[Joint House and Senate Hearing, 117 Congress]
[From the U.S. Government Publishing Office]


                  CARE FOR OUR COMMUNITIES: INVESTING
                      IN THE DIRECT CARE WORKFORCE

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

                             JOINT HEARING

                               BEFORE THE

                            SUBCOMMITTEE ON
                          HEALTH, EMPLOYMENT,
                          LABOR, AND PENSIONS


                                AND THE

                            SUBCOMMITTEE ON
                          HIGHER EDUCATION AND
                          WORKFORCE INVESTMENT

                                 of the

                    COMMITTEE ON EDUCATION AND LABOR
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION
                               __________

             HEARING HELD IN WASHINGTON, DC, JULY 20, 2021
                               __________

                           Serial No. 117-23
                               __________

      Printed for the use of the Committee on Education and Labor

                                     
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
                                     

          Available via: edlabor.house.gov or www.govinfo.gov

                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
46-174 PDF                WASHINGTON : 2022   
                               
                               
                               
                               

                    COMMITTEE ON EDUCATION AND LABOR

             ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

RAUL M. GRIJALVA, Arizona            VIRGINIA FOXX, North Carolina,
JOE COURTNEY, Connecticut              Ranking Member
GREGORIO KILILI CAMACHO SABLAN,      JOE WILSON, South Carolina
  Northern Mariana Islands           GLENN THOMPSON, Pennsylvania
FREDERICA S. WILSON, Florida         TIM WALBERG, Michigan
SUZANNE BONAMICI, Oregon             GLENN GROTHMAN, Wisconsin
MARK TAKANO, California              ELISE M. STEFANIK, New York
ALMA S. ADAMS, North Carolina        RICK W. ALLEN, Georgia
MARK DeSAULNIER, California          JIM BANKS, Indiana
DONALD NORCROSS, New Jersey          JAMES COMER, Kentucky
PRAMILA JAYAPAL, Washington          RUSS FULCHER, Idaho
JOSEPH D. MORELLE, New York          FRED KELLER, Pennsylvania
SUSAN WILD, Pennsylvania             GREGORY F. MURPHY, North Carolina
LUCY McBATH, Georgia                 MARIANNETTE MILLER-MEEKS, Iowa
JAHANA HAYES, Connecticut            BURGESS OWENS, Utah
ANDY LEVIN, Michigan                 BOB GOOD, Virginia
ILHAN OMAR, Minnesota                LISA C. McCLAIN, Michigan
HALEY M. STEVENS, Michigan           DIANA HARSHBARGER, Tennessee
TERESA LEGER FERNANDEZ, New Mexico   MARY E. MILLER, Illinois
MONDAIRE JONES, New York             VICTORIA SPARTZ, Indiana
KATHY E. MANNING, North Carolina     SCOTT FITZGERALD, Wisconsin
FRANK J. MRVAN, Indiana              MADISON CAWTHORN, North Carolina
JAMAAL BOWMAN, New York, Vice-Chair  MICHELLE STEEL, California
MARK POCAN, Wisconsin                JULIA LETLOW, Louisiana
JOAQUIN CASTRO, Texas                Vacancy
MIKIE SHERRILL, New Jersey
JOHN A. YARMUTH, Kentucky
ADRIANO ESPAILLAT, New York
KWEISI MFUME, Maryland

                   Veronique Pluviose, Staff Director
                  Cyrus Artz, Minority Staff Director
                                 ------                                

        SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR, AND PENSIONS

                 MARK DeSAULNIER, California, Chairman

JOE COURTNEY, Connecticut            RICK W. ALLEN, Georgia
DONALD NORCROSS, New Jersey            Ranking Member
JOSEPH D. MORELLE, New York          JOE WILSON, South Carolina
SUSAN WILD, Pennsylvania             TIM WALBERG, Michigan
LUCY McBATH, Georgia                 JIM BANKS, Indiana
ANDY LEVIN, Michigan                 DIANA HARSHBARGER, Tennessee
HALEY M. STEVENS, Michigan           MARY E. MILLER, Illinois
FRANK J. MRVAN, Indiana              SCOTT FITZGERALD, Wisconsin
ROBERT C. ``BOBBY'' SCOTT, Virginia  VIRGINIA FOXX, North Carolina
  (ex officio)                         (ex officio)

       SUBCOMMITTEE ON HIGHER EDUCATION AND WORKFORCE INVESTMENT

                FREDERICA S. WILSON, Florida, Chairwoman

MARK TAKANO, California              GREGORY F. MURPHY, North Carolina
PRAMILA JAYAPAL, Washington            Ranking Member
ILHAN OMAR, Minnesota                GLENN GROTHMAN, Wisconsin
TERESA LEGER FERNANDEZ, New Mexico   ELISE M. STEFANIK, New York
MONDAIRE JONES, New York             JIM BANKS, Indiana
KATHY E. MANNING, North Carolina     JAMES COMER, Kentucky
JAMAAL BOWMAN, New York              RUSS FULCHER, Idaho
MARK POCAN, Wisconsin                MARIANNETTE MILLER-MEEKS, Iowa
JOAQUIN CASTRO, Texas                BOB GOOD, Virginia
MIKIE SHERRILL, New Jersey           LISA C. McCLAIN, Michigan
ARIANO ESPAILLAT, New York           DIANA HARSHBARGER, Tennessee
RAUL M. GRIJALVA, Arizona            VICTORIA SPARTZ, Indiana
JOE COURTNEY, Connecticut            JULIA LETLOW, Louisiana
SUZANNE BONAMICI, Oregon             VIRGINIA FOXX, North Carolina
ROBERT C. ``BOBBY'' SCOTT, Virginia    (ex officio)
  (ex officio)


                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on July, 20 2021....................................     1

Statement of Members:
    DeSaulnier, Hon. Mark, Chairman, Subcommittee on Health, 
      Employment, Labor, and Pensions............................     1
        Prepared statement of....................................     3
    Allen, Hon. Rick, Ranking Member, Subcommittee on Health, 
      Employment, Labor, and Pensions............................     4
        Prepared statement of....................................     5
    Wilson, Hon. Frederica S., Chairwoman, Subcommittee on Higher 
      Education and Workforce Investment.........................     6
        Prepared statement of....................................     7
     Murphy, Hon. Gregory F., Ranking Member, Subcommittee on 
      Higher Education and Workforce Investment..................     7
        Prepared statement of....................................     8

Statement of Witnesses:
    Burani, Paul, Head of Business Development in North America, 
      Udacity....................................................    25
        Prepared statement of....................................    28
    Espinoza, Robert, Vice President of Policy, PHI..............     9
        Prepared statement of....................................    11
    Fay, Hon. Jessica, State Representative, Maine House of 
      Representatives............................................    34
        Prepared statement of....................................    36
    Torres, Zulma, Home Health Aide, Cooperative Home Care 
      Associates.................................................    19
        Prepared statement of....................................    21

Additional Submissions:
    Questions submitted for the record by:
        Chairman Scott...........................................   135
    Response to question submitted for the record by:
        Rep. Fay.................................................   136

