[Senate Hearing 116-276]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 116-276

                            ACCESS TO CARE:
                    HEALTH CENTERS AND PROVIDERS IN
                        UNDERSERVED COMMUNITIES

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                                   ON

 EXAMINING ACCESS TO CARE, FOCUSING ON HEALTH CENTERS AND PROVIDERS IN 
                        UNDERSERVED COMMUNITIES

                               __________

                            JANUARY 29, 2019

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman
                  
                  
 COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
          
                    LAMAR ALEXANDER, Tennessee, Chairman                   
                   
                    
MICHAEL B. ENZI, Wyoming		PATTY MURRAY, Washington
RICHARD BURR, North Carolina		BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia			ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky			MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D.,Louisiana		TAMMY BALDWIN, Wisconsin
PAT ROBERTS, Kansas			CHRISTOPHER S. MURPHY, Connecticut
LISA MURKOWSKI, Alaska			ELIZABETH WARREN, Massachusetts
TIM SCOTT, South Carolina		TIM KAINE, Virginia
MITT ROMNEY, Utah			MARGARET WOOD HASSAN, New Hampshire
MIKE BRAUN, Indiana			TINA SMITH, Minnesota
                        		DOUG JONES, Alabama                         
                  			JACKY ROSEN, Nevada
                                  
               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                  Evan Schatz, Minority Staff Director
              John Righter, Minority Deputy Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                       TUESDAY, JANUARY 29, 2019

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State 
  of Washington, Opening statement...............................     4

                               Witnesses

Freeman, Dennis, Ph.D., Chief Executive Officer, Cherokee Health 
  Systems, Knoxville, TN.........................................     7
    Prepared statement...........................................     8
    Summary statement............................................    14
Waits, John B., M.D., F.A.A.F.P., Residency Director, Cahaba 
  Family Medicine Residency, Chief Executive Officer, Cahaba 
  Medical Care, Centreville, AL..................................    14
    Prepared statement...........................................    16
    Summary statement............................................    19
Anderson, Andrea, M.D., F.A.A.F.P., Director of Family Medicine, 
  Unity Health Care, Inc., Core Faculty, Wright Center for 
  Graduate Medical Education in conjunction with Unity Health 
  Care, Inc., Washington, DC.....................................    20
    Prepared statement...........................................    21
    Summary statement............................................    26
Trompeter, Thomas, President and Chief Executive Officer, 
  HealthPoint, Renton, WA........................................    27
    Prepared statement...........................................    28
    Summary statement............................................    30

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Jones, Hon. Doug:
    American Academy of Family Physicians, Prepared statement....    53
    American College of Osteopathic Family Physicians, Joint 
      statement..................................................    59

 
                            ACCESS TO CARE:
                    HEALTH CENTERS AND PROVIDERS IN
                        UNDERSERVED COMMUNITIES

                              ----------                              


                       Tuesday, January 29, 2019

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:00 a.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Murray, Romney, 
Braun, Cassidy, Scott, Murkowski, Casey, Hassan, Jones, Rosen, 
Murphy, Baldwin, Warren, and Kaine.

                 OPENING STATEMENT OF SENATOR ALEXANDER

    The Chairman. Good morning.
    The Senate Committee on Health, Education, Labor, and 
Pensions will please come to order. Senator Murray and I will 
each have an opening statement and then we will introduce the 
witnesses. After their testimony, Senators will each have five 
minutes of questions. I am going to take just two, three 
minutes longer than I usually do in my opening remarks, which I 
hope everybody will allow me to do this morning because this is 
our first hearing of the year.
    I want to begin by welcoming new Members of the Committee. 
Senator Romney from Utah, welcome, former Governor--always glad 
to have a former Governor in our midst, if I may say that. Mike 
Braun from Indiana is also a new Member of the Committee. We 
welcome him--he has a background in business. Jacky Rosen from 
Nevada is also a new Member of the Committee--we welcome you, 
Jacky.
    I think you will find this a spirited Committee dealing 
with lots of difficulties, and on a fairly regular basis, we 
find ways, thanks to Senator Murray and her staff and our 
staff, to work together and come up with some pretty good 
results. So, we are proud of that. This is the first hearing, 
as I said--and let us talk about what we hope to accomplish in 
the next two years. In my view, number one, reducing health 
care costs--not just health insurance, but the overall health 
care cost. Number two, making sure a college degree is worth 
students' time and money.
    On health care costs, we have had five hearings on reducing 
health care costs towards the end of last year. We heard from 
Dr. Brent James, a member of the National Academy of Medicine, 
that up to half of health, spending in this country is 
unnecessary and no one seems to contradict that. That startled 
me and I hope it startles the American people. It is a massive 
burden on family, businesses, state and Federal budgets. So, I 
have sent a letter to experts, including witnesses at our five 
hearings, asking to suggest to Senator Murray and me and our 
Committee, specific recommendations to reduce health care 
costs. And I would like to renew that invitation to anyone to 
submit your comments by March 1, to lower healthcare costs, at 
help.senate.gov.
    The second priority is updating the Higher Education Act, 
to ensure the expense of a college education is worth it for 
students. The last time we did that seriously was in 2007, and 
a lot has happened since then. For example, there was no iPhone 
in 2007, a micro-blogging named Twitter had just gained its own 
platform and started to scale globally, and Amazon released 
something called Kindle in 2007. Tom Friedman, the New York 
Times columnist puts his finger on 2007 as the technological 
inflection point. So, we need to take a look at Federal support 
for Higher Education that affects 20 million students, 6,000 
institutions, and make sure we catch up with what is happening 
in the world.
    Our goal includes simplifying Federal Aid application, a 
fair way for students to repay their loans, and a better system 
of accountability for colleges. I have been visiting with 
Members of the Committee, both Democrat and Republican Members, 
to ask their advice. They have a number of good suggestions. 
And we, over the last four years in Higher Education--actually, 
there are a number of bipartisan bills that have been 
introduced during that time that should be ready for us to 
consider. Senator Murray and I sat down with the leaders of the 
Finance Committee, Senator Grassley, Senator Wyden, on which a 
number of Members on this Committee serve. We have shared 
jurisdiction on much of healthcare, and we are trying to see, 
are there things we can do to work together. I hope we can 
complete our work on both, reducing healthcare costs and 
updating higher education, in the first six months of this 
year, so we can get something to the President before the end 
of the year.
    In addition, on the next few months, we need to reauthorize 
the Older Americans Act, which supports the organization and 
the delivery of social and nutrition services to older adults 
and caregivers, and reauthorize the Child Abuse, Prevention and 
Treatment Act.
    Today's topic, extending Federal funding for community 
health centers, as well as four other Federal health programs, 
all of which are set to expire at the end of the year--they fit 
into a larger topic, which is of great interest to this 
Committee, which is primary healthcare.
    There are more than 300,000 primary healthcare doctors in 
the United States according to the American Medical 
Association--that is, the doctor that most of us go to for our 
day-to-day medical care. Our annual physical flu vaccine, 
helping to manage a chronic condition, is our access to 
healthcare, and a reference point usually for a specialist for 
such things as an MRI or hip replacement. Adam Boehler, who 
heads the Center for Medicare and Medicaid Innovation, 
estimated that while primary care is only up to say 7 percent 
of healthcare spending, it could impact at least half of 
healthcare spending because that is how we get into the rest of 
healthcare spending. So, we will be having a hearing next week 
on how primary care can help control healthcare cost, but 
today, we are talking about a primary example of primary 
healthcare.
    27 million Americans receive their primary care and other 
services at community health centers. For example, in Lewis 
County, Tennessee, the hospital closed. The closest emergency 
room for 12,000 people was 30 minutes away, so the old hospital 
building became Lewis Health Center, a community health center 
which operates as something between a clinic and a hospital. I 
visited there. It is a nice, clean place, a couple of doctors, 
nurses. They believe they can deal with 90 percent of the 
issues people walk in with every day. They have a full 
laboratory. They run tests, perform X-rays, give IVs, and keep 
an ambulance ready to take someone to a hospital if they need 
that. Because Lewis Health Center is a community health center, 
they charge based upon a sliding scale. Community health 
centers like Lewis are one way American families can have 
access to affordable healthcare close to home, and this 
includes a wide range of healthcare, including preventive care, 
which we hear in every hearing is the most important care, 
helping to manage chronic conditions like asthma, high blood 
pressure, vaccines, prenatal care--there are about 1,400 
federally funded health centers that provide outpatient care to 
approximately 27 million people, including 400,000 Tennesseans, 
and about 12,000 sites across the United States. Those other 
locations could be a mobile clinic, or a homeless shelter or 
school. They have been especially important in battling the 
Opioid Crisis.
    Last year, the Department of Health and Human Services 
provided over 350 million in funding specifically to support 
community health centers, providing care for Americans in need 
of substance use, disorder, or mental health services. These 
centers accept private insurance, Medicare, and Medicaid, and 
charge, based, as I said, up on the sliding scale. Community 
health centers also receive Federal funding. In FY2019, that 
was 4 billion in mandatory funds and 1.6 billion in 
discretionary funds. We must act by the end of September in 
Congress to make sure the community health centers receive this 
Federal funding and keep their doors open. That is why two 
weeks ago, Senator Murray and I took the first step by 
introducing legislation that will extend funding for community 
health centers for five years and $4 billion a year in 
mandatory funding. The legislation also extends funding for 
four additional Federal health programs set to expire in 
September, the Teaching Health Center Graduate Medical 
Education Program, the National Health Service Corps, Special 
Diabetes Program, and Special Diabetes Program for Indians. 
Today, we will hear about how the community health centers are 
working, and how to insure 27 million Americans closer to home.
    These centers rely on a well-trained workforce. Two 
federally funded workforce programs, which train doctors and 
nurses, expire this year. The Teaching Health Center Graduate 
Medical Education Program is one. The National Health Service 
Corps is another. More than half of those doctors choose to 
work at one of the 12,000 community health centers and 
affiliated sites. We look forward to hearing more about that 
from witnesses.
    Senator Murray.

                  OPENING STATEMENT OF SENATOR MURRAY

    Senator Murray. Well, thank you very much Mr. Chairman. 
Thank you to all of our witnesses who joined us today. We 
appreciate it.
    Mr. Chairman, my colleagues and I look forward to working 
with you again this Congress on behalf of workers, and 
communities, and families across our Nation, as we have under 
your leadership for the past two Congresses. This is the first 
time we have met since your announcement, and on behalf of all 
of us, thank you for your bipartisan approach to the work we do 
on this Committee and this institution. You and I, along with a 
lot of Members in this room, have been able to work in a really 
important bipartisan fashion to address a lot of the issues 
that our families face, as you will know, to 21st-century 
cures, Opioids epidemic, and a lot more. So on behalf of all of 
us on this side of the dais, I hope we continue that tradition 
and thank you for your tremendous work.
    The Chairman. Thank you very much.
    Senator Murray. I would also like to welcome our new 
Members of the Committee. I look forward to having our new 
colleagues, Senator Romney, welcome. Senator Braun, who has 
joined us. Senator Rosen. You joined a long tradition in this 
Committee of bipartisan work as we address, as the Chairman 
outlined, the primary care cliff, higher education, healthcare 
cost, retirement security, and many other issues. So, welcome 
to this Committee, look forward to working with all of you. And 
finally, I just want to say, I am really glad that President 
Trump listened to the workers and families, and communities who 
were harmed by this shutdown, and ended it. That pointless 35-
day shutdown not only cost a lot of damage but also wasted the 
first month of this Congress. We have a lot of important work 
to do starting with the topic of today's hearing of primary 
care providers.
    After hearing from families across my State of Washington 
about the role that community health centers play in their 
lives and visiting a lot of centers across my state to see the 
good work that they do firsthand, I am really looking forward 
to all of our witnesses' testimony and perspective on this 
issue. Community health centers serve over 27 million patients 
a year, many of them in rural and underserved communities. And 
teaching health centers and programs, like the National Health 
Service Corps, help bring qualified health professionals to 
communities who are in need. These programs make it possible 
for millions of patients and families to get the care they can 
afford close to their home, and they play a critical role in 
the local response to national health challenges like the 
Opioid Crisis. But at this time last year, they were in the 
middle of a different kind of crisis. Community health centers 
were left waiting without funding, and uncertain when Congress 
would extend funding for programs to support them and their 
staff, and give patients access to the care that they rely on.
    This time last year, community health centers across the 
country were forced to cut back hours, and staff, and services, 
and halt planned expansions like in Spokane, Washington, where 
a new Opioid addiction treatment services initiated to combat 
the Opioid epidemic was jeopardized by that funding freeze, or 
out on our Olympic Peninsula, where plans to expand behavioral 
health services was put on hold, or in Whatcom County where 
they considered canceling construction plans for new medical, 
dental, and behavioral healthcare facilities.
    This time last year, community health centers were left 
wondering how to pay their current staff and attract new 
professionals. Ferry County is a rural area with fewer than 
four people per square mile, where the funding uncertainty left 
the center unable to sign annual contracts for needed medical 
staff and managers. This time last year, some community health 
centers had to figure out ways to cover basic but crucial 
annual reoccurring expenses like renewing the lease for their 
building.
    In Yakima, Washington, clinics in some of our most 
vulnerable communities were at risk of closing, and it was not 
just Washington State. Senators across the country faced these 
challenges. Elsewhere, a teaching health center closed, meaning 
the residents there, the healthcare residents, healthcare 
providers who were willing to forgo the draws of an academic 
hospital, roll up their sleeves, and serve patients and 
families and communities with severe professional shortages, 
faced the harrowing prospects of having to scramble to find a 
new residency program and possibly redo an entire year of their 
residency.
    Fortunately, one of our witnesses today, Dr. Waits, stepped 
in and helped many of them to avoid that catastrophe and I hope 
we will be able to hear more about that in his testimony today. 
In the end, Congress was able to come together in a bipartisan 
way to fund those community health centers and the other 
critical primary care funding. But if funding runs out again 
this year, we will be right back where we were a year ago that 
I was just talking about.
    It is clear to Members of both sides of this isle, we need 
to do more to provide stability for communities and the health 
centers they depend on. So, I am very glad that Chairman 
Alexander and I were able to introduce legislation to do just 
that. Whilst it is not the bill either one of us would have 
written on our own, it lays down a very clear bipartisan marker 
for providing these programs with long-term funding. Our 
bipartisan bill will provide five years of stable funding for 
our community health centers and give them the certainty that 
they need to bring on new, skilled staff, and offer new 
services, and make sure patients have the care that they need 
close to their home. And as the Chairman said, it extends 
funding for teaching health centers and the National Service 
Corps, which encourages medical students and doctors to work in 
underserved communities and fund at least one entire cycle of a 
family medicine residency.
    Funding these programs for the next five years will give 
health centers greater confidence. They can recruit the 
professionals that they need and medical students, residents, 
and others to have greater confidence in their decision to work 
in an underserved community. So, I am very pleased that we were 
able to introduce this. I very much look forward to the hearing 
today, Mr. Chairman, and thank you for all that.
    The Chairman. Thank you Senator Murray, and thank you for 
your leadership on this legislation and for your remarks at the 
beginning of your statement. I suggest to people in Tennessee 
that they look at Washington, D.C. sometimes as a split screen 
television, and I said look at October, there you had the 
Kavanaugh hearing on one side with mud going on every 
direction, but on the other side you had 72 Senators working 
with Senator Murray and me, both sides of the aisle, on 
landmark Opioid legislation that helped nearly every community, 
which was then signed into law by the President the next month.
    We know how to get things done, despite differences of 
opinion, and one reason we are able to do that is because of 
Senator Murray's skill and leadership at getting results, and 
the respect she has on her side of isle, but on our side of 
isle as well, and I thank her for that. This is an example of 
it, this bill--this is what we call a bipartisan hearing--that 
means we agree on who the witnesses are, we agree on what the 
subject is, and we hope to agree on a result.
    I welcomed the other new Senators before, Senator Braun, it 
was just before you walked in and I want to welcome you as 
well. Well now, we will hear from our witnesses and then 
Senators, I am sure, will have questions. I would ask each of 
you summarize your remarks, please and within five minutes that 
will give us more time for conversation.
    The first witness is Dr. Dennis Freeman, a licensed 
psychologist--he is the Chief Executive Officer of Cherokee 
Health Systems in Knoxville, Tennessee. It has 23 clinics in 14 
counties in Tennessee and offers a full range of services, 
including primary care, behavioral health, and dental services 
to over 70,000 patients. Senator Jones, would you like to 
introduce the next witness?
    Senator Jones. Yes, thank you Mr. Chairman and Ranking 
Member Murray. I am pleased to introduce Dr. John B. Waits this 
morning. Dr. Waits is the Co-founder and Chief Executive 
Officer of the Cahaba Medical Care, which is a community health 
center and teaching health center training program in Alabama. 
Dr. Waits opened his health center in rural Bibb County, which 
is just south of Birmingham, in 2004, and has since expanded to 
seven delivery sights in six different counties throughout 
central Alabama. He brings a unique perspective to our hearing 
because he trains residents and treats patients in both rural 
and urban underserved settings. I have had the pleasure of 
visiting the Bibb County facilities and seeing firsthand the 
impact, his team has on their community, and I am grateful for 
him being here with us today. Dr. Waits, thank you, we look 
forward to hearing your testimony.
    The Chairman. Thank you, Senator Jones. The third witness 
is Dr. Andrea Anderson, Director of Family Medicine at Unity 
Medical Center, a system of community health centers around 
Washington, D.C.--she is chair of the Washington, D.C. Board of 
Medicine. She serves as a core faculty member with the Wright 
Center for Graduate Medical Education. And finally, Senator 
Murray would you like to introduce our fourth witness?
    Senator Murray. Thank you very much Mr. Chairman. This 
morning I really have the pleasure of introducing a fellow 
Washingtonian, Thomas Trompeter. He is the President and CEO of 
HealthPoint. It is an organization which runs health centers 
and communities across our state to provide affordable care in 
underserved areas. Last year HealthPoint served tens of 
thousands of people. Almost two-thirds of their patients relied 
on programs like Medicaid and CHIP, and many had no insurance 
at all. Mr. Trompeter himself has helped families and 
communities in the northwest stay healthy for years for the 
past two decades at HealthPoint, and at the Northwest Regional 
Primary Care Association a decade before that.
    Thank you, Mr. Trompeter, for your ongoing dedication to 
making sure families across our state can find healthcare close 
to home regardless of their ability to pay. And thank you again 
for traveling all the way out here from, what we call, the 
better Washington to this Washington----
    [Laughter.]
    Senator Murray.----to be here today.
    The Chairman. Thank you, Senator Murray. Dr. Freeman, why 
don't you begin.

 STATEMENT OF DENNIS FREEMAN, PH.D., CHIEF EXECUTIVE OFFICER, 
             CHEROKEE HEALTH SYSTEMS, KNOXVILLE, TN

    Dr. Freeman. Mr. Chairman and my great Senator, Lamar 
Alexander, Ranking Member Murray, and Members of the Committee, 
it is an honor to be asked to share my views on the Health 
Center Program. I am Dennis Freeman, a psychologist and Chief 
Executive Officer of Cherokee Health Systems, a health center 
in Tennessee.
    Before sharing my perspectives, I want to acknowledge the 
past support of this Committee, on a bipartisan basis, for 
community health centers. We are truly grateful for that 
support. Today I intend to share some insights gleaned from my 
long experience participating in the Health Center Program. I 
have submitted written testimony, which expands on the comments 
I am going to make, and I hope you will read my written 
testimony and consider me a resource in your ongoing 
discussion.
    By mission and by law, health centers serve the Nation's 
least fortunate residents in the Nation's most remote and 
economically challenged communities. At Cherokee, we speak of 
going where the grass is browner, and we feel blessed to have 
this mission, knowing in many cases we are caring for those who 
really have few if any other, healthcare alternatives. Cherokee 
began providing services in 1960. Last year, we saw 70,000 
people--30 percent were uninsured, 40 percent were on Medicaid. 
Many years ago, we recognized that primary care is really the 
most common access point for people with behavioral health 
concerns. And so, we began blending behavioral health into the 
primary care team. We have pioneered this work and we have 
shared our model of care with health centers across the 
country.
    Our commitment to the provision of both, medical and 
behavioral healthcare in a truly integrated model, allows us to 
provide comprehensive care to patients who present with 
complex, chronic medical and psychiatric conditions. This model 
works well for patients suffering substance use disorders, 
including Opiate addictions--additions are clearly a complex 
disorder, and in most circumstances, chronic disorders. This 
Committee has recognized that health centers are in a unique 
position to lead the treatment response to the Nation in the 
Opioid Crisis, and have provided resources for us to do so. At 
Cherokee, we have used these grant funds to organize care teams 
to care for these patients. I do however want to caution 
against a singular focus on the Opioid addiction alone--both in 
terms of treatment approach and in terms of funding in 
inflexible, narrow funding streams. Addiction to opioids is 
commonly mingled with other addictions, other substances, not 
to mention the serious medical consequences that follow in the 
wake of addiction. So, health centers really need comprehensive 
clinical teams to address the complexity of addiction.
    Over the years, the partnership between the Federal 
Government and the health center community has been enormously 
effective in improving health outcomes and in boosting access 
to comprehensive primary care, including behavioral health and 
substance use disorders. Our organization and every health 
center in the country is dependent on the core financial 
support we receive in our annual grant from HRSA. While we are 
able to generate much of our revenue from patient services and 
other sources, the 330 funding is the solid rock of our funding 
base.
    Over the past several years, health centers have faced 
uncertainty over the renewal of this funding on several 
occasions. While demand for our services was always 
unrelenting, we were restrained from making investments in 
staff and programs to meet that demand. So, I am really 
grateful to learn legislation has been introduced by Members of 
this Committee, including Chairman Alexander, to assure that 
the Federal funding base for health centers is there in place 
for five years. When health centers are financially secure, we 
are able to respond to national concerns like the crisis of 
Opiate abuse and the pernicious problem of childhood obesity.
    I am truly grateful for the opportunity to speak with you 
today, and I look forward to your questions.
    [The prepared statement of Dr. Freeman follows:]
                  prepared statement of dennis freeman
    Chairman Alexander, Ranking Member Murray and Members of the 
Committee.

