano. Early prenatal care, getting women in the 
first trimester, really critical. Getting them tucked into 
prenatal care and then we can help monitor and support them 
through their pregnancy. I think that can make a world of 
difference.
    Mr. Carter. And, you know, scope of practice is pretty much 
a State issue. But at the same time, if we--if we empower some 
of these other healthcare professionals to give them the 
opportunity to serve, I think they can help us to achieve what 
we are trying to achieve here.
    Mr. Germano. I agree.
    Mr. Carter. Very good. Again, thank all of you. This is 
extremely important and we certainly support what we are trying 
to do here. The question is how we are going to pay for all 
this. But nevertheless, this is very important.
    And thank you, Madam Chair, and I yield back.
    Ms. Eshoo. The gentleman yields back.
    And now the ever-patient gentlewoman from the State of 
Washington, Mrs. McMorris Rodgers, also the sponsor of H.R. 
2818, which we thank you for. It is an important bill. You are 
recognized for 5 minutes.
    Mrs. Rodgers. Thank you, Madam Chair, and just thank you 
everyone who has been a part of this, the witnesses, and your 
testimony today.
    I am pleased that you are bringing this legislation forward 
today. Earlier, Representative Ruiz was talking about the 
Teaching Health Centers and how important they are.
    I am proud in Spokane to represent one of the Teaching 
Health Centers that is making a big difference in our region. 
We are excited that Washington State University has built a 
medical school. The University of Washington and Gonzaga are 
partnering on a rural training track.
    I represent an area that has a lot of rural communities and 
these--this effort in Spokane is definitely part of the 
solution.
    When you--when I look at the partnership between the 
Teaching Health Center, the universities, the local hospitals, 
and then our local VA, we need more doctors. We need more 
doctors throughout eastern Washington.
    And I am also reminded that where the doctor does their 
residency they are more likely to practice. I met a guy, a 
doctor, not too long ago who had come from California to 
Spokane 30 years ago to do his residence and he is still there.
    And it underscores how important it is, these residency 
programs. So I am a strong supporter of the Teaching Health 
Center Graduate Medical Education Program, that legislation 
that is before the committee today.
    You know, it is estimated that nationwide we will have more 
than 23,000 shortage--we will be short 23,000 doctors by 2025, 
and it is really unacceptable. And you see it further in the 
rural communities where the physician-to-patient ratio is 
especially stark.
    Only 10 percent of physicians practice in these areas, even 
though a quarter of the population lives there. Compared to 
doctors who trained in the traditional Medicare program, those 
trained at Teaching Health Centers are 60 percent more likely 
to practice primary care and 30 percent more likely to work in 
a rural or underserved community.
    I was proud to help lead this legislation in the last 
Congress where we doubled the funding, and I am excited and 
encouraged that we are continued that effort in this Congress.
    Representative Ruiz, Torres Small, Representative Roe and I 
have joined in introducing H.R. 2815. What it does is continue 
the support for this program by extending it for another 5 
years and increasing the funding and providing more certainty, 
which we need across the country.
    This legislation and this program is important--meeting the 
needs of rural and underserved communities for a new generation 
of primary care medical professionals.
    The Teaching Health Center has programs that are meeting 
important needs in psychiatry, OB/GYN, primary care, internal 
medicine--you know, the very fields that we need more of our 
doctors to be pursuing.
    So I have a few questions to Mr. Germano. I wanted to--in 
your testimony you talked about the Shasta Community Health 
Center electing to become a Teaching Health Center as a means 
of addressing the ongoing physician shortage.
    And I just wanted you to elaborate on that decision and 
just comment on how positively that may have impacted your 
effort to meet the needs in your community.
    Mr. Germano. It is a big decision for a health center to be 
a sponsoring entity. You have to meet all the accrediting 
requirements. There are resources that go into it.
    In the beginning it is tough because your best clinicians 
become your teachers, which means you take them out of the 
direct services and now you're teaching.
    So the investment is more medium to long-term when you make 
that decision. But my job and my board's job is to look ahead 
and look at what's coming at us, and the shortage was very real 
then. It is even more so now.
    So the Teaching Health Center Program is a huge investment 
in our future--in our current and into our future, and we are 
seeing the paybacks now.
    Mrs. Rodgers. Would you just address how your facility 
compares to other Teaching Health Centers across the country, 
and then also--I am afraid I am going to run out of time--the 
importance of the 5-year reauthorization?
    Mr. Germano. Well, each health center has their own sort of 
reality that they are--the resources they have available to 
them. So we are all a little different in that respect. Some 
are urban. Some are rural. Some are frontier.
    So, you know, we are very rural and, hence, I think we have 
a few more challenges we are starting to get our hands around. 
We are not having the same exact retention rates as some of the 
city programs but we are getting there. So I am really excited 
about that.
    And, I am sorry--the second question was?
    Mrs. Rodgers. Well, the importance of a 5-year 
reauthorization.
    Mr. Germano. We have to--we commit 3 years to every class. 
They have to know when we are recruiting. I can't have a 
medical student say to me, are you going to be around in 2 
years if this program is going away? That is not a great 
recruitment tool into our program. We need to know--we have to 
have certainty.
    Mrs. Rodgers. All right. A 2-year reauthorization for a 3-
year program just----
    Mr. Germano. Doesn't make sense. Thank you.
    Mrs. Rodgers. Doesn't make--OK. I appreciate the chairwoman 
for allowing me to waive on today. Thank you.
    Ms. Eshoo. Thank you for your patience and thank you for 
your important work on the--on the legislation. I think that we 
have really very strong bipartisan support on this and which is 
really pleasing.
    Now I am going to recognize the gentleman from Arizona, Mr. 
O'Halleran, who is one of the sponsors--key sponsors--of H.R. 
2328, 2822, and 2680, 5 minutes of questioning.
    And then I think after Mr. O'Halleran we'll be--we'll ask 
the staff to ready the table for the next panel. But I want to 
recognize the gentleman now and thank him for his patience, 
too.
    Mr. O'Halleran. Thank you, Madam Chair.
    A little perspective--my district is larger than the State 
of Arizona--I mean, Illinois--60 percent of Arizona. It goes 
from a few small urban areas to frontier--a Navajo reservation, 
a Hopi reservation, 12 Native American Tribes.
    Economic conditions on the Tribal lands anywhere from--most 
of them 50 to 85 percent unemployment rate, getting worse. You 
can imagine the problems associated with that and the quality 
of life that people coming in to those areas have to address 
their lives to and the change.
    You know, Mr. Germano, the National Health Service Corps 
provides vital scholarship and loan repayment programs that 
reduce workforce shortages in medically underserved areas and 
it has a successful retention program.
    For instance, a 2012 study found that an amazing--more than 
half of the participants in the National Health Service Corps 
stayed in a health shortage area 10 years after their 
participation in the program ended.
    My anecdotal information in my district, that is not true. 
Not that it is not true nationwide, but the realities of this 
district are different, and thank God for Community Health 
Centers.
    What effects could we expect to see in rural and medically 
underserved areas if we--in the longer authorized and increased 
funding for this program?
    Mr. Germano. Well, I think if it is tough now, I can only 
imagine how tough it would be without that loan repayment. The 
cost of medical education has gone out of sight and these young 
people are making decisions about where they're going to 
practice and what they're going to practice.
    And if they don't see the opportunity of loan repayment as 
an option, it is going to be very difficult for us as Community 
Health Centers or any real provider in rural communities to be 
able to recruit them to our communities.
    Mr. O'Halleran. Thank you.
    Mr. Kowalski, thank you for your testimony here today. And 
as you are well aware, the Special Diabetes Program for Indians 
is tremendously important.
    According to the Centers for Disease Control and 
Prevention, the American Indian and Alaska Native communities 
suffer from disproportionately high rates of diabetes.
    This high prevalence, coupled with food deserts and limited 
access to healthcare facilities, can lead to more negative 
outcomes for these communities.
    In addition, the high level of unemployment, Tribes with 
the inability to find jobs even if there was the ability to 
find the economic conditions under which those were to survive, 
will you please highlight how this program effectively 
supplements the Indian Health Care Services work in preventing 
diabetes and related complications among Native American 
populations?
    Dr. Kowalski. Thank you, Representative, for that question 
and thank you for your leadership in introducing H.R. 2680, 
which would increase funding and extend funding for this 
incredibly important program.
    As you point out, in your State we have Tribes that have 
diabetes incidence rates of over 50 percent, some Tribes 
upwards of 80 percent, and they are very underserved.
    It is this program that has made significant differences. 
We talk about the importance of culturally tailored 
interventions and we have seen that in this program.
    And I said earlier the proof is in the pudding. We have 
data-driven metrics in terms of the impact, in terms of glucose 
control levels being better, reducing the risk of 
complications.
    For those complications, significant decreases, for 
example, in kidney disease and eye disease, which will save 
money. This is a critical program for underserved community--
the Tribal communities in your State and across the country 
that deserves renewal and re-upping and I, again, thank you for 
your leadership.
    Mr. O'Halleran. Well, thank you. And another question for 
you is this program has remained flat since fiscal year 2004. 
It is amazing. At the same time, the population served by 
Indian Health Care Services increased.
    Will you please explain what the effects would be if 
Congress simply reauthorized the program but did not increase 
its annual appropriations?
    Dr. Kowalski. So since 2004, if you did just the simple 
math of inflation, we are talking about $150 million versus 
what would now be $230 million for a problem that has only 
grown.
    So we are, again, under resourced for a problem that is 
hurting these communities and costing our economy. We need to 
do better and we are seeing results from the program, I think. 
The up side is huge here.
    Mr. O'Halleran. Thank you, Madam Chair. Sorry for taking so 
much time, and I yield.