 
                  CARE FOR OUR COMMUNITIES: INVESTING
                    IN THE DIRECT CARE WORKFORCE

                              ----------                              


                         Tuesday, July 20, 2021

                  House of Representatives,
                Subcommittee on Health, Employment,
                               Labor, and Pensions,
    Subcommittee on Higher Education and Workforce 
                                        Investment,
                          Committee on Education and Labor,
                                                    Washington, DC.
    The subcommittees met, pursuant to notice, at 10:17 a.m., 
via Zoom, Hon. Mark DeSaulnier (Chairman of the Subcommittee on 
Health, Employment, Labor and Pensions) presiding.
    Present: DeSaulnier, Wilson, Courtney, Bonamici, Takano, 
Norcross, Jayapal, Morelle, Wild, McBath, Levin, Stevens, 
Fernandez, Manning, Mrvan, Bowman, Pocan, Castro, Sherrill, 
Espaillat, Scott (ex officio), Murphy, Allen, Walberg, 
Grothman, Banks, Fulcher, Miller-Meeks, Good, McClain, 
Harshbarger, Spartz, Fitzgerald, Letlow, and Foxx (ex officio).
    Staff present: Phoebe Ball, Disability Counsel; Ilana 
Brunner, General Counsel; Rasheedah Hasan, Chief Clerk; Sheila 
Havenner, Director of Information Technology; Eli Hovland, 
Policy Associate; Carrie Hughes, Director of Health and Human 
Services; Ariel Jona, Policy Associate; Andre Lindsay, Policy 
Associate; Richard Miller, Director of Labor Policy; Max Moore, 
Staff Assistant; Mariah Mowbray, Clerk/Special Assistant to the 
Staff Director; Lorin Obler, GAO Detailee; Kayla Pennebecker, 
Staff Assistant; Veronique Pluviose, Staff Director; Banyon 
Vassar, Deputy Director of Information Technology; Cyrus Artz, 
Minority Staff Director; Rob Green, Minority Director of 
Workforce Policy; Amy Raaf Jones, Minority Director of 
Education and Human Resources Policy; Dean Johnson, Minority 
Legislative Assistant; Georgie Littlefair, Minority Legislative 
Assistant; Hannah Matesic, Minority Director of Operations; 
Audra McGeorge, Minority Communications Director; Chance 
Russell, Minority Legislative Assistant; Mandy Schaumburg, 
Minority Chief Counsel and Deputy Director of Education Policy; 
Michael Davis, Minority Operations Assistant; and Taylor 
Hittle, Minority Professional Staff Member.
    Chairman DeSaulnier. The Subcommittee on Health, 
Employment, Labor, Pensions, and the Subcommittee on Higher 
Education and Workforce Investment will come to order. Welcome 
again, everyone. I note that a quorum is present.
    The subcommittees are meeting today for a joint hearing on 
Care for Our Communities: Investing in the Direct Care 
Workforce.
    This is an entirely remote hearing, and, as such, the 
Committee's hearing room is officially closed. All microphones 
will be kept muted as a general rule to avoid unnecessary 
background noise.
    Members and witnesses will be responsible for unmuting 
themselves when they are recognized to speak, or when they wish 
to seek recognition.
    If a Member or witness experiences technical difficulties 
during the hearing, please stay connected in the platform. Make 
sure you are muted and use your phone immediately to call the 
Committee's IT director, whose number was provided in advance.
    Should the Chair experience technical difficulty or need to 
step away, Chairwoman Wilson or another majority Member is 
hereby authorized to assume the gavel in the Chair's absence.
    In order to ensure the Committee's five-minute rule is 
adhered to, staff will be keeping track of time using the 
Committee's remote timer, which appears in its own thumbnail 
picture. Members and witnesses are asked to wrap up promptly 
when their time is expired.
    Pursuant to Committee Rule 8(c), opening statements are 
limited to the Chairs and Ranking Members. This allows us to 
hear from our witnesses sooner and provides all Members with 
adequate time to ask questions.
    I now recognize myself for the purpose of making an opening 
statement.
    Today, we will be hearing about the valuable work performed 
by America's direct care workforce and the urgent care and need 
to expand these services for aging Americans and Americans with 
disabilities.
    Direct care makes it possible for millions of Americans to 
live independently in their homes and their communities. The 
degree to which these vital services enhance the quality of 
life for aging and disabled Americans cannot be overstated.
    They enable individuals who need assistance with activities 
of daily living to live healthy and productive lives and remain 
active participants in their communities. We know that people 
want to stay at home, and they want to stay in their 
communities as long as possible and as much as possible. Direct 
care workers are a crucial part to ending the unnecessary 
segregation and advancing the civil rights of individuals with 
disabilities as outlined in the Supreme Court's 1990 Olmstead 
decision.
    Unfortunately these services are often unaffordable and 
inaccessible for those who need them most. Private insurance 
and Medicare often provide only limited coverage for home-and 
community-based services, forcing family Members and friends to 
care for loved ones, or, alternatively, to pay out of pocket 
for those services until their resources are depleted enough 
for Medicaid to kick in.
    The demand for direct care is also rapidly outpacing the 
growth of the direct care workforce, and, unfortunately, 
individuals who need home-and community-based services often 
find it impossible to access the support they need.
    The direct care sector is expected to add more than 1.3 
million jobs between 2018 and 2028. Yet the number of people 
who will need direct care continues to exceed the number of 
workers who can provide it. To address this shortage, we must 
understand the causes.
    Direct care workers, disproportionately women of color, are 
chronically undervalued and overworked. Medicaid is, by far, 
the largest funding source for direct care services, and 
Medicaid reimbursement rates have not allowed wages to increase 
as fast as those in these occupations.
    Today, roughly one in six in direct care workers lives in 
poverty, one in six of these workers lives in poverty. The 
turnover rate for direct care workforce in 2018 was 82 percent. 
And that was before the pandemic, which forced more than 
200,000 direct care workers to leave their jobs.
    Today, we will discuss the need to ensure access to direct 
care services for those who need them, and also support the 
worker force that delivers these services.
    The American Jobs Plan calls for robust investments to 
expand access to home-and community-based services for Medicaid 
and to strengthen the workforce through higher wages, better 
benefits, and sector-based job training and supports.
    The Direct Creation, Advancement, and Retention of 
Employment Opportunity Act, or Direct CARE Opportunity Act, 
also expands workers' earning potential and provides the 
financial assistance for transportation, childcare, and housing 
that workers need to stay in their jobs.
    Our society and our economy depend on direct care workers. 
They deserve better, as do their clients. We are committed to 
that goal.
    I now recognize the distinguished Ranking Member of the 
Subcommittee on Health--I am sorry. I now recognize the 
distinguished Ranking Member of the Subcommittee on Health, 
Employment, Labor, and Pensions for the purpose of making an 
opening statement.
    [The statement of Chairman DeSaulnier follows:]

             Statement of Hon. Mark DeSaulnier, Chairman, 
        Subcommittee on Health, Employment, Labor, and Pensions

    Today we will be hearing about the valuable work informed by 
America's direct care workforce, and the urgent need to expand these 
services for aging Americans and individuals with disabilities.
    Direct care makes it possible for millions of people to live 
independently in their homes and communities. The degree to which these 
vital services enhance the quality of life for aging and disabled 
Americans cannot be overstated. They enable individuals who need 
assistance with activities of daily living to live healthy and 
productive lives and remain active participants in their communities.
    We know that people want to stay at home, and they want to stay in 
their communities as long as possible and as much as possible. Direct 
care workers are a crucial part to ending the unnecessary segregation 
and advancing the civil rights of individuals with disabilities, as 
outlined in Supreme Court's 1999 Olmstead decision.
    Unfortunately, these services are often unaffordable and 
inaccessible for those who need it most.
    Private insurance and Medicare often provide only limited coverage 
for home and community-based services, forcing family members and 
friends to care for loved ones or, alternatively, pay out-of-pocket for 
these services until their resources are depleted enough for Medicaid 
to kick in.
    The demand for direct care is also rapidly outpacing the growth of 
the direct care workforce. And unfortunately, individuals who need home 
and community-based services often find it impossible to access the 
support they need.
    The direct care sector is expected to add more than 1.3 million 
jobs between 2018 and 2028. Yet, the number of people who will need 
direct care continues to exceed the number of workers who can provide 
it. To address this shortage, we must understand the causes.
    Direct care workers--disproportionally women of color--are 
chronically undervalued and overworked.
    Medicaid is, by far, the largest funding source for direct care 
services, and Medicaid reimbursement rates have not allowed wages to 
increase as fast as those these occupations. Today, roughly 1 in 6 
direct care workers lives in poverty. 1 in 6 of these workers lives in 
poverty.
    The turnover rate for the direct care workforce in 2018 was 82 
percent. And that was before the pandemic, which forced more than 
200,000 direct care workers to leave their jobs.
    Today, we will discuss the need to ensure access to direct care 
services for those who need them and also support the workforce that 
delivers these services.
    The American Jobs Plan calls for robust investments to expand 
access to home and community-based services from Medicaid and 
strengthen the workforce through higher wages, better benefits, and 
sector-based job training and supports.
    The Direct Creation, Advancement, and Retention of Employment 
Opportunity Act of 2021, or Direct CARE Opportunity Act also expands 
workers' earning potential and provides the financial assistance for 
transportation, child care, and housing that workers need to stay in 
their jobs.
    Our society and our economy depend on direct care workers. They 
deserve better-as do their clients. We are committed to that cause.
    I now recognize the distinguished Ranking Member of the 
Subcommittee on Health, Employment, Labor and Pensions for the purpose 
of making an opening statement. Mr. Allen, good morning.
                                 ______
                                 