    It is an honor to be asked to share my views on the Federally 
Qualified Health Center Program (Health Centers) and the National 
Health Service Corps (NHSC) with you today. I am Dennis Freeman, a 
psychologist and Chief Executive Officer of Cherokee Health Systems, a 
Health Center in Tennessee. In 2018 Cherokee served 70,000 patients in 
23 clinics located in 14 Tennessee counties.


    Cherokee operates clinics in isolated, rural mountain hamlets, mid-
size east Tennessee communities and inner city Memphis, Knoxville and 
Chattanooga. Our staff outreaches into area schools, public housing 
complexes, homeless shelters, hospital emergency departments and 
patient's homes. Thirty present of our patients are uninsured and forty 
percent are on Medicaid.

    Before I share my perspective on today's topic, I briefly want to 
acknowledge and recognize the depth of support that has been shown by 
this Committee, on a bipartisan basis, for the three programs we will 
discuss today. Thanks to that support, 1,400 health center 
organizations now serve 28 million patients in over 11,000 communities 
nationwide. The investments you've made have had a profound impact on 
the patients and communities we serve, not to mention the healthcare 
system as a whole, and for that we are truly grateful.
      Cherokee Health Systems--A Federally Qualified Health Center
    Cherokee Health Systems began providing services as a Community 
Mental Health Center in 1960. As was customary for Mental Health 
Centers in those days we did outreach into other parts of the 
healthcare delivery and social services sectors. Through our outreach 
into primary care we quickly saw primary care was the most common 
access point for people seeking help for behavioral health concerns. 
Our clinicians began circuit riding to area primary clinics on a 
regularly scheduled basis so we could increase access to behavioral 
health services to residents in our service area. After a few years we 
recognized that many portions of our service regions had a critical 
shortage of primary care providers so we began opening primary clinics 
with behavioral health professionals working in close collaboration 
with their primary care colleagues. When an opportunity to apply for a 
grant to become a Health Center presented itself in 2002, we seized 
upon it. Thankfully, our application was successful and we have been 
proud and contented member of the Health Center community ever since.

    The graph below shows clearly how Cherokee's growth has been 
buoyed, but not totally dependent upon, our annual Health Center grant. 
Our overall revenue has grown at a faster pace over time than our 
federal Health center grant has. As expected, our trend line of 
patients in care parallels our growth in revenue. The graph shows that 
our grant has covered a good share of the amount of sliding fee 
discounts we offer our low income patients in many years. During 
economic hard times people lose employment, employers stop providing 
insurance and more people show up on our doorstep needing healthcare 
they can afford. As you can see, our grant has not covered our charity 
care the last two years and the widening gap is worrisome.


    The increases in our grant over the years have been for expansions 
into new geographic areas or for new programs. The increases have 
allowed us to open new offices in underserved areas and expand or start 
new programs. For example, we have opened a clinic to serve homeless 
residents in Knoxville. We have opened services near public housing 
complexes. We have opened specialized services to treat patients 
addicted to opiates. Most of these grants fueled program expansions 
that decreased the percentage of our patients who had any healthcare 
coverage to pay for their care.

    At Cherokee we act on our expansion strategy of going where the 
grass is browner. The program expansions cited above are fully in line 
with that development strategy. Typically, the increases in our grant 
are a critical piece but do not fully fund these expansions. We make 
the program work financially by being frugal and efficient. Our reward 
is reaching many of our neighbors who are in desperate need of care.

    I expect a Member of Congress will look at the graph above and feel 
good about the government's investment. Our grant is a relatively small 
percent of our financing (currently 13.5 percent) but it spurs the 
growth, and helps sustain the operation, of an effective and efficient 
healthcare system. I'm quite sure the Cherokee picture is not unique 
but is replicated by the community of Health Centers who are extending 
primary care access into many, but by no means all, underserved areas 
of our country. Additional investment in Health Centers is needed in 
order to reach populations and communities not yet served by a Health 
Center.
                       Cherokee's Clinical Model
    At Cherokee we have blended behavioral health services into our 
primary care clinical model and embedded behavioral health 
professionals in our primary care teams for many years. This approach 
to care is known, of course, as integrated care. This model of care is 
rapidly gaining traction across the country, especially among Health 
Centers. Without question, access to appropriate and timely care is the 
greatest challenge facing the mental health and substance misuse 
treatment sectors of the nation's healthcare system. In our experience 
providing access to behavioral health assessment and intervention 
within primary care goes a long way toward reducing the access barrier 
to behavioral healthcare so prevalent across the country.

    Primary care is the front door to the health care system. It's the 
primary access point for all healthcare concerns and medical 
conditions, including behavioral health issues. In addition to the 
frequent presentation of psychiatric conditions and substance use 
disorders in primary care, the personality and the lifestyle of the 
patient are always factors in a patient's healthcare outcomes. Personal 
health habits; a history of trauma; and resiliency in response to 
stress all influence the etiology, the response to treatment and the 
prognosis of all medical conditions that are presented in primary care. 
The patient's behavioral health is a factor in every primary care 
patient visit. This is especially true for patients coping with chronic 
medical conditions. Encouraging these patients to adopt appropriate 
health behaviors is the key to the medical management of complex and 
chronic conditions. The presence of behavioral health professionals 
within the primary care setting brings a clearer focus on the 
psychosocial factors which influence health status. The integrated care 
strategy has broadened the scope of primary care and enhanced the 
effectiveness and efficiency of primary care practice.

    Over the past few years the Patient-Centered Medical Home (PCMH) 
model has come to be considered the best practice when it comes to 
primary care delivery. At Cherokee we have embraced this model and have 
enhanced it in a number of ways. We embed uniquely skilled behavioral 
health professionals, referred to as Behavioral Health Consultants 
(BHC), in the primary care team. BHCs are available to their primary 
care colleagues for consultation at the point of care. They provide 
assessment and intervention with patients during their primary care 
visit. Community Health Coordinators are available to help patients 
negotiate social determinates of health. In effect, they extend the 
exam room into the community. When indicated, psychiatric consultation 
is also available, in real time, to the primary care team. Psychiatric 
consultation is one of the telehealth services Cherokee makes available 
across its network of clinics. All providers on the team share an 
electronic health record, treatment planning and the responsibility for 
the overall care of all the patients on the panel.

    Patients appreciate the comprehensiveness of the integrated care 
model. Our primary care providers are enthralled with the support the 
behavioral health and community-based staff provide them. The 
integrated care team lightens the individual burden on primary care 
providers and enhances their satisfaction with their work. Insurance 
companies are pleased because the overall cost of care declines. Best 
of all, patient outcomes improve.

    The integrated Patient-Centered Medical Home is the best practice 
model for treating patients with chronic conditions. Patient with a 
chronic condition rarely present with only one chronic condition. This 
is especially true with persons suffering a psychiatric or substance 
use disorder. In our experience more than two-thirds of these patients 
have one or more co-existing medical problems that need treatment. The 
recent national attention on opioid addiction has illuminated the need 
to identify effective treatment models and has brought additional focus 
on integrated primary care as an effective treatment approach.
                Treatment of Opioid Addiction in Context
    The opioid epidemic has garnered the nation's attention for a 
number of very good reasons. Few if any families have been spared the 
devastating impact of a family member addicted to opioids. Healthcare, 
law enforcement, the courts, social services--every sector of our 
society has felt the impact. Death rates from opiate overdoses have 
skyrocketed, medical providers have been indicted for over prescribing 
and state Attorneys General are suing pharmaceutical companies for 
misleading marketing and advertising strategies. Obviously, bringing 
the opioid epidemic under control will require a multi-faceted approach 
beginning with more public awareness of the dangerous, addictive 
potential of these drug and much broader availability of effective 
treatment for those who become addicted.

    It is tempting to isolate on opiate addiction as a singular problem 
and formulate overly simplistic treatment and financing strategies to 
address the problem. This has led to some targeted funding streams 
narrowly restricting providers in how grant funds may be use and how 
third party payers reimburse for services. Some grants will only 
support the treatment of patients with a specific diagnosis of opiate 
addiction; some grants require that certain medications which block the 
effect of opioids be part of the treatment; and some grants and payers 
limit reimbursement to those clinical activities that take place in the 
exam room.

    Successful treatment of addiction, including treatment of those 
addicted to opiates, requires a more comprehensive approach. Most 
patients who present with opiate addiction are abusing other substances 
as well. Many have co-occurring psychiatric conditions that need 
treatment. Most have serious co-morbid medical conditions that need 
immediate attention, conditions that are the direct result of their 
substance abuse or an outcome of their unhealthy lifestyle. Many with 
addictions have alienated their families and are without positive 
social support. Addiction is a complex condition. The words of 
Cherokee's Director of Addiction Medicine, Dr. Mark McGrail, are 
instructive, ``cross addiction is a real phenomenon and patients who 
suffer from addiction will find something to fill the void if we ``just 
take the opioids away''.

    At Cherokee we have adapted our integrated medical home model to 
treat patients presenting with opioid addiction. We provide 
accelerated, walk-in access because we know this is critically 
important for some patients. We use medication assisted treatment as 
appropriate. Patients participate in group treatment and receive 
additional individual behavioral health services when indicated. Most 
patients participate in an Intensive Outpatient Program which meets 
several times a week for several hours at each session. We've had a 30-
day retention in treatment of 68 percent for these patients compared 
with national data cited in the professional literature in the 35-40 
percent range. We have teams to care for women who are pregnant and 
abusing drugs and/or alcohol. We're beginning to incorporate pediatric 
care into the model in order to provide concurrent care for mother and 
infant after delivery. We always seek to become the healthcare home for 
these patients, just as we are for patients living with other serious 
chronic conditions. In 2018 Cherokee saw 6571 patients with a Substance 
Use Disorder, including 2003 with a diagnosis of Opioid Use Disorder. 
The integrated medical home has proven effective for the care of our 
patients with addictions, including those abusing or addicted to 
opiates.
                   The National Health Service Corps
    Payment of educational debt by the National Health Service Corps is 
life changing for clinicians who receive it. I frequently hear heart-
warming stories from a Cherokee staff member who speak passionately 
about how being relieved of their debt allowed them to see their way 
clear to follow their heart and work with their population of choice. 
Concerns about purchasing a home and starting a family are eased. The 
prospect of a financially secure future seems possible. At any point in 
time Cherokee has a couple dozen clinicians who are receiving loan 
repayment. Currently, seven clinicians are in the process of applying. 
The majority stay on after their loans are paid and many envision long 
careers at Cherokee. Cherokee has benefited greatly from the service of 
clinicians who have received scholarships or have had educational loans 
repaid by the NHSC.

    Despite the success of the program, as an employer we are reluctant 
to use the NHSC as a recruiting tool when funding for the program 
remains uncertain. While the possibility for the payment of educational 
debt is there for a prospective hire, to dangle the NHSC before them is 
to ask them to make a leap of faith. In the black and white world of 
personal finance that would be unfair to the applicant. Every year 
there are many more applicants for NHSC slots than the program is able 
to pay for at the current funding level. We should be doing more to 
help support the recruitment of these applicants who have the will to 
practice in medically underserved communities. In order to maximize the 
effectiveness of the program we need to see long term, stable 
investment in the program as well as the opportunity for growth so more 
providers can be accepted into the program. It would be enormously 
beneficial if Health Centers had designated NHSC slots they could use 
as actual tools in recruiting clinicians.
                      Cherokee's Teaching Mission
    At Cherokee Health Systems we consider training the next generation 
of healthcare providers a core part of our mission. We want 
professionals-in-training to have a good experience working in 
underserved areas and providing care to a needy population. We know 
most who enter the health professions do so with the motivation to help 
others. Given a positive experience of working alongside highly 
competent professional mentors who are committed to this work, many 
will make a commitment to follow suit. We partner with area academic 
institutions to train psychologists, nurses, nurse practitioners, 
social workers, pharmacists and primary care physicians.

    Cherokee does not participate in HRSA's Teaching Health Center 
program, though we have been a wistful observer of the program and 
wished that it had the size and the stability of funding to make the 
impact needed in the Health Center community. At this point in time it 
would be hard to find a Health Center that doesn't have available 
positions for physicians.

    Shortages in the workforce of Health Centers extends to other 
professions besides physicians. Dentists, pharmacists and behavioral 
health professionals are especially difficult to recruit for most 
Health Centers. Dentists willing to work with underserved populations 
seem to be in short supply. As we all know, professionals tend to stay 
in the environments where they trained. I'm not aware of many health 
centers who are training dentists and pharmacists. Heretofore, most 
behavioral health professionals trained in behavioral health settings 
and upon graduation went to work in behavioral health organizations. 
These new graduates had neither the vision nor the skills to 
contemplate a career in a Health Center working as a member of a 
primary care team.

    Fortunately, the education of healthcare professionals is changing. 
More training is occurring in team-based models and, when that is the 
case, the setting is usually in primary care. Health Centers are active 
in these training opportunities. A couple of small but visionary 
federal programs, the Graduate Psychology Education program (GPE) and 
the Area Health Education Center's program (AHEC), are leading the 
team-based training agenda and provide support for training of health 
professionals in settings serving underserved populations.

    The Area Health Education Center program (AHEC) was developed by 
Congress in 1971 to recruit, train and retain a health professions 
workforce committed to underserved populations. The AHEC program helps 
bring the resources of academic medicine to address local community 
health needs. The mission of AHEC is to enhance access to quality 
healthcare, particularly primary and preventive care, by improving the 
distribution of healthcare professionals via strategic partnerships 
between academic programs and community organizations. Recently, the 
national AHEC program has intensified its focus on multidisciplinary 
training. In September 2007 Cherokee Health Systems entered into a 
partnership with Meharry Medical College to serve as the east Tennessee 
Area Health Education Center. In 2017 Cherokee expanded its role with 
Meharry and is now the regional center for both east and west 
Tennessee.

    The GPE program prepares doctoral level psychologists to provide 
behavioral healthcare, including substance abuse prevention and 
treatment services, in settings that provide integrated primary and 
behavioral health services to underserved and/or rural populations. 
This program supports the inter-professional training of doctoral level 
psychology interns and postdoctoral fellows while also providing 
behavioral health services to underserved populations such as older 
adults, rural populations, children, those suffering from chronic 
medical conditions, veterans, victims of trauma and victims of abuse. 
Grants are provided to accredited psychology internships and 
fellowships. Cherokee's training of psychologists is partially 
supported by a GPE grant.

    Cherokee began an internship for psychologists in 2003 and started 
accepting psychology postdoctoral fellows in 2013. To date we have 
graduated 55 interns and 20 fellows with nine more currently in 
training. More than a third of the interns have stayed with us upon 
completion of their internship year. Nearly two thirds chose to work in 
safety net organizations. Most of the fellows accepted staff positions 
at Cherokee and the few who left all went to work with underserved 
populations. We have demonstrated, as has been shown many times over in 
many settings, training providers is the best recruitment strategy.

 
                                                   Internship                      Postdoctoral Fellowship
 
                   Current Trainees                                     5                                     4
                          Graduates                                    55                                    20
     Stayed with Cherokee following                            35 percent                            85 percent
                         graduation
Working with Underserved Populations                           65 percent                           100 percent
                     Received NHSC Loan Repayment              20 percent                            35 percent
 


                               Conclusion
    I commend the Committee for their review of the Teaching Health 
Centers, the National Health Service Corps and the Health Center 
program. These vital programs, and the synergy among them, have an 
important impact on the health of the nation and a profound impact on 
isolated, remote and disadvantaged communities. Without these programs 
many of our fellow citizens would not have access to timely and 
affordable health care.

    I'm grateful to learn legislation was introduced and supported by 
Members of this Committee, including Chairman Alexander, to assure the 
federal funding base of these critical programs for an additional five 
years. If secured, this will enable us to continue to thrive and remain 
a trusted partner of the Federal Government to address the nation's 
healthcare challenges.

    I encourage you to continue to build upon the prior investments you 
have made in these programs and assure the benefits they bring to the 
communities we serve. Your continued support is vital.
                                 ______
                                 
                 [summary statement of dennis freeman]
    Mr. Chairman and my Senator, Lamar Alexander, Ranking Member Murray 
and Members of the Committee,

    It is an honor to be asked to share my views on the Health Center 
program. I am Dennis Freeman, Chief Executive Officer of Cherokee 
Health Systems, a Health Center in Tennessee. Before sharing my 
perspectives, I want to acknowledge the past support shown by this 
Committee, on a bipartisan basis, for Community Health Centers. We are 
truly grateful.

    Today I intend to share some insights gleaned from my experience 
participating in the Health Center Program. I have submitted written 
testimony which expands on the comments I will make this morning. I 
hope you will read my written testimony and consider me a resource in 
your ongoing discussion.

    Cherokee Health Systems began providing services in 1960. Many 
years ago we recognized that primary care was the most common access 
point for people with behavioral health concerns and began blending 
behavioral health professionals into the primary care team. We've 
pioneered this work and have shared our model of care with our Health 
Center colleagues across the country.

    Our commitment to the provision of both medical and behavioral care 
in a truly integrated model allows us to provide comprehensive care to 
patients who present with complex, chronic medical and psychiatric 
conditions. This model works well with patients suffering substance use 
disorders, including opiate addictions. This Committee has recognized 
that Health Centers are in a unique position to lead the treatment 
response to the nation's opioid epidemic and has provided resources to 
enable us to do so. At Cherokee we have these grant funds to organize 
care teams to care for these patients. I want to caution against a 
singular focus on opiate addiction alone. Addiction to opioids is 
commonly mingled with addiction to other substances, not to mention the 
other serious medical complications that follow in the wake of 
addiction. Health Centers need comprehensive clinical teams to address 
the complexity.

    Over the years, the partnership between the Federal Government and 
the health center community has been enormously effective in improving 
health outcomes and boosting access to comprehensive primary care, 
including behavioral health and substances use disorder services. Our 
organization, and every Health Center in the country, is dependent on 
the core financial support we receive in our annual grant from HRSA. 
While we are able to generate much of our revenue from patient services 
and other sources, 330 funding is the solid rock of our funding base.

    Over the past several years Health Centers have faced uncertainty 
over the renewal of federal 330 grant support. While the demand for our 
services was unrelenting, we were restrained from making investments in 
staff and programs to meet the demand. I'm grateful to learn 
legislation was introduced by Members of this Committee, including 
Chairman Alexander, to assure the federal funding base for Health 
Centers for five years. When Health Centers are financially secure, we 
are able to respond to national concerns like the crisis of opiate 
abuse and the pernicious problem of childhood obesity.

    I'm truly grateful for the opportunity to speak with you today. I 
look forward to your questions.
                                 ______
                                 
    The Chairman. Thanks, Dr. Freeman.
    Dr. Waits.