    Ms. Eshoo. The gentleman yields back.
    And that concludes our first panel. I want to thank each 
one of the witnesses. You have done a superb job. I know that 
this has been a long hearing. You haven't had a break.
    But we are taking up 12 bills and these are all important 
to the American people. So you have given marvellous testimony.
    You have underscored the need for stability and confidence 
in the program so that we--in our reauthorizations that they 
have a longer pathway before reexamination by the Congress, and 
I think that that's a very prudent way to go.
    But I just--I couldn't help but think during the hearing 
what would we ever do without what each one of you testified 
about. All the people in our country that are being cared for 
as a result of your work and your leadership.
    So every blessing on each one of you in your work. We thank 
you for being here, and we will ask the staff to prepare the 
table for the next panel of witnesses.
    Thank you, everyone.
    [Pause.]
    Ms. Eshoo. We now will hear from the second panel of 
witnesses and we want to thank you for--I think you were all 
waiting patiently. I think you have been here for the better 
part of the day and we thank you for that and what you are 
about to do.
    Mr. Thomas Barker, partner and cochair of Healthcare 
Practice at Foley Hoag; Ms. Mary-Catherine Bohan, vice 
president of outpatient services at Rutgers University 
Behavioral Health Care; Mr. Fred Riccardi, who is president of 
the Medicare Rights Center, and I want to call on our--the vice 
chair of our committee to introduce his constituent, Dr. 
Michael Waldrum.
    Mr. Butterfield. Thank you very much, Madam Chair, and I 
realize the hour is late. It looks like we are going to have 
votes in just a few minutes.
    But I would like to recognize and to join the subcommittee 
in receiving the chief executive officer of--and distinguished 
professor of internal medicine and pulmonary and critical care 
at the Brody School of Medicine at East Carolina University.
    Very briefly, my district consists of 14 counties and one 
of those counties is called Pitt County, and this university is 
a major economic engine in Pitt County.
    And so I want to welcome Dr. Michael Waldrum to the 
subcommittee and look forward to his testimony. Thank you.
    Ms. Eshoo. Thank you.
    So we will--at this time the Chair recognizes Dr. Green for 
5 minutes for your opening statement.
    Mr. Barker. I am sorry.

 STATEMENTS OF THOMAS R. BARKER, PARTNER, COCHAIR, HEALTHCARE 
  PRACTICE, FOLEY HOAG; MARY-CATHERINE BOHAN, VICE PRESIDENT, 
OUTPATIENT SERVICES, RUTGERS UNIVERSITY BEHAVIORAL HEALTH CARE; 
MICHAEL WALDRUM, M.D., CHIEF EXECUTIVE OFFICER, VIDANT HEALTH; 
    AND FREDERIC RICCARDI, PRESIDENT, MEDICARE RIGHTS CENTER

                 STATEMENT OF THOMAS R. BARKER

    Mr. Barker. Thank you, Madam Chair--Chairwoman Eshoo, Dr. 
Burgess. Thank you very much for the opportunity to appear 
before the subcommittee today.
    Thirty-eight years ago this week, I started my first job on 
Capitol Hill as an intern in this building, and when I walked 
through the Rayburn Horseshoe from the Capitol South Metro I 
never in a million years would have imagined that I would have 
had the honor of appearing before this subcommittee. So thank 
you very much for this opportunity.
    I want to clarify at the outset, Madam Chair--you mentioned 
my affiliation with my law firm. I want to clarify at the 
outset that although I was recently appointed the MACPAC, I am 
not appearing today on behalf of the Commission.
    Rather, I am speaking to you as a healthcare lawyer with 
many years' experience representing both the Government as the 
chief legal officer of CMS and HHS. I also represent healthcare 
providers and payers in private practice and as a former 
professor of healthcare law and policy at George Washington 
University and Suffolk University School of Law.
    My remarks today focus on the bill that was introduced by 
Mr. Engel that deals with the pending cuts in Medicaid DSH 
payments that were enacted as part of the Affordable Care Act 
and that had been deferred several times since then under 
current law.
    As the members of the subcommittee know, the first round of 
DSH cuts will occur in fiscal year 2020. So my testimony, which 
I am not going to, obviously, repeat but my testimony focuses 
on those pending cuts and it gives a little bit of history of 
the DSH payment system, which I hope will be helpful to the 
subcommittee as it begins its deliberations on an extenders 
package.
    I think it is important to understand that the DSH cuts of 
the ACA did not happen in isolation but, rather, as a part of a 
nearly 40-year history of Congress recognizing the special 
needs of Disproportionate Share Hospitals.
    In my testimony I went through the history of DSH, which 
actually started in 1981, probably in this room, when the House 
was beginning deliberations over the Omnibus Budget 
Reconciliation Act of '81, which was the first time that 
Congress told the States to focus on the needs of DSH 
hospitals, and that statute was amended again in 1987, 1991, 
1993, the BBA in 1997 and then again in 2010 when the ACA was 
enacted into law.
    And my testimony concludes by referring the subcommittee to 
recommendations that MACPAC made to structure the DSH cuts 
differently by phasing them in over a longer period of time to 
allocate the cuts first to States that have unspent DSH 
allocations and then really--and most importantly, in my view, 
to restructure the DSH allotments or the DSH caps to better 
align the State-specific DSH caps to the percentage of low-
income nonelderly individuals in a State.
    After all, that was the real original intent of DSH when it 
was enacted in 1981, which was an agreement by the Reagan 
administration, by the Governors, and by the Congress over how 
Medicaid rates should be set by States.
    So let me conclude by thank you for the opportunity to 
testify before the subcommittee this afternoon. I would be 
pleased to answer any questions that you have and I am happy to 
make myself available to the members of your staff if you have 
any questions about DSH.
    Thank you.
    [The prepared statement of Mr. Barker follows:]
    
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    Ms. Eshoo. We thank you for that, Mr. Barker, and I love 
the history. We never know what paths in life--where they are 
going to lead us and take us.
    Mr. Barker. Well, Mr. Waxman was here then. Mr. Dingell was 
here then. I certainly remember working for them. Thank you.
    Ms. Eshoo. Yes. It is a wonderful story. We stand on great 
shoulders.
    Now I would like to recognize Ms. Bohan. You are recognized 
for your 5 minutes of testimony, and thank you.

               STATEMENT OF MARY-CATHERINE BOHAN

    Ms. Bohan. Thank you for the opportunity to testify in 
support of the Excellence in Mental Health and Addiction 
Treatment Expansion Act, and to share with you how becoming a 
certified community behavioral health clinic--CCBHC--has 
impacted my organization and community.
    I am honored to be there today on behalf of the National 
Council for Behavioral Health, a national association that 
represents 3,100 member organizations who, collectively, serve 
more than 10 million adults and children living with mental 
illness and addiction.
    I am further honored to represent Rutgers University 
Behavioral Health Care, one of the seven CCBHCs participating 
in the 2-year demonstration project in New Jersey.
    Established in 1972, UBHC is one of the largest academic 
behavioral healthcare delivery systems in the Nation and is the 
largest behavioral health provider in the State of New Jersey, 
serving over 18,000 individuals per year.
    I have been vice president of outpatient services at UBHC 
since 2016. I am a clinical social worker by training and I 
have been a direct provider and administrator of mental health, 
addiction treatment, and community-based services for over 35 
years in three different States.
    I know only too well how siloed mental health and addiction 
services can be. Historically, neither system assessed the 
physical well-being of their clients, often missing vital 
information that should be part of their care.
    At Rutgers, CCBHCs have been the vehicle that has allowed 
us to finally offer integrated services and provide holistic 
care to those we serve.
    I would like to take a moment to share what behavioral 
health services at Rutgers UBHC look like now as compared to 
before the CCBHC implementation.
    The three outpatient clinics that were transitioned to 
CCBHC served about 3,300 individuals. In the first year of the 
program, we increased the number of people served to 5,000. In 
year 2, we have treated 6,000 individuals and families.
    We currently maintain 300 clients on medication-assisted 
treatment, or MAT, versus the 30 individuals that we treated 
the year prior to CCBHC.
    Before the demonstration, the average wait time for first 
appointment was 21 days with a no-show rate of 50 percent. 
Individuals with behavioral health issues need immediate access 
to care and we were losing the opportunity to help people at 
the time that they identified their need.
    Now we proudly offer same-day/next-day access. Our no-show 
rate is down to about 24 percent and continues to drop. When 
individuals were disengaged in treatment, outreach was limited 
to phone calls or letters. We now engage clients face to face 
in the community, person to person.
    In one instance, a clinician was concerned about an 
adolescent who had missed an appointment and could not be 
reached by phone. The case manager did a wellness visit at her 
home and intervened with the client, who was in the middle of a 
self-harm episode.
    The case manager contacted EMS, the family, and facilitated 
getting this client to the appropriate level of care. This type 
of intervention simply would not have been available to us 
prior to the CCBHC.
    Two years into this program, Rutgers UBHC is just hitting 
its stride. We are positioned to go further and do more for our 
community. But with the continued funding at risk, we have been 
unable to hire additional staff or pursue initiatives that 
would drive further innovation.
    If the CCBHC demonstration project is not extended past 
June 30th, the impact on Rutgers UBHC is enormous. Case 
management and peer support services will be discontinued, 
which means our ability to engage individuals in the community 
will end.
    Without case management and peer support, our same-day/
next-day access model, which relies on a team approach to 
function, will be greatly impacted and I fear that wait times 
will again grow to be weeks long.
    Health screens and subsequent linkage to primary care will 
be greatly reduced. The ambulatory withdrawal management 
program that treats individuals with opiate use disorder will 
likely close.