    Chairman DeSaulnier. Mr. Allen? Good morning.
    I think you might be muted, Mr. Allen.
    Mr. Allen. All right. There we go.
    Chairman DeSaulnier. There you are.
    Mr. Allen. You got me?
    Chairman DeSaulnier. We got you.
    Mr. Allen. Hey, thanks, Mr. Chairman. I thought I was right 
on schedule. I couldn't get in the hearing room, so I finally 
got in here. But we're here, and I want to thank my colleague, 
Dr. Murphy, for joining us in his role on his Subcommittee.
    I do find it ridiculous that, even unelected bureaucrats 
are back to working in person before Democrats in Congress, the 
Workforce Investment and Opportunity Act, WIOA, provides an 
important source of funding for State and local workforce 
development systems that are tasked with addressing needs of 
the community.
    The Federal Government does not have the knowledge or 
foresight required to dictate what States need. I believe we 
should err on the side of flexibility when designing and 
funding workforce development systems with taxpayer dollars.
    Direct care workers are an important part of the healthcare 
workforce and care for our most vulnerable patients. Their work 
is often difficult and unrecognized, but our healthcare workers 
are valuable and should be recognized for the sacrifices they 
have made, especially during the COVID-19 pandemic.
    We know there is an incredible amount of turnover in the 
labor market for direct care workers. We also know that most 
direct care workers did not pursue additional education after 
high school.
    As Ranking Member of the Subcommittee on Health, 
Employment, Labor, and Pensions, I hope today's hearing can 
shed light on how Congress can help all workers, including 
direct care workers, gain the skills they need to improve their 
upward mobility, and sustain a fulfilling career.
    New technologies and practices developed in the private 
marketplace are revolutionizing the healthcare field. We must 
ensure workers are not left behind. The Federal Government has 
an interest in sustaining a workforce pipeline that recruits, 
retains, and assists individuals interested in finding the 
right career for them, including careers within the healthcare 
workforce. But Congress cannot fall into the trap of having 
hundreds of different programs, each devoted to one particular 
occupation.
    This is why I advocate for apprentice-style programs. 
Combining structured on-the-job learning, and classroom-based 
instruction gives individuals a low-risk option to determine if 
a job is a good fit for them. In the same way, earn-and-learn 
programs are another way to help folks find that rewarding 
career.
    I look forward to working with my colleagues on both sides 
of the aisle to find innovative solutions to address the 
healthcare workforce challenges facing our Nation, and I look 
forward to hearing the witnesses' testimony today.
    And, with that, Mr. Chairman, I thank you, and I yield 
back.
    [The prepared statement of Mr. Allen follows:]

             Statement of Hon. Rick Allen, Ranking Member, 
        Subcommittee on Health, Employment, Labor, and Pensions

    Thank you, Chairman DeSaulnier.
    And thank you to my colleague Dr. Murphy for your remarks.
    I find it ridiculous that even unelected bureaucrats are back to 
working in person before Democrats in Congress.
    The Workforce Investment and Opportunity Act (WIOA) provides an 
important source of funding for State and local workforce development 
systems that are tasked with addressing the needs of the community. The 
Federal Government does not have the knowledge or foresight required to 
dictate what states need. I believe we should err on the side of 
flexibility when designing and funding workforce development systems 
with taxpayer dollars.
    Direct care workers are an important part of the health care 
workforce, and care for our most vulnerable patients. Their work is 
often difficult and unrecognized, but our health care workers are 
valuable and should be recognized for the sacrifices they have made, 
especially during the COVID-19 pandemic.
    We know there is an incredible amount of turnover in the labor 
market for direct care workers. We also know that most direct care 
workers did not pursue additional education after high school.
    As Ranking Member of the Subcommittee on Health, Employment, Labor, 
and Pensions, I hope today's hearing can shed light on how Congress can 
help all workers, including direct care workers, gain the skills they 
need to improve their upward mobility and sustain a fulfilling career. 
New technologies and practices developed in the private marketplace are 
revolutionizing the health care field. We must ensure workers are not 
left behind.
    The Federal Government has an interest in sustaining a workforce 
pipeline that recruits, retains, and assists individuals interested in 
finding the right career for them, including careers within the health 
care workforce. But Congress cannot fall into the trap of having 
hundreds of different programs, each devoted to one particular 
occupation.
    This is why I advocate for apprenticeship-style programs. Combining 
structured on-the-job learning and classroom-based instruction gives 
individuals a low-risk option to determine if a job is a good fit for 
them. In the same way, earn-and-learn programs are another way to help 
folks find a rewarding career.
    I look forward to working with my colleagues on both sides of the 
aisle to find innovative solutions to address the health care workforce 
challenges facing our Nation. And I look forward to hearing the 
witnesses' testimony today.
    Thank you and I yield back.
                                 ______
                                 
    Chairman DeSaulnier. Thank you, Mr. Allen.
    I now want to recognize the distinguished Chairwoman of the 
Subcommittee on Higher Education and Workforce Investment for 
the purpose of making an opening statement.
    Chairwoman Wilson?
    Chairwoman Wilson. Thank you, Chair DeSaulnier.
    I want to add my thanks for our distinguished witnesses' 
time today. In addition to low pay and difficult working 
conditions, the direct care sector lacks the training and 
career pathways that workers need to join and remain in this 
profession.
    Direct care is hard work. It is physically and emotionally 
demanding, and also requires knowledge of complex health 
conditions, such as Alzheimer's disease and dementia. Yet, 
training for entry level direct care workers varies widely, and 
is not reimbursed by Medicaid or Medicare, leaving many workers 
unprepared to safety--to safely provide quality, long-term 
care.
    In addition, these workers often do not have the required 
education, qualifications to enroll in training programs, and 
would offer professional growth. Without these pathways, direct 
care workers often become stagnant without the opportunity to 
advance into higher-paying positions.
    In most professions, workers can increase their pay as they 
increase their skills and experience. Direct care workers 
should have that same opportunity.
    The American Jobs Plan dedicates resources to improve the 
lives of direct care workers. This mirrors the Direct CARE 
Opportunity Act, which invests in recruiting, retaining, and 
advancing the direct care workforce pipeline. Those resources 
will allow States and local organizations to pursue the best 
solutions in their regions, from training programs and 
registered apprenticeships to mentorship opportunities, to make 
direct care a more sustainable career.
    Supporting a well-paid and well-trained direct care 
workforce is vital. It is vital for aging Americans; it is 
vital for individuals with disabilities.
    In 2015, in my home State of Florida, 6,000 people died 
while waiting for home care services according to the 
Department of Elder Affairs. Sadly, this underscores the 
desperate need for increased investment in the direct care 
sector.
    Strengthening this workforce pipeline is not only the right 
thing to do to support our Nation's direct care workers; it is 
also the smart thing to do. With the right investments, the 
direct care field will be able to offer millions of good-paying 
jobs with lower barriers to carrying--to entry, and ample 
opportunities for career growth.
    As we recover from the pandemic, which erased millions of 
jobs, enhancing the direct care workforce would help people get 
back to work immediately, and secure quality long-term care for 
those who need it most.
    I look forward to our discussions today, and I now yield to 
the Ranking Member, Mr. Murphy--Dr. Murphy, for his opening 
statement.
    [The prepared statement of Chairwoman Wilson follows:]

  Statement of Hon. Frederica S. Wilson, Chairwoman, Subcommittee on 
               Higher Education and Workforce Investment

    Thank you, Chair DeSaulnier. I want to add my thanks for our 
distinguished witnesses' time today.
    In addition to low pay and difficult working conditions, the direct 
care sector lacks the training and career pathways that workers need to 
join-and remain-in this profession.
    Direct care is hard work. It is physically and emotionally 
demanding and also requires knowledge of complex health conditions, 
such as Alzheimer's disease and dementia. Yet, training for entry-level 
direct care workers varies widely and is not reimbursed by Medicaid or 
Medicare, leaving many workers unprepared to safely provide quality, 
long-term care.
    In addition, these workers often do not have the required education 
qualifications to enroll in the training programs that would offer 
professional growth. Without these pathways, direct care workers often 
become stagnant without the opportunity to advance into higher-paying 
positions.
    In most professions, workers can increase their pay as they 
increase their skills and experience. Direct care workers should have 
that same opportunity.
    The American Jobs Plan dedicates resources to improve the lives of 
direct care workers. This mirrors the Direct CARE Opportunity Act, 
which invests in recruiting, retaining, and advancing the direct care 
workforce pipeline.
    These resources will allow states and local organizations to pursue 
the best solutions in their regions-from training programs and 
registered apprenticeships to mentorship opportunities-to make direct 
care a more sustainable career.
    Supporting a well-paid and well-trained direct care workforce is 
vital. It's vital for aging Americans, it's vital for individuals with 
disabilities.
    In 2015, in my home State of Florida, 6,000 people died while 
waiting for home care services, according to the Department of Elder 
Affairs. Sadly, this underscores the desperate need for increased 
investment in the direct care sector.
    Strengthening this workforce pipeline is not only the right thing 
to do to support our Nation's direct care workers. It is also the smart 
thing to do.
    With the right investments, the direct care field will be able to 
offer millions of good-paying jobs with low barriers to entry and ample 
opportunities for career growth.
    As we recover from the pandemic-which erased millions of jobs-
enhancing the direct care workforce would help people get back to work 
immediately and secure quality long-term care for those who need it 
most.
    I look forward to our discussions today and I now yield to the 
Ranking Member, Dr. Murphy, for his opening statement.
                                 ______
                                 