 STATEMENT OF JOHN B. WAITS, M.D., RESIDENCY DIRECTOR, CAHABA 
  FAMILY MEDICINE RESIDENCY, CHIEF EXECUTIVE OFFICER, CAHABA 
                 MEDICAL CARE, CENTREVILLE, AL

    Dr. Waits. Chairman Alexander, Ranking Member Murray, and 
distinguished Members of the Committee thank you for inviting 
me to speak about the Teaching Health Center Graduate Medical 
Education Program. I am here on behalf of the American 
Association of Teaching Health Centers, as long with executives 
and clinicians from many of the Nation's teaching health 
centers and several medical residents who are in the audience.
    I am a family physician and the CEO of Cahaba Medical Care, 
a federally qualified health center with 10 locations in 
Alabama. I also direct the Cahaba Family Medicine Residency. 
Cahaba is Alabama's only teaching health center and started its 
inaugural class in 2013. 71 percent of our graduates are now 
practicing in medically underserved areas, a rate almost three 
times higher than in traditional residency programs. We were 
honored to host Senator Jones at our Centreville campus, and 
are grateful that he is a leader on this issue.
    Our experience proofs that the Teaching Health Centers 
Program works and deserves an extension. Without Congressional 
action, however, as has been alluded to, the program will lapse 
again on September 30th. So it is great that you are holding 
such an early hearing and that the Chairman and Ranking Member 
have introduced bipartisan legislation to extend it for five 
years. Cahaba employs 266 people, including over 50 healthcare 
providers, 31 of whom have utilized the National Health Service 
Corps loan repayment as a crucial incentive.
    We have grown from 2,100 patients in 2012 to over 17,000 
unique patients served and over 80,000 patient encounters in 
2018. Each of our sites sits within a health professional 
shortage area and offers comprehensive care. 46 percent of our 
patient population lives at or below the Federal poverty level, 
and 15 percent are uninsured. There is also a high burden of 
uncontrolled chronic diseases. The Teaching Health Centers 
Program helps us respond to these medical needs. For example, 
before we opened a new clinic in 2015, the small rural town of 
Maplesville, Alabama had not seen a new physician in over 50 
years, and its one physician was active only part-time and 
nearing retirement.
    We purchased a building and renovated it into a modern 
primary care clinic, equipped with X-ray and in-house lab, 
then, a graduating resident from Cahaba's first Teaching Health 
Center class, Dr. Andrea White who is in the audience, joined a 
nurse practitioner and provides primary care in that community. 
Since then, Cahaba has been able to serve 50 percent of the 
low-income population within Maplesville and has also helped 
revitalize the economy and the small downtown square.
    As you know, our Nation faces a severe doctor shortage. By 
2030 the U.S. will require nearly 50,000 more primary care 
physicians, and the shortage is felt most deeply in health 
professional shortage areas and medically underserved areas. As 
many as 84 million people experience disparities in health care 
access because they are uninsured, or because they live in 
rural and urban areas without enough primary care physicians.
    While patient care increasingly occurs in ambulatory 
settings, such as community health centers, traditional medical 
education in the U.S. occurs mainly in inpatient hospital 
facilities. Hospital-based training produces a health care 
workforce whose skills and experiences are often poorly matched 
to the primary care needs of the ambulatory population, and who 
rarely choose to practice in rural or underserved urban 
locations. By contrast, the Teaching Health Center model uses 
community-based ambulatory health centers to train primary care 
residents who will practice in urban and rural underserved 
communities during their training and after they complete their 
residencies.
    Evidence has shown that resident physicians who train in 
health center settings are nearly three times as likely to 
practice in underserved settings after graduation. Only 
investment in the community health workforce pipeline will 
overcome recruiting difficulties and meet the demand.
    We were very grateful that in 2018 Congress generously 
brought the per-resident allocation back up to a more 
sustainable level, but the last two reauthorizations were each 
for two years and did not always provide sufficient certainty 
for teaching health centers to make binding three-year 
commitments to the recruits we were authorized to hire and 
train. We are so glad that Chairman Alexander and Ranking 
Member Murray have listened so carefully to our concerns over 
the years, and have expressed strong support for Teaching 
Health Centers by offering legislation to extend funding five 
years. What a difference it will make if Congress gives us 
stable funding for five years. We can budget more efficiently, 
keep our doors open. The Alexander-Murray bill recognizes that 
the Teaching Health Centers Program will improve medical 
education and save lives in many of our communities.
    I also want to encourage the Committee to consider 
reauthorization legislation that we are working on with 
Senators Collins and Jones, which would fund three of our other 
needs. First, we need to restore some resident slots that were 
authorized by HRSA but not filled during the last couple of 
years of uncertainty. Second, we need a very modest increase in 
the per-resident allocation because our clinics and residency 
programs will face rising costs during this five-year 
authorization period.
    Lastly, the Collins-Jones bill would fund an expansion of 
the Teaching Health Center Program to meet pent-up demand in 
many communities for residency programs such as Cahaba's. Thank 
you for giving me the time to testify this morning.
    [The prepared statement of Dr. Waits follows:]
                  prepared statement of john b. waits
    Chairman Alexander, Ranking Member Murray, and Distinguished 
Members of the Committee.

    Thank you for inviting me to speak to you about the Teaching Health 
Center Graduate Medical Education Program, which we call ``THCGME.'' I 
am a family physician and serve as the Chief Executive Officer of 
Cahaba Medical Care (``CMC''), a Federally Qualified Health Center with 
ten locations serving Bibb, Chilton, Perry, and Jefferson Counties. I 
am also the Residency Director of the Cahaba Family Medicine Residency, 
based in Centreville, AL. Cahaba Family Medicine Residency is Alabama's 
only Teaching Health Center and started its inaugural class in 2013. I 
am pleased to share that 71 percent of our graduated residents are now 
practicing in a Medically Underserved Area, a rate almost three times 
higher than in traditional residency programs.

    As you can see, Cahaba's experience is proof that the THCGME 
program works and deserves to be extended this year. In 2018, Congress 
enacted a two-year reauthorization of the THCGME program through Fiscal 
Year 2019, getting us back to a more sustainable level of $150,000 per 
resident by providing $126.5 million in appropriations per year for 
FY18 and FY19. Without Congressional action, the program will lapse 
again on September 30, so I am very grateful that the Committee is 
holding such an early hearing and that the Chairman and Ranking Member 
have introduced bipartisan legislation to provide a five-year 
extension. The leadership shown by Chairman Alexander and Senator 
Murray in recognizing the need for a robust extension of our program is 
greatly appreciated by the many teaching health center representatives 
here in the Committee room and our medical residents here and across 
the nation.

    Members of the Committee can best understand why reauthorization is 
so critical, please permit me to share some background about our own 
teaching health center programs, our residents, and our patients.
        Cahaba Medical Care--Teaching Health Centers in Alabama
    CMC serves a portion of central Alabama that includes Bibb, Perry, 
Chilton, and Jefferson Counties and currently employs 266 people. Prior 
to becoming a FQHC/THC, CMC employed 11 people. Today, CMC employs over 
50 providers, including physicians, resident physicians, physician 
assistants, nurse practitioners, and licensed behavioral health 
counselors. Since the National Health Service Corps program is also the 
subject of today's hearing, I want to note that over 30 Cahaba 
providers, including faculty physicians, have utilized the National 
Health Service Corps loan repayment as a crucial incentive, since there 
are often salary constraints for physicians working in an non-profit 
setting.

    The growth CMC experienced on the employee side has logically 
enabled us to serve far more patients, increasing from approximately 
2,100 patients in 2012 to over 17,000 unique patients served and over 
80,000 patient encounters in 2018. Each of CMC's 10 sites sits within a 
Health Profession Shortage Area for medical, dental, and behavioral 
health and offers comprehensive care to everyone no matter their 
insurance status. In our service area, 46 percent of the population 
lives at or below the federal poverty level, and 15 percent are 
uninsured. Among the patients seen by CMC, 17 percent are uninsured, 35 
percent are Medicaid and 25 percent are Medicare. Also, there is a high 
burden of uncontrolled chronic diseases such as diabetes, hypertension, 
heart disease, mental health conditions, kidney disease, and late 
presentation of diseases such as lung and colon cancers. In order to 
meet the wide array of medical conditions that are also often 
coexistent with significant social, emotional, financial, and 
transportation barriers to receiving adequate care, CMC also employs a 
team of social workers and counselors to help address the patients care 
holistically.

    CMC serves eight distinct communities, each of which has its own 
story, its own strengths, its own challenges, and its own gaps in the 
healthcare and other industries. One such community is Maplesville, AL, 
a small rural town in Chilton County. Prior to our opening a new clinic 
in 2015, Maplesville hadn't seen a new physician enter the community in 
over 50 years, and the one physician in the community was active only 
part time and nearing retirement. CMC purchased three buildings in the 
historic, but antiquated, downtown, and renovated them into a modern 
primary care clinic, fully equipped with a x-ray and in-house lab 
capabilities. Patient care began in late 2015 with a nurse 
practitioner. Then, a graduating resident from CMC's first THCGME 
Residency class, Dr. Andreia White, DO, originally from Marengo County, 
AL, joined as the second provider in August of 2016. Since that time, 
according to the Federal Uniform Data Services Mapper (UDSMapper), CMC 
has served over 50 percent of the low income population within 
Maplesville and has also helped to revitalize the small downtown 
square.

    We were honored to host Senator Doug Jones at our Centreville 
campus after he had heard this and other stories about the communities 
we serve. During his visit, he learned more about our FQHC and the 
integral part the Teaching Health Center has played in training, 
recruiting, and retaining Family Medicine physicians to underserved 
communities in Alabama.
    The Primary Care Physician Shortage and Teaching Health Centers
    Beyond the borders of Alabama, the entire nation also faces a 
severe doctor shortage. In fact, by 2030 we will need more than 120,000 
physicians to meet the growing demand for health care services across 
the country. According to the Association of American Medical Colleges, 
by 2030, the United States will require nearly 50,000 primary care 
physicians, and the shortage is being felt most deeply in health 
professional shortage areas (HPSAs) and medically underserved areas 
(MUAs). As many as 84 million people living in these areas experience 
disparities in health care access either because they are uninsured, or 
because they live in rural, urban, or suburban areas without enough 
primary care physicians. Additionally, we are reaching a critical time 
when the number of medical school graduates will be greater than the 
number of residency slots. Without a residency, medical school 
graduates are unable to obtain a medical license.

    While patient care increasingly occurs in ambulatory settings, such 
as community health centers, medical education occurs mainly in 
inpatient hospital facilities, funded primarily by CMS under a Medicare 
formula. This hospital-based training produces a health care workforce 
whose skills and experiences are poorly matched to the primary care 
needs of the population, and who rarely choose to practice in rural or 
underserved areas. In order to address the changing healthcare system 
and address the disparities in the health care workforce, the THCGME 
model uses community-based ambulatory health centers, such as nonprofit 
community health centers and community consortia, to train primary care 
residents who will practice 21st century care in urban and rural 
underserved communities during their training and after they complete 
their residencies. During their residency training, THC residents 
practice in the approved primary care specialties of Family Medicine, 
General Internal Medicine, Obstetrics and Gynecology, Pediatrics, 
Psychiatry and General Dentistry.

    According to the 20th Report of the Council on Graduate Medical 
Education (COGME), ``the shortage in primary care providers, 
particularly those capable of caring for adults with chronic disease 
(Family Medicine and General Internal Medicine), overshadows the 
deficits in all other specialties.'' One way to address the physician 
workforce shortage is to train resident physicians in underserved 
settings, based on the precept that training providers in areas of need 
will produce the workforce with the necessary skills to serve in 
underserved areas. Evidence has shown that resident physicians who 
train in health center settings are nearly three times as likely to 
practice in underserved settings after graduation. They are also 3.4 
times more likely to work in a health center, compared to residents who 
did not train in health centers. The difficulties in recruiting 
community-based primary care physicians is also well documented; only 
investment in the community health care workforce pipeline will help 
meet the workforce demands. By moving primary care training into the 
community, THCGME programs are on the leading edge of innovative 
educational programming dedicated to meeting future health care 
workforce needs.

    Analysis of the THCGME programs continue to show promising results:
    
    
                      Reauthorization Legislation
    With the looming primary care shortage on the horizon, investments 
in graduate medical education training will be critical to meet the 
needs of the evolving healthcare delivery system. The THCGME program is 
one of the most reliable training models for primary care physicians 
and has an overwhelming documented success, but has been critically 
underfunded and is at the brink of collapse. Without immediately 
strengthening and expanding, the program will unravel just as it is 
beginning to produce the urban and rural primary care workforce that is 
desperately needed.

    As I noted earlier, we were very grateful that as an initial step 
last year, Congress provided sufficient funding to bring the per 
resident allocation back up to a more sustainable level. We are very 
heartened that the Alexander-Murray bill would provide another element 
of sustainability by reauthorizing the THCGME program for five years. 
The last two reauthorizations were each for two years and did not 
always provide sufficient certainty for teaching health centers to make 
binding three-year commitments to all the recruits that they were 
authorized to hire. The longer timelines are so important because the 
training itself three years in duration and the medical student 
recruiting process starts one to two years prior to the training, and 
certainty of sustainable funding for training is utterly essential to 
recruit qualified medical graduates into Teaching Health Centers. We 
are so glad that Chairman Alexander and Ranking Member Murray have 
listened so carefully to our concerns and have expressed such strong 
support for THCGME by offering legislation to extend funding through 
FY24. What a difference it will make if Congress gives us stable 
funding for five years! We can budget more efficiently and ensure that 
we can keep our doors open for enthusiastic future doctors who are 
committed to practicing medicine in underserved communities. Primary 
care saves lives and saves money and it is clear that the Alexander-
Murray five-year reauthorization bill recognizes how the Teaching 
Health Center Graduate Medical Education program helps solve our 
primary care crisis. Simply put, the Alexander-Murray reauthorization 
proposal will improve medical education and save lives in many of our 
communities.

    In addition to the Alexander-Murray proposal, I want to encourage 
the Committee to consider reauthorization legislation that the teaching 
health centers have worked on with Senators Collins and Jones, which 
would augment the $126.5 million current funding level by adding some 
additional appropriations to meet three of our other needs. We are 
grateful to Senators Collins and Jones for their willingness to work 
with supporters of the Teaching Health Centers. We are hopeful that 
Congress will consider favorably any proposal to help THCs restore some 
resident slots that were authorized by HRSA but not filled during the 
last couple years of uncertainty. Second, we are hopeful that Congress 
will include funding for a very modest increase in the per resident 
allocation to help offset inflation over the next five years. While 
Congress was very generous in restoring the $150,000 PRA in last year's 
law, our clinics and residency programs facing rising costs and we are 
hopeful that Congress can find some funds to help us preserve our 
purchasing power during this five-year reauthorization period.

    Lastly, we are hopeful that Congress will include additional 
funding for expansion of the THCGME program to meet pent-up demand in 
many communities for a residency program such as Cahaba's. It has been 
five years since HRSA last approved a new Teaching Health Center in 
2014 and many potential sponsors of such centers have reached out to 
our association asking for advice on how they can obtain such a 
designation and the accompanying funding. HRSA has correctly 
prioritized trying to sustain existing Centers for the past two years 
and we are hopeful that this reauthorization process will include 
additional funds that permit HRSA to solicit proposals and approve 
entirely new centers or expansion of programs offered at existing 
centers. Every dollar spent on expansion will generate tangible 
benefits for your communities and those of other Senators. Lives will 
be saved, economic growth generated, and we will make a dent in the 
medical care shortage that plagues too many parts of our country to 
this day.

    Thank you for giving me the time to testify this morning.
                                 ______
                                 
                  [summary statement of john b. waits]
    Chairman Alexander, Ranking Member Murray, and Distinguished 
Members of the Committee: Thank you for inviting me to speak about the 
Teaching Health Center Graduate Medical Education Program.

    I am here on behalf of the American Association of Teaching Health 
Centers. Cahaba is Alabama's only Teaching Health Center. 71 percent of 
our graduated residents are now practicing in Medically Underserved 
Areas, a rate almost three times higher than in traditional residency 
programs. Many of them are in Alabama, in underserved areas that 
haven't seen a new physician come to town in decades.

    Our experience is proof that the THCGME program works and deserves 
extension. Without Congressional action, the program will lapse again 
on September 30.

    In 2018, Congress gave us a two-year extension and a more 
sustainable level of $150,000 per resident by providing $126.5 million 
in appropriations per year. The Alexander-Murray bill would further 
sustain us by reauthorizing the THCGME program for five years. The last 
two reauthorizations were each for two years and did not always provide 
sufficient certainty for teaching health centers to make binding three-
year commitments to all the recruits that they were authorized to hire. 
The Alexander-Murray reauthorization proposal will improve medical 
education and save lives in many of our communities.
    Additionally, legislation that the AATHC has worked on with 
Senators Collins and Jones, would add funding to meet three of our 
other needs.

          1. restoring some resident slots that were authorized by HRSA 
        but not filled during the last couple years of uncertainty.

          2. a very modest increase in the per resident allocation to 
        help offset inflation because our clinics and residency 
        programs will face rising costs

          3. funding expansion of the THCGME program to meet pent-up 
        demand in many communities for a residency program such as 
        Cahaba's. HRSA last approved a new Teaching Health Center in 
        2014 and many potential sponsors of such centers have reached 
        out to our association asking how they can obtain such a 
        designation and the accompanying funding.

    Every dollar spent on expansion will generate tangible benefits for 
communities with a new THC. Lives will be saved, economic growth 
generated, and we will make a dent in the medical care shortage that 
plagues too many parts of our country to this day.
                                 ______
                                 
    The Chairman. Thank you, Dr. Waits.
    Dr. Anderson, welcome.

    STATEMENT OF ANDREA ANDERSON, M.D., DIRECTOR OF FAMILY 
MEDICINE, UNITY HEALTH CARE, INC., CORE FACULTY, WRIGHT CENTER 
         FOR GRADUATE MEDICAL EDUCATION, WASHINGTON, DC

    Dr. Anderson. Good morning. My name is Dr. Andrea Anderson, 
and I am a Family Physician, with Unity Health Care here in 
Washington, D.C. In addition to caring for my patients, as the 
Medical Director of Family Medicine, I direct clinical policy 
for the care of all of our patients. I signed my National 
Health Service Corps contract in 1997, as a young medical 
student, and came to Unity in 2004 to fulfill my obligation. I 
subsequently became an NSHC loan repayer, and I have stayed 
ever since - a total of nearly 22 years with the NHSC. I am 
proud to care for multiple generations of families through all 
the phases of life. In addition to carrying for them medically, 
I advocate for my patients, helping them to navigate their way 
through a complex healthcare system. I have held my patients as 
newborns, visited them in the hospital, cared for their 
pregnancies, celebrated their birthdays and graduations, and 
mourned at their funerals.
    I run into them at the grocery store and the playground, 
and smile when they wave and rush over to me to report how they 
are heeding my advice to eat more vegetables, or to walk more, 
or whatever the small victory of the moment is. Even in a big 
city, I can enjoy the personal relationships that one might 
only imagine possible in a small town. The NHSC has a national 
reach with an individual face. By making it possible for 
physicians like me to serve these populations, the NHSC 
addresses provider workforce shortages, health disparities, and 
the social determinants of health. I am proud to be part of 
such a profound legacy.
    Since it is founding, the NHSC has placed more than 50,000 
providers in underserved communities, with more than 10,000 
placements in the last year alone. Despite this level of 
service, it would still take more than 20,000 additional 
providers to meet the existing need across the country. The 
NHSC supports a wide variety of primary care providers, 
including physicians like me. It includes PAs, NPs, dentists, 
mental and behavioral health professionals, just to name a few. 
Our providers serve in more than just FQHCs. We are in critical 
access hospitals, mental health centers, prisons, Indian health 
service, and rural health clinics--places where primary care is 
needed most.
    I also provide that NHSC providers tend to reflect the 
communities they serve. Underrepresented minority students are 
often the very ones who are more likely to serve populations 
similar to their cultural background, and studies show that 
having providers in underserved communities has a positive 
benefit on the health outcomes of the patients, especially the 
patients of color.
    In addition, their presence is impactful and inspirational 
to the next generation, fostering a positive cycle of 
representation and encouragement. I am here today to ask your 
help funding this incredibly important program. In October 
2017, funding for the NHSC expired and the program's future was 
uncertain. Without Congressional, before this October the NHSC 
will once again face a funding cliff.
    We are very thankful for the introduction of legislation 
that has already shown the bipartisan support for the NHSC, 
including S. 192 and S. 106 in this Congress, and S. 1441 in 
the last Congress. And we look forward to working with this 
Committee to ensure that the NHSC is stable and strengthened 
for years to come. To accomplish this goal, we ask you to 
consider expanding the funding for the NHSC to ensure all 
current applicants are funded. There are clinicians across this 
country ready and willing to serve in our highest need areas. 
It is imperative to the health of our Nation that we do not 
miss this opportunity. Today, the NHSC is only able to fund 10 
percent of the scholarship applications, and less than half of 
the loan-repayment applicants. To fund all these clinicians who 
are ready to serve, and on behalf of the 41 national 
organizations and the friends of the NHSC coalition, I would 
ask you to consider a systematic doubling of the current 
funding for the program.
    It is clear the need exists today. This would be 
tremendously beneficial to the program, to primary care 
clinicians, but mostly, to the families and the friends, I 
serve each day. They have hopes and dreams. They are the babies 
that I welcome to this world and the wrinkled hands that I hold 
as they exit this same world. They are the present and the 
future of America, and I know this program works for all of us. 
I appreciate the opportunity to testify before you today, and 
we thank you for making the National Health Service Corps a 
priority. I would be glad to answer any questions that you 
have.
    [The prepared statement of Dr. Anderson follows:]
                 prepared statement of andrea anderson
    Chairman Alexander, Ranking Member Murray, and Members of the 
Committee,

    Thank you for inviting me to speak to you today on this very 
important topic. My name is Dr. Andrea Anderson, a Family Physician, 
and the Medical Director of Family Medicine at Unity Health Care here 
in Washington DC. Unity is the largest federally qualified health 
center network in the District, and I have had the honor of serving 
patients there since 2004. I came Unity in fulfillment of my National 
Health Service Corps (NHSC) scholarship, subsequently became a NSHC 
loan repayor, and I have stayed ever since - a total of nearly 15 
years. I am here today on behalf of the Association of Clinicians for 
the Underserved (ACU), the American Academy of Family Physicians 
(AAFP), and 39 other organizations that participate in the Friends of 
the NHSC Coalition. In all, these organizations represent thousands of 
physicians, nurse practitioners, physician assistants and other health 
related professionals who are united in their support for this crucial 
program.

    As you know, the NHSC was created 45 years ago in a bipartisan 
manner, and since then has proven to be a highly effective program 
placing quality health care providers in the highest need areas of our 
country. As both a NHSC Scholar and Loan Repayor, I am honored to be 
here today to give you a firsthand perspective of the significance this 
program has on medical students, health professionals, underserved 
communities, your constituents, and ultimately the country as a whole.
                        Personal History/Mission
    I deeply believe in the mission and purpose of the National Health 
Service Corps. As you can see in my background document, I have served 
many roles at Unity in addition to delivering primary care to my 
patients for close to 15 years. Currently, I serve as the Director of 
Family Medicine. In this capacity I direct clinical policy for over 80 
Family Medicine clinicians. I am the former Medical Director of the 
Upper Cardozo health center, the largest of our 13 community health 
centers serving approximately 25,000 active patients. Previously, I 
directed Student and Resident placements at Unity for over 300 learners 
who passed through our doors during my tenure. Finally, I also directed 
our Health Literacy and Cultural Competency program and our Reach Out 
and Read Early Childhood literacy program because we know that research 
demonstrates direct and indirect effects on health outcomes, especially 
in vulnerable communities. In addition to delivering care to my 
patients, I also to help train the next generation of providers in my 
work as a core faculty member for the National Family Medicine 
Residency, a Teaching Health Center program with the Wright Center for 
GME. In this way I am actively involved with molding the next 
generation of culturally competent, community minded, dedicated, and 
committed members of the physician workforce. So I am a NHSC provider, 
at a Federally-Qualified Health Center, who teaches at a federally-
supported Teaching Health Center. I am very happy to see the Committee 
take up all three programs today as I can positively attest to how they 
all work together to help us fill the shortage areas of the country and 
truly enable everyone to have access to primary care.