    To be frank, if the program expires all of the success I 
shared with you today is at risk. We cannot go back to business 
as usual. Not Rutgers, not the other UBHCs, and most 
importantly, not our clients, because those are the ones who 
will lose out the most if this program ends.
    So today I am asking for the committee's support in passing 
the Excellence in Mental Health and Addiction Treatment 
Expansion Act so that the eight States who are currently 
operating CCBHC can continue this work and additional States 
can be afforded the opportunity to transform their behavioral 
health delivery systems.
    On behalf of the individuals and families we serve, I would 
like to thank this committee for your focused attention on this 
issue and I would especially like to thank Congresswoman Doris 
Matsui and Congressman Markwayne Mullin for their leadership in 
sponsoring the Excellence Act expansion bill.
    Thank you, and I look forward to your questions.
    [The prepared statement of Ms. Bohan follows:]
    
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    Ms. Eshoo. Thank you for your outstanding work. It is very 
hopeful, what you described to us. Thank you for your 
testimony. Powerful testimony.
    Now I'd like to recognize Dr. Waldrum. You have 5 minutes 
for your testimony, sir. Thank you.

               STATEMENT OF MICHAEL WALDRUM, M.D.

    Dr. Waldrum. Thank you, and good afternoon.
    And thank you, Chairwoman Eshoo, Ranking Member Burgess, 
and distinguished members of this subcommittee for inviting 
Vidant Health to testify at today's hearing.
    I am Michael Waldrum, chief executive officer of Vidant 
Health, a health system guided by its mission: to improve the 
health and well-being of the people of eastern North Carolina, 
a geographic region the size of Maryland that 1.5 million 
people call home, including the subcommittee's vice chair, 
Congressman Butterfield.
    I am honored to speak to you today about the vital 
importance of Medicaid Disproportionate Share Hospital, known 
as DSH, funding is for my health system and the people and 
communities we serve.
    Vidant Health is a nine-hospital system and includes one of 
four academic medical centers in North Carolina, the Vidant 
Medical Center, which is a tertiary referral center and the 
only level one trauma center on the Eastern Seaboard between 
Norfolk, Virginia, and eastern--and Charleston, South Carolina.
    We employ more than 14,000 North Carolinians and contribute 
$3.5 billion to North Carolina's gross State product.
    Vidant Health and the hundreds of essential hospitals like 
it across the country reach well beyond our walls to meet 
people where they live and help communities cope with social, 
economic, and environmental factors that affect their health.
    We have ample experience with this. The majority of the 
counties we serve are among the most economically distressed 
areas in our State.
    In the Vidant Medical Center primary service area, Pitt 
County, 60 percent of the public school students are enrolled 
in free or reduced lunch programs and the poverty rate is 24 
percent.
    Our providers work hard every day to combat obesity, 
chronic conditions, the infant and maternal mortality crisis, 
the opioid epidemic, and to support our communities where they 
live who are disproportionately burdened by these illnesses.
    So we fund programs that empower community partners to 
overcome social economic factors that contribute to poor 
health, from chronic conditions support to food banks for 
school health programs and many other initiatives we are making 
a difference.
    In fact, last year Vidant Health partnered with more than 
159 different programs across eastern North Carolina, 
contributing almost $2 million in grant contributions to other 
social service organizations which serve more than half a 
million of our neighbors.
    Today's hearing is about investment in healthcare and these 
programs represent our investment in the health and 
productivity of our community.
    We can do these things because Medicaid DSH helps us ease 
the financial pressure that comes with our commitment to 
meeting the healthcare needs of all of our people, including 
those faced with severe financial hardships.
    That commitment to mission translates to more than $200 
million in uncompensated care costs annually for Vidant Health. 
Medicaid DSH helps close that gap.
    Our situation is not unique. The 300 hospitals in our 
national association, America's Essential Hospitals, alone 
provide nearly a quarter of all charity care nationally and 
more than nine times the amount of uncompensated care on 
average than other U.S. hospitals.
    Vidant Health and the Nation's other essential hospitals 
depend on Medicaid DSH to offset the financial losses we 
sustain caring for our Nation's most vulnerable people who are 
often are the most complex and costliest patients.
    This leaves essential hospitals with no financial cushion 
to absorb a cut the magnitude of this year's DSH reduction, $4 
billion, or a total of a third of the DSH funding.
    A cut this size would deeply change our ability to meet the 
needs of the individuals and families who depend on Vidant 
Health. These cuts will be felt even more so by the patients in 
States that have not expanded Medicaid, such as North Carolina.
    DSH cuts would devastate the Nation's safety net and 
jeopardize healthcare access and jobs in eastern North Carolina 
and the communities in the country with a particularly acute 
impact of rural America and including the rural environment 
that we serve.
    Congress has wisely chosen to delay these cuts four times 
previously, each time with strong bipartisan votes. We greatly 
encourage--we are greatly encouraged to see the same 
bipartisanship on this issue this year.
    We thank Congressman Engel and Olson for organizing a 
letter to the House leaders calling for a further delay and we 
thank the 300 bipartisan House colleagues including the members 
of this subcommittee who signed that letter.
    Thank you for allowing me to share Vidant's story.
    [The prepared statement of Dr. Waldrum follows:]
    
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    Ms. Eshoo. Thank you, Dr. Waldrum, very much.
    Mr. Riccardi, you are recognized for 5 minutes for your 
testimony.

                 STATEMENT OF FREDERIC RICCARDI

    Mr. Riccardi. Good afternoon, and thank you.
    Chairwoman Eshoo, Dr. Burgess, and members of the 
subcommittee, I am Fred Riccardi, president of the Medicare 
Rights Center.
    Medicare Rights is a national nonprofit organization that 
works to ensure access to affordable healthcare for older 
adults and individuals with disabilities through counselling 
and advocacy, educational programs, and public policy 
initiatives.
    Thank you for the opportunity to speak with you today about 
several bipartisan Medicare-related programs that we urge you 
to address in extenders legislation this year.
    Specifically, there are three points I would like to share. 
I request that for permanent authorization for the low-income 
program outreach assistance, the Part D safety net program 
known as LI NET, and continue funding for the National Quality 
Forum.
    Doing so will ensure that these initiatives continue to 
help improve the health and financial stability for people with 
Medicare.
    Every day on our national consumer help line we hear from 
people who are struggling to cover healthcare and prescription 
drug costs. For many, particularly those with low or fixed 
incomes, the program's premiums and cost-sharing amounts are 
just out of reach.
    Already half of Medicare beneficiaries--nearly 30 million 
people--live on approximately $26,000 or less a year and a 
quarter of them live on approximately $15,000 or less a year, 
and healthcare costs are taking up larger and more 
disproportionate share of beneficiaries' very limited budgets.
    Thankfully, assistance is available. The Medicare Part D 
extra help benefit helps beneficiaries access the prescription 
drug program by paying their premiums and lowering the cost of 
their copayments.
     Additionally, the Medicare savings program pays for 
Medicare Part B premiums. But people don't always know how to 
access these programs or how to apply for them and, as a 
result, they may not be getting the help or the care that they 
need, which can lead to worse health outcomes and higher costs.
    The extra help in the Medicare savings program benefits 
increase affordability and access to care can truly be 
lifesaving, helping beneficiaries manage chronic conditions and 
better meet the needs of daily living.
    At Medicare Rights, we have seen people access extra health 
benefit in the Medicare savings program and acquire transplants 
and heart surgery and treatment for Parkinson's disease.
    One such program encompasses outreach and enrollment 
efforts aimed at enrolling more people into the extra help and 
Medicare savings program benefit, authorized by the Medicare 
Improvements for Patients and Providers Act--known as MIPPA--of 
2008.
    This funding allows community-based organizations to 
connect beneficiaries with limited incomes to these programs, 
and since 2009 the program has helped nearly 3 million Medicare 
beneficiaries.
    Additionally, the Limited Income Newly Eligible Transition 
program--LI NET--is a safety net program for people who are not 
currently enrolled in a prescription drug plan but are eligible 
for extra help or have Medicaid or supplemental security 
income.
    We are pleased to endorse H.R. 3029, which would 
permanently authorize this critical program and we are grateful 
to Representatives Olson, Barragan, Marchant, and Lewis for 
championing this effort.
    We also support continued funding for the National Quality 
Forum introduced by Representatives Chu, Engel, and Carter. 
H.R. 3031 would allow the National Quality Forum to build upon 
quality measurement, advancements already underway to create 
high-quality, high-impact, and more cost-efficient healthcare 
system.
    Finally, as you develop an extender's package or otherwise 
look for opportunities to improve the Medicare program, we 
respectfully ask that you prioritize the bipartisan bicameral 
BENES Act, championed in the House of Representatives by 
Representatives Ruiz, Walorski, Schneider, and Bilirakis.
    The BENES Act would, in part, simplify the Part B 
enrollment process and better inform those approaching Medicare 
eligibility about the responsibilities.
    Thank you for your time and consideration. Again, 
healthcare and prescription drug affordability are ongoing 
challenges.
    Adequately funding and making permanent these programs I've 
discussed today will help ensure that older adults and people 
with disabilities can access and afford high-quality care.
    [The prepared statement of Mr. Riccardi follows:]
    
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    Ms. Eshoo. Thank you very much, Mr. Riccardi, and to each 
one of the witnesses.
    We have now concluded your statements for this panel. But 
there are votes on the floor. So what we are going to do is 
recess for about 25 minutes to a half hour. Depends on how long 
the votes are. I think there are three of them.
    Let us just say we'll resume in 30 minutes, and to ask our 
questions of you. So you have a little bit of a break, and we 
are going to run over to the Capitol and we will see you in a 
bit, OK?
    Thank you. The committee is in recess.