    Mr. Murphy. Thank you, Chairwoman Wilson, for yielding.
    I would like to thank the witnesses for joining us today.
    Direct care workers are an essential part of the healthcare 
sector. I personally have worked with these individuals for 
over 30 years and understand the dedication that they have to 
their craft. These individuals act as primary care providers of 
care, supervision, and emotional support for older Americans, 
people with disabilities, and individuals with chronic needs. 
As a physician, I understand the value that they bring to our 
healthcare system and the sacrifices that they make to serve 
our patients.
    Data from the Bureau of Labor Statistics estimate that 
there are over 3 million direct care workers employed in the 
U.S. today. These jobs provide an important source of income 
for a diverse array of individuals.
    As the United States population ages, and the need for 
direct care workers blossom, the Federal Government must 
consider how its programs foster an environment where more 
people are encouraged to enter the healthcare workforce. I 
believe the reauthorization of the Workforce Innovation and 
Opportunity Act is the appropriate time for this Committee to 
reassess Congress' role in us supporting a robust healthcare 
labor market.
    In the existing WIOA structure, each State must create a 
one-stop delivery system that connects job seekers with in-
demand jobs. Direct care services should be a part of those 
State and local workforce development board conversations.
    But Congress cannot predict the future. Our laws must be 
nimble and allow each community to address its unique needs. I 
believe that supporting direct care workers through a 
comprehensive WIOA reauthorization will give individuals 
interested in these careers in the direct care field access to 
programs that will help gain the skills necessary to succeed.
    Legislation like H.R. 2999, the Direct CARE Opportunity 
Act, is a duplicative--is duplicative to workforce programs 
that we already have in place. I am concerned that a new 
Federal program devoted exclusively to direct care workers may 
threaten the performance of the broader workforce development 
system.
    Republicans on this Committee want to help all workers, 
including those in the direct care sector, by strengthening 
WIOA and other workforce development programs.
    I look forward to hearing from witnesses today on how we 
can buildup the healthcare workforce sector without detracting 
from other critical professions.
    Thank you, Madam Chair. Thank you, and I yield back.
    [The prepared statement of Mr. Murphy follows:]

 Statement of Hon. Gregory F. Murphy, Ranking Member, Subcommittee on 
               Higher Education and Workforce Investment

    Thank you, Chairwoman Wilson, for yielding. I'd like to thank the 
witnesses for joining us today.
    Direct care workers are an essential part of the health care 
sector. I have personally worked with these individuals for over 30 
years. These individuals act as primary providers of care, supervision, 
and emotional support for older Americans, people with disabilities, 
and individuals with chronic needs. As a physician, I understand the 
value they bring to our health care system, and the sacrifices they 
make to serve patients.
    Data from the Bureau of Labor Statistics estimate that there are 
over 3 million direct care workers employed today. These jobs provide 
an important source of income for a diverse array of individuals.
    As the United States' population ages, and the need for direct care 
workers blossoms, the Federal Government must consider how its programs 
foster an environment where more people are encouraged to enter the 
health care workforce.
    I believe the reauthorization of the Workforce Innovation and 
Opportunity Act (WIOA) is the appropriate time for this Committee to 
reassess Congress's role in supporting a robust health care labor 
market.
    In the existing WIOA structure, each State must create a one-stop 
delivery system that connects jobseekers with in-demand jobs. Direct 
care services should be a part of those State and local workforce 
development board conversations.
    But Congress cannot predict the future. Our laws must be nimble and 
allow each community to address its unique needs. I believe that 
supporting direct care workers through a comprehensive WIOA 
reauthorization will give individuals interested in careers in the 
direct care field access to programs that will help them gain the 
skills necessary to succeed.
    Legislation like H.R. 2999, the Direct CARE Opportunity Act, is 
duplicative to workforce programs that we already have in place. I am 
concerned that a new Federal program devoted exclusively to direct care 
workers may threaten the performance of the broader workforce 
development system.
    Republicans on this Committee want to help all workers, including 
those in the direct care sector, by strengthening WIOA and other 
workforce development programs. I look forward to hearing from the 
witnesses today how we can buildup the health care workforce without 
detracting from other critical professions.
    Thank you and I yield back.
                                 ______
                                 
    Chairman DeSaulnier. Thank you, Ranking Member Murphy.
    Thank you, Chair Wilson, very much for those comments.
    We will now go to our witnesses, and it is my pleasure to 
introduce them. Thank you again for being here. We really 
appreciate it.
    Robert Espinoza is the Vice President of Policy at PHI, 
where he oversees the National Advocacy Research and Public 
Education Division on the Direct Care Workforce.
    Zulma Torres has worked in direct care for over 23 years, 
and works for Cooperative Healthcare Associates, a worker-owned 
licensed home care service agencies located in the Bronx.
    Paul Burani is the head of business development for North 
America for Udacity, a company founded in 2011 to provide 
training services for workers facing changing technological 
landscapes.
    And Representative Jessica Fay is a third-term Member of 
the Maine House of Representatives. She was appointed to serve 
as House Chair of the Commission on Study of Long-Term Care 
Workforce Issues.
    Our instructions for the speakers are as follows.
    Again, we appreciate the witnesses for participating today 
and look forward to your testimony. Your written statement will 
appear in full in the hearing record, and you are asked to 
limit your oral presentation to five minutes, please. After 
your presentation, we will move to Member questions.
    The witnesses are aware of their responsibility to provide 
accurate information to the Joint Subcommittees, and, 
therefore, we will proceed with their testimony.
    And, first, we will recognize Mr. Espinoza.

  STATEMENT OF ROBERT ESPINOZA, VICE PRESIDENT OF POLICY, PHI

    Mr. Espinoza. Thank you, Chairman, and good morning.
    On behalf of PHI, I would like to start by thanking 
Chairwoman Wilson, Ranking Member Murphy, and the other Members 
of the Higher Education and Workforce Investment Subcommittee, 
as well as Chairman DeSaulnier, Ranking Member Allen, and the 
other Members of the Health, Employment, Labor and Pension 
Subcommittee, for the opportunity today to discuss the direct 
care workforce and how the Direct CARE Opportunity Act would 
support this vital job sector.
    Across the country, 4.6 million direct care workers support 
millions of older adults and people with disabilities in a 
range of long-term care settings, from their private homes to 
residential care homes, such as assisted living, to skilled 
nursing homes. Most of these workers are women, people of 
color, and/or immigrants, and 1 in 4 is aged 55 and older, all 
facts that underscore the entrenched societal inequities that 
many of these workers face both on the job and in their 
communities.
    Largely because our country is aging rapidly, the direct 
care workforce has grown significantly over the years, and it 
will continue this trend. Between 2018 and 2028, the direct 
care workforce will add more than 1.3 million jobs--new jobs, 
including nearly 1.1 million jobs in home care, representing 
the largest growth of any job sector in the country. Already, 
the direct care workforce is larger than any other single 
occupation in the country.
    However, despite their enormous value, direct care jobs 
have been poorer-quality jobs for decades, which harms workers, 
employers, consumers, and family caregivers. These workers 
struggle with poverty level wages, which our research shows are 
lower in all 50 States and D.C. than wages for other 
occupations with similar entry level requirements, such as 
janitors and retail salespeople. Training and advancement 
opportunities are also inadequate, which makes it increasingly 
difficult to recruit and retain these workers. These challenges 
affect everyone in the long-term care system.
    Forced into crushing poverty, workers too often leave the 
sector for other fields. Employers struggle to recruit and 
retain workers and will need to fill millions of direct care 
job openings in the next decade. Without enough workers, older 
adults and people with disabilities cannot access the services 
they deserve, and family caregivers are often left without paid 
respite and support. The COVID-19 pandemic has amplified all 
these challenges.
    To address these issues, the Direct CARE Opportunity Act 
would provide a significant and much-needed investment in the 
direct care workforce, coordinated at the national level to 
ensure that funding goes where it is most needed. It would 
invest more than $1 billion over 5 years in recruitment, 
retention, and advancement strategies.
    In direct care, it would require careful planning, needs 
assessment, and evaluation that would help build the evidence 
base on this workforce related to care outcomes, employment 
outcomes, and cost outcomes. Specifically, this funding could 
be used to support interventions related to entry level and 
specialized training, advanced roles, recruitment and 
retention, supervision and technology.
    It could help create new models of long-term care service 
delivery related to upscaling care integration, career 
advancement, and universal worker roles. And it would support 
individuals with prevalent conditions, such as dementia, and 
more vulnerable people, such as people of color and LGBT 
people, just to name a few. It would help professionalize and 
transform these jobs, making them more attractive to job 
candidates now and in the future.
    Already, the field has designed numerous examples of 
effective interventions, though it needs significant funding 
and coordination at the Federal level. We have seen successful 
training, recruitment and advancement programs in Arkansas, 
California, and New Mexico, among many other States. And these 
interventions have benefited workers, consumers, employers, and 
the economy alike, but they are small in scale, and they 
represent a tiny fraction of what will be needed to address the 
national workforce crisis in direct care.
    I will close by saying that strategically investing in 
workforce development for this workforce is also a matter of 
economic development. High-quality jobs and workforce 
interventions can increase consumer spending, decrease public 
assistance rates, reduce costly turnover, and promote cost 
savings in healthcare spending in an already expensive system 
with costs that balloon every year.
    We encourage Congress to enact the Direct CARE Opportunity 
Act and begin transforming this critical workforce. As Marisol 
Rivera, care coordinator at Cooperative Home Care Associates in 
the Bronx, said, I think the role of the home health aide 
should be considered just as important as any other healthcare 
role.
    Thank you, and I look forward to your questions and to your 
ideas.
    [The prepared statement of Mr. Espinoza follows:]

                 Prepared Statement of Robert Espinoza

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Chairman DeSaulnier. Thank you, Mr. Espinoza, and thank you 
on the time. And thank you for your work as Vice President of 
Policy at PHI. I need to wear my glasses when I read.
    I now recognize Mr. Torres--Ms. Torres.