    I signed my contract with the NHSC as a first-year medical student 
at Brown University because I believed as much then as I do now, and if 
not more today, in the mission and ideals of this program. The 
knowledge that I had committed to serving my community after school 
shaped the way I approached my studies and enhanced my outlook as a 
young student physician who would ultimately be assigned to an area 
somewhere in America in high need of health care professionals. By 
addressing the primary care shortage, NHSC physicians and other health 
professionals ensure access to healthcare for everyone, regardless of 
their ability to pay. We prevent disease and illness as we care for the 
most vulnerable people who have limited access to health care and might 
otherwise go without needed primary health care services.

    As a Family Physician, I received rigorous training to care for 
children, adults, and pregnant women during my residency and Chief 
Resident/Academic Fellowship year at Harbor-UCLA in Southern 
California. Family physicians care for patients of all genders and 
every age through an ongoing, personal patient-physician relationship. 
Family doctors conduct one out of every five office visits - about 192 
million visits annually. I am proud as a family physician to provide 
front line medical care to people of all socioeconomic strata and 
experiences.

    In my time at Unity Health Care, I have cared for thousands of 
patients, walking with them through the challenges and choices of life 
and everything in between. I am proud to care for multiple generations 
of families through all the imaginable phases of this thing we call 
life. In addition to caring for them medically, I advocate for my 
patients, helping them navigate their way through a complex community 
and health care system. I have held my patients as newborns, visited 
them in the hospital, cared for their pregnancies, attended their 
school recitals and career days, celebrated their birthdays and 
graduations, and mourned at their funerals. I run into them at the 
grocery store and the barber shop and smile when they wave and rush 
over to me to report how they are heeding my advice to eat more 
vegetables, or to walk more, or whatever the small victory of the 
moment is. Even in a bustling metropolis, I can enjoy the personal 
relationships that one might only imagine possible in a small town. The 
NHSC has a national reach with an individual face. By making it 
possible for physicians like me to serve these populations, the NHSC 
addresses provider workforce shortages, health disparities and the 
social determinants of health. I am proud of be a part of such a 
profound legacy and urge you to continue the funding that would make it 
possible for the NHSC to continue recruiting top primary care providers 
to serve your constituents and all Americans.
                     Current Status of NHSC Funding
    Beginning in 1972, funding for the NHSC had been through regular, 
annual appropriations. This changed under the American Recovery and 
Reinvestment Act (ARRA) and the Affordable Care Act (ACA). Both of 
these laws provided new mandatory funding to expand the program to 
additional communities. However in FY2011, recognizing this new program 
funding stream, Congress dramatically decreased the regular 
appropriation. By FY2012, all regular appropriations had been 
eliminated and the program became 100 percent reliant on the mandatory 
trust fund created under the ACA. When that initial funding stream 
expired at the end of FY2015, Congress extended the fund for two 
additional years within the Medicare Access and CHIP Reauthorization 
Act (MACRA) of 2015. Unfortunately that funding expired in October of 
2017 without a new agreement, sending the program into turmoil and 
unable to make any new awards. By February of 2018 Congress was able to 
extend funding for the NHSC for another two years, through FY2019. That 
bill, the Bipartisan Budget Act of 2018, maintained level funding for 
the NHSC at $310 million.

    Without Congressional action before October of this year, the NHSC 
will once again face the prospect of losing the $310 million currently 
provided through the mandatory trust fund. We are very thankful for the 
introduction of S. 192, by Chairman Alexander and Ranking Member Murray 
that shows your clear support for extending NHSC funding for an 
additional five years. This kind of stability is critical to the 
program's future. In addition, we are very grateful for S. 106, 
introduced by Senators Blunt and Stabenow, which calls for increased 
funding for the NHSC over the same five year period. We are also aware 
that other Senators on this very Committee previously introduced 
legislation calling for even more rapid growth for the NHSC, meeting 
the need in all shortage areas across the country. We are very grateful 
for this bipartisan show of support and look forward to working with 
Congress and the Administration to ensure the NHSC is stable and 
strengthened.
                            NHSC Background
    The NHSC program, established in 1972, is designed to incentivize 
primary care professionals to work in urban, rural, and frontier 
communities designated as having a health professional shortage. Since 
its founding, the NHSC has placed more than 50,000 providers in 
underserved communities, with more than 10,000 placements in the last 
year alone. In exchange for their service, the program helps to 
alleviate the burden of debt accumulated during the course of their 
education through scholarship and loan repayment programs.

    The four NHSC programs are:

    The Scholarship Program (SP)--Provides a full scholarship for 
eligible medical, dental, mental and behavioral health students in 
exchange for service after their training in high need health 
professional shortage areas (HPSAs). Awards are very competitive, with 
the program only able to fund 10 percent of current applications. They 
look for students who have a real interest in delivering care to 
underserved communities, and have a high probability of success in 
their primary care careers. There are about 1,000 scholars now, who 
will be serving in the field in the years ahead.

    The Loan Repayment Program (LRP)--This is by far the largest part 
of the NHSC program, with over 8,800 of the current field strength 
receiving loan repayment. The program helps students repay school loans 
in exchange for service, starting with a two year commitment at $25,000 
per year. In order to fund the highest need areas, the program awards 
loan repayment contracts to applicants serving in the highest scoring 
HPSAs first. Last year the program was only able to fund applicants 
down to a HPSA score of 16.

    The State Loan Repayment Program (SLRP)--This program provides 
matching funds for qualifying state loan repayment programs. Not all 
states take advantage of this program, but there are 1,350 placements 
in the field through the state loan repayment programs. This is a very 
cost-effective program from a federal perspective because of the state 
matching requirement. In addition, since the state is putting up half 
the funding, they also have more flexibility on how they structure 
their program within their state. Some fund lower scoring HPSAs and 
others fund additional provider types not currently eligible under the 
federal loan repayment program, such as pharmacists and nurses.

    The Students to Service Program (S2S)--The Students to Service 
program is the most recent addition to the NHSC toolbox, and the 
smallest in terms of field strength. However, it is a critical link 
between the scholarship program and the loan repayment program. The S2S 
program enables those students who are at a key decision point in their 
education to be able to choose the primary care path with financial 
support from the NHSC program.

    NHSC placements are made at approved sites providing primary 
medical, dental and/or mental and behavioral health services. All NHSC 
providers must be open to all, regardless of ability to pay. Eligible 
facilities include:

          Federally-Qualified Health Centers

          Indian Health Facilities

          Correctional or Detention Facilities

          Certified Rural Health Clinics

          Critical Access Hospitals

          Community Mental Health Centers

          State or Local Health Departments

          School-Based Clinics

          Certain Private Practices

          Mobile Units

          Free Clinics

    Current provider types include:

 
 
 
35 percent..........................  Nurse practitioners, physician
                                       assistants, certified nurse-
                                       midwives
9 percent...........................  Mental and behavioral health
                                       professionals
20 percent..........................  Physicians
16 percent..........................  Dentists and dental hygienists
 

    The NHSC has proven to be a successful, sustainable solution to the 
shortage of providers in thousands of communities across the United 
States. According to HRSA, 82 percent of NHSC clinicians who complete 
their service obligation continue to practice in a shortage area up to 
one year later, and a majority continue to practice in a shortage area 
for more than 10 years after completing their service obligation. 
Despite this level of service, it would still take more than 20,000 
additional providers to meet the existing need in the more than 15,000 
federally-designated HPSAs across the country.
               NHSC Impact on Clinicians and Communities
    I can say without hesitation that the more you dig into the 
statistics on the NHSC, the more supportive you will be. I want to 
highlight a few more things that I believe show the value of the 
program as well. First of all, NHSC providers tend to reflect the 
communities they serve. This means that NHSC placements in rural areas 
tend to come from other rural areas, underrepresented minority 
communities tend to see more of their NHSC providers with similar 
cultural and geographic backgrounds. This is because the NHSC gives 
students a chance to see themselves as clinicians, whether that be a 
PA, a dentist, or a physician. The Scholarship program enabled me to 
envision how I could finance my path to become a doctor. The Loan 
Repayment program enables literally thousands of students to afford to 
repay their loans and work in the communities that they care about and 
are committed to. Over the years, medical school debt has increased 
some 20-fold. According to the Association of American Medical 
Colleges, the median four-year cost to attend a public medical school 
is about $240,000 and a private medical school degree can be more than 
$340,000. The average medical school graduate comes out carrying about 
$190,000 or more in debt. Fourteen percent start their residency 
training owing $300,000 or more. These debt levels are larger than most 
mortgages. I can tell you first hand that my family could not have 
afforded to send me through medical school alone. When I was in high 
school I couldn't even imagine how I could possibly afford to be a 
doctor. Like most physicians, I was a top student. I was accepted into 
several highly competitive universities. I was accepted to an eight-
year combined medical program out of high school at Brown University. 
Fortunately, I learned of the NHSC from an advisor at Brown when I was 
an undergraduate. I already had a desire to work in community medicine 
and public health with underserved populations and I was glad to know 
that there was a way this could be possible. I had to apply, and I was 
so grateful to be accepted as a scholar to fund my attendance of the 
Warren Alpert Medical School of Brown University. We know that the NHSC 
is a resource for all providers, regardless of their background who are 
committed to serving the most vulnerable communities. However, one 
hidden benefit of the NHSC is the opportunity that it affords for 
educationally or economically disadvantaged students. Research shows 
that among students who incur debt, Underrepresented Racial Minority 
(URM) students face similar levels of total debt. However, URM students 
are twice as likely to carry some educational debt because they are 
often more likely to hail from low-income families.

    These astute student doctors are often the very ones who are more 
likely to serve populations similar to their cultural background and 
studies show that having these doctors in communities actually has a 
positive benefit on the health outcomes of the patients, especially the 
patients of color. In addition, their presence is impactful and 
inspirational to the next generation, fostering a positive cycle of 
representation and encouragement. Having the NHSC Scholarship Program 
available was one of the things that encouraged me and allowed me to 
see myself as a physician. I know it helps diversify the field of 
clinicians among all the eligible provider types.

    In addition to enabling lower-income, rural, urban, and 
underrepresented minority students to become clinicians, there is one 
other aspect I would like to emphasize for the Committee. As you know, 
many times rigid structures discourage our best and brightest from 
helping those most in need. It is easier to take a job in a well-off 
community, often making much more in salary alone, than to fight your 
way through the red-tape in order to help an underserved community. 
Fortunately, with some urging from Congress, the NHSC has enabled more 
and more part-time placements. This flexibility has enabled a new 
generation of providers to serve in high need areas, while maintaining 
the mission of the program. For example, the part-time commitment 
allows participants to care for a new family, obtain a public health 
degree, or work in academia or health policy enacting research or 
policies that can reach a wider breath and impact these communities 
while providing face to face clinical care part-time. More importantly, 
this improves and extends retention and increases patient access to 
their regular primary care provider. There is still room for 
improvement, but these communities also benefit by ensuring that the 
next generation can participate in the NHSC, by extending their 
commitment concomitant to their part-time status.
                          NHSC Funding Request
    While thankful for the support shown by this Committee, we remain 
very concerned about the base funding for the program provided through 
the trust fund. As evident during the last extension debate, even 
strong bipartisan support may not enable passage before October. The 
loss of this base funding will cause even greater damage to the program 
as people lose faith in the stability of the program. This will result 
in a dramatic decrease in field strength, jeopardizing access to care 
for millions of people.

    We understand that our country faces record debt levels and there 
are nearly continuous negotiations on federal spending levels. However, 
I truly believe that based on the merits of the program, the NHSC can 
withstand any kind of debate that focuses on value, impact, and long--
term savings. We know that access to primary care saves lives and saves 
money, and the NHSC is designed to increase access to primary care 
services where we need it most. For this reason, we urge the Congress 
to fund the NHSC at a level that would enable it to fund at least the 
current applicants for the program.This is possible through a 
systematic doubling of the current funding for the program.

    Doubling the funding for the NHSC would enable an additional 11 
million people to have access to primary care. We know the need far 
exceeds this, with more than 72 million people living in primary care 
shortage areas, 54 million living in dental shortage areas, and more 
than 111 million living in mental health shortage areas. We know there 
are thousands of applicants already looking to serve.

    The current funding level for the program allows for only 40 
percent of Loan Repayment applicants and a mere 10 percent of 
scholarship applicants to be granted awards. I mention this to bring 
attention to the fact that although it is usually difficult to recruit 
primary care clinicians to these shortage areas, the NHSC is clearly an 
effective and popular way to overcome this difficulty. As we look for 
ways to increase access to primary care, we have literally thousands of 
passionate health professionals applying to the NHSC to serve in our 
most needed areas of the country. I would urge you to fund as many of 
these applicants as possible and help our rural and underserved 
communities get the primary care access they need today.
                               Conclusion
    Today, more than 10,000 NHSC clinicians serve 11 million people 
across the country. I stand before you proud to be one of them. We are 
hopeful that we can strengthen and grow the program to help address the 
urgent need of millions of people for primary health care services. 
These millions of people have faces and names. They have hopes and 
dreams. They are my patients that I see every day. They are our 
neighbors. They are your constituents. They are the babies that I 
welcome to this world and the wrinkled hands that I hold as they exit 
that same world. They are you and they are me. They are the present and 
the future of America. Without action by Congress, $310 million in 
funding for the NHSC will expire later this year. The NHSC program has 
proven time and time again to be an effective program, and I can assure 
you, as an alumnus, in my opinion, that the NHSC is one of the best 
programs this country has devised to incentivize primary care medical 
providers to be able to choose primary care and to serve in underserved 
communities. I appreciate the opportunity to testify before you today, 
and we thank you for making the National Health Service Corps a 
priority. I would be glad to answer any questions you may have.
                                 ______
                                 
                 [summary statement of andrea anderson]
    My name is Dr. Andrea Anderson, a Family Physician, and the Medical 
Director of Family Medicine at Unity Health Care here in Washington DC. 
Unity is the largest federally qualified health center network in the 
District, serving over 100,000 patients. I have had the honor of 
serving patients there since 2004, and I am proud to care for multiple 
generations of families through all imaginable phases of life. I came 
to Unity in fulfillment of my National Health Service Corps (NHSC) 
scholarship, subsequently became a NSHC loan repayor, and I have stayed 
ever since--a total of nearly 15 years. I deeply believe in the mission 
and purpose of the NHSC program; a program with a national reach and an 
individual face. By making it possible for physicians like me to serve 
high need communities, the NHSC addresses provider workforce shortages, 
health disparities and the social determinants of health. I am here 
today on behalf of the ACU, AAFP, and 39 other organizations that 
participate in the Friends of the NHSC Coalition.

    Since its founding, the NHSC has placed more than 50,000 providers 
in underserved communities, with more than 10,000 placements in the 
last year alone. Despite this level of service, it would take an 
additional 20,000 providers to meet the existing needs across the 
country. In exchange for their clinical service in high need areas, the 
NHSC helps to alleviate the burden of debt accumulated during the 
course of their education through scholarship and loan repayment 
programs. The program includes the Scholarship Program, the Loan 
Repayment Program, the Students to Service Program and the State Loan 
Repayment Program. Eligible providers include nurse practitioners, 
physician assistance, certified nurse-midwives, mental and behavioral 
health professionals, physicians, dentists and dental hygienists. 
Eligible organizations include Health Centers, IHS facilities, rural 
health clinics, critical access hospitals, community mental health 
centers, correctional facilities and more.

    NHSC providers tend to reflect the communities they serve. 
Underrepresented Racial Minority students are often the very ones who 
are more likely to serve populations similar to their cultural 
background and studies show that having these doctors in communities 
actually has a positive benefit on the health outcomes of the patients, 
especially the patients of color. In addition, their presence is 
impactful and inspirational to the next generation, fostering a 
positive cycle of representation and encouragement.

    We know that access to primary care saves lives and saves money, 
and the NHSC program has proven time and time again to be an effective 
federal program. Unfortunately, without Congressional action before 
October of this year, the NHSC will once again face the prospect of 
losing the $310 million currently provided through the mandatory trust 
fund. Additionally, the NHSC is only able to fund 10 percent of 
scholarship applicants and less than half of loan repayment 
applications today. For these reasons, we urge Congress to extend and 
increase the funding available for the NHSC to enable all current 
applicants to receive awards. This would be possible through a 
systematic doubling of the current funding for the program.

    We are very thankful for the introduction of legislation that has 
already shown the bipartisan support for the NHSC (S. 192, S. 106, and 
S.1441 in the 115th Congress) and look we forward to working with this 
Committee to ensure the NHSC is stable and strengthened for years to 
come.
                                 ______
                                 
    The Chairman. Thank you, Dr. Anderson, and Mr. Trompeter, 
welcome.

 STATEMENT OF THOMAS TROMPETER, PRESIDENT AND CHIEF EXECUTIVE 
                OFFICER, HEALTHPOINT, RENTON, WA

    Mr. Trompeter. Chairman Alexander, Ranking Member Murray 
and Members of the Committee, thank you for the opportunity to 
provide testimony in support of the Community Health Center 
Fund, the National Health Service Corps, and the Teaching 
Health Center program, and to address the importance of fixing 
the primary care funding cliff we face this year.
    My name is Thomas Trompeter, and I am the President and 
Chief Executive Officer for HealthPoint. We are a federally 
qualified health center, serving people in need in suburban 
King County, outside the City of Seattle.
    We provide the full spectrum of primary medical, dental, 
and behavioral health care through ten full-service clinics, 
three school-based clinics, three out-stationed primary care 
clinics, and a mobile medical van that focuses on the homeless. 
In 2018, we took of 89,000 people, 17 percent of whom had no 
insurance, and 65 percent of whom relied on Medicaid and CHIP 
for their coverage.
    In addition to emphasizing the essential role our base 
federal grant plays, I would like to thank you for the recent 
supplemental funding for integrated mental health and substance 
use disorder services. The opioid epidemic in our area 
continues to increase. This funding allows us to expand 
services for existing as well as new patients and has allowed 
us to add a behavioral health consultant, a chemical dependency 
counselor, and a psychiatric nurse practitioner.
    Like many health centers, we participate in the National 
Health Service Corps Loan Repayment Program. We also 
participate in Washington's own Health Professions Loan 
Repayment Program, which is made possible by federal matching 
funds. These programs support medical and dental providers, 
behavioral health providers, and pharmacists working at 
HealthPoint. 20 percent of our current workforce receives this 
support. Another 30 percent has received this support in the 
past--so that is half our providers relying on these programs, 
this is key.
    Loan repayment is our most effective tool to introduce new 
clinicians to our work and to keep them in that work for the 
long haul. We are also a teaching health center through The 
Wright Center National Family Medicine Residency Consortium. We 
have graduated three classes of residents--that is 11 new 
physicians. Of that 11, seven are working in community health 
centers, including four at HealthPoint and two other at other 
Washington community health centers. Here is a great success 
story. In 2017, we graduated from our residency a woman who 
began her journey as one of our patients. She was inspired by 
her primary care provider, and after completing her 
undergraduate degree and her medical degree, entered our 
residency and is now a practicing physician in our community.
    For the last two authorization and appropriation cycles, 
HealthPoint and health centers everywhere have experienced 
serious uncertainty because of the cliff. In the fall of 2017, 
when funding for all three programs expired and we actually 
went over the cliff, we scrambled to make sure that we would 
not have to cut services or disrupt the education of our future 
doctors. This was especially acute for our family medicine 
residents and the faculty who were really afraid that we would 
renege on our promise to complete their education.
    It is understandable that some might question the ongoing 
need for Federal grant support in a state like Washington with 
our adoption of the Medicaid expansion. However, like the other 
health centers in Washington, we serve a significant number of 
people with no insurance--over 15,000 every year. And many of 
our insured patients are still low-income and have insurance 
plans that have copays and deductibles that are simply not 
affordable for them. In addition to all that, we provide a wide 
array of wraparound services that are not reimbursed by most 
insurances, including things like interpretation services and 
care coordination. Our support through the Federal program also 
helps us leverage other needed grant support. Like all the 
health centers, we are supported with a patch-work quilt of 
grants and reimbursements, all of which are critically 
important to our ability to serve the underserved. The Federal 
330 grant is the essential support for our ability to provide 
care to these uninsured and underinsured patients--it is often 
the seal of approval that others look to, to provide us with 
support.
    We must arrive at a more durable solution and provide 
stable and adequate long-term funding for the care we provide. 
Without your continued support, all this work is in serious 
jeopardy.
    I am grateful that the Chairman and Ranking Member, who 
just happens to be my own Senator, have introduced legislation 
to extend funding for the Community Health Center Fund, the 
National Health Service Corps, and the Teaching Health Centers 
program for an additional five years. I know other Members of 
the Committee have also sponsored legislation to extend long 
term funding and we are grateful for all of this support. I 
urge the HELP Committee to move this legislation forward in 
order to provide stable and full funding for the health center 
programs and to prevent a repeat of the uncertainty and 
disruption that occurred in the last two authorization and 
appropriation cycles. Our staff, our patients, and our 
community are counting on you. Thank you.
    [The prepared statement of Mr. Trompeter follows:]
                 prepared statement of thomas trompeter
    Chairman Alexander, Ranking Member Murray and Members of the 
Committee, thank you for the opportunity to provide testimony in 
support of the Community Health Center Fund, the National Health 
Service Corps, and the Teaching Health Center Graduate Medical 
Education program, as well as the importance of addressing the Primary 
Care Funding Cliff we face in Federal Fiscal Year 2020.