    [Recess.]
    Mr. Butterfield [presiding]. All right. I guess we need to 
proceed, if we can. We will now move to Member questions and I 
will recognize myself for 5 minutes.
    Dr. Waldrum, thank you again for your testimony today and 
for the work that you do in eastern North Carolina, 
particularly for vulnerable populations. It has been very 
helpful to understand the potentially devastating impact onto 
Vidant Health if Medicaid DSH reductions were to take place 
this year.
    The Affordable Care Act included DSH reductions with the 
expectation--the expectation that Medicaid expansion would lead 
to a decrease in hospital uncompensated care costs.
    However, only 33 States and the District of Columbia have 
expanded Medicaid.
    Dr. Waldrum, North Carolina has yet to expand Medicaid. Is 
that correct?
    Dr. Waldrum. Yes.
    Mr. Butterfield. The majority of the counties that you 
serve are among the most economically distressed areas in our 
State. I can certainly say that for a fact.
    Can you discuss the difficulties of being a safety net 
provider in a nonexpansion State?
    Dr. Waldrum. Thank you for the question.
    Yes. So Medicaid expansion, clearly, is important to us and 
our region, and providing care in a distressed safety net 
organization and region is always a challenge.
    As you know, we serve primarily a rural environment and 
North Carolina has the second largest rural population in the 
country and eastern North Carolina has 1.3 million citizens in 
rural environments.
    And so we are always looking at how we provide care to 
those environments, and hospitals and providers in rural 
environments are challenged. You have had a lot of the 
discussion about that today as I listened to the deliberations 
this morning and we all know some of the issues.
    There is a higher burden of disease in the citizens that 
live in rural environments with obesity, cancer, cardiovascular 
disease, and diabetes, as you have heard this morning, and the 
aging population in rural environments with a shrinking 
population.
    And but people still live there, and in some services with 
some of the dialogue this morning, OB services, for instance, 
in a number of our hospitals we only have on average one baby a 
day. And so you have to have the infrastructure to provide 
services to those patients. But we do not get enough revenue to 
cover the cost for those services.
    So that puts a burden on us. But if we didn't have those 
services, the mothers and babies would have to travel in some 
areas over an hour to have their baby.
    Mr. Butterfield. So this is affecting your bottom line, to 
be sure.
    Dr. Waldrum. For sure.
    Mr. Butterfield. And when your bottom line is impacted, 
other things are impacted as well?
    Dr. Waldrum. Well, it just compromises our mission to 
support our communities.
    Mr. Butterfield. And you have a concentration in critical 
care. Can you discuss the impact that Medicaid expansion could 
have on access to critical healthcare services for your 
patients?
    Dr. Waldrum. Yes. I appreciate that.
    So it would--it would give coverage for many types of 
services and critical care services. With uncovered care, which 
is a very high-cost service, which is my specialty--critical 
care--having coverage for those services would really help our 
institution provide and cover those costs, obviously.
    But there are other important services such as behavioral 
health and we know that having covered lives with Medicaid 
expansion helps us cover things like behavioral health, which 
helps with the opioid epidemic.
    And so it really goes from ambulatory services like 
behavioral health all the way to critical care.
    Mr. Butterfield. Now, the Census Bureau has identified 386 
counties in the United States as persistent poverty counties, 
which means that a county has been in poverty 20 percent or 
better for the last 30 years.
    That's a persistent poverty county--486 in the U.S. and 12 
are North Carolina. Six are in the area covered by your 
hospital.
    Can you speak to the impact that poverty and hunger and 
nutrition and safe housing have on a person's health?
    Dr. Waldrum. I can speak to it because I've frequently 
visited our communities and one of the communities I think 
you're referring to is Bertie County, which we have a hospital 
in, and travel, food insecurity, access to care or coverage, 
but just to drive to get access the distance--so access to 
social services, I mean, you name it, it affects the people we 
serve.
    Mr. Butterfield. Has your hospital or your association 
taken a position on Medicaid expansion in North Carolina?
    Dr. Waldrum. Yes. We support it fully.
    Mr. Butterfield. OK. Thank you. I have some more, but I 
think I am going to yield back and pass it on to one of the 
other Members.
    All right. To the ranking member, Mr. Burgess.
    Mr. Burgess. Thank you, Mr. Butterfield.
    Mr. Barker, let me be a little bit provocative. Do we still 
need DSH?
    Mr. Barker. I am sorry. Could you repeat?
    Mr. Burgess. Do we still need the disproportionate share 
funding?
    Mr. Barker. Oh, I think so.
    Mr. Burgess. And given that context, what about just the 
proposed removal of the proposed cuts, just DSH funding goes 
forward with no structural reforms? Good idea? Bad idea? 
Neutral idea?
    Mr. Barker. Well, I guess I would say, again, not speaking 
for MACPAC because I am not--technically, I am not yet on 
MACPAC. I will be tomorrow. But I do think that MACPAC had a 
very thoughtful approach toward the--ending DSH cuts.
    I think that MACPAC was trying to be sensitive to the 
budgetary impact and that they were concerned that just flat 
out repeal of the DSH cuts would have a budgetary impact and so 
they proposed a more gradual implementation of the cuts 
combined with what I think is equally important and that is 
rebalancing the State DSH allocations with low income 
nonelderly population in a particular State.
    The DSH caps were set at a time that--were set over 20 
years ago and they weren't based at the time on poverty levels 
in a State, and I think maybe it is time to revisit how they're 
allocated.
    Mr. Burgess. So if the DSH cuts were wiped out in their 
entirety, the problems with the formula would still exist?
    Mr. Barker. Yes.
    Mr. Burgess. So--and I think you make this point in your 
testimony, in your written testimony, certainly--but maybe you 
can elaborate a little bit on the fact that historic spending 
in the disproportionate share funding may bear little or no 
relationship to the low income nonelderly population in a given 
State today?
    Mr. Barker. Yes, I think that is true because the way that 
the DSH caps were first established happened at a time when 
Congress and I think the--it was the George H. W. Bush 
administration were very concerned about the explosion in DSH 
spending.
    I pointed out in my testimony that DSH spending went from a 
little over a billion dollars in 1990 to $17 billion in 1992, 
and something was going on and they wanted to get a handle on 
it.
    And so they imposed a cap, but the cap was just based on 
what States were spending in DSH at that particular time. It 
really didn't bear any relationship to the low income or the--
the low income rate or the poverty level in a State.
    Mr. Burgess. So I am going to ask you something because 
I've always been a little sensitive about this as a physician. 
I mean, you look at hospitals who get disproportionate share 
funding but, of course, the physician workforce in that area 
may also be taking care of a very low income population or 
uninsured or under insured population.
    There has never really been anything that balances what it 
costs providers to be in that area versus what it costs 
hospitals. As we heard, one delivery a day doesn't fund the 
entire labor and delivery unit.
    But it can also be very difficult for a provider to run a 
practice with that type of through put.
    Mr. Barker. Yes, absolutely.
    Mr. Burgess. And has there ever been anything looked at 
that would balance the equation for docs as well as hospitals?
    Mr. Barker. I think that is why you are seeing a lot of 
hospital acquisition of physician practices just because--that 
is one of the reasons that there has been a growth in hospital 
acquisition of physician practices because physicians can't 
manage it on their own.
    Mr. Burgess. Which brings us then to what I consider the 
great conundrum. It is OK for hospitals to own physicians but 
physicians can't own hospitals, right?
    Mr. Barker. That's--I think that is correct.
    Mr. Burgess. And we need to fix that. I wait for the 
judges' input and we will do that.
    Do you think that a full repeal of the DSH cuts makes 
critical reforms of the program more or less likely?
    Mr. Barker. I think it would make it less likely just 
because the--there wouldn't be the political impetus.
    Mr. Burgess. And, ultimately, then that is to the detriment 
of those populations that DSH was set up to serve in the first 
place.
    Mr. Barker. Yes.
    Mr. Burgess. Is that--is that a fair assumption?
    Mr. Barker. Yes. Yes.
    Mr. Burgess. Thank you, Mr. Chairman. Oh, that struck----
    Mr. Butterfield. Thank you, Dr. Burgess. Thank you so very 
much.
    Mr. Burgess. I had a hard time getting that out.
    I will yield back.
    Mr. Butterfield. Thank you.
    At this time I will recognize the gentleman from New York, 
Mr. Engel.
    Mr. Engel. Thank you, Mr. Chairman.
    Medicaid DSH payments--I want to talk about those--they 
help hospitals and health systems, serve some of our Nation's 
most vulnerable communities.
    In fiscal year 2017, Medicaid DSH payments amounted to 
$18.1 billion, allowing safety net providers to deliver free or 
subsidized care to millions of Americans.
    In October, these vital payments will be cut by $4 billion 
for the upcoming fiscal year and $8 billion for the following 
year. That is not a good thing to do.
    Safety net hospitals regularly operate on thin or negative 
margins. In fact, New York hospitals have some of the narrowest 
margins in the country. If Congress fails to delay Medicaid DSH 
cuts, some of our Nation's safety net providers will be forced 
to close, leaving our constituents in communities without 
access to an important source of care.
    Fortunately, there is broad bipartisan support for 
addressing these cuts. On May 13th, 300 Members of the House 
joined Congressman Olson and me in pushing for a delay. I urge 
my colleagues to join me in helping preserve access to care for 
the most vulnerable among us.
    Mr. Chairman, I also want to thank you and the committee 
for including legislation which would reauthorize funding for 
the National Quality Forum. I am pleased to sponsor this 
bipartisan legislation with Congresswoman Chu and Congressman 
Carter.
    The National Quality Forum is one of the Nation's leaders 
when it comes to developing tools for improving healthcare 
quality and outcomes.