 STATEMENT OF ZULMA TORRES, HOME HEALTH AID, COOPERATIVE HOME 
                        CARE ASSOCIATES

    Ms. Torres. Good morning. Thank you to the Members of the 
Committee for inviting me to speak today.
    My name is Zulma Torres. I am a wife, a mother, and a 
grandmother. I have worked at Cooperative Home Care Associates 
as a home health aide for over 23 years. I am also a proud 
Member of the 1199 SEIU Labor Union.
    I am very honored to have the opportunity to bring my voice 
to support your efforts to make our jobs better and help our 
union. My company employers and training providers provide 
better programs and services. My training to become a personal 
care aide and home health aide was intense. Attendance, 
punctuality were very important. And if you were late or missed 
a day, you had to make up the work you missed. We learned and 
practiced demonstrating the required skills.
    Cooperative wanted to make sure new recruits were serious 
about the work. At first, the job was challenging. I went into 
strangers' home introducing myself, and then providing some of 
the most intimate care and assistance possible. I learned early 
on that I had to understand my clients' situation and put 
myself in their shoes. I had to separate my personal feelings 
from my personal responsibilities.
    My employer, Cooperative, is one of the best, both because 
it is a union employer, and is a worker owner. Cooperative 
supports us, and we have the opportunity to purchase a share of 
the company. We have financial literacy classes and peer 
mentoring to help with difficult work assignments. There are 
also opportunities to become promoted into office-based jobs.
    Also, I am grateful to be part of the 1199 SEIU Union with 
60,000 home care workers. In 2018, the union fought to increase 
our wages to $15 an hour. Now that minimum wage is in New York 
City.
    We have health insurance, dental, a Member assistance 
program, and a home care pension benefit. We also have 
education benefits that cover everything from citizenship 
program, to register apprenticeships, to college tuition 
vouchers.
    Now, the union is fighting for higher wages and to keep our 
great benefits. We should be salary workers with guaranteed 
hours. Home care worker is not minimum wage work. The union 
gives me a voice, advocates for us, and allows us opportunities 
like this to testify in front of Congress.
    Today, I am happy to say that I am a home care worker, and 
we need more people to come--to go into the role so that they 
can live with dignity in their community and be able to stay in 
their home instead of high-cost emergency room visits and 
hospitalizations or be moved into an institution.
    We need to make home care jobs good union careers with 
opportunities for care--for careers, advancement of higher 
wages. The quality of the job must improve with excellent 
recruitment, training, scheduling, and a good supervision 
worker opportunity, so they stay in the field.
    This is why President Joe Biden committed to investing in 
home and community care jobs and providing workers with better 
opportunities to join unions as part of the Build Back Better 
Plan. It is so exciting.
    Finally, I am happy that home care and community care 
workers are being treated as essential workers that we are.
    Thank you.
    [The prepared statement of Ms. Torres follows:]

                   Prepared Statement of Zulma Torres

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    Chairman DeSaulnier. Thank you, Ms. Torres, very much. 
Thanks for being here.
    We will now go to Mr. Burani.
    Mr. Burani, you are on for five minutes.

 STATEMENT OF PAUL BURANI, HEAD OF BUSINESS DEVELOPMENT, NORTH 
                     AMERICA UDACITY, INC.

    Mr. Burani. Thank you.
    Good morning, Chairwoman Wilson, Chairman DeSaulnier, 
Ranking Member Murphy, Ranking Member Allen, and Members of the 
subcommittees. Thank you for the opportunity to appear before 
the subcommittees to discuss workforce development in the 
United States.
    I serve as head of business development for public-sector 
partnerships at Udacity, an online education platform committed 
to preparing the Nation's workforce for the careers of the 
future.
    In today's world, technology is advancing at an accelerated 
pace. Corporations have invested about $2 trillion in digital 
transformation to avoid getting left behind. Leveraging these 
technologies requires them to adapt, but executives 
consistently rank the shortage of skilled talent as their No. 1 
risk factor. But they are not the only ones with something to 
lose.
    A recent McKinsey Report had estimated that automation will 
displace up to 800 million jobs by the year 2030. Many of these 
jobs will be in the U.S. If we don't plan appropriately, that 
skill gap will widen, causing irreparable damage to our 
economy.
    At Udacity, closing this skill gap is what we do. We design 
our curriculum with tech industry partners like Google, Amazon, 
Microsoft, and IBM. We deliver it through our Nanodegree 
programs, which provide instruction for employable technical 
job skills in fields like programming, data science, 
cybersecurity, and artificial intelligence.
    These programs include both coursework taught by the 
experts and hands-on projects for students to demonstrate 
competency as practitioners in their field.
    Udacity has educated over 15 million learners worldwide. We 
work with over 110 corporate clients, companies like Shell, 
Credit Suisse, Airbus, Mazda, and the U.S. Air Force. They 
trust us to help their employees acquire the skills needed to 
accelerate their company's digital transformation.
    And, in the public sector, we upskill government employees, 
we build partnerships for social impact, and we run ambitious 
workforce development initiatives.
    The reauthorization of the Workforce Innovation and 
Opportunity Act, or WIOA, presents a world of possibility. Our 
workforce system has successfully trained millions, but it 
needs to be modernized. Employers still face challenges hiring 
and retaining skilled talent, and millions of unemployed and 
underemployed Americans deserve a chance to land in a 
motivating career with growth potential.
    To unlock this possibility, we can start with proposed 
structural changes. WIOA maintains a vast array of data about 
education providers, their programs, and performance. But these 
systems use outdated mechanisms, and are siloed by State, 
creating administrative burdens. Funding is mainly allocated 
locally to distinct workforce areas, raising barriers between 
employers and citizens across geographies, including those 
aligned to remote work.
    Let's envision a WIOA system in which funding, governance, 
and operations are all executed at a more aggregated level, and 
support that with incentives for neighboring workforce areas to 
collaborate. Providers could better tailor their solutions to 
fit market needs. The system would enjoy better budget 
utilization, helping it educate more citizens, and job seekers 
would benefit from more diverse choices in the marketplace.
    Next, we will look at channel investment. Among the diverse 
WIOA stakeholders, consider community colleges, for example. 
They have a history of thriving in the U.S. workforce system 
with strong employer connections, but they also have gaps in 
their curriculum, which could be addressed through partnerships 
with other providers.
    Another example is the relationship between workforce 
boards and the public. They sponsor programs that need to 
inspire citizens to summon all their motivation and commit to 
self-improvement. It is a pretty tall order.
    A more modern WIOA would increase its focus on marketing 
and operations to help the public better understand the role of 
the workforce system, and the opportunity it can deliver. This 
would improve the utilization of WIOA funds, speed up the 
delivery of solutions, and create a better fit between 
citizens' needs and the programs they pursue, leading to better 
performance outcomes overall.
    Finally, a word about labor market innovation. The pace of 
technological change has created ripple effects that impact 
many facets of modern life. Consider the word ``ransomware,'' 
which has permeated our daily news cycle. In 2014, the first 
year of WIOA, it was barely a part of the public lexicon, but 
this world is changing faster than ever before.
    Investing in pathways to high-growth occupations helps to 
ensure that as trends like ransomware evolve, our solutions to 
combat them evolve even faster. This fast-paced evolution also 
causes collateral damage in our communities. Some learners 
might just worry about graduating, but others have a host of 
curve balls to worry about. Maybe they lack healthcare, or they 
can't find a babysitter. Maybe they study from the one corner 
of the house that gets a free Wi-Fi signal.
    The WIOA of today incentivizes important outcomes, but many 
people in distressed communities are structurally disadvantaged 
from achieving those outcomes and get turned away. The WIOA of 
tomorrow should level the playing field for them, too.
    We are here today because we know what the U.S. workforce 
system is capable of achieving. A more modern dynamic WIOA 
could help to fulfill that potential.
    Thank you for listening and for joining the cause.
    [The prepared statement of Mr. Burani follows:]

                   Prepared Statement of Paul Burani

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Chairman DeSaulnier. Thank you so much for your time. 
Thanks for your timeliness.
    And that will bring us to our final witness. We will now 
hear from Representative Fay.
    Representative Fay, the floor is yours.