    My name is Thomas Trompeter. I am the President and Chief Executive 
Officer for HealthPoint. HealthPoint is a Federally Qualified Health 
Center, founded in 1971, serving people in need in suburban King 
County, outside the City of Seattle.

    In 2018, we provided care to underserved communities in King County 
through 10 ``full service'' health centers, 3 school based clinics, 3 
out-stationed primary care clinics, and a mobile medical van which 
focuses on serving people who are homeless. We provide the full 
spectrum of primary medical, dental, and behavioral health care.

    Here are a few key metrics for HealthPoint in 2018:

          We served 89,000 patients
          16 percent of our patients have no insurance
          65 percent of our patients are covered by Medicaid/
        CHIP
          We provided $8.5 million in care that was not paid 
        for by our patients or their insurance

    In addition to emphasizing the essential role our base federal 
grant plays in providing high quality primary care to underserved 
communities, I would like to thank you for the recent supplemental 
funding for increased access to critical integrated mental health and 
substance use disorder services. With funding through the recent AIMS 
and SUDS service expansions, HealthPoint has added (and is adding) new 
personnel to expand access to integrated SUD and MH treatment for our 
patients. The opioid epidemic in our service area continues to 
increase, with no end in sight. As a Federally Qualified Health Center, 
HealthPoint is at the forefront of responding to this community-wide 
crisis. We are dedicated to meeting the challenge by removing barriers 
and providing opportunities for more high-risk patients to access care. 
With the epidemic creating the need for increased staff capacity, these 
supplemental awards provide critical funding needed to better respond 
to this crisis. Our increase in integrated SUD and MH personnel 
(Behavioral Health Consultant, Chemical Dependency Counselor and a 
Psychiatric Nurse Practitioner) will expand access to services for 
existing as well as new patients and strengthen our capacity and 
commitment to making sure that care is within reach for everyone who 
seeks help.

    Like many health centers across the country, we participate in the 
National Health Service Corps Loan Repayment Program, as well as 
Washington State's own health professions loan repayment program, which 
is made possible by federal matching funds. These programs provide 
support for medical and dental providers, behavioral health providers 
and pharmacists working at HealthPoint.

          About 20 percent of this workforce at HealthPoint is 
        currently receiving support through these programs.
          Nearly 50 percent of all our providers are either 
        currently receiving support or have received support in the 
        past.

    This is key. Loan repayment is an essential recruiting tool for 
HealthPoint and for health centers in general. It is the most effective 
tool we have at HealthPoint to introduce new clinicians to our work. It 
is not uncommon for providers--once exposed to the rewarding work we 
do--to decide that working in a Health Center is a truly worthwhile 
career and to stay with us.

    We are also deeply engaged in training the next generation of 
health center providers. We are a community campus of the AT Still 
School of Osteopathic Medicine in Arizona (SOMA). 79 percent of our 
graduates pursue residencies in primary care--a percentage that is far 
greater than in most medical schools.

    We are a Teaching Health Center through The Wright Center National 
Family Medicine Residency Consortium. We have graduated 3 classes of 
residents for a total of 11 new physicians. Of that 11:

          7 are working in Community Health Centers--4 at 
        HealthPoint, 2 at other Washington CHCs, and one in a 
        California CHC
          Of the remaining 4, 3 are working in our local area 
        and 1 is practicing out of state.

    It is worth noting that for each of the three years we have 
operated the residency program, the number of graduates choosing to 
work in a Health Center has increased. We are thrilled with the 
Teaching Health Center program.

    I would like to offer one example of the success of our involvement 
with the Teaching Health Center program. In 2017, we graduated from our 
residency a woman who was a patient at HealthPoint. She was inspired by 
her HealthPoint provider and, after completing her undergraduate 
degree, entered our SOMA community campus and then was accepted into 
our residency program. She is now a practicing physician in our 
community.

    I am grateful that the Committee is holding this hearing to discuss 
the importance of resolving the Primary Care Funding Cliff. For the 
last two authorization and appropriation cycles, HealthPoint and CHCs 
in Washington State and around the nation have experienced serious 
uncertainty due to the challenges we have faced with the Cliff. We must 
arrive at a more durable solution and provide stable and adequate long 
term funding for the critical care we provide for underserved 
communities.

    In the fall of 2017, when funding for all three programs expired 
and we actually went over the cliff, we at HealthPoint scrambled to 
make sure that we would not have to curtail services to people in need 
and to the medical students and residents who rely on us. Fortunately 
for us, the gap in funding was ultimately resolved prior to the end of 
our own grant budget period, thereby saving us from having to make even 
more difficult decisions. Nonetheless, the level of uncertainty created 
serious difficulty for us as an organization. And, while I remained 
relatively confident that a solution would be found, I cannot say the 
same for our staff. Perhaps the most powerful example of the effects of 
this uncertainty is with our Family Medicine Residents and faculty. Our 
residents were understandably concerned that the promise we made to 
them would be unfulfilled due to loss of THC funding. Our faculty were 
understandably concerned that we would be forced to renege on our 
commitment to these future Family Physicians. This, then, created 
serious concern that our Federal Government would abandon a program 
that has shown great promise in helping to address the shortage of 
primary care physicians dedicated to caring for underserved 
populations.

    It is understandable that some might question the need for federal 
grant support in a state like Washington with our adoption of the 
Medicaid expansion under the Affordable Care Act. However, like the 
other CHCs in Washington, HealthPoint still serves a significant number 
of people with no insurance. 17 percent of our patients have no 
insurance. In addition to that, many of our insured patients are still 
low-income with policies that have copay and deductible provisions that 
are not affordable for them. The federal 330 grant is the essential 
support for our ability to provide care to these uninsured and 
underinsured patients.

    I would also point out that in many ways--our support through the 
federal CHC program helps HealthPoint leverage other needed grant 
support. Like all CHCs, we are supported by a ``patch-work quilt'' of 
grants and reimbursements--all of which are critically important to our 
ability to serve our communities. Chief among these sources is the 
support we receive through the CHC programs--it is in many ways the 
seal of approval that our other sources of support look to as an 
assurance that we are a high quality organization worth their 
investment.

    All the programs I have briefly described here--whether directly 
supported with federal funding or indirectly supported because of the 
foundation that federal support provides--are made possible by the 
stable and adequate funding we have historically received through the 
CHC programs portfolio. Without your continued support, all this work 
is in serious jeopardy.

    I am grateful that the Chairman and Ranking Member, who just 
happens to be my own Senator, have introduced legislation to extend 
funding for the Community Health Center Fund, the National Health 
Service Corps, and the Teaching Health Centers program for an 
additional five years. I know other esteemed Members of this Committee 
have also sponsored legislation to extend long term funding. On behalf 
of health centers in Washington and across the country I want to thank 
you all for these efforts. I urge the HELP Committee to move this 
legislation forward in order to provide stable and full funding for the 
CHC programs, and to prevent a repeat of the uncertainty and disruption 
that occurred in the last two authorization and appropriation cycles. 
Our staff, our patients, and our community our counting on you.
                                 ______
                                 
                [summary statement of thomas trompeter]
    HealthPoint is a Federally Qualified Health Center, founded in 
1971, in King County, Washington.

          10 ``full service'' health centers; 6 ancillary 
        sites; one mobile van
          Full spectrum of primary medical, dental, and 
        behavioral health care.
          89,000 patients; 17 percent uninsured; 65 percent 
        Medicaid/CHIP
          $8.5 million in care that was not paid for by our 
        patients or their insurance

    Our base federal grant is critical to our ability to care for the 
uninsured and underinsured

    The opioid epidemic in our service area continues to increase, with 
no end in sight. Recent expansions funds have let us add needed staff 
and expand services.

    NHSC is a critical resource for HealthPoint. It provides (a) direct 
assistance and (b) leverages resources for a state program that also 
provides similar assistance;

          20 percent of our provider workforce currently 
        receives support; 50 percent of all our providers are current 
        or past recipients
          Loan repayment is the most effective tool recruitment 
        we have, and recipients often stay.
    We are a community campus of the AT Still Medical School and a THC 
through The Wright Center National Family Medicine Residency 
Consortium.
          79 percent of our medical school graduates pursue 
        residencies in primary
          Our residency has graduated 11 new physicians. Of 
        that 7 are in CHCs

    In the fall of 2017, when funding for all three programs expired 
and we actually went over the cliff, we at HealthPoint scrambled to 
make sure that we would not have to curtail services to people in need 
or to the Family Medicine Residents who rely on us. For HealthPoint, 
the level of uncertainty created serious difficulty. The effects of 
this uncertainty were especially acute with our Family Medicine 
Residents and faculty. Our residents were understandably concerned that 
the promise we made to them would be unfulfilled due to loss of THC 
funding.

    Our 330 grant is essential to our ability to provide care to 
uninsured and underinsured people. It also leverages other resources 
for our ``patch work quilt'' of support--it is the seal of approval for 
other funders.

    Without your continued support, all this work is in serious 
jeopardy.

    I am grateful that the Chairman and Ranking Member, who just 
happens to be my own Senator, have introduced legislation to extend 
funding for the Community Health Center Fund, the

    National Health Service Corps, and the Teaching Health Centers 
program for an additional five years. I know other esteemed Members of 
this Committee have also sponsored legislation to extend long term 
funding.

    On behalf of health centers in Washington and across the country I 
want to thank you all for these efforts. I urge the HELP Committee to 
move this legislation forward in order to provide stable and full 
funding for the CHC programs, and to prevent a repeat of the 
uncertainty and disruption that occurred in the last two authorization 
and appropriation cycles. Our staff, our patients, and our community 
are counting on you.
                                 ______
                                 