    Before asking questions of our witnesses, I ask unanimous 
consent to submit two letters of support into the record, the 
first from the American Hospitals Association in support of the 
Patient Access Protection Act, and the second from the Friends 
of NQF, supporting H.R. 3031.
    Mr. Butterfield. Without objection on both of those 
requests.
    [The information appears at the conclusion of the hearing.]
    Mr. Engel. Thank you, Mr. Chairman.
    Let me ask Mr. Riccardi--in recent years Medicare has made 
numerous efforts to move away from fee for service, instead 
toward a system that rewards value over volume. It is critical 
that we continue to find ways to measure and incentivize the 
highest quality of care.
    So let me ask you, Mr. Riccardi, as we continue to pursue a 
healthcare system that pays for value instead of volume, what 
role do you see for the National Quality Forum's work?
    Mr. Riccardi. An increasingly important one. NQF--we need 
to ensure that they remain funded and sustainable for the 
direction of value-based care.
    NQF has a membership of 450 organizations and the Medicare 
Rights Center is an active member of NQF. NQF facilitates 
dialogue across the private and the public sector, creating 
measures that operate throughout the Medicare program. In fact, 
hospital readmission rates have fallen by 8 percent and as 
States pursue value-based care arrangements and also focus on a 
variety of initiatives, these measures are key.
    Increasingly, we are hearing beneficiaries calling our help 
line with questions about quality, and as CMS has improved 
tools for--to evaluate and determine the quality of a variety 
of different facilities and settings, these measure are also 
key in that in helping beneficiaries access valuable efficient 
care. Thank you.
    Mr. Engel. Thank you. Hospitals use Medicaid DSH payments 
to support vital community health programs including 
initiatives to address opioid prescription abuse and improve 
maternal health.
    Mr. Waldrum, could you please describe how your hospitals 
use Medicaid DSH payments to better care for your local 
community?
    Dr. Waldrum. I would say I don't have time and we partner 
with our communities. But I will tell you to deal with all of 
those issues.
    But we support a number of local initiatives and I will 
tell you one that happens in Conetoe, North Carolina, with 
Reverend Richard Joyner.
    And so we have funded an initiative because the burden of 
the disease in those folks was very high, and so we helped him 
engage with the community to build a sustainable model where 
they educate children about healthy lifestyles and give them 
employment on a farm, and that has brought the parents in and 
they have a sustainable model to sell their product in our 
hospitals, and that has created a college fund and those kids 
are going to college and are breaking the cycle of poverty and 
ill health that they have been burdened with for decades.
    And Ms. Bush, who is a 72-year-old woman in that community, 
actually fought against it happening, and today, this morning, 
she was on that farm working and she's been working there for 
the last year and she is off 22 of her medicines because she 
has adopted the lifestyle and the habits that are being taught 
by that farm. So she is one example, and then these kids are 
the future of eastern North Carolina.
    Mr. Engel. Well, thank you both. I think what you have said 
is very important and we all should heed it. Thank you.
    Thank you, Mr. Chairman.
    Mr. Butterfield. Thank you, Mr. Engel.
    Richard Joyner is a dear friend of mine and I will let him 
know that you have acknowledged him today.
    The Chair now recognizes the gentlelady from California, 
Ms. Matsui.
    Ms. Matsui. Thank you, Mr. Chairman.
    Ms. Bohan, thank you for sharing with us how becoming a 
certified community behavioral health clinic has benefited your 
organization and community.
    And we are hearing similar successes from clinics across 
the country where the demonstration has expanded treatment 
capacity and transformed their ability to meet the growing 
demands for community-based services.
    Ninety-four percent of all CCBHCs have increased the number 
of patients they treat for addiction and nearly two-thirds have 
been able to decrease wait times.
    With the June 30th funding expiration looming, our CCBHC 
demonstration States are now stressing the extreme financial 
threat they face to sustain operations and provide vital 
continuous care.
    I was glad to hear Ranking Member Walden express his 
support for extending the Excellence in Mental Health 
demonstration for additional 2 years.
    Just this morning, I heard from a CCBHC in Oregon how a 
sustained investment in the program would allow its providers 
to reach into the community to further extend access to 
behavioral health services for individuals with serious mental 
illnesses.
    In the midst of an opioid epidemic, we should be supporting 
innovative approaches like CCBHCs to provide integrative 
primary and behavioral healthcare. That is why expanding the 
Excellence in Mental Health demonstration as the support of 
interdepartmental serious mental illness coordinating committee 
of SAMHSA has been endorsed by Dr. Sally Satel of the American 
Enterprise Institute and has the support of 14 of my Republican 
colleagues.
    People struggling with mental illness and substance use 
disorder across the country should be able to benefit the same 
as patients in the eight States participating in the demo.
    That is why I am fiercely advocating to extend this 
demonstration for the participating States and expand it to 11 
more States in my bill with Representative Mullin, H.R. 1767.
    In a new report entitled ``Bridging the Treatment Gap,'' 
the National Council for Behavioral Health surveyed the CCBHCs 
and the results offer hope in our Nation's battle against the 
opioid crisis.
    The report showed, among other things, nearly universal 
adoption of medication-assisted treatment--MAT--and decreased 
patient wait times for these lifesaving interventions.
    There is strong evidence that the program is leading to 
reduced overdose deaths in upstate New York, and I am also 
encouraged that CCBHCs in Oklahoma are reporting huge 
reductions in hospital emergency room utilization.
    With that as background, Ms. Bohan, I would like to ask you 
a few questions. First, I understand that in New Jersey CCBHCs 
have opened new service lines like the 24-hour emergency 
psychiatric care and medication-assisted treatment while 
serving patients who have never received care before.
    With the sustained funding including in my bill, how can 
your CCBHC further integrate and expand services for vulnerable 
patient populations?
    Ms. Bohan. Thank you very much for your question and your 
support. Can you hear me? Yes. OK.
    So you are absolutely right. We have expanded service lines 
across the State of New Jersey. Twenty-four-hour mobile crisis 
services that did not exist previously in counties like 
Monmouth County are now really an integral part of the delivery 
there and they have quickly become the--community resources 
have quickly become dependent on these services and being able 
to reach out directly to CCBHCs.
    We are linked in with the Health Information Exchange so 
that community partners can really identify that someone 
belongs to a CCBHC and we are able to see if someone lands in 
an emergency room, and we can quickly get case management out 
and so forth to perhaps avoid a hospitalization and reengage 
them quickly.
    Ms. Matsui. That is wonderful.
    Ms. Bohan. And in terms of the opioid epidemic, many of 
the--including Rutgers, the programs are looking at bridge 
programs from local emergency departments directly to CCBHCs so 
that individuals can be started on medication-assisted 
treatment and bridged directly over to the CCBHC where they 
could be maintained on this really lifesaving intervention.
    Ms. Matsui. That's great. What risk would a lapse in 
demonstration funding have on your ability to provide holistic 
services that address the ongoing opioid epidemic?
    Ms. Bohan. It'll have a huge impact. As I said in my 
testimony, there are--all of us have expanded our services, 
which also means expanding our workforce.
    So we have individuals in place. We've expanded our ability 
to prescribe MAT. We have all established ambulatory withdrawal 
management programs so the individuals can come in and be 
inducted on MAT safely, and we are also able to deal with other 
medications as well in that setting.
    So that is a program that is at great risk across the 
State.
    Ms. Matsui. Well, thank you so much and I really appreciate 
your participation. Thank you so much, and I yield back.
    Mr. Butterfield. The gentlelady yields back.
    At this time, I will recognize the gentleman from Florida, 
my friend, Mr. Bilirakis.
    Mr. Bilirakis. Thank you, my friend. Thank you, Mr. 
Chairman. I appreciate it.
    Mr. Barker, the DSH program--and I know that this has been 
covered but it is so very important to my State and other 
States as well, taking care of the indigent--but the DSH 
program provides payments to hospitals, as you know, serving a 
disproportionate number of Medicaid patients and the uninsured.
    ACA reduces this payment--the payments by $14 billion from 
2014 to 2019. Additionally, due to an arbitrary cap on DSH 
payments frozen since the early 1990s, Florida has been 
inequitably funded, and I know we are not the only State--
funded for DSH payments compared to other States with much 
lower uninsured populations, and this is a bipartisan issue.
    So while I am supportive of delaying the cuts, certainly, I 
am concerned that simply repealing the cuts would not address 
the underlying issue.
    The antiquated formula created in the early '90s that 
continues to negatively impact Florida and other good States, 
Florida's Medicaid patients and uninsured they are impacted by 
this and it is a real problem.
    Should Congress update the DSH formula? Why or why not, 
sir?
    Mr. Barker. Mr. Bilirakis, were you directing that question 
at----
    Mr. Bilirakis. The question is for Mr. Barker.
    Mr. Barker. Yes.
    Mr. Bilirakis. Thank you.
    Mr. Barker. So Dr. Burgess raised this issue----
    Mr. Bilirakis. Yes.
    Mr. Barker [continuing]. When he was here before, and I do 
think that repealing the DSH cuts in their entirety would 
remove the impetus to reform the DSH formula. Yes, I agree with 
that statement.
    Mr. Bilirakis. OK. All right. Very good. Thanks for--you 
know, and, again, this is a time to get it done. So how might 
Congress consider reforming the DSH formula to better reflect 
the current patient population in States like Florida and South 
Carolina, North Carolina, but all over the country--New Jersey?
    Mr. Barker. So the DSH caps that are in the statute right 
now were based on how much States were spending on DSH in 1991 
or 1992.
    Mr. Bilirakis. Right.
    Mr. Barker. It doesn't bear any relationship to the number 
of low income or uninsured patients in the State whereas the 
whole purpose of DSH is to account for the situation of 
hospitals that treat a disproportionate number of low income 
individuals.