  STATEMENT OF HON. JESSICA FAY, STATE REPRESENTATIVE, MAINE 
                    HOUSE OF REPRESENTATIVES

    Ms. Fay. Thank you.
    Good morning, Subcommittee Chairs DeSaulnier and Wilson, 
Ranking Members Allen and Murphy, and Members of the 
subcommittees.
    I am Maine State Representative Jessica Fay, and I 
represent House District 66 in the Maine Legislature. Thank you 
for inviting me here today.
    In 2019, I served as the house Chair of Maine's commission 
to study long-term care workforce issues, and I am pleased to 
be able to share some of our findings.
    Because Maine is the oldest State in the country, we are 
seeing the crisis build, and be exacerbated by the COVID-19 
pandemic. I came at this issue with an open mind as a 
legislator, but also as a consumer and a family caregiver.
    Statistically, most of us will need some form of assistance 
with activities of daily living during our lifetimes. In a pre-
pandemic visit to a local high school vocational program, the 
director gave me a tour. The classrooms for coding, carpentry, 
and automotive were busy and full. When it came to healthcare, 
there were only a few students, notably all female, in the 
class.
    As we walked away, I asked about participation in their CNA 
program, and learned that it was declining. I asked why, and 
his answer really disturbed me. He said, kids are smart and 
don't want to go into dead-end jobs. They understand the 
earning potential of various professions and choose their paths 
based on that.
    If the public perception is that caring for older adults 
and people with disabilities is dead-end work, then an 
important part of the solution is to change that perception. We 
must address not only the workforce challenges, but also ageism 
and ableism that leads to the devaluation of the care necessary 
for older people and people with disabilities to live their 
best, most independent lives.
    When we have an undervalued workforce caring for an 
undervalued population, we have a system that doesn't work for 
anyone. Increasing the pay for essential caregivers is a 
necessary component of attracting and retaining a diverse set 
of people to do this economically foundational work. It is a 
necessary piece of this solution, but not sufficient on its own 
to solve the crisis we face.
    Another barrier is that this workforce is seldom included 
in conversations about economic development. In the quest for 
high-paying jobs, the foundational jobs are often left out of 
the conversation. It is important that when designing programs 
for economic development, we include caregiving jobs as a 
career choice.
    During the pandemic, the lack of childcare had a 
significant impact on local economies as people left the 
workforce to care for their children. This is also true 
concerning care for older family Members and people with 
disabilities.
    Professionalizing the workforce by offering ongoing paid 
professional development, supportive supervision, and 
opportunities for advancement in terms of both responsibility 
and compensation were all recommendations of the commission I 
Chaired. This will enhance the efficacy of programs designed to 
attract and retain direct care workers. Making sure personal 
care workers are considered part of the care plan and care team 
will aid in elevating the status of the work that they do.
    With some guidance, educational facilities could develop 
and target education and certification programs for direct care 
workers. Apprenticeships, earn as you learn, and pre-
apprenticeship programs are all ways to enhance the workforce. 
Creating a path to professional growth through career ladders 
will also be a critical piece of the puzzle.
    Funding is a significant barrier to implementing the 
Committee's recommendations. MaineCare, known as--what Medicaid 
is known as in Maine--MaineCare providers are barely scraping 
by and even closing. They don't have money to train or do 
professional development with their workforce, let alone offer 
career advancement opportunities. Access to funding for 
training and retention and developing methods to increase the 
workforce as proposed in the Direct CARE Opportunity Act will 
certainly increase our ability to care for Mainers who need it.
    In Maine, there are over 2,000 older Mainers and even more 
Mainers with disabilities who cannot access services they 
qualify for. There are empty beds in nursing homes and assisted 
living facilities due to staffing shortages, and people are 
spending longer time than necessary in hospitals because there 
is nowhere to discharge them to.
    Maine is a small State with a population of 1.3 million 
people. We are older and more rural than any other State in the 
lower 48. We have significant work to do to address this crisis 
and to elevate and value the work that so many find so 
rewarding, yet difficult to make ends meet doing. We need to 
use many different strategies to make a change, and I am 
grateful to the Members here today for recognizing there is a 
crisis and who are working to craft solutions that will allow 
caregivers and those they care for to live their best lives.
    Thank you.
    [The prepared statement of Ms. Fay follows:]