    The Chairman. Thank you, Mr. Trompeter and all the 
witnesses, thank you very much. We will now begin a round of 
five-minute questions. Senator Cassidy.
    Senator Cassidy. Hey, thank you all for your good work. My 
work as a physician was in an inner-city hospital, so I applaud 
what you do. Dr. Anderson, my wife did her residency at Harbor-
UCLA. A good friend of hers was probably one of your part-time 
faculty. So anyway, just to say that and I did mine at a big 
County. So anyway, I am going to probe, and I probe not to do 
anything but to be able to explain this program better to 
others. Dr. Waits, you mentioned the $150,000 per position per 
year. Now, the average resident earns about $57,000 a year, 
maybe 20 percent benefits will move it up to $65,000 because of 
the delta there. Now obviously you have to pay faculty, but 
faculty are also billing. So, if I am defending the program to 
others, how do I defend that delta between the average salary 
of a resident and the $150,000 we are allocating per year?
    Dr. Waits. Well, thanks for the question. I guess the first 
thing I would say is a lot of the delta is very understandable, 
with fringe benefits----
    Senator Cassidy. From 25 percent right?
    Dr. Waits.----and then their malpractice insurance and the 
efficiency of a resident in a health center that is already 
seeing uninsured patients and nonprofit--our interns typically 
see three patients in a half day, whereas a faculty member 
might see 15 or 20. And so they are just cost to the 
institution that it takes to host an accredited training 
program. This number was independently assessed in the peer-
reviewed literature by George Washington University and it is 
it is consistent with the cost of graduate medical education in 
the CMS program that has been somewhat standard for decades.
    Senator Cassidy. Sounds great.
    Dr. Waits. Yes.
    Senator Cassidy. Mr. Trompeter, are these grants kind of 
stackable if you will? Can someone get loan forgiveness, but 
also fill a slot that is financed by the--whenever I say THC I 
think of THC meaning something else--but THC Graduate Medical 
Education Program. Can you have somebody who is loan forgiven 
and then put into one of those slots?
    Mr. Trompeter. I am not quite following the question.
    Senator Cassidy. Can we have two different incentive 
programs to try and move people to these areas? Maybe Dr. Waits 
should be the one to answer. And in the question--ideally, they 
were both operating independently, but if we have the loan 
forgiveness program that would attract somebody, but we attract 
them into a residency position, which is otherwise financed by 
the THCGME, then you are using two different incentive programs 
to attract one person. I do not know the answer. That is why--
--
    Mr. Trompeter. Well let me try and maybe Dr. Waits can help 
me out here. The loan repayment program is for providers who 
are hired on as full-time staff providers. They are not 
residents----
    Senator Cassidy. I see. That is not the residency that 
comes out.
    Mr. Trompeter. That is correct.
    Senator Cassidy. Okay. Got you. Okay and that helps me 
tremendously. I assume you all are 340b providers?
    I see a lot of his nodding behind you. Dr. Freeman, how 
does that 340b program interact with what you all are doing? I 
say that because obviously, that could be a source of revenue. 
Do you pass those savings on to your patient if you have a 
drug, which is coming to you to at a below cost?
    The Chairman. Microphone, please.
    Dr. Freeman. Yes. In our state with Medicaid patients the 
revenue really is subbed out to a subcontractor. So we are paid 
only a filing fee on Medicaid patients. You know, it is a great 
benefit to our patients to give them lower-cost prescriptions.
    Senator Cassidy. Dr. Waits, Mr. Trompeter, do you all also 
pass those savings on to your clients?
    Dr. Waits. Absolutely. It is a crucial revenue stream to 
pass on the savings on the cost of medications to our uninsured 
patients from our in-house dispensaries.
    Senator Cassidy. If you bill insurance, do you similarly 
pass those savings on to the insurance company? I see, Mr. 
Trompeter, 16 percent of your patients are insured.
    Mr. Trompeter. 17 percent are uninsured, Senator Cassidy. 
We do pass those savings on to our patients. It is the tool 
that allows us to provide medications to our uninsured patients 
at a sliding scale discount.
    Senator Cassidy. Got you. Yes, but also to the insurance 
company? I am sorry. I got the wrong percentage, but a certain 
percent of your patients do have private commercial insurance, 
at least as I was trying to figure out your statistics. Are 
those savings passed on to them as well?
    Mr. Trompeter. We normally do not use the 340b program for 
those patients.
    Senator Cassidy. Oh, really?
    Mr. Trompeter. Yes.
    Senator Cassidy. An honest man, so I just say most----
    Mr. Trompeter. Well and they will go to a commercial 
pharmacy. It is a very small portion of our patients.
    Senator Cassidy. Got it. Okay. Mr. Chair, thank you for 
deferring to me. I appreciate that. I yield back.
    The Chairman. Thank you, Senator Cassidy, for your usual, 
well-informed questions.
    Senator Murray.
    Senator Murray. Thank you. And thank you to all of our 
witnesses--really appreciate again your testimony and being 
here today. It really seems to me that our community health 
centers are sort of the backbone of our country's primary care 
infrastructure. And Mr. Trompeter, you talked a little bit 
about it, but can you speak more broadly to the importance of 
the community health center grants and how they have supported 
your mission in strengthening communities in Washington and 
providing access to all?
    Mr. Trompeter. Sure. The grants, as I said, really are the 
fundamental support that we have for taking care particularly 
of the uninsured, but also the underinsured and for our whole 
program. They also help us provide services that are not 
covered by most insurances, including Medicaid and these 
include things like care coordination, social work, referral 
coordinator, interpretation services. There is a wide variety 
of sort of wrap-around services that, particularly the patients 
that we all take care of, really need in order for the medical 
and dental care that we provide to be effective.
    Senator Murray. Okay, and can you describe for us the 
impact of the lapse in funding that occurred last year on your 
day-to-day operations and strategic planning? Just tell us what 
happened.
    Mr. Trompeter. Sure. We had a lot of conversation. It 
really did throw things into uncertainty, and like I said in my 
testimony it was particularly acute with our teaching health 
center folks who were really very nervous. Our faculty was also 
very nervous that we were going to have to renege on a promise 
that we made in order to help people complete their medical 
education. From a strategic planning standpoint, it made us 
just kind of step back and say we are not really ready to make 
certain kinds of expansion decisions or service depth decisions 
until we are more confident that we have actually got the 
support that we need in order to do these things. It created 
enough uncertainty that it was kind of like no way to run a 
business, and it really did make us slow down and reconsider 
things that we knew we needed to do in order to serve our 
communities.
    Senator Murray. Thank you for that. Dr. Waits, thank you 
for being here. My home state has six teaching health centers, 
and I have really seen the importance of how they helped get 
physicians into rural communities as a result of those teaching 
centers. From your experience, talk a little bit about how 
training providers in rural areas better prepare them to 
actually practice in those kinds of settings.
    Dr. Waits. Well, thank you. A rural area or an inner city 
under-resourced clinic is challenging. I have been in practice 
in central Alabama for 15 years and it is very different when 
you are the doctor in the hospital or in the clinic, and maybe 
the only one that is on call for a weekend in a county of 
25,000 people and your nearest consultant is an ambulance ride 
or a helicopter away, and that is often daunting for someone 
that has trained for a decade of their medical education in a 
university-based, city-based training program. The beauty of 
these teaching health centers that are situated in rural or 
urban community health centers is that it matches the training 
to the very needs that our society needs. And so a graduate of 
a teaching health center would not be deterred from practicing 
in a community health center environment, either rural or urban 
because they were not trained in that environment. So there is 
a degree of nervousness that is alleviated from choosing that 
job and that career path.
    Senator Murray. Okay. Thank you. Dr. Anderson, thank you 
for your testimony. The National Health Service Corps is so 
important, providing loan repayments and scholarships, and I 
think I heard you in your testimony talk about how you yourself 
were helped by the National Health Service Corps. Can you 
describe how that got you involved and what it has meant for 
you?
    Senator Murray. I--turn on your mic there.
    Dr. Anderson. Thank you. I always had a heart to serve the 
underserved. When I signed my contract in 1997, I made a pledge 
to serve these communities. I graduated in the year 2000 from 
Brown University and I took an oath. I brought it with me 
today. It is scratched up and tattered, but it talks about my 
commitment to serve humanity regardless of their social 
standing, and the National Health Service Corps made it 
possible for me to serve to the truest letter of this promise 
that I made 22 years ago. I signed that contract eight years 
before I was even in the workforce and I came to Unity Health 
Care, as I mentioned. I served in a community health center, 
and I now teach in a teaching health center residency. Some of 
my residents are behind me today and I can say that I would 
send any one of my family members to those residents because I 
am confident that they have the skills and the passion to serve 
and to stand in the gap of what America's healthcare needs are 
today.
    Senator Murray. Okay, thank you. Thank you very much. Thank 
you to all of our witnesses.
    The Chairman. Thank you Senator Murray, and welcome to the 
residents of Dr. Anderson.
    Senator Romney.
    Senator Romney. I am going to ask my first question to Mr. 
Trompeter, but then ask a question to all of you from Mr. 
Trompeter on down. First, I just wonder how you were able to 
make this patchwork of financial resources fill the gap when 
the Federal Government backed away. You said you had to 
scramble. Just what did you do? But then we let me turn with a 
second question for you and for the other Members of the panel, 
and this may be particularly attuned to you and also to Dr. 
Freeman, but that is, to what extent is their involvement on 
the part of the state for the program that you administer, and 
what coordination is there between Federal and state dollars 
and direction? And is that a help? Is that a hindrance? I know 
that we on this side of the dais, and I mean on this side of 
the bench all the way around, sometimes we are overwhelmed with 
all the programs that exist--my guess is that you have to, not 
only deal with us but the states and counties and so forth. So 
what is the involvement of the state, and how coordinated is 
that with what is happening at the Federal level? But first, 
how did you make it work? How did you make that patchwork work 
when things fell through at the Federal level?
    Mr. Trompeter. Senator, fortunately, our grant period was 
outside the bubble of the cliff, when the cliff happened the 
last time around. Many of my colleagues were not in that 
position. Nonetheless, we were still very nervous about whether 
the cliff would actually get fixed until it actually did get 
fixed. And there is a certain amount of faith that all of us 
have got to have in order to do this work. And frankly, this 
Committee is one of the reasons we get to have that faith 
because this Committee has done such a good job of working in a 
bipartisan way to make sure that the folks that we take care of 
are getting taken care of. So personally, I had faith and I was 
by hook or by crook, we are not going to close our doors. We 
are going to make sure that they stay open.
    Like I said earlier, I think it was--the conversations were 
the most involved with the folks who were relying on us for 
their medical education because they are new in the world here 
and they are still uncertain about who is going to fulfill 
their promise and how that is going to happen. And when they 
hear all of the news and the talk around that cliff, you made 
them very nervous. So I spent a lot of time calming people 
down, which kind of goes with the territory. So we made it, but 
that way. And I do know that some of the examples that Senator 
Murray spoke to early on are very close to us. I know those 
folks and I know that they went through them. I know that bank 
loans were denied. I know that bank loans were put on hold. I 
know that expansions were delayed and I know that providers who 
were looking to come to work in some of those health centers 
decided to go to work elsewhere because they read the news and 
they did not understand whether they were going to have a 
secure job.
    The recruitment cycle for physicians particularly is long, 
and if people are uncertain, it creates not just an immediate 
problem but a problem further on down the road. So I just want 
to emphasize that this was no small thing that we faced there. 
With regard to the answer for the state, we are fortunate to 
live in a--I am fortunate and Senator Murray is fortunate to 
live in a state with a really great state government and a 
really great health care approach. And we are well coordinated 
with the state. We do not get state grant dollars. So the 
coordination that we do with the state is really through the 
Medicaid program. But yes, I think we have had the good fortune 
of working with folks in our state both at the governor's 
office, and the legislature on both sides of the aisle, and 
with the healthcare authority, who understand the work that we 
do and really try to be additive to that work rather than 
duplicative.
    Dr. Anderson. I would say that any degree of uncertainty in 
any of these programs causes a ripple effect. I would say from 
the perspective of the National Health Service Corps, 
especially for loan repayment extenders--so the way the program 
works is you get a certain lump sum the first two years, but 
then you have the option to continue to extend it as long as 
you have a loan balance. And so, this creates stability within 
the community when your patients have the same doctor that they 
come to for years and years. I am fortunate to have taken care 
of multiple generations of patients. Some patients I saw for 
their school physicals, and now I am taking care of their 
children 15 years later. So the importance of the funding 
cannot be emphasized enough. That in order to capture the 
talent, the providers, the medical students, to interest them 
to stay in these communities, we need consistent sustained 
funding, especially for the residents. Funding that will cover 
their entire residency and not be renewed every day every two 
years. So we thank you for your support in keeping this funding 
stable.
    The Chairman. I am afraid the five minutes has expired. 
Maybe the two of you will have a chance to answer Senator 
Romney's question a little later.
    Senator Casey.
    Senator Casey. Mr. Chairman, thank you very much. I want to 
thank you and the Ranking Member for the legislation that you 
have--I guess it is Senate Bill 192--and the work you have 
done. Dr. Anderson, I will direct my questions to you 
principally. I wanted to ask you about teaching health centers 
generally, but in particular, to use by way of example as a--I 
guess a predicate for my question. We are joined today by 
individuals from my hometown of Scranton who are here from the 
Wright Center, Dr. Thomas Hemak and two residents here with 
this on this side of the room--I am sorry, that side of the 
room. And the Wright Center in Scranton is well known as both, 
a community health center and a teaching health center. They 
have been able to respond to and serve the specific needs of 
that particular community. They have programs to assist 
patients with addiction, with pain management, and also with 
counseling, to help patients adhere to their medication 
program. So my first question to you is, can you discuss how 
teaching health centers are able to both adapt their programs 
to meet those unique needs of a community, and also how they 
are able to train residents to respond to those particular 
needs? I know some of this you may have provided by way of your 
testimony, which I was not here for, at least the oral version 
of the testimony.
    Dr. Anderson. Yes. Thank you. The teaching health center 
program is incredibly important to train the next generation of 
physicians who are interested and willing to stay in these 
types of communities. Actually, the program that I teach is 
also a part of the Wright Center. It is the National Family 
Medicine Residency Program. It is a consortium model that 
happens in four sites throughout the country including a 
HealthPoint. So these residents have signed on to train in the 
community health centers. And even in our current graduating 
class alone, there are seven graduates coming out, five have 
signed contracts to stay at our center. So this shows that this 
is a pipeline where students are willing to stay in these 
communities, and I would agree this is a skill set that is 
learned. It is incredibly daunting for a physician who has 
trained in a site where they do not have any type of experience 
with patients or underserved patients who do not have 
insurance, patients who might speak another language, patients 
who have an addiction or mental health challenges, or any of 
these things that we deal with every day in the community 
health center. So by training these residents in these 
settings, they are more likely to stay in these settings 
afterward.
    Senator Casey. Do you have, in particular, any specific 
examples of models or good examples for us to follow?
    Dr. Anderson. Training models?
    Senator Casey. Right.
    Dr. Anderson. For example, our site employees group visits. 
Now this is a very important innovation where instead of me 
telling each individual person one after the other about 
healthy eating for example or weight loss, we can combine the 
patients together in a group of 10 or 12 and the residents can 
be part of that, thus employing the expertise of the medical 
professional and the collective wisdom of the group. So for 
example, if I say, hey, everyone has to eat more vegetables, 
and one of the other patients might say, oh I tried it and look 
I have lost 10 pounds, and then the other patient says, oh, 
yes, and these vegetables are on sale this week at Safeway, and 
the other patient says, oh, yes, let's all go afterwards.
    [Laughter.]
    Dr. Anderson. You know, that kind of community model is 
what these centers are invested in. It is said that once you 
see one community health center, you see one community health 
center because we are trained to respond to the individual 
needs of those patients and be flexible in adapting our 
training to the needs that the patients are exhibiting at that 
time.
    Senator Casey. Dr. Waits, anything on this that you would 
want to add?
    Dr. Waits. Yes. Thank you for the question. I would just 
add that the Teaching Health Center Program itself is an 
innovation. You know, as we have alluded to, it is such an 
accountable program. It has such transparent outcomes of--it is 
targeting the training to the exact location where the 
workforce need is the greatest in our community health centers. 
We have got great outcomes of graduates staying with the 
program, being comfortable in taking care of patients in the 
program, and it is a transparent program where you can see 
those outcomes. And I think that is innovation itself, and it 
is a reproducible model. That looking at this reauthorization, 
there could be more teaching health centers to do what we all 
have done.
    Senator Casey. Before I wrap up and you can answer it more 
fully in a written form, but as you know, we have had--recent 
events have proved we are really good at stopping, starting 
government. The Congress now has expertise in short term, 
really short-term government. And one of the problems here is 
of course the authorization period. We have had a lot of 
examples of two-year authorization periods, so maybe, for a 
fuller written version--I will just present the question now, 
you can answer in writing--but the positive impact, which I 
will assume, of a five-year authorization, reauthorization as 
opposed to the shorter term. So I will leave that for the 
record. Thanks to Chairman.
    The Chairman. Thank you, Senator Casey.
    Senator Murkowski.
    Senator Murkowski. Thank you. Mr. Chairman, and I want to 
thank you and the Ranking Member for your introduction of this 
package that focuses on our community health centers, and the 
training, and our National Health Service Corps. My colleagues 
here on the Committee know very well that when I ask, questions 
are always very Alaska centric because I listened with great, 
almost envy, that we have these opportunities for some training 
facilities, the teaching health centers, the opportunities to 
really work to build this is workforce of professionals, but we 
struggle in Alaska to be able to attract those good folks that 
you are training up, whether they are in Alabama or whether 
they are in Tennessee, wherever they may be, we would like to 
have them up north----
    [Laughter.]
    Senator Murkowski.----and we don't have our own medical 
school and that is not going to happen anytime soon. And so you 
point to a real reality, Dr. Waits, that when you have somebody 
who has been trained and in perhaps a more urban setting and 
when they get the Alaska bug and they decide they want to have 
this great adventure up there, they get into a setting where 
they are it. They don't have any support that you have 
mentioned, Dr. Anderson, and it is not that they are an 
ambulance away or an airlift there. They are hours, perhaps 
even days, from being able to be with anybody else that can 
help them with this particular issue. So you really have to be 
an independent individual. So I am recruiting for independent, 
smart people----
    [Laughter.]
    Senator Murkowski.----who really want to practice medicine.
    Dr. Freeman. You will be pleased to know Senator, we lost a 
really good physician who moved to Alaska.
    [Laughter.]
    Senator Murkowski. Loving it. Thank you. Thank you, we will 
keep them coming, but my question to you and the challenge is, 
what more can we be doing? We have looked at National Health 
Service Corps as an opportunity to again be able to attract 
those individuals into these medically underserved areas. Is 
there more partnering that we can do--we do a lot of partnering 
obviously with the State of Washington, our closest neighbor 
with some of the training and the residencies--but what more 
can we do? What more can you offer us in these very remote, 
often frontier practice areas? And I throw that out to any one 
of you. I am looking for good ideas, help me.
    Dr. Anderson. I would go back to the as you know, we are 
asking for a doubling of funding for the National Health 
Service Corps, and even if we could have a tripling of funding 
because right now we are only able to fund 10 percent of the 
scholarship applicants and have less than half of the loan 
repayment applicants----
    Senator Murkowski. 10 percent of scholarship applicants?
    Dr. Anderson. Right. And had less than half of the loan 
repairs. So there might be great people who want to go back to 
Alaska but they don't get the scholarship that year, or they 
don't get the loan repayment, and what cannot be 
underemphasized is that these health professional shortage 
areas, the money goes to the highest need and then it trickles 
down until the funding runs out. That doesn't mean that the 
numbers at the bottom of the list don't have need----
    Senator Murkowski. Right.
    Dr. Anderson.----they do but we cannot fund them. And so 
those areas go--the needs go unmet. And I just want to 
emphasize the recruitment tool of having a provider, let us say 
from Alaska, who grows up in Alaska, sees a doctor who is from 
Alaska come back to Alaska--that is inspirational for a young 
boy, a young girl who is thinking, you know what, I can be a 
doctor too, I can do this too. I can come back and serve my 
community, and there is a way for them to do it.
    Senator Murkowski. Other ideas?
    Dr. Waits.
    Dr. Waits. I would just add additionally from the 
educational standpoint, in terms of the reproducibility of the 
teaching health center model, this legislation, the Alexander-
Murray legislation and the Collins-Jones legislation, goes a 
long way. This five-year reauthorization is so critical. So if 
we were going to set up a teaching health center in Alaska, the 
organization itself would need to know if we take the two or 
three years to get accredited as a teaching institution and 
then we start recruiting first, second, third year medical 
students. Well, we have used that five-year reauthorization 
building the program and looking at medical students and 
convincing them to come train with us. And so the stability, 
the permanence, and the growth of this program, that again is 
so accountable, has such good outcomes. I think that is one of 
your key models right there. It could be done if there was 
stability for that funding.
    Dr. Freeman. Here is a suggestion. You know, with the 
National Health Service Corps, great program, life-changing for 
people who receive it but when we are recruiting providers, we 
cannot promise them that they are going to receive it. You 
know, we can tell them about it. They can apply, but if Alaska 
health centers had slots and your providers could say this is 
loan repayment. This is part of the deal. You know, I think 
that would really help in the recruitment there. I have been of 
your health centers. We have done consulting. I have been in 
Talkeetna. I have been in the Kenai Peninsula. Wonderful 
places, wonderful providers. You can get them there. I think 
you can keep them there. But if they could use the core as a 
certain recruitment tool, I think that would really help 
recruit providers.
    Senator Murkowski. Thank you.
    Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski. Senator Hassan.
    Senator Hassan. Thank you, Mr. Chairman and Ranking Member 
Murray for holding this hearing. And thank you to all the 
witnesses for being here, but also for all that you do to help 
people throughout our country.
    I think there is a question for each of you. As I am sure 
you all know, we are experiencing a significant healthcare 
workforce shortage, particularly when it comes to the 
behavioral health workforce in my home State of New Hampshire. 
Communities are especially in need of help to fill shortage of 
behavioral health. Professionals community health centers in 
New Hampshire have played a key role in addressing the deadly 
fentanyl, heroin, and Opioid Crisis that has devastated our 
communities, and they have done it in part by incorporating 
medication-assisted treatment into each of the eleven health 
centers in our state. Last Congress I worked with Democrats and 
Republicans on this Committee to help pass the Support Act, 
which included a provision I helped to introduce, to expand 
access to substance use disorder services by taking steps to 
increase the number of behavioral health professionals who can 
provide those services. It is an important step, but we 
obviously have a lot more to do.
    Maybe starting with you, Dr. Freeman, I am interested in 
hearing from all of you about how additional funding for 
community health centers could be used to address the need for 
behavioral health services and professionals, particularly in 
those states hardest hit by the Opioid epidemic?
    Dr. Freeman. It is interesting--we trained behavioral 
health professionals typically in behavioral health settings--
--
    Senator Hassan. Right.
    Dr. Freeman. They generally then go to work in behavioral 
health settings. The primary point of access though, for folks 
who have behavioral health needs, are in primary care.
    Senator Hassan. Right.
    Dr. Freeman. If we did more training, a behaviorist within 
primary care settings--many, many more would stay in those 
settings----
    Senator Hassan. Yes.
    Dr. Freeman.----and the efficiency of practice would be 
much greater than if they were in isolated behavioral health 
silos. There are a few programs that are kind of like the 
Teaching Health Center Program. There is a Graduate Psychology 
Education Program. It really trains--psychologists, who work in 
primary care settings--the AHEC program is another model--where 
we could get more behavioral health training and primary care 
psychology internships. You know, any of these models where we 
train--I have got some data in my written testimony that shows 
kind of when we train interns or fellows in psychology at 
Cherokee, we retain a high percentage of them and I would to 
see those programs expand to community health centers.
    Senator Hassan. Thank you. Does anybody else quickly want 
to add anything to that?
    Dr. Anderson. I can add as a provider, as a family 
physician, in a community health center. It is invaluable to my 
practice to have a mental health provider working alongside me. 
About 10 years ago in our clinic, we abolish the mental health 
department and we co-located those providers along with the 
primary care. This takes off the stigma for someone to have to 
go to mental health department and we teach our patients their 
brain is a part of their body. So it is the same kind of 
illness and we are here to help them take care of their total 
health. And so it is invaluable if the patient gets up the 
courage to reveal depression, to reveal an addiction, to their 
primary care provider, I can say, you know what, thank you for 
telling me that. I want to help you with that. Here is my 
colleague right down the hall and I can walk you down the hall 
and do what we call a warm handoff.
    Senator Hassan. Right.
    Dr. Anderson.----here, we are going to help you together 
and the patient feels taken care of as a member of the team. So 
it is not just me as the physician caring for the patient. It 
is the entire brevity of the healthcare staff.
    Senator Hassan. Thank you.
    Mr. Trompeter.
    Mr. Trompeter. Senator, I would simply add to what my two 
colleagues have said, we train postdoc psychologists and it is 
the kind of thing that we are able to do when we have a stable 
base to work from.
    Senator Hassan. Yes.
    Mr. Trompeter. The first thing you could do is fund the 
health centers, and then I think additional resources would be 
great. But the first thing is to make sure we are working on a 
stable base.
    Senator Hassan. Thank you. And Dr. Waits, did you have 
anything to add?
    Dr. Waits. Just echoing that point--the stability is 
important. This is something that we are training our residents 
to do as well. And so as we begin to co-locate behavioral 
health and primary care, reducing that stigma, taking care of 
addiction and depression, and these sorts of things. Just a 
reduction in sometimes the regulatory burden of reporting--are 
you a mental health facility? Are you primary care facility? We 
are bringing down these barriers and so that can be an 
important point as well.
    Senator Hassan. Thank you. I think you are all echoing the 
need for the right treatment, at the right place, at the right 
time. And so I appreciate it. You all anticipated my second 
question, which was about the need for stability for the 
program and funding, so thank you for touching on that as well.
    Thank you. Mr. Chair.
    The Chairman. Thank you Senator Hassan.
    Senator Braun.
    Senator Braun. Thank you. First of all, it is a real 
pleasure to be on this Committee. I told you that in my own 
backyard of Southern Indiana, health care delivery through my 
own company has been a challenge in a taken on the effort and 
mantle to try to do the best we can through employer-provided 
insurance, and have really been looking into different ways to 
make this more effective. I was in Indiana last week and spoke 
to the folks that--they have 196 health center delivery sites 
there and was surprised the voids that they were filling in to 
provide services in underserved areas. In all my discussions on 
this and anything else, it is such a complicated dynamic where 
health care delivery is going in his country. You know, it is 
way too large percentage of our GDP.
    It has got to be more effective. You got to cover pre-
existing conditions and no cap on coverage, generally speaking, 
and you got to fill the voids that are in many places. You had 
mentioned, and I am going to be interested in revenue sources, 
if you could whoever feels comfortable with it, describe--you 
mentioned patient services--and tell me how much revenue you 
generate, and you don't have to get detailed but generally, 
from folks that are not availing themselves of something that 
would be supplemented through government? Patient services--
somebody referred to that earlier in terms of what component 
that is. Anyone that feels comfortable with it?
    Dr. Freeman. Let me tell you a little bit about how our 
revenue comes. We are a $60 million company.
    Senator Braun. Yes.
    Dr. Freeman. You know, we get a Federal grant of a little 
bit over $8 million. So, 13.5 percent of our revenue comes from 
our HRSA grant. We get a few other Federal grants, but the bulk 
of the revenue comes from patient services. You know, 30 
percent of our patients are uninsured. You know, our minimum 
fee for those patients is $30--$20, I am sorry. We sometimes 
collect that. If we have homeless folks, we don't charge any 