    And so one idea would be that the DSH allocations be set 
based on a measure of low income nonelderly individuals in a 
State.
    Mr. Bilirakis. Yes. I mean, again, it has affected so many 
States because things have changed since '91. So it is 
antiquated, and I appreciate--thank you for the input and 
hopefully we can get something done about it.
    Thank you, and I yield back, Mr. Chairman.
    Mr. Butterfield. The gentleman yields back.
    At this time I will recognize the gentleman from 
California, Dr. Ruiz.
    Mr. Ruiz. Thank you, Mr. Chairman. There are many issues 
surrounding the outreach and enrollment for Medicare. So I 
would first like to thank my colleague and friend, 
Congresswoman Dingell, for her work on H.R. 3039, which 
provides the 5-year extension of funding for Medicare outreach, 
enrollment in education for low income beneficiaries.
    This funding will help connect those most in need with 
critical assistant programs. But we know that difficulties with 
Medicaid enrollment extend beyond this much-needed targeted 
specific funding which this funding will help. There are still 
many who fall through the cracks through the Medicare 
enrollment and suffer because of that.
     In fact, most people that are newly eligible for Medicare 
are automatically enrolled in Part B because they are 
collecting Social Security retirement at the age of 65 and 
there is that communication so they automatically enroll.
    But a growing number are not, as they are working later in 
life and deferring their Social Security benefits. Many of them 
are in under insured or uninsured or very little benefits to 
cover health insurance in those type of employments.
    So unlike those who are auto enrolled in Part B, these 
individuals make an active Medicare enrollment choice. So 
taking into consideration specific time lines and existing 
coverage.
    Far too many seniors make honest mistakes when trying to 
understand and navigate this confusing enrollment system. The 
consequences of Part B enrollment mistakes are significant.
    So if you are working, you are not automatically enrolled, 
you haven't enrolled, you don't have health insurance, you find 
out later that you don't have--you're not enrolled in Medicare, 
you missed the deadline and that includes--the penalties are 
late enrollment penalties, higher out-of-pocket healthcare 
costs, gas and coverage, and barriers to accessing needed 
services.
    In 2018, an estimated 760,000 people--760,000 people with 
Medicare were paying a Part B late enrollment penalty with the 
average penalty amounting to a 28 percent increase in the 
monthly premium.
    So I introduced a bill that will hopefully close this gap 
for seniors who are falling through and it is called the BENES 
Act, which will direct HHS to send enrollment notices to 
individuals approaching eligibility to educate them on how and 
when to enroll in Medicare Part B and close a coverage gap that 
currently exists for individuals that do not enroll at a 
specific time.
    In other words, it gives these working seniors who deferred 
their Social Security a heads up proactively and giving them 
the opportunity to learn how and when to enroll so they don't 
miss that gap or fall through the cracks and miss the 
enrollment.
    So, Mr. Riccardi, can you explain this underlying issue as 
well as the extent of the problem and what you are hearing from 
folks calling in to the Medicare Rights national help line?
    Mr. Riccardi. Yes. And thank you, and thank you for 
championing the BENES Act and also Representative Bilirakis for 
sponsoring the bill also.
    This trend emerged on our help line as confusion abounds. 
Medicare rules are complicated and, as you mentioned, a 
majority of individuals are automatically enrolled into 
Medicare if they're collecting Social Security.
    But 20,000 people are turning 65 every day, people are 
working longer, and they are waiting to also collect their 
Social Security retirement benefits since the full retirement 
age for Social Security benefits is now age 66 and it is 
continuing to increase.
    And so confusion is found from people of all backgrounds, 
of all incomes, and all educational backgrounds, and in 
particular we are seeing problems with individuals who may have 
some other type of coverage since our healthcare system and 
health insurance is confusing, and HR specialists and employers 
are also confused about how to guide people through Medicare 
enrollment.
    One barrier that could be easily addressed legislatively is 
to require that notice be sent to people before they're turning 
65 to inform them about their eligibility for Medicare Part B 
and for Medicare.
    And just remember, these individuals are entitled to the 
Medicare program but they are going without. This trend had 
emerged a few years ago on Medicare rights help line and to 
this day I still recall speaking to a client who had worked for 
a large company, and he had retiree coverage and he had worked 
for many years and contributed to Social Security and the 
Medicare program, but he was without Medicare Part B.
    And for years, he had this retiree coverage. But it wasn't 
until he had stage four cancer that they no longer would pay 
for his cancer bills.
    And so he was caught within this very catastrophic gap in 
coverage when you are waiting to enroll into Part B but you 
can't. And so he had to go, you know, close to 12 months, 14 
months, without coverage and in his case, him and his wife had 
to take out a reverse mortgage.
    And this was one of the first calls that we received on 
this issue, and every day we are hearing more and more from 
people who are missing their enrollment period through no fault 
of their own.
    And so the BENES Act would do, as you had mentioned, three 
really important things. First, it would inform people about 
their Medicare eligibility as they are turning 65.
    It would simplify the enrollment periods. Generally, people 
are very confused about when to enroll into Part B and 
prescription drug coverage. It would simplify these enrollment 
periods.
    And lastly, it would do away with this catastrophic gap in 
coverage that is in place. So thank you for your support.
    Mr. Ruiz. Well, thank you for that information and I too 
want to thank my good friend, Representative Bilirakis. We join 
efforts on a multitude of bipartisan bills together and this is 
one, I think, that we are going to pass through the House and 
get signed by the President.
    Thank you.
    Ms. Eshoo [presiding]. Thank you.
    I was on the floor to handle a bill. So excuse me for not 
being here for a good part of your testimony and thank you 
again for really essentially being here all day with us.
    Let me just circle back, Mr. Riccardi. I got the tail end 
of this. At one time, Social Security would notify an 
individual that they--that they would become--becoming eligible 
by whatever date and have an explanation, and I've always 
thought out of all the government agencies that Social Security 
materials are really understandable. They are written so 
clearly. It is not written in federalese and all of that.
    So people are not notified anymore by Social Security that 
they are--that they are about to become eligible for their 
benefits?
    Mr. Riccardi. For individuals who are not collecting Social 
Security benefits there is no information or separate notice 
that is provided to individuals to inform them that they are 
turning 65 and that they're within the window of time to enroll 
into Medicare.
    So, currently, that is not happening.
    Ms. Eshoo. Maybe I am confusing Social Security with AARP 
because when you are 55 they start telling you that you are 
going to turn 65 in 10 years.
    Thank you for that. And your legislation addresses this; it 
closes the gap. So they will get a notice?
    I am sorry. You need to--he can't hear you.
    Mr. Ruiz. So yes, correct. So for those who aren't drawing 
Social Security and retiring, they either continue to work and 
don't have health coverage or enough health coverage, then they 
don't get a notice.
    So my bill will send--be proactive and let them know about 
their enrolling.
    Ms. Eshoo. Let me ask this. Is there still going to be 
anyone left out, without a notice?
    Mr. Riccardi. The notice--the notice will improve 
people's--the information that they can access around 
enrolling, and with that information people should be able to 
make a more informed decision.
    Going back to my earlier point, there are a number of 
beneficiaries who are living on very limited incomes. As I had 
mentioned, a quarter of people are living under, you know, 
$15,000 a year. So the cost of Medicare and the Part B premiums 
can still be prohibitive to some.
    So that's why we encourage enrollment into the Medicare 
savings program because there are some reasons why somebody may 
not be enrolled in Medicare because they can't afford it.
    Ms. Eshoo. We had--Mr. Barker, you have--I heard your 
testimony on disproportionate share of hospitals.
    Mr. Barker. Yes.
    Ms. Eshoo. Yes. I would like to know if you know the 
following. And I don't recall exactly how many States decided 
not to participate in the expansion of Medicaid with the ACA. 
Were there 22 or something like that?
    Mr. Barker. I think 33 States have expanded Medicaid so----
    Ms. Eshoo. Thirty-three States. Thirty-three States left--
the expansion, right? And they left a great deal of money on 
the table. But, to me, the worst of it all was that the people 
that they represented in their States didn't have the 
opportunity to enroll.
    Having said that, do you know of--in those States how those 
Disproportionate Share Hospitals have fared? Has their 
population--the people that they serve gone up and, if so, 
exponentially? Do you have any information on that?
    I can't help but think that there is a nexus between the 
two. Do you know?
    Mr. Barker. I don't know. I actually think that Dr. 
Waldrum----
    Ms. Eshoo. Does anyone on the panel know?
    Mr. Barker [continuing]. Might know more than I do 
because----
    Ms. Eshoo. Dr. Waldrum?
    Mr. Barker [continuing]. His hospital is in a State that 
has not expanded Medicaid.
    Dr. Waldrum. Yes, I very much appreciate the question, and 
I think it is a very valid point. The States that did not 
expand Medicaid, the facts are pretty clear that we have had 
more rural hospital closures in those States than we have in 
States that expanded.
    And so the burden that it has placed because of the issues, 
primarily rural nonexpansion States, that is where the 
hospitals are closing and there is literature to support that 
it has to do with the lack of----
    Ms. Eshoo. Do you think that you could get that information 
to us?
    Dr. Waldrum. Yes, we would be happy to.
    Ms. Eshoo. You know, around here rural is a big issue on--
no matter what we do, whether it is telecommunications, 
technology, the digital divide, the homework divide, 
healthcare, transportation, you name it, rural areas in our 
country are affected and I that this is another one.
    And when you say that a hospital has closed, that is a very 
big deal in Anyplace, USA, much less in a rural area. So I 
would really appreciate getting that information and my own 
sense is, understanding pretty well--very well--how DSH works 
that without another appropriation of those funds, what will 
happen to these places?