                   Prepared Statement of Jessica Fay

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Chairman DeSaulnier. Thank you, Representative. Thank you 
for your testimony and your work and your commitment in this 
field.
    Under Committee Rule 9(a), we will now question witnesses 
under the five-minute rule.
    As this is a joint Subcommittee hearing, after the Chairs 
and Ranking Members, I will be recognizing Subcommittee Members 
based on seniority order of the full Committee.
    I will be followed, after my questions, by Ranking Member 
Allen, and then Chair Wilson, and then Ranking Member Murphy.
    So let me begin.
    Again, Representative Fay and all the witnesses, thank you 
so much for your testimony. For a lot of us, we have 
experienced this with our parents and friends and neighbors and 
loved ones. My mom passed away a couple years ago at the ripe 
old age of 94, and my siblings and I were all very engaged in 
taking care of her. And it was a struggle. And her last 5 
years, when she was in a nursing home after she lost her 
independence in San Francisco, I had multiple conversations 
with the staff there and with the employers of the difficulty 
of trying to provide services in that setting in a high-cost 
area like San Francisco.
    But, equally, as someone who was involved in our public 
authority in the county that I represent and represented as a 
county supervisor many years ago, the challenges to provide for 
this care is really daunting.
    So thank you all, and thank you, Representative Fay.
    I want to ask you a question, Representative Fay. With the 
Olmstead decision and the ADA, our understanding of the 
position of people with disabilities in America has changed, 
and our social context has changed. The social model has 
changed dramatically from when I was young. We live farther 
apart from each other. Families are not always able to provide 
care and support.
    Can you talk about the importance of strengthening the 
direct care workforce and meeting the goals of the ADA and 
meeting the needs of people with disabilities and the aged, 
particularly in the context of this changing environment, where 
young people and family Members have economic pressures of 
their own to travel further and further to get employed, and 
they have to move employment frequently?
    So, the social model having changed, it seems to me that we 
are slowly trying to adapt to this new social model that 
doesn't have families as closely located where traditionally 
they would provide many of these support systems.
    Ms. Fay. Thank you, Mr. Chair, for the question.
    The--the goal of the ADA is to allow people with 
disabilities to live as part of our communities, with barriers 
to that participation removed, and I think, if you require 
assistance in order to do that, and then there is no one there 
to provide that assistance, whether it is personal care, 
transportation, or other activities of daily living, then you 
are really unable to fully participate.
    And so a direct care workforce shortage really is in 
opposition to the goals of the ADA.
    Chairman DeSaulnier. Thanks.
    I want to ask you. As somebody who served in local 
government and in the State legislature, now at the Federal 
level, this difficulty of our roles and the genius of our 
Founders in having local control, but also having a United 
States, and coming from a large State, the largest State, 
challenges, and from a large county in an urban area, as one of 
the Ranking Members mentioned--Mr. Allen, I believe--the 
importance of making it fit for the local community, what do 
you think is the appropriate role, again, in this very 
demanding, changing social model--the right role for the 
Federal Government to play in this regard, so that we can have 
a really effective conversation with our partners at the State 
and local level?
    Ms. Fay. I think that is a really good question, and I 
think the word ``partnership'' is really important. Maine is a 
State that values our local control a great deal.
    I will say that one of the significant barriers for--for us 
implementing any of the direct care workforce reforms that my 
commission recommended was funding. And I think, you know, 
allowing programs or funding programs--pilot programs that 
would--would allow us to do some evidence-based work on what is 
successful could be really, really helpful. But I think the 
term ``partnership'' is a really key word.
    Chairman DeSaulnier. Thank you for that.
    And I would say one of the challenges with--I agree with 
you, the part that pilot programs, but at a certain point, you 
have to bring them to scale, and I always found that was one of 
the biggest challenges. We were behind that. Great ideas, but 
actually deploying it and having it be client-based strikes me 
as a real struggle. And, of course, those goes to some of the 
comments we have had earlier.
    With that, it is my pleasure to recognize the Ranking 
Member of the Health Subcommittee, Mr. Allen, for your five 
minutes of questions.
    Mr. Allen. Thank you, Mr. Chairman.
    Can you hear me OK? I think I am unmuted. Good.
    Chairman DeSaulnier. Nope, you are on.
    Mr. Allen. OK. Great. Super.
    Well, listen, thank each of the witnesses for your 
testimony. I have firsthand experience with this in dealing 
with my mom and dad and my wife's mom and dad. And it is 
difficult, and--but I do believe that it is important that it 
not be a top-down approach, that it be a bottom-up approach.
    And that is why I want to work with the States and all of 
our local communities to solve this problem, which is going to 
grow, as our Chairman reported. It is going to be--as our 
population ages, it is going to be more and more significant to 
our responsibility to take care of folks--and I am getting 
there--in our golden ages.
    But, Mr. Burani, the COVID-19 pandemic revolutionized the 
doctor-patient relationship by accelerating the use of 
telemedicine and further integrating technology into treatment 
models. However, the modernization of this part of the 
healthcare industry could, unfortunately, leave some healthcare 
workers behind.
    What are you and other similar education providers doing to 
make sure that healthcare workers have the tools and skills 
they need to adapt to technology and thrive during this period 
of rapid modernization?
    Mr. Burani. Thank you for the question, Congressman Allen.
    I think that we need to appreciate, it is a relatively low-
tech problem that we are solving for. We all, as individuals, 
can relate to the inconvenience of sitting in a waiting room, 
you know, waiting some unexpected amount of time for treatment. 
We know how hard it is to fit an appointment into a busy 
workday, or to juggle that with other constraints.
    And I think that, to some degree, we have to appreciate 
that, due to the COVID-19 pandemic, as with many technologies 
that were adopted to adapt to this change, the genie is out of 
the bottle. And, as a result, the conveniences, the benefits of 
telemedicine have now become--let's call it mainstream.
    As a result, I think what is important is to appreciate the 
benefits of it, the ability to lower costs, to reach more 
patients, and, in the process, make life less burdensome for 
practitioners and patients alike.
    As--with respect to your question around upscaling 
healthcare workers to this rapid modernization, I think it 
really comes down to--I believe it was Chairwoman Wilson made 
reference to career pathways in her opening statement, and I 
think that is an important concept.
    To appreciate the fact that these individuals have spent 
years, decades even, really entrenched in the system, they 
understand care innately and intuitively. And, for those that 
have a desire and an appetite to advance in their career, 
perhaps using the insights and perspectives from direct care in 
order to contribute to the modernization of the industry, we 
look at that through the lens of Nanodegree programs that my 
company represents at Udacity.
    However, I think, more broadly speaking, we all just need 
to appreciate that skill development is an industry-agnostic 
topic. The skill shortage is affecting all sectors and 
represents a massive opportunity, but what comes with it is the 
risk of being left behind.
    Mr. Allen. Right. Right.
    Mr. Burani. And so anything which provides that growth 
opportunity, we are in favor, and hope to support.
    Mr. Allen. I remember talking to my mom and dad checking in 
with them, and I said, what did you do today? And they said, we 
spent the day at the doctor's office. So--and that was a 
regular occasion.
    As far as the ransomware and cyber attacks that have 
wreaked havoc on our hospital's healthcare systems, recently a 
hospital just outside my district experienced a ransomware 
attack. From your experience, what can Congress do to improve 
data security, especially when it comes to health data, and how 
can we better educate healthcare workers to protect and secure 
patient health data?
    And we have got about 34 seconds.
    Mr. Burani. Big topic for 34 seconds. But what I would say 
is, at a high level, we need to think about basic hygiene for 
safeguarding data. It comes to having a basic skill set broadly 
applied to a workforce that people understand how to lock down 
internal systems. But we also need to create governance models 
and accountability so that there is, you know, a clear sense of 
how this can be done at scale.
    Mr. Allen. Great. Thank you, sir.
    And, with that, Mr. Chairman, I will yield back.
    Chairman DeSaulnier. Thank you, Mr. Allen. You're a fine 
son.
    I now recognize Chairwoman Wilson for her five minutes of 
questions.
    Chairwoman Wilson. Thank you so much, Chair DeSaulnier, and 
thank you to all of our witnesses for lending your expertise 
and time.
    Mr. Espinoza, you emphasized career advancement for direct 
care workers with 30 percent of funds reserved for career 
advancement activities. In your written testimony, you describe 
examples of promising career advancement and career pathway 
initiatives.
    Tell us, what are the challenges to developing career 
pathways and advancement opportunities for the direct care 
workforce, and how can we develop additional rungs in the 
career pathways that offer meaningful increases in pay and 
responsibilities and incentivize long-term retention?
    Mr. Espinoza. Thank you for the question, Chairwoman.
    I think part of the problem is in our failure as a sector 
and as a country to understand the value that direct care 
workers offer, and to create meaningful career advancement 
opportunities for them to contribute more to the care team, and 
to optimizing the health of the clients and residents that they 
support.
    I think, in most settings, the next formally recognized 
healthcare title above home health aide and nursing assistant 
positions is a licensed practical nurse. And yet, too often, 
arriving at that level requires weeks and months--years of 
training, I should say, and specifically to get into those 
roles and to be able to offer those opportunities. And, yet 
there are a number of ways in which we can create advancement 
opportunities that State--that keep workers within the direct 
care sector.
    We also know that a lack of career growth opportunities 
contributes to poor job quality. It has been identified really 
as a barrier to attracting new workers and to retaining workers 
over time. And, so, it's really important that we create these 
opportunities with an elevation in title, function, and 
compensation.
    Some examples within direct care, direct care workers can 
advance into peer mentors, where they are supporting fellow 
workers and integrating them into these roles; care 
coordination, so that workers are communicating changes in 
clients' conditions and symptoms to other Members of the 
healthcare team; and, also, into internal administrative 
positions, such as assistant trainers or clinical coordinators.
    One example is that, in 2015, PHI created a Care 
Connections senior aide role. Following 240 hours of training 
specifically in chronic disease knowledge; communication 
skills; enhanced observe, record, and report skills; and care 
team participation, home health aides were elevated to salaried 
Care Connections senior aide roles.
    They made home visits to support the upscaling of hundreds 
of entry level home care workers, and they helped improve care 
transitions, solve caregiving challenges in the home. And it 
led--our evaluation showed that, from the initial 18-month 
demonstration project, there was an 8 percent reduction in the 
rate of emergency room admission among the 1,400 consumers 
impacted, reduced caregiving strain among family Members, and 
improved job satisfaction among home care workers.
    The challenge for our field is there are not enough of 
these career advancement opportunities in this country to 
really grow to scale and to meet the growing demand that 
consumers and workers need and deserve.
    Also, we need more coordination at the Federal level, where 
are the gaps within career advancement opportunities and 
advanced roles that our government should invest in.
    Chairwoman Wilson. Thank you. Thank you so much.
    Ms. Torres, you have been in the field a long time, and we 
know there is a very high turnover, and few workers stay in the 
field as long as you have. How do you think the high rate of 