fee at all. 40 percent of our patients are Medicaid. Medicaid 
is our best payer. There is some Federal regulation that helps 
support--a special rate for us to get basically a cost base 
rate with Medicaid. About 15 percent of our patients are 
commercially insured. We negotiate those contracts as best we 
can, and about 15 percent are Medicare. With almost all of our 
contracts now, we have value-based provisions--so that if we 
show good clinical outcomes, if we can reduce the total cost of 
care, we will sometimes earn bonus dollars from the insurer.
    Senator Braun. To tally that up. It was roughly 83 percent. 
Do you get some folks that just come in and pay a fee because 
they are not income constrained but need the service because it 
is in an underserved area?
    Dr. Freeman. We do--we get some full fee patients. Yes. 
Yes, but it's 40 percent Medicaid, 30 percent uninsured, 15 and 
15, I think 100 percent, right----
    Senator Braun. Of the 13.5 percent were the grant source, 
and that is going towards uninsured. So what makes up the 
difference between the 13.5 percent and the 30 percent that is 
uninsured? How do you fill that gap?
    Dr. Freeman. Of the payer base--I gave you that break down 
which is 100 percent of how those patients are classified. The 
Federal grant, basically, underwrites the sliding fee scale 
discounts.
    Senator Braun. Okay, very good, I get that. One other 
question on recruiting, I understand how we are getting 
residents and doctors into the system. What do you do with 
other staff? How hard is it to staff locations outside of the 
doctor or resident? Is that tougher? Is it easy to staff?
    Dr. Freeman. Go ahead.
    Dr. Waits. It is tough as well. And we have, I think, each 
of us in our own way. For example, we have created a medical 
assistant orientation program where we start with the high 
school health professions courses, where they volunteer some of 
their time and take coursework, and we work with them in the 
sciences and in the health professions education. And some of 
them stay on. And typically, their first six months, to 
sometimes a year or two, it takes to take to train them to be 
able to assist the providers, and it is difficult to staff each 
of the positions.
    Senator Braun. Thank you.
    The Chairman. Thank you, Senator Braun.
    Senator Jones.
    Senator Jones. Thank You, Mr. Chairman. And Mr. Chairman, I 
would like to submit two statements for the record. First is a 
statement from the American Academy of Family Physicians in 
support of the Teaching Health Center Graduate Medical 
Education Program, the National Health Service Corps Program, 
and the Community Health Center Program. The second is a 
statement from the American Osteopathic Association, the 
American College of Osteopathic Family Physicians, the American 
College of Osteopathic Internist, the American College of 
Osteopathic OBGYNs--surreal osteopathic class for sure.
    [Laughter.]
    Senator Jones. The American College of Osteopathic 
Neurologists and Psychiatrists, and the American College of 
Osteopathic Pediatricians in support of the Teaching Health 
Center Graduate Medical Education Program.
    [The following information can be found on pages 53 and 59 
in the Additional Materials:]
    The Chairman. Order.
    Senator Jones. Thank you. Mr. Chairman. Dr. Waits, thank 
you so much for being here again. I really appreciate it, and I 
have been so impressed with what you have been able to do in 
Alabama. And we have still got a long way to go, particularly 
in our rural areas in underserved areas. I particularly want to 
thank you for mentioning the bill that Senator Collins and 
Tester and Capito and I will be introducing, the Training The 
Next Generation Of Primary Care Doctors Act of 2019, which will 
increase the authorization for the Training Health Center 
Graduate Medical Education Program and reauthorize it for five 
years, and I would like to ask you about that a little bit. I 
would like for you, if you would, just to explain to the 
Committee a little bit more about how your teaching health 
center could benefit from an increase in funds over the next 
five years. How do you use those funds to help folks in the 
areas in Alabama, would you expand? And how the bill would 
allow for the creation of new teaching health centers 
throughout the area, because Alabama is certainly one of those 
states that is beginning to suffer from a drain of physicians 
and a drain of health centers in our rural areas. So I will 
just give you the floor for a little bit.
    Dr. Waits. Well, thanks. So the increase in your debt 
legislation would be critical. There is rising cost of 
inflation for our centers, for our residents, for the Residency 
Education Program, all costs go up. And so this rising a little 
bit over the course of the five years is critical for our 
bottom line and for us to run a good non-profit business and 
educational center. In terms of the five-year authorization, it 
is so critical. We are persuading medical students to follow 
through on their dream. Often in the application to medical 
school you write a personal statement saying that you want to 
go to an underserved area, you want to take care of the least 
of these, and we feel like we get to wake up every day and live 
out the dream that we wrote in our medical school personal 
statements. As you get to the end of medical school, as in the 
third or fourth year, you find yourself with often on average 
$200,000-$250,000 in debt. And if you look at training in a 
program that may not have funding for two more years and you 
may find yourself in the middle of a training program without 
funding, it becomes daunting when you think about your family 
and your career. So that is just speaking to the fact that the 
five-year reauthorization is so critical. And then, was there 
another question that you had----
    Senator Jones. I think you covered most of that. I am 
assuming that you would consider expanding, much like you did 
in Maplesville, to help folks down in those areas. If we can 
get this reauthorized for five years?
    Dr. Waits. Right. And you know the last the last teaching 
health center that was funded with 2014 and we have heard from 
the Senator from Alaska, and there are many places in Alabama 
that could open a teaching health center. It is such a 
reproducible model. The new funding for new centers is really 
something that could speak to the health workforce crisis that 
we have in this country.
    Senator Jones. Just out of curiosity, do you assume, even 
though it is primary care, you probably still see a lot of 
women who come in who are pregnant who are having babies and 
there is a need for that in those rural areas. Would that be 
correct?
    Dr. Waits. That is right.
    Senator Jones. You handle that as well those centers?
    Dr. Waits. That is right. Among our 54 healthcare 
providers, seven of us are family doctors who deliver babies. 
In our center, we have three different labor and deliveries 
that we help staff, one of them rural, and so it is definitely 
a part of family medicine, especially underserved rural family 
medicine--delivering babies, taking care of women and children.
    Senator Jones. Well, we are going to be looking at some 
legislation dealing with that, too. So thank you very much 
again for being here. Thank you all for being here, by the way. 
Thank you very much. Thank you.
    The Chairman. Thank you, Senator Jones. Let me pose a 
question to all of you, in our hearings on reducing health care 
costs last year, as I mentioned, the uniform testimony was as 
much as one half of healthcare spending in the United States is 
unnecessary. And Senator Murray and I, Senator Grassley and 
Wyden sat down recently and I said look, if that is even close 
to true given the positions we have here, we ought to be able 
to agree on something to help reduce the cost of healthcare, 
which is an enormous tax on family's budgets, states, Federal 
Government. And one of the obvious ways into that seems to be 
through primary care, because while primary healthcare is only 
2 points to 7 percent of the total spending the access, the 
access that most of us have to healthcare is through our 
primary healthcare doctors, which includes many of the people 
who are part of your part of your systems.
    One of the things we hear most frequently is that well we 
need more transparency. If people just knew what the prices 
were of everything, prices would go down. Well, I wonder about 
that because most people who are sick or who are busy, get a 
bunch of information about healthcare and they are not likely 
in a very good position to do anything about it. Others might 
say, well if this hip replacement costs more, it might be like 
going to Harvard, if it costs more, it is a better place to go 
and so they don't go for the lower price. Again, the primary 
healthcare doctor is a person who might help if you want to use 
a Papa John's Pizza analogy, looking for better outcomes, 
better experience, lower cost, your primary healthcare doctor 
should be the person who might be able to help you do that. So, 
let me ask you based on your experience. What could we do to 
remove barriers or create incentives so the primary healthcare 
doctors throughout our country, so the 300,000, I am including 
those at your centers, can help us help patients, get better 
outcomes, better experience, but at a lower cost? Doctor 
Freeman.
    Dr. Freeman. Yes, I know the data is really clear. You 
know, the systems in other countries that stress utilization of 
primary care have lower costs. Australia is a good example--it 
is often written about. There is really good data to show that 
health centers are cost-effective. There is published data that 
health centers are cheaper than other primary care system.
    The Chairman. A lot of that is, as Dr. Anderson was saying, 
eat your vegetables type of advice as a primary care doctor. 
Dr. Roizen at the Cleveland Clinic will tell you that 80 
percent of the costs of chronic conditions has to do with 
wellness.
    Dr. Freeman. Certainly, the patient is the most important 
person in the primary care team, so getting patient engagement 
in their care and really helping.
    The Chairman. But what can we do in Congress to remove 
barriers or create incentives that would make the primary care 
doctor more effective in creating better outcome, better 
experience, lower costs? What specifically can we do? Any of 
you.
    Mr. Trompeter. Senator, I would urge you to support the 
models that we already know work.
    The Chairman. Such as?
    Mr. Trompeter. Teaching Health Centers, Community Health 
Center Program, the National Service Corps. If we are to 
build----
    The Chairman. You cannot think of anything that we could be 
doing?
    Mr. Trompeter. I would expand on it.
    The Chairman. Just more of what we are doing?
    Mr. Trompeter. Double down on it.
    The Chairman. Yes.
    Mr. Trompeter. We know that this works. We know that we 
don't have enough primary care in this country. It is true that 
most people with what we would normally consider regular 
insurance, get access to care through their primary care 
physician. It is also true that a lot of folks who are 
underserved don't have access to a primary care physician, 
unless they are coming to a health center and they get their 
care through an emergency room. And that is more expensive in 
the system and less effective for health. We also know that the 
health centers help people address, what Dr. Anderson termed 
the social determinants of health. This has to do with what you 
spoke about, diet, exercise, and things like that, which are 
harder to come by and underserved communities. So I think if we 
really want to start bending the cost curve, we in that portion 
of the primary care system that is really shown to be effective 
in helping bend that curve and in the communities that probably 
need it most.
    The Chairman. Okay. I have got another 40 seconds.
    Dr. Freeman. I am not sure what the mechanism is, but 
anyway that you can help get healthcare data to the primary 
care provider. You know, when we start getting information on 
our patients from insurance companies, we are shocked about the 
doctor hopping that is going on--the referrals out to 
specialists that we don't know anything about.
    The Chairman. Well, that is something we can do. And one of 
the problems I have had my own mind is if we make that data 
available, generally many people don't know what to do with it.
    Dr. Freeman. Yes.
    The Chairman. Primary care doctors should know what to do 
with it.
    Dr. Freeman. They should and what has to happen is--it is 
very complicated and so really healthcare systems really have 
to have data analytics. You know, so we modified our electronic 
health record so that when a chart is open on a primary care 
patient, our primary care provider can see was that patient in 
the hospital--where they recently in the emergency room--what 
other kinds of claims, information, do we have from the 
insurer? So I think first data has to flow from the payer to 
the system, and then there has to be some massaging of that 
data so it comes to the providers at the point of care. They 
say they see what their patient has had and what their patient 
needs.
    The Chairman. Thank you very much. Senator Smith--Senator 
Rosen, excuse me, Senator Rosen.
    Senator Rosen. Thank you. Thank you Chairman Alexander. 
Thank you. Thank you. I appreciate that. And I thank you 
Ranking Member Murray, I want to tell you how thrilled I am to 
be part of this Committee and excited for our first hearing and 
I really appreciate everything that you have done for your 
patients, for your communities, and for this Nation, it really 
makes a huge difference.
    I want to tell--I am from Nevada, my home state. We ranked 
48th in the nation in terms of primary care physicians per 
capita, but community health centers have made a tremendous 
contribution for us, not only in our low income population, but 
also in our rural and underserved communities in Nevada, and we 
serve over 93,000 patients each year, including more than 
29,000 children. So I am really deeply concerned about the 
pending primary healthcare cliff and its impact on Nevada and 
across our Nation. I know we have talked a lot about what we 
can do, the funding, how much more robust we can make it, how 
you can plan a long-term strategic planning, and funding really 
makes a difference for people and removing that uncertainty. 
But I want to go in just a little bit different way to expand 
on what I like to think of as our people pipeline. So, of 
course you have the physician, my husband is a physician, and 
so that is one kind of provider. There is nurses, there is a 
respiratory tax. There is people who wrap your arm if you break 
it----
    [Laughter.]
    Senator Rosen. But across the medical spectrum, there are a 
variety of jobs from A to Z. No one-job being more important 
than the other--a person who draws your blood as important as 
the person who does the surgery, you need it all. So you have 
these wonderful models of the community health centers, the 
teaching health centers and in underserved communities that 
often have issues with people getting good paying jobs that are 
going to last or being able to get trained for that. So, how 
can we expand on this with some of our funding or do you think 
that would be a good thing to do to grow that people pipeline? 
Like you said, right from the community, giving those jobs 
across the across the medical spectrum. How can we help you do 
that, if you think that is a viable way to grow on these 
healthcare teaching centers?
    Dr. Anderson. I can say as a provider that in your state 
there were 83 National Health Service Corps placements last 
year. These providers are working in team-based models. In our 
Center, we employ the patient-centered medical home model, 
meaning that when the patient comes in they always have the 
same person that registered them, the same doc, the same MA, 
the same this, the same that. They develop a familiarity with 
that team. Many times the patient might reveal something to my 
MA that they don't tell me. It is part of the whole team based 
model. So I think investing in all of those levels of the team 
makes the center be solvent and makes for better healthcare 
outcomes. Actually touching on what Senator Alexander had 
mentioned, funding the community health centers funds proven 
success because the community health centers have to report 
everything. We have to account for every dollar. We have to 
account for healthcare outcomes. We have to look at how are we 
doing with diabetes? How are we doing with blood pressure? How 
are we doing with this and with that, and make changes that 
tweak even to the very point, one or point two of the 
hemoglobin A1C, for example, for diabetes.
    Senator Rosen. Right.
    Dr. Anderson. Funding those models actually does result in 
positive healthcare outcome. And what you said, it is a 
pipeline for people in the community to see--I become an MA. I 
can become a nurse. We have this all the time in the center. 
They grow, they go to med-school, they come back to serve the 
same community. And so it is a great cycle to invest in.
    Senator Rosen. Thank you. I have one other question and you 
were talking about sharing of electronic health records and all 
of that information and course you are serving rural 
communities, so we have the issue of course of rural broadband 
across this Nation, and how that is going to impact your 
ability to get data across platforms in, I guess we will say a 
speedy fashion, or any fashion at all if you will. And so do 
you think that an investment in rural broadband in telemedicine 
would help amplify the ability of your community health centers 
and teaching health centers to provide better and more access 
to specialized care if necessary, or care in general?
    Dr. Waits. It is absolutely critical for our electronic 
medical records--they are often in the cloud. And so you need 
any broadband just to access the patient's charts. We are 
sending X-rays and other secure encrypted images of patients 
broken bones and other images, so it is critical and the USDA--
there are some USDA programs that help with some rural 
broadband, but definitely that level of investment would help, 
not only the hospitals and the community health centers in 
rural areas, but the education systems as well.
    Senator Rosen. Thank you.
    The Chairman. Thank you, Senator Rosen.
    Senator Warren.
    Senator Warren. Thank you. Mr. Chairman. Community health 
centers provide essential services to our communities, but they 
need Federal funding to do their work and they need that 
funding to be predictable and sustainable. So exactly one year 
ago right now, community health centers across the country were 
running out of funding because Congress failed to reauthorize 
critical programs before they expired--some of you may remember 
that. For four uncertain months until Congress finally acted in 
February of 2018, health centers and their patients were in 
limbo. They held back on hiring new people, on replacement 
staff. They deferred opportunities to make vital improvements 
in their programs. And while most funding directed to health 
centers was still flowing during the government shutdown that 
ended last week, other vital funding sources that patients rely 
on were cut off.
    The next primary care cliff is only eight months away. So 
today I wanted to dig into the impact of unpredictable funding 
streams on the patients who are served by health centers. Mr. 
Trompeter, your health center has several sites in Washington 
State. Do many of your patients rely on federal food and 
nutrition programs like SNAP and WIC, or Federal housing 
vouchers all programs that were affected by the recent 
government shutdown?
    Mr. Trompeter. They do.
    Senator Warren. How did your patients deal with the 
uncertainty caused by the 35-day shut down?
    Mr. Trompeter. Senator, we have seen an increase in anxiety 
amongst our patients. Most of this is anecdotal at this 
juncture, but we have queried our front desk who are usually 
the folks who get told this stuff first, and we do know that a 
lot of our patients, particularly those that rely on benefits 
like SNAP and WIC, have been worried about whether or not they 
were going to have the nutrition that they needed in order to 
follow that advice of their doctors. I am also aware of two 
patients, and this is small-scale stuff, but who made what we 
might consider short-term smart financial decisions, maybe not 
so much in the long term. One of our patients just decided that 
he was going to stop paying his bills for a while.
    If you don't pay your rent, sometimes you don't have a 
house. Another patient decided that he would just use his 
credit card in the meantime, and we have tried to counsel these 
folks, but in the face of the kind of uncertainty that they 
were facing, it is really kind of futile.
    Senator Warren. Yes. I understand. These are people who 
don't have a lot of financial alternatives. Now, health centers 
also saw other impacts. In Massachusetts, on Cape Cod, one 
health center was not able to pay the bills on a critical 
facility replacement projects because they were no longer 
receiving funding allotted for the projects from the U.S. 
Department of Agriculture. The shutdown also had indirect 
effects on health centers in the DC area. Dr. Anderson many of 
your patients livelihood depends on Federal Government 
functioning, with some family members of your staff as Federal 
employees. What impact did the shutdown have on your patients 
and staff?
    Dr. Anderson. Thank you, Senator Warren. I can definitely 
say that anecdotally the shutdown did have an effect on both 
staff and patients. Many staff members are married to Federal 
workers who rely on that two-income household to live in the 
Washington, D.C. area and pay their bills, but I would say also 
for our patients, many of them rely on the foot traffic 
generated by the Federal workers. So for example, I might not 
be seeing the actual Federal worker, but I am seeing the person 
they buy coffee from. I am seeing the person they stop and get 
a hot dog from on the way in, or the person that maybe that is 
a shoeshine guy or, there is the person that delivers food to 
the to the corporate boardroom meeting those are the unseen 
patients that we see and we give dignity to at the health 
center level. And for so many of Americans, as we all know, 
that live from paycheck to paycheck and don't have an emergency 
plan, there was definitely a huge impact and a lot of anxiety 
in our patients when that type of supplemental income was not 
was not guaranteed.
    Senator Warren. Thank you. Dr. Anderson. I appreciate that 
and I am sure everyone has stories around this. You know, while 
President Trump demanded a border wall and Republicans let him 
hold our government hostage, American families were struggling 
to make ends meet. I am glad that the government is open again, 
but we cannot do this again in two and a half weeks when the 
next deadline comes. And whether it is due to a shutdown or 
because Federal programs aren't reauthorized until months after 
funding expires, we cannot keep putting our community health 
centers and their patients in these uncertain and unsustainable 
positions. I am glad that Chairman Alexander and Ranking Member 
Murray have proposed a five-year extension of primary care 
programs so that health centers have more certainty and 
predictability. Patients are depending on us to make sure that 
they have consistent access to care.
    Thank you. Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    Senator Murray do you have any other comments?
    Senator Murray. No, thank you again. Mr. Chairman, for this 
hearing and for working with us on this bipartisan legislation. 
I think we have heard today how critical this certainty is, and 
hopefully we can move this long get it through. And thank you 
again to all of our folks who are here today testifying.
    The Chairman. Senator Romney, I think you get the 
attendance award for today coming early.
    [Laughter.]
    The Chairman. Do you have any other comments you would like 
to make?
    Senator Romney. Let me ask one closing question, that is I 
am astonished by the idea that 50 percent of healthcare cost 
might be unnecessary, but I am curious as to whether you and 
your positions see that kind of unnecessary health care costs 
or expenditure. And if not--and my guess is you are going to 
tell me everything you do is entirely necessary--if not, where 
do you think that kind of excess lies and why it might exist in 
our system today?
    Dr. Waits. You are right in anticipating that we would not 
say 50 percent of our healthcare is unnecessary. But this is 
the community health center program and the other programs is a 
proven model. And let me make it granular from a patient care 
standpoint. You know, when a community health center opens up 
in a community, we often find dozens if not hundreds of 
patients who have gone a decade without getting a pap smear or 
taking care of their diabetes, and often what comes to the 
floor is 20 years of undiagnosed diabetes or, God forbid, a 
cancer case and all of that could have been prevented by 
preventative care. That is why we recommended, not meaning to 
be self-serving, but doubling down on this type of program. 
Across the world primary care has been proven as reducing 
health care costs as well as enhancing access and enhancing 
quality of care. Having a patient center medical home, having a 
primary care physician as your healthcare quarterback, can help 
reduce unnecessary referrals. So if someone is in a rural area 
without a reliable primary care physician and they are 
commuting to different big cities, different emergency rooms, 
getting unnecessary scans, and no one person is advising them 
that we need to do this, you have already had this done, this 
is how community health centers primary care physicians and 
interdisciplinary teams can really make a dent in the 
healthcare costs.
    The Chairman. Thank you. Well thanks to the all four of you 
and Senator Romney. I was startled to when that testimony came 
from people who are affiliated with the National Academy of 
Medicine about the estimate of as much as 50 percent 
unnecessary, now I am not saying wasted, just saying 
unnecessary. I asked all the other witnesses if they agreed 
with that and they all did. They thought 30 to 50 percent was. 
And so we began to ask for suggestions for what to do that 
might create better outcomes, better experiences, and lower 
cost, and obviously empowering primary care doctors to be more 
effective in what they are able to do is one obvious way to do 
that. So, Dr. Freeman has suggested better access to data. The 
witnesses from Cleveland Clinic suggested tying employer 
healthcare to wellness so that more people eat vegetables, keep 
their weight under control, do other things that are proven to 
lower costs. So we are looking for specific steps we can take 
to remove barriers, create incentives, to do that. You have 
been very helpful. If you have further suggestions, we would 
like to have them in writing.
    I want to thank Senator Murray for working, as she so often 
does, in effective and bipartisan way to get ahead of the game 
here introducing five-year legislation so there can be some 
resolution of funding for our primary care community health 
centers. So, you can plan ahead and do the things that you did, 
so your testimony today will be very----
    [Laughter.]
    Mr. Chairman. I spoke too long.
    [Laughter.]
    Senator Kaine. Mr. Chairman, I yield my time back to you--
--
    Mr. Chairman. No, I just gave Senator Romney the attendance 
award for staying the whole time. But you are welcome to have 
five minutes of questions if you would like to do that, Senator 
Kaine, and then we will conclude the hearing.
    Senator Kaine. Well, let me just jump in and I apologize 
for being late because of an Armed Services hearing, but what I 
am most interested in and you all have a wonderful perspective 
on it, and I am sure you have talked a good bit about it 
already is making sure we have an adequate healthcare 
workforce, especially in rural Virginia. We have had real 
challenges and obviously as part of the Higher Education Act 
reauthorization will do will have an opportunity to deal with 
programs like public service loan forgiveness that could impact 
upon rural workforce. But I think, is it Dr. Freeman, your work 
is in Tennessee and touches on Virginia, correct?
    Dr. Freeman. Right.
    Senator Kaine. Talk to me a little bit about some of the 
workforce challenges that you guys grapple with and how you 
deal with them in rural Tennessee and Virginia.
    Dr. Freeman. I think what we found--is training is the best 
recruitment. So, whenever we can get different health 
professionals into our place and train--so we train a lot of 
psychologists. We train social workers. We train nurse 
practitioners, we train nurses and then we are able to keep 
many of those. You know, we have looked wistfully at the 
teaching health center program and if it had more stability in 
funding longer-term, that is something else we might do. But I 
think training within our workforce, if you look at people who 
enter the health professions--they come in there because they 
want to help. You know, they want to help other people and 
there is often a lot of passion about going and helping those 
who really need it the most--but then the cost of education is 
so high--that especially positions are drawn to higher-paying 
specialties so they can get those paid off. If we have got 
training tracks--where--idealistic young medical students are 
working with my colleagues here--and they see they see how 
rewarding it is to work in that environment, they stay.
    Senator Kaine. For each of you, how important is well-
designed public service loan forgiveness programs to attracting 
health care professional, not just Physicians but all 
healthcare professions, especially to underserved communities?
    Dr. Anderson. Yes, thank you. I can say that I had the 
National Health Service Corps scholarship when I was a medical 
student. And then I also have the National Health Service Corps 
loan repayment program after my scholarship commitment finished 
and I can say that these programs are critical in recruiting 
the workforce that we need to serve our communities. Even at my 
site, I would say a large number of our providers have been 
either currently in the program or in the past, and I would say 
a majority of those also teach in our residency program. And so 
continuing the pipeline like Dr. Freeman was saying, training 
the next generation and showing people how it is possible to 
help these communities.
    Senator Kaine. Mr. Trumpeter, where you going to speak a 
word about public service loan forgiveness also?
    Mr. Trompeter. I was and it is, like Dr. Anderson said, 
critical. 50 percent of our providers are either current 
recipients or past recipients of loan repayment programs. It is 
the way that we could get people and the way that we can keep 
them.
    Senator Kaine. Let me ask go switching to another topic, I 
notice when I am in rural Virginia that there is a significant 
percentage of doctors, especially, but some of their health 
professionals, who are immigrants, who have come from other 
countries and may be trained in other countries. Sometimes they 
have done a medical training in other country and done a 
residency after matching in the United States. And I have gone 
through other parts of rural America and seen the same thing--
in terms of meeting our workforce needs, and I think Dr. 
Anderson, you are bilingual, correct?
    Dr. Anderson. Yes.
    Senator Kaine. In meeting our workforce needs to deal with 
a diverse population, isn't it important that we think about 
the immigration topic--we often of the immigration topic as a 
security issue, is not it also important that we really think 
about workforce and the need especially in some harder hit 
communities. The right immigration policy can help us even in 
healthcare workforce. Would you not agree with that?
    Dr. Anderson. I would say that the community health centers 
serve everyone that comes to our doors regardless of their 
ability to pay and we serve everyone in the community 
regardless of where that community is. Earlier in the in the 
testimony, I held up the oath that I took at Brown University 
to serve patients and serve humanity and the National Health 
Service Corps and the community health center program has made 
it possible to serve all patients regardless of their ability 
to pay or their social standing.
    Senator Kaine. Let me focus on the work force though as I 
conclude. Do you also believe that for the workforce that you 
need to serve populations may be especially in rural America, 
that thinking about immigration policy is one way of dealing 
with meeting workforce needs in rural America?
    Dr. Waits. Definitely, we are here representing the idea of 
training local high school students that go through the 
pipeline to medical school and to our training programs, but we 
all definitely have colleagues who did medical school in 
another country and have provided awesome service to our rural 
communities to our inner city communities. We have had 
colleagues that we were residency and did fellowship with that 
were from other countries, and so a very clearly articulated 
set of rules for our colleagues that did medical school in 
other countries and come here to train and graduate medical 
education and often choose to stay as a destination to serve--
this exact workforce need we are talking about--A clearly 
articulated policy around that would be would be helpful in 
terms of workforce.
    Senator Kaine. Thank you.
    Mr. Chairman.
    The Chairman. Thank you Senator Kaine. The hearing record 
will remain open for 10 days. Members may submit additional 
information for the record within that time if they would like.
    The Chairman. Our Committee will meet again on Tuesday at 
10:00 a.m. for a hearing on how primary care affects health 
care costs. Thank you for being here. The Committee will stand 
adjourned.