    Dr. Waldrum. I am certain that more----
    Ms. Eshoo. What will happen to the people in these places?
    Dr. Waldrum. More hospitals will close. There will be 
reduction in services and we know that what happens is that 
services are curtailed initially. One that we mentioned 
earlier, OB services--so in a lot of rural hospitals they have 
gotten out of OB services because of the low volume and that 
limits access and that is contributing to the maternal and 
fetal--I mean, infant mortality crisis in rural America, and 
actually there is data that shows that when that happens the 
next thing is that the hospital closes and then the town, the 
community, suffers and in some cases actually goes away.
    Ms. Eshoo. Wow. What a description. That doesn't belong in 
America. Thank you very, very much.
    I now would like to recognize the gentleman from Oregon, 
Mr. Schrader, for his 5 minutes of questions.
    Oh, I am sorry. Should I go to Mr. Guthrie then?
    OK. Mr. Guthrie?
    Mr. Guthrie. Thanks. Thank you very much. Appreciate it.
    Ms. Eshoo. The gentleman from Kentucky. We need to 
introduce you appropriately. The gentleman from Kentucky, Mr. 
Guthrie.
    Mr. Guthrie. Well, thank you. I appreciate that very much.
    Thank you very much.
    So, Mr. Barker, the--I know in one of the opening 
statements about the responsibility to stop the DSH cuts--the 
DSH cuts were implemented by--what legislation brought forth 
the DSH cuts? Do you know?
    Mr. Barker. The ACA.
    Mr. Guthrie. And the concept--and I understand the question 
of my friend from California who was asking about States that 
didn't expand.
    I am from Kentucky and we did expand Medicaid. We also set 
up exchanges that Kentucky fully embraced and I know our 
current Governor has made some changes but still essentially 
fully embraced the Affordable Care Act with--given some 
changes, going from State marketplaces to the Federal exchange, 
but still there.
    And my hospitals still--well, first of all, to the 
hospitals you described closing the DSH cuts have never taken 
place. There has been no cuts in DSH is my understanding. Is 
that correct, I think, Dr. Waldrum?
    Dr. Waldrum. I believe that is correct.
    Mr. Guthrie. It is correct. So this is----
    Dr. Waldrum. It is the lack--it is the lack of the covered 
lives by expansion.
    Mr. Guthrie. Well, Kentucky is having similar issues and we 
have the same--we did expand. Do you know--Dr. Barker--Mr. 
Barker, so the concept was that you wouldn't have to have DSH 
because everybody is going to be covered if they expand and 
created the exchanges.
    Kentucky expanded and created the exchanges, and our 
hospitals they'll have to close if they--some hospitals if they 
didn't have DSH. We are seeing consolidation.
    Do you know why the premise of the Affordable Care Act in 
terms of DSH hasn't worked?
    Mr. Barker. My understanding was exactly what you said, 
which is that the thinking was that as the number of uninsured 
individuals declined, there would be less need for DSH--both 
Medicare DSH and Medicaid DSH.
    Mr. Guthrie. Right. But so that didn't happen, did it? I 
mean, Kentucky expanded Medicaid. Kentucky created exchanges 
and still rely on DSH heavily.
    So it seems like that didn't work. Whatever the concept was 
didn't work. Do you know why it didn't work? I understand the 
premise what was supposed to happen, but it didn't work.
    Mr. Barker. I can't comment on why it didn't work.
    Mr. Guthrie. OK. So the second thing--so Mr. Waldrum, about 
DSH--it is something that, you know, I support. We are going to 
have to maintain because of what the effects on hospitals, 
particularly rural areas.
    But let us see if we had a hypothetical to your delay and 
then Congress should update the formula to better align the 
relationship between DSH allotments in a State and the number 
of low-income nonelderly individuals.
    So my question, Dr. Waldrum, would your State--would your 
hospital--how would--if we realigned that formula, would your 
hospital be affected positively and would all of you commit to 
working with us to find a long-term solution that can steer DSH 
funding to where it should do the most good?
    So would you like to see a change in the formula? I mean--
--
    Dr. Waldrum. So I am not an expert in the complex 
calculations and how those are passed down to the States and 
then how that would be allocated locally. I am really----
    Mr. Guthrie. It is to the hospitals. It would be the 
hospitals.
    Dr. Waldrum. To the local hospitals, correct. And so how 
that would flow I am not an expert from a technical 
perspective. I am a provider, a physician, and a hospital 
administrator that tries to provide services to these 
communities and cuts promulgated on, as you described, very 
fragile communities and how we serve those folks.
    We wouldn't want and would oppose those cuts. And so I am 
not here to address the technicalities and I am not an expert 
in that area.
    Mr. Guthrie. Any comment on that, Mr. Barker, on the 
formula of DSH and how DSH is allocated?
    Mr. Barker. On the Medicaid side, that's a State-by-State 
determination. So the Federal statute----
    Mr. Guthrie. Right.
    Mr. Barker [continuing]. Sets a minimum threshold for 
classes of hospitals that have to be designated as DSH but then 
it is up to a State to decide within those parameters.
    Mr. Guthrie. But there is a Federal formula that allots 
that money, correct? Like Tennessee doesn't get much DSH----
    Mr. Barker. Oh, you mean the overall DSH?
    [Simultaneous speaking.]
    Mr. Barker. I am sorry, Congressman. I didn't understand 
your question. Yes, you are right. There is a statutory DSH 
cap.
    Mr. Guthrie. Right.
    Mr. Barker. Tennessee was not getting any DSH funds back in 
1992. But that DSH cap was set on the level of DSH spending in 
a State in 1991 or 1992, and the reason Tennessee doesn't have 
one is because they weren't using any DSH funding back----
    Mr. Guthrie. Do you think that should be--I think that 
might have been when they had TennCare. I am not sure. I don't 
know if there are some Tennesseans who--so do you think that 
formula should be--to be fair, to other States, that it be 
reallocated instead of based on a 1991-92 number?
    Mr. Barker. I do think--Dr. Burgess raised this issue 
earlier. Yes, I do----
    Mr. Guthrie. Sorry. I was in another meeting.
    Mr. Barker. No. No. No. No. I think that it would be a good 
idea to revisit the DSH allocations.
    Mr. Guthrie. OK. Thanks. I appreciate that. With my last 10 
seconds, you know, that DSH was a big pay for the Affordable 
Care Act and here we are, and we are going to need to do it. I 
am not saying we don't need to do it. But now reallocating 
money that has already been allocated to make sure that 
hospitals don't close.
    So I appreciate the time, Madam Chair, and I yield back.
    Ms. Eshoo. The gentleman--let us see. I now would like to 
recognize the gentleman, and he is a gentleman, from Oregon, 
Mr. Schrader, for his 5 minutes of questioning.
    Mr. Schrader. Thank you again, Madam Chair. I appreciate 
it.
    I will follow up a little bit on the line of concern that 
Congressman Guthrie and Congressman Burgess--Dr. Burgess--had 
talked about because it sounds like from what we have heard 
today that the DSH payment thinking with the ACA didn't work 
out quite as well as we had thought.
    Charity care has decreased. That is a good thing. Medicaid 
care has increased and, as we all know, Medicaid doesn't pay 
full freight. So I think some of the hospitals, perhaps in Mr. 
Guthrie's district, are still having some trouble balancing the 
commercial rates, obviously, with the increase in Medicaid 
population.
    But I think it gets to the central point that, you know, 
big proponent of making sure, you know, we make sure these 
hospitals and rural hospitals in particular stay in place. You 
know, prefigure, recontour this formula that is 20-plus, maybe 
30-plus years old at this point in time makes sense.
    I would put in though, as a person whose State actually did 
to the Medicaid expansion that whenever if we redo this formula 
we should take into account the fact that those States that 
stepped up and actually provided healthcare for our low income 
people there ought to be no penalty at least for them having 
done so.
    The original Senate language, you know, that was finally 
implemented when this was all done many years ago, talked about 
low income and I think that should still be the major guiding 
force for how we approach these payments.
    To me, you know, based on what we have heard today, the 
MACPAC stuff will be a great starting point in terms of how we 
deal with any gradual elimination or reduction--probably not 
elimination but reduction in the DSH payments with some tweaks 
to make sure that we take into account what's actually 
happened, you know, over the last 20 years and particularly 
since the ACA has put into effect.
    Mr. Riccardi, just chat a little bit if you don't mind and 
follow up--I talked about this a little bit and it has been 
talked about with the previous panel, you know, how important 
the FQHCs and the CHCs are for delivering healthcare for a lot 
of folks that are uninsured or don't have access to healthcare, 
basically.
    In trying to incentivize aligning the quality metrics, 
Oregon has gone a long way in trying to match up managed care 
metrics, you know, with those for FQHCs and trying to make all 
your guys' lives hopefully a little bit easier. You have enough 
widgets to count. Be nice just to count, you know, one widget 
for--one metric, if you will, for each of those widgets.
    So while the States are starting to do some stuff--and I 
have some folks in my State rather it just be a State function. 
I don't know if that is the best way to go.
    Would you support aligning these, you know, quality metrics 
between managed care, Medicaid basically, in the FQHCs and 
CHCs?
    Mr. Riccardi. Yes. In New York there is an example. I am a 
member of a work group where we are partnering with the public 
and the private sector, looking at, you know, a variety of 
quality metrics in determining, you know, what makes the most 
sense for patients and also for providers and other healthcare 
professionals to ensure that that information is readily 
understandable by the healthcare workforce and also the 
patients who need that information.
    So I do see that collaboration happening. But I think there 
is, you know, more that can be done and that's something that 
we are supportive of.
    Mr. Schrader. So I wonder if it is the role of the Federal 
Government to help provide an opportunity or incentivize that 
and then let the States, depending on their own culture, figure 
out what outcomes are most important to them to align 
themselves with and hopefully run through CMS, at the end of 
the day.
    Mr. Riccardi. Yes, and I think that's why it is so 
important that an organization like National Quality Forum is 
supportive because they are able to assist, you know, every 
State with these measures. And so agreed.
    Mr. Schrader. Good. Well, that's all the questions that I 
had, Madam Chair. Thank you much and I will yield back.
    Ms. Eshoo. The gentleman yields.
    And I recognize the gentleman from Georgia, the only 
pharmacist in the Congress, Mr. Carter. How is that?
    Mr. Carter. That is very good. Thank you.
    Ms. Eshoo. I know that. What was my first clue?
    [Laughter.]
    Mr. Carter. Thank you, Madam Chair, and thank all of you 
for being here. This is certainly important and we appreciate 
your being here and helping us with this.
    I wanted to start by saying that, you know, I am very 
honored to be the Republican lead on H.R. 3031, working with 
Representative Chu and Engel on the National Quality Forum.
    I think it is very important. It is very important because 
it is a valuable resource for making sure that we have and that 
we achieve cost-efficient and high-quality and value-based 
healthcare that ensures that all Americans will have quality 
healthcare, and we certainly need to continue this program and 
that is why I am proud to be a part of that.
    I will start with you, Mr. Riccardi, and just ask you, you 
mentioned it in your testimony and I wanted to ask you if you 
could just expand a little bit more on the value of the 
National Quality Forum, particularly as it relates to Medicare 
recipients.
    Mr. Riccardi. Thank you for that question, and to add, you 
know, the saying goes that it is important that an individual 
gets the right care at the right time at the right setting. You 
may want to add also at the right cost.
    And the National Quality Forum has created the highest 
level of quality standards that are available to States and 
agencies and both, as I mentioned, the private the public 
sector.
    And, in particular, with the Medicare program with the 
preventable readmissions program, we have seen some success and 
decrease in those admissions, and I know from my background I 
also am a lecturer at the Columbia School of Social Work, and a 
number of my students have been involved in some of those 
demonstration programs, helping prevent readmissions.
    And the accessibility and the use of those quality measures 
have been key to ensure that people are receiving the right 
care at the right time in the right setting.
    Mr. Carter. I can't help but remember--I was a consultant 
pharmacist in long-term care for many years and we used to have 
the seven rights of drug administration--the right drug for the 
right patient in the right dose at the right time, the right 
administration, so on and so on.
    So you are exactly right and I appreciate you reiterating 
that.
    Mr. Barker, I want to change gears real quick and talk 
about DSH payments. I have got a very rural district in Georgia 
and south Georgia particularly--very rural area--and my 
district, certainly to the western portion of my district is 
very rural, and DSH payments are extremely important to our 
rural hospitals.
    And some of them are totally reliant on this. So I 
understand that there are some hospitals or some States that 
aren't using their full DSH allotment and I find that hard to 
believe, and just wondered if you can--if you can explain how 
that can happen and what's going on there.
    Mr. Barker. So my understanding is that there are three 
States--if I am not mistaken, there are three States that are 
not using their full DSH allotments, and I assume that that is 
because that there is, as well as a State-specific cap, in DSH 
there is also a hospital-specific cap.
    Medicaid DSH payments cannot exceed the amount of 
uncompensated care that a hospital has. And so the only thing 
that I can think of is in those three States those hospitals 
are being paid at least the cost of their uncompensated care.
    Mr. Carter. MACPAC had made some recommendations that--on 
potential reforms, and I think you may have mentioned some of 
these. Do you have any other ideas or any other suggestions on 
what we can do in Congress to make sure that this program is 
being utilized like it is supposed to be?
    Mr. Barker. Thank you for that question.
    You are right, I did mention the MACPAC recommendations and 
one of them addresses exactly the issue that you mentioned, 
which is applying the DSH reductions to those States that have 
not expended their full allotment, which is--would sort of hold 
for at least a portion of the DSH cuts hold everyone harmless.
    Another recommendation that MACPAC made is to rethink the 
way that the DSH caps are allocated right now because they 
don't really bear any relationship to low income or uninsured 
patients.
    Mr. Carter. That is important. Thank you for bringing that 
up because we do need to look at that, and if there is reform 
needed we need to address it.
    Mr. Barker. Thank you, sir.
    Mr. Carter. Well, again, thank all of you for being here. 
This is extremely important. We all understand that. I am 
concerned about how we are going to pay for all this.
    But at the same time, there is no question that these are 
quality programs that need to be continuing on and, certainly, 
whereas we need to look at some reforms on certain programs 
like the DSH payment system, you know, I want to make sure that 
particularly the rural hospitals understand that we understand 
how important it is to them for their survival.
    So thank you, Madam Chair, and I yield back.
    Ms. Eshoo. The gentleman yields back, and I want to thank 
each one of the witnesses. I think you have given really high-
value testimony today. I know that I have learned from you and, 
Ms. Bohan, the numbers in your program are really stunning--
really stunning--and I think when the time comes that the 
secretary has to review your pilot I want to be able to lean in 
at that time because when you talk about those wait times being 
brought down and reaching out to people, it is exactly what we 
need in our country.
    And while I am not going to say something to each one of 
your individually, I could--thank you. Congress is so dependent 
upon the experts that come here to answer our questions and I 
am proud of the members of the entire subcommittee because 
their questions were all serious and well directed, and you 
gave us answers and we can build on that foundation as we move 
forward to reauthorize.
    So all of our thanks for your participation. I also would 
like to submit the following statements or letters for the 
record. There are several of them:
    A statement from the American Osteopathic Association in 
support of H.R. 2815; a letter from American Federation of 
State, County, and Municipal Employees regarding certified 
community behavioral health clinics; a letter from Oregon 
AFSCME in support of H.R. 1767; a letter from AFSCME 1199(j) 
and Care Plus New Jersey regarding CCBHCs; a letter from the 
American Hospital Association in support of 1767; a letter from 
AHA in support of 3022; a statement from the Endocrine Society 
regarding the Special Diabetes Program; a letter from 
Representatives DeGette and Reed regarding the Special Diabetes 
Program; a letter from Friends of NQF in support of 3031; a 
letter from Healthcare Leadership Council regarding NQF and 
PCORI; a letter from the American Academy of Family Physicians 
regarding THCGME and CHCs; a letter from the Alliance of 
Community Health Plans regarding the Patient-Centered Outcomes 
Research Institute; a letter from the National Kidney 
Foundation regarding PCORI; a letter from Friends of PCORI 
Reauthorization regarding PCORI; a statement from the PCORI 
Board of Governors regarding PCORI; a letter from the Council 
of Academic Family Medicine in support of 2815; a letter from 
the Leadership Council of Aging Organizations regarding 
outreach and enrollment to low-income Medicare beneficiaries; a 
letter from the Children's Hospital Association regarding DSH; 
a letter from Representatives Engel and Olson regarding DSH; a 
letter from America's Essential Hospitals in support of 3022; a 
letter from Texas Parent to Parent in support of 2822; letters 
from Family-to-Family Health Information Centers regarding 
2822; a letter from the Catholic Health Association in support 
of 3022.
    So are there any objections to these letters and documents 
being placed in the record?
    If not, so ordered.
    [The information appears at the conclusion of the 
hearing.]\1\
---------------------------------------------------------------------------
    \1\ The information has been retained in committee files. The 
DeGette/Reed letter is available at https://docs.house.gov/meetings/IF/
IF14/20190604/109583/HHRG-116-IF14-20190604-SD022.pdf. The Family-to-
Family Health Information Centers letters are available at https://
docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=109583.
---------------------------------------------------------------------------
    Ms. Eshoo. And I think with that, remind Members--there are 
only two of us here, but staffers are still here--that, 
pursuant to committee rules, they have 10 business days to 
submit additional questions for the record to be answered by 
the witness who has appeared.
    We know that you will be highly cooperative, and full 
answers in a straightforward way in a short period of time. How 
is that? Everyone agree to that?
    I think so. So with that--yes, Dr. Burgess?
    Mr. Burgess. If I may----
    Ms. Eshoo. Yes.
    Mr. Burgess. This afternoon marked the passage finally of 
the Pandemic All-Hazard Preparedness Act on the 100-year 
anniversary of the Spanish flu. So you are to be congratulated 
for this entire subcommittee that worked so hard on this for 
the past 3 years, and we have now gotten it across the finish 
line.
    So I will be looking forward to seeing you at the signing 
ceremony down at the White House.
    Ms. Eshoo. That will be wonderful, Mr. Burgess.
    And huge, huge kudos to Representative Susan Brooks, who 
was and is, I think, just the best partner I could ever have on 
a bipartisan basis, and certainly to you, Dr. Burgess, to the 
chairman of the full committee, and to the ranking member of 
the full committee.
    They say it takes a village. It takes a team here and----
    Mr. Burgess. And your staff.
    Ms. Eshoo. I haven't finished. I haven't finished. You 
always want to correct me.
    Certainly, to the staff, too. Catherine--is it Catherine 
Wallens or Willins--on Representative Brooks' staff, and Rachel 
Fybel on mine. They work late into many nights with the bouncy 
ball going over on what was taking place in the Senate.
    But it is about our national security and public health and 
response to whatever God has in store for us. So kudos, and 
thank you for raising it.
    So I don't think that there is anything else to come before 
the committee. It is quarter to 4 in the afternoon, and at this 
time the Health Subcommittee is adjourned.
    Thank you, everyone.
    [Whereupon, at 3:44 p.m., the committee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
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