                          Additional Material

                                American Academy of
                                 Family Physicians.

Hon. Lamar Alexander, Chairman,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.

Hon. Patty Murray, Ranking Member,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.

    On behalf of the American Academy of Family Physicians 
(AAFP) thank you for the opportunity to submit this Statement 
for the Record for the U.S. Senate Health, Education, Labor, 
and Pensions Committee's hearing, Access to Care: Health 
Centers and Providers in Underserved Communities.

    The AAFP appreciates the Committee's interest in examining 
health care access and underserved communities. Consistent with 
the World Health Organization's definition, the AAFP believes 
that health is ``a state of complete physical, mental, and 
social well-being and not merely the absence of disease or 
infirmity.'' As the largest society of primary care physicians, 
we are committed to helping patients achieve health and in 
supporting initiatives that build healthy communities. It is 
also our view that community health does not occur by 
coincidence. Healthy communities develop through robust 
research as well as investments from citizens, community-based 
organizations, educational institutions, governments, and the 
private sector.

         Primary Care is Associated with Healthier Communities

    The AAFP acknowledges that family physicians play an 
important role in community health, both as clinicians, but 
also as community partners who understand that factors outside 
of the doctor's office (the social determinants of health) 
impact patient health and the health of a community. Still, 
primary care (comprehensive, first contact, whole person, 
continuing care) is the foundation of an efficient health 
system. It is not limited to a single disease or condition, and 
can be accessed in a variety of settings. Primary care (family 
medicine, general internal medicine and general pediatrics) is 
provided and managed by a personal physician, based on a strong 
physician-patient relationship, and requires communication and 
coordination with other health professionals and medical 
specialists. The benefits of primary care do not just accrue to 
the individual patient. Primary care also translates into 
healthier communities. For instance, U.S. states with higher 
ratios of primary care physician-to-population ratios have 
better health outcomes, including lower rates of all causes of 
mortality: mortality from heart disease, cancer, or stroke; 
infant mortality; low birth weight; and poor self-reported 
health. This is true even after controlling for 
sociodemographic measures (percentages of elderly, urban, and 
minority; education; income; unemployment; pollution) and 
lifestyle factors (seatbelt use, obesity, and tobacco use). \1\
---------------------------------------------------------------------------
    \1\  Shi L, The relationship between primary care and life chances. 
J Health Care Poor Underserved. 1992 Fall; 3(2):321-35

    The dose of primary care can even be measured - an increase 
of one primary care physician per 10,000 people is associated 
with an average mortality reduction of 5.3 percent, or 49 fewer 
deaths per 100,000 per year. \2\ High quality primary care is 
necessary to achieve the triple aim of improving population 
health, enhancing the patient experience and lowering per 
capita costs. \3\
---------------------------------------------------------------------------
    \2\  Macinko J, Starfield B, Shi L. Quantifying the health benefits 
of primary care physician supply in the United States. Int J Health 
Serv. 2007;37(1):111-26.
    \3\  Shi L, Starfield B, Primary care, income inequality, and self-
rated health in the United States: a mixed-level analysis. Int J Health 
Serv. 2000; 30(3):541-55.

    Patients, particularly the elderly, with a usual source of 
care are healthier and have lower medical costs because they 
use fewer health care resources and can resolve their health 
needs more efficiently. \4\ In contrast, those without a usual 
source of care have more problems accessing health care and 
more often do not receive appropriate medical help when it is 
necessary. \5\ Patients with a usual source of care have fewer 
expensive emergency room visits, unnecessary tests and 
procedures. They also enjoy better care coordination. \6\ We 
believe it is in the national interest to support programs with 
the potential to help improve patient access for primary 
medical care, particularly for vulnerable populations.
---------------------------------------------------------------------------
    \4\  Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D. 
E., Graham, J., Roy, J. A., & Steele, J. D. (2010). Value and the 
Medical Home: Effects of Transformed Primary Care. American Journal of 
Managed Care, 16(8), 607-615
    \5\  Ibid.
    \6\  Liaw, W., Jetty, A., Petterson, S., Bazemore, A. and Green, L. 
(2017), Trends in the Types of Usual Sources of Care: A Shift from 
People to Places or Nothing at All. Health Serv Res. doi:10.1111/1475-
6773.12753
---------------------------------------------------------------------------

           Primary Care Workforce and Underserved Communities

    The current physician shortage and uneven distribution of 
physicians impacts population health. A U.S. Centers for 
Disease Control and Prevention study indicated that patients in 
rural areas tend to have shorter life spans, and access to 
health care is one of several factors contributing to rural 
health disparities. \7\ The report recommended greater patient 
access to basic primary care interventions such as high blood 
pressure screening, early disease intervention, and health 
promotion (tobacco cessation, physical activity, healthy 
eating). \8\ The findings highlighted in the CDC's report are 
consistent with numerous others on health equity, including a 
longitudinal study published in JAMA Internal Medicine, 
indicating that a person's zip code may have as much influence 
on their health and life expectancy as their genetic code. \9\ 
Therefore, it is imperative that physician care is accessible 
to all.
---------------------------------------------------------------------------
    \7\  Moy E, Garcia MC, Bastian B, et al, Leading Cause sof Death in 
Nonmetropolitan and Metropolitan Areas - United States, 1999 - 2014, 
MMWR, Surveil Summ, 2017; 66 (No.SS-1); 1-8. DOI: https://www.cdc.gov/
mmwr/volumes/66/ss/ss6601a1.htm
    \8\  MMWR, 2017
    \9\  Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C, 
Mackenbach JP, van Lenthe FJ, Mokdad AH, Murray CJL. Inequalities in 
Life Expectancy Among US Counties, 1980 to 2014Temporal Trends and Key 
Drivers. JAMA Intern Med. 2017;177(7):1003-1011. doi:10.1001/
jamainternmed.2017.0918

    The current primary care physician shortage and 
maldistribution remain significant physician workforce 
challenges. An Annals of Family Medicine study projects that 
the changing needs of the U.S. population will require an 
additional 33,000 practicing primary care physicians by 2035. 
\10\ A 2017 Government Accountability Office (GAO) report 
indicates that physician maldistribution significantly impacts 
rural communities. \11\ The patient-to-primary care physician 
ratio in rural areas is only 39.8 physicians per 100,000 
people, compared to 53.3 physicians per 100,000 in urban areas. 
\12\ According to GAO, one of the major drivers of physician 
maldistribution is that medical residents are highly 
concentrated in very few parts of the country. The report 
stated that graduate medication education (GME) training 
remained concentrated in the Northeast and in urban areas, 
which continue to house 99 percent of medical residents. \13\ 
The GAO also indicated that while the total number of residents 
increased by 13.6 percent from 2001 to 2010, the number 
expected to enter primary care decreased by 6.3 percent. \14\
---------------------------------------------------------------------------
    \10\  http://www.annfammed.org/content/13/2/107.full
    \11\  U.S. Government Accountability Office, May 2017, GAO 17-411, 
http://www.gao.gov/assets/690/684946.pdf
    \12\  Hing, E, Hsiao, C. US Department of Health and Human 
Services. State Variability in Supply of Office-based Primary Care 
Providers: United States 2012. NCHS Data Brief, No. 151, May 2014
    \13\  GAO, 2017
    \14\  Ibid

    Primary care workforce programs, such as the Teaching 
Health Center Graduate Medical Education Program and the 
National Health Service Corp Program, are essential resources 
to begin to increase the number of primary care physicians and 
to ensure they work in communities that need them most. The 
THCGME program appropriately trains residents who then stay in 
the community. THCGME residents are trained in delivery system 
models using electronic health records, providing culturally 
competent care, and following care coordination protocols. \15\ 
Some are also able to operate in environments where they are 
trained in mental health, drug and substance use treatment, and 
chronic pain management. \16\ Residents who train in 
underserved communities are likely to continue practicing in 
those same environments. \17\
---------------------------------------------------------------------------
    \15\  Candice Chen, Frederick Chen, and Fitzhugh Mullan. Teaching 
Health Centers: A New Paradigm in Graduate Medical Education.'' 
Academic Medicine: Journal of the Association of American Medical 
Colleges 87.12 (2012): 1752-1756. PMC. available at https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3761371/
    \16\  David Mitchell, Residency Directors Tout Benefits of Teaching 
Health Center GME Program, AAFP News, (September 6, 2013), available at 
http://www.aafp.org/news/education-professional-development/
20130906thcroundtable.html
    \17\  Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching 
Health Center GME Funding Instability Threatens Program Viability, Am 
Fam Physician. (Feb. 2015);91(3):168-170. Available at http://
www.aafp.org/afp/2015/0201/p168.html

    American Medical Association Physician Masterfile data 
confirms that a majority of family medicine residents practice 
within 100 miles of their residency training location. \18\ By 
comparison, fewer than 5 percent of physicians who complete 
training in hospital-based GME programs provide direct patient 
care in rural areas. \19\ Thus, the most effective way to 
encourage family and other primary-care physicians to practice 
in rural and underserved areas is not to recruit them from 
remote academic medical centers but to train them in these 
settings. Similarly, the National Health Service Corps (NHSC) 
offers financial assistance to recruit and retain health care 
providers to meet the workforce needs of communities across the 
nation designated as health professional shortage areas 
(HPSAs). The NHSC is vital for supporting the needs of our 
nation's vulnerable communities. The AAFP believes building the 
primary care workforce is an important return on investment. We 
also believe that workforce programs help ensure high quality, 
efficient medical care is more readily available. By reducing 
physician shortages and attracting physicians to serve in 
communities that need them, these programs also help improve 
the way care is delivered and help meet the nation's health 
care goals.
---------------------------------------------------------------------------
    \18\  E. Blake Fagan, MD, et al., Family Medicine Graduate 
Proximity to Their Site of Training, Family Medicine, Vol. 47, No. 2, 
at 126 (Feb. 2015).
    \19\  Candice Chen, MD, MPH, et al., Toward Graduate Medical 
Education (GME) Accountability: Measuring the Outcomes of GME 
Institutions, Academic Medicine, Vol. 88, No. 9, p. 1269 (Sept. 2013).

    Community health centers (CHCs) play an important role in 
primary care graduate medical education as well. The nation's 
9,800 CHCs provide care for 25 million patients, 71 percent of 
whom are low-income. \20\ CHC facilities, along with other 
safety net providers, are also valuable training settings for 
THCGME residents who care for patients like those they are 
likely to treat in primary care outpatient settings. Residents 
who train in CHCs also have the unique opportunity to be 
trained in delivery system models using electronic health 
records, providing culturally competent care, and following 
care coordination protocols. \21\ Some are also able to operate 
in environments where they are trained in mental health, drug 
and substance use treatment, and chronic pain management. \22\ 
Residents who train in underserved communities are likely to 
continue practicing in those same environments. \23\ An 
important, but unique element within the THCGME program is that 
its accountability measures require an evaluation of the number 
of physicians who continue practicing after residency and if 
they continue serving in rural and underserved communities.
---------------------------------------------------------------------------
    \20\  National Association of Community Health Centers, About Our 
Health Centers, available at http://www.nachc.org/about-our-health-
centers/
    \21\  Candice Chen, Frederick Chen, and Fitzhugh Mullan. Teaching 
Health Centers: A New Paradigm in Graduate Medical Education.'' 
Academic Medicine: Journal of the Association of American Medical 
Colleges 87.12 (2012): 1752-1756. PMC. available at https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3761371/
    \22\  David Mitchell, Residency Directors Tout Benefits of Teaching 
Health Center GME Program, AAFP News, (September 6, 2013), available at 
http://www.aafp.org/news/education-professional-development/
20130906thcroundtable.html
    \23\  Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching 
Health Center GME Funding Instability Threatens Program Viability, Am 
Fam Physician. (Feb. 2015);91(3):168-170. Available at http://
www.aafp.org/afp/2015/0201/p168.html

    We appreciate Senators Lamar Alexander and Patty Murray's 
leadership in introducing S. 192, a bill that will reauthorize 
the Teaching Health Center Graduate Medical Education program, 
National Health Service Corps program, and Community Health 
Centers programs. This five-year reauthorization will help lay 
the foundation for much-needed stability and funding adequacy 
for these important programs.

               Family Physicians and Health Care for All

    The AAFP also supports health care for all, consistent with 
the public health mission of the specialty of family medicine. 
The AAFP promotes health care for all in the form of a primary 
care benefit design featuring the patient-centered medical 
home, and a payment system to support it for everyone in the 
United States. \24\ AAFP believes that all Americans should 
have access to primary care services (e.g. in the case of 
infants and children, immunizations and other evidence-based 
preventive services, prenatal care, and well-child care), 
without cost sharing. The AAFP believes that health care for 
all should also include services outside the medical home (e.g. 
hospitalizations) with reasonable and appropriate cost sharing 
allowed, but with protections from financial hardship. 
Supporting access to care for everyone in the United States is 
consistent with the ``triple aim'' of improving patient 
experience, improving population health, and lowering the total 
cost of health care. Having both health insurance and a usual 
source of care (e.g., through an ongoing relationship with a 
family physician) contributes to better health outcomes, 
reduced disparities along socioeconomic lines, and reduced 
costs. \25\
---------------------------------------------------------------------------
    \24\  AAFP, Health Care For All (2014), available athttp://
www.aafp.org/about/policies/all/health-care-for-all.html
    \25\  See, e.g., The Robert Graham Center, The Importance of Having 
Health Insurance and a Usual Source of Care, Am. Fam. Physician (Sept. 
15, 2004), available at http://www.aafp.org/afp/2004/0915/p1035.html.

    The AAFP urges each and every one of its members to become 
involved personally in improving the health of people from 
minority and socioeconomically disadvantaged groups. The 
Academy supports: cooperation between local family physicians 
and community health centers; promotion of health education in 
schools, faith-based organizations, and community groups; 
continuation of beneficial programs that serve to promote 
health and disease prevention; simplified regulations and 
improved payment to encourage the establishment and success 
\26\ of physician practices in underserved areas; and 
development of programs to encourage the provision of services 
by physicians and other health care professionals in 
underserved areas.
---------------------------------------------------------------------------
    \26\  AAFP, Medically Underserved (2013), available at https://
www.aafp.org/about/policies/all/medically-underserved.html

    Health care access is also a significant barrier, 
especially for low-income individuals. The AAFP first adopted a 
policy supporting health care coverage for all three decades 
ago. For the past 28 years the AAFP has advanced and supported 
policies that ensure a greater number of Americans enjoy the 
security of health care coverage. The AAFP appreciates the 
bipartisan support for the Medicare Access and CHIP 
Reauthorization Act's (MACRA) landmark reforms that have the 
potential for improving patient care outcomes by emphasizing 
value over fee-for-service. We welcome the opportunity to work 
with policymakers to evaluate MACRA's implementation process 
---------------------------------------------------------------------------
and the potential to improve patient outcomes.

    It is also important to acknowledge that passage of the 
Patient Protection and Affordable Care Act represented a sea 
change for millions of patients. We are pleased the Committee 
has engaged in bipartisan hearings to examine ways to improve 
the individual market as well as proposals to maintain cost-
sharing reduction payments. Medicaid expansion and the law's 
Essential Health Benefits were particularly important for 
vulnerable populations. Medicaid assists the most vulnerable 
patients who are often members of minority groups, homeless, 
formerly incarcerated, foster and former foster youth, mentally 
ill, addicted, and/or in military families. Insurance coverage 
rates among minorities are lower than rates among the non-
Hispanic white population. \27\ Minorities experience 
disproportionate rates of illness, premature death, and 
disability compared to the general population. \28\ In 
addition, virtually all of the estimated individuals nationally 
who are homeless could be eligible for Medicaid. Many in this 
population would benefit from the mental health and addiction 
treatment requirement included under the law. \29\ Forty 
percent of our nation's veterans who are under 65 years of age 
have incomes that could qualify them for Medicaid under the 
ACA's expanded coverage. \30\ In general, family members of 
veterans are not covered by the Veteran's Administration, but 
may seek coverage through Medicaid or the marketplace. \31\ 
Many patients in this category are unaware that they qualify 
for health benefits.
---------------------------------------------------------------------------
    \27\  Center for Health Care Statistics (CHCS), Reaching Vulnerable 
Populations Through Health Reform, April 2014, available athttp://
www.chcs.org/media/Vulnerable-Populations--April-2014.pdf
    \28\  Center for Health Care Statistics, April 2014
    \29\  Id.
    \30\  Id.
    \31\  Id.

    A New England Journal of Medicine article indicates that 
the law's coverage expansion was associated with higher rates 
of having a usual source of care, greater access to primary 
care access, and, higher rates of preventive health screenings. 
\32\ Anecdotal evidence among family physicians also reveals 
that health care access is saving lives and improving patient 
health for those who are accessing much-needed care for chronic 
diseases or detecting health challenges in their initial 
stages. Again, achieving optimal health does not occur by 
accident. Realizing the vision of healthy communities, like 
other national priorities, requires that we identify goals, 
invest resources, and eliminate barriers, especially for 
vulnerable citizens.
---------------------------------------------------------------------------
    \32\  Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., 
M.P.H., and Katherine Baicker, Ph.D., N Engl J Med 2017; 377:586-593
---------------------------------------------------------------------------

                               Conclusion

    The AAFP appreciates the opportunity to share these 
comments on health access and vulnerable communities and 
welcomes the opportunity to work with policy makers to achieve 
positive outcomes on these and other policies. For more 
information, please contact Sonya Clay, Government Relations 
Representative, at 202-232-9033 or [email protected].
                                ------                                

                                   American College
                                     of Osteopathic
                                  Family Physicians

Hon. Lamar Alexander, Chairman,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.

Hon. Patty Murray, Ranking Member,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.
    On behalf of the more than 145,000 osteopathic physicians 
and medical students we represent, we applaud the Committee's 
leadership and bipartisan effort to address the shortage in our 
health care workforce. We are thankful for the Chairman and 
Ranking Member for introducing legislation that would 
reauthorize the Teaching Health Centers Graduate Medical 
Education Program (THCGME). In anticipation of the upcoming 
hearing, Access to Care: Health Centers and Providers in 
Underserved Communities, we would like to highlight the need, 
and encourage the Committee, to support funding for growth in 
the reauthorization of the THCGME program to help address the 
shortage in our health care workforce.

    The majority of THCGME programs are currently accredited by 
the AOA or are dually accredited (DO/MD) programs, supporting 
nearly 800 osteopathic resident physicians through their 
training since the program's inception. Located in 27 states 
and the District of Columbia, THCGME programs train residents 
in much-needed primary care fields that have the largest 
shortages nationally, including family medicine, internal 
medicine, pediatrics, obstetrics and gynecology, psychiatry, 
geriatrics, and dentistry. It is a vital source of training for 
primary care residents to help expand access to care in rural 
and underserved communities throughout the country.

    Osteopathic physicians (DOs) are fully-licensed to practice 
in all specialty areas of medicine, with nearly 57 percent of 
active DOs in primary care. Our training emphasizes a whole-
person approach to treatment and care, where we partner with 
our patients to help them get healthy and stay well. 
Osteopathic medical education also has a long history of 
establishing educational programs for medical students and 
residents that target the health care needs of rural and 
underserved populations. Given this strong presence in primary 
care, osteopathic medicine aligns naturally with the mission 
and goals of the THCGME program that has proven successful in 
helping address the existing gaps in our nation's primary care 
workforce.

    Residents who train in THC programs are far more likely to 
specialize in primary care and remain in the communities in 
which they have trained. Data shows that, when compared to 
traditional postgraduate trainees, residents who train at THCs 
are more likely to practice primary care (82 percent vs. 23 
percent) and remain in underserved (55 percent vs. 26 percent) 
or rural (20 percent vs. 5 percent) communities. It is clear 
that a well-designed THCGME program not only plays a vital role 
in training our next generation of primary care physicians, but 
helps to bridge our nation's physician shortfall. The program 
also tackles the issue of physician maldistribution, and helps 
address the need to attract and retain physicians in rural 
areas and medically underserved communities. In the 2016-2017 
academic year, nearly all residents received training in 
primary care settings and 83 percent of residents trained in 
Medically Underserved Communities.

    However, reauthorizing the THCGME program at its current 
level funding, for the next five years, would lead to a 
reduction of approximately 70 residency slots from the 
currently funded 737 residency positions.

    We respectfully ask the Committee to consider legislation 
by Senators Susan Collins (R-ME), Doug Jones (D-AL), Shelley 
Moore Capito (R-WV), Jon Tester (D-MT), and John Boozman (R-AR) 
the ``Training the Next Generation of Primary Care Doctors Act 
of 2019.'' In addition to reauthorizing the THCGME program for 
the next five years, this bill also provides funding and a 
pathway for growth in the number of residents trained in 
underserved rural and urban communities. This represents a much 
needed expansion to address the physician shortages in our 
country.

    We would also like to briefly highlight the broader role 
osteopathic physicians have in reducing our nation's physician 
shortage. Since 2010, the number of DOs has increased by 54 
percent. Today, more than 65 percent of all DOs are under the 
age of 45, and if current enrollment trends continue, DOs are 
projected to represent more than 20 percent of practicing 
physicians by 2030. Because of the whole-person approach to 
patient care that is inherent in osteopathic medicine, the 
increasing share of DOs in the physician workforce, and the 
number of DOs in primary care specialties, we have a unique and 
important perspective on the needs of our nation's health care 
workforce and would welcome the opportunity to contribute to 
your work on this issue.

    We appreciate your bipartisan effort to address the 
shortage in our country's health care workforce, and we stand 
ready to assist in your effort.

            Sincerely,

          American College of Osteopathic Family Physicians
                 American College of Osteopathic Internists
         American College of Osteopathic Obstetricians and 
                                              Gynecologists
          American College of Osteopathic Neurologists and 
                                              Psychiatrists
              American College of Osteopathic Pediatricians
                           American Osteopathic Association

    [Whereupon, at 11:55 a.m., the hearing was adjourned.]

                                   [all]