turnover impacts the quality-of-care individuals receiving 
long-term care, and how do you think turnover impacts your job 
satisfaction? Do you think it makes your job more difficult?
    Ms. Torres. I know that a lot of home health aides stopped 
working during the COVID, and some clients refused services 
because they were afraid of infection. It was and still is 
difficult.
    For me, I have a great team. All of us who care for our 
current clients that have a lot of need to get overnight care. 
We work together. It is difficult--it is a difficult job, but 
we have to find joy and satisfaction in our work.
    Still, many workers, myself included, thinks that we should 
be paid more. We make a lot of sacrifices, and our job has been 
more difficult since the COVID. We have to put a lot of extra 
time and effort to make sure we are safe, and our clients are 
safe, and our families are safe.
    For me, I care for my patients. I never stop coming to 
work.
    Chairwoman Wilson. Thank you so much. Thank you.
    I yield back.
    Chairman DeSaulnier. Thank you, Madam Chair.
    We will now recognize the Ranking Member, Mr. Murphy. The 
floor is yours.
    Mr. Murphy. Thank you, Chairman. I just kind of want to 
reiterate a few of the comments that were just made, because I 
have dealt, as I have said before, just as a physician, with 
direct care workers for over 30 years. And I truly, truly 
understand the dedication and devotion and difficulty that 
these individuals have in their workforce.
    We are going to be faced now with a growing, aging 
population. Also, a lot more families are scattered, where 
eastern North Carolina, where I live, there are a lot more 
families that are staying close, and so their family Members 
can take care of other individuals. But, in other areas of the 
country, that is just not the case.
    And, so, the increase in need for our direct care workers 
is going to increase exponentially. Actually, now, as I 
understand, it is the second largest occupational group in 
United States after retail sales, and we are going to have a 
problem in the future, really, if we don't connect--if we don't 
fix this problem.
    Obviously, we talked about turnover. Turnover can be 50 
percent in a year, or 80 or 90 percent in 2 years. So there is 
a massive turnover. I have really seen, however, firsthand, how 
dedicated individuals can truly, truly help those at home. They 
decrease emergency department visits. They save money. But 
then, on the other hand, sometimes the quality is not that 
great, and it actually affects poorly for patient care. So I 
just really appreciate the problem that we are facing.
    Mr. Burani, let me just ask you a question. As you noted in 
your testimony, only seven of 10 learners programs actually 
graduate from the WIOA program. While this completion rate 
exceeds that of a lot of post-secondary institutions, it is 
Congress' job--and this is what our job is, to ensure that 
taxpayer dollars are spent efficiently and effectively.
    In your testimony, you mentioned that a learner's incentive 
to persevere through a challenging program can be diluted when 
their own money is not invested. Do you have any suggestions 
about how we can reform the system to essentially give folks 
skin in the game, to allow individual buy-in that would also 
not exclude low-income individuals from participating?
    Mr. Burani. Thank you for the question, Congressman Murphy.
    So, I think it is an important discussion, right, because 
seven out of 10 is a standard for the U.S. workforce system, 
and it is a classic case of glass half full, glass half empty. 
We certainly like to see that a majority of these enrolled 
students are making it through, but it does beg the question: 
What's holding back the other three out of 10?
    I think that one thing that is important is to look at the 
training providers themselves, and understand what are the 
interventions and support and wraparound services that they are 
providing in order to sort of optimize those rates? It's not 
enough just to open a textbook and study. That didn't get 
anyone through college. And, nowadays, it is not enough to 
click on a video and watch it.
    We need to participate, and we need to get our hands on the 
learning. Project work that creates practitioner-level skills 
is, you know, one of our sort of mantras at Udacity.
    The other way to look at this is let's take a page from the 
book of traditional higher ed. Financial aid has very clear 
channels of engagement. We have merit-based financial aid. We 
have need-based financial aid. This really is a model that we 
could look at for short-term or nontraditional credentials.
    And I do think that a combination of all of these factors 
would help to maximize those outcomes and get more value out of 
these tax dollars.
    Mr. Murphy. Thank you for the response. We do have a 
challenging problem in front of us. As I said, as we age a 
Nation, as we grow as a population, we are going to need more 
of these individuals. And the turnover rate that we have noted 
is just not acceptable, because it leads to a deficiency in 
care for these individuals.
    And, when they are being taken care of, a family Member who 
is far away from, you know, children, et cetera, you want to 
leave them in good hands.
    So thank you for your comments, panel Members. I am going 
to actually yield back.
    Thank you, Mr. Chairman.
    Chairman DeSaulnier. Thank you, Dr. Murphy, appreciate all 
those comments.
    And now we will go to the distinguished gentleman from 
Connecticut, Mr. Courtney. And after Mr. Courtney, Mr. Walberg 
is next in the queue.
    Mr. Courtney, the floor is yours for five minutes.
    Mr. Courtney. Thank you, Mr. Chairman.
    And thank you to the witnesses to talk about, obviously, an 
issue which is even bigger than COVID with the aging of our 
population, but certainly COVID I think put the spotlight on 
why the direct care workforce, you know, is so essential for 
the country.
    You know, as we sort of talk about strategies to, you know, 
enhance and strengthen that workforce, I think it is important 
for a moment at least to look at the American Rescue Plan, 
which was signed into law on March 11th by President Biden.
    One of the key components of it was to boost the Federal 
match in the Medicaid program, FMAP, by 10 percent for home-and 
community-based services.
    Again, it sort of tracks somewhat the CARES Act, which, 
again, was a very bipartisan bill where Republicans and 
Democrats supported increasing FMAP, but, again, it was for a 
temporary period of time that was for the whole Medicaid 
program. Again, what we did in the Rescue Plan was surgically 
target that increase to home-and community-based services.
    The State of Connecticut just released their plan a few 
days ago in terms of how they propose to use the allotment we 
will enjoy as a result of the Rescue Plan. And it will come as 
no great surprise that most of it is going to go into provider 
rates. It also targeted increases in terms of wages. It is not 
a short-term clip. They have actually come up with a way to 
sort of extend that out to 2025.
    But clearly, you know, Representative Fay, you know, 
talking about her experience, you know, with, you know, the 
pecking order of direct care employment for job training is 
sort of dead end.
    I mean, if we are going to have a strong demand signal for 
people who are contemplating going into this, we need to push 
out the American Rescue Plan match to make sure that that 
financial base is going to be there.
    Again, I Chaired the Medicaid Committee back in the day 
when I was in the Connecticut legislature and I know, you know, 
how that is now the biggest line item in Connecticut's and most 
State governments.
    Representative Fay, what would it mean to have, again, a 
targeted boost for FMAP for Maine, as was contemplated in the 
families plan bill from the President to really provide, again, 
the financial underpinning so that we can, you know, implement 
some of these changes?
    Ms. Fay. Thank you, Congressman Courtney. I think it would 
be a wonderful opportunity. One of the biggest barriers that we 
identified as a commission were reimbursement rates.
    So our main care reimbursement rates for the work being 
done by essential caregivers was in some cases less than 
minimum wage. And one of the things that the 10 percent FMAP 
bump has allowed is--and our plan hasn't been completely 
released yet, so I am not 100 percent sure of what's going to 
be in it, but I do know that there will be some one-time 
bonuses for people who have been working to be able to continue 
to pay them a higher wage and to reimburse providers at a 
higher rate and a rate that allows them to compete with other 
sectors.
    You know, hospitality and retail would be huge, because 
right now we are just not reimbursing them as if we value the 
work that's being done.
    Mr. Courtney. Well, thank you. And, again, you know, at 
some point, you know, to try and tell a young person, you know, 
you should go into a training program for, you know, home 
healthcare or institutional healthcare but, you know, the 
financing system is just going to lapse back to its prior sort 
of State is just not, you know, going to really get people's 
blood excited.
    You know, the other just point is, you know, we passed H.R. 
447, which was the National Apprenticeship Act, earlier this 
year, which would was size up the Fitzgerald Act apprenticeship 
program to get into healthcare as a way of getting not just 
pre-apprenticeship training, as is contemplated by WIOA, but 
also full apprenticeship training, so people really have that 
he were earn-as-you-learn ladder to acquire more skills.
    I mean, would that model work, again, based on your 
experience, Representative Fay?
    Ms. Fay. I do think so. I think one of the things that 
would be helpful to providers is to allow their employees to 
work. And if you can earn while you are working, I think that 
would be a wonderful thing.
    Mr. Courtney. Thank you.
    Thank you, Mr. Chairman. I yield back.
    Chairman DeSaulnier. Thank you, Mr. Courtney. Thanks for 
being so punctual and thank you for not bringing up the Red Sox 
during your testimony, questions.
    We will now go to Mr. Walberg, who will be followed by 
Representative Bonamici. Tim.
    Mr. Walberg. Thank you, Mr. Chair.
    This is an important topic, of course, and I appreciate the 
panel being here. And we could go all sorts of directions but 
let me go to Mr. Burani.
    One of the things I hear from employers across my district 
is that today's college graduates don't always have the skills 
needed by employers for in-demand jobs. In your testimony, you 
note that community colleges maintain strong employer 
relationships, which keeps them firmly rooted in the WIOA 
system. And you indicate that WIOA funds could be enhanced by 
allowing community colleges to reach out to nontraditional 
educational institutions to fill curriculum gaps.
    Could you elaborate a little more on what you mean with 
this recommendation?
    Mr. Burani. Sure. Thank you, Congressman, for the question. 
I think it is an important topic because, as we know, in a 
diverse marketplace there are always going to be point players, 
and it's certainly not a case where you have one-size-fits-all 
solutions.
    So starting with community colleges, their strengths are 
hyper-local relevance, right? They have been pillars of that 
community that they serve, which means strong relationships 
with the employers, endemically very well-entrenched in the 
WIOA system. But they suffer what a lot of institutions of 
higher learning suffer, which is the natural cycle of 
generating the learning content that is timely for the 
environment in which students are learning it.
    So we use the example of cybersecurity, which came up 
earlier in this hearing. This is literally changing every day. 
Every attack, every response is an evolution and a pretty 
radical one in some cases. And so the need to be able to time 
the delivery to market as quickly as possible becomes 
important. Who better than a specialist provider of that 
learning content to partner with said community college to be 
able to allow both entities to play to their strengths.
    Hopefully, that helps shed light on my earlier testimony.
    Mr. Walberg. Yes, I think that is important to understand, 
that we have capabilities. And if we promote flexibility in our 
educational system, that meets the needs of the real world as 
opposed to turfs. That could be a significant help to us.
    You note in your testimony that Udacity works with over 200 
industry experts, including companies such as IBM and Amazon. 
Can you describe the value of partnering with employers when 
developing course curriculums?
    Mr. Burani. There are a range of reasons why this is 
important from a partnership point of view. I will speak to two 
of them. The first one I touched on a moment ago, and it comes 
down to the refresh cycle. Technology is changing so fast that 
in order for this information to be timely, it needs to be--we 
need to minimize middlemen, so to speak.
    It is the same reason that Encyclopedia Britannicas are 
disappearing from shelves around the homes nationwide, because 
the format and the vehicle for information dissemination has 
now become a barrier. And so having direct access to the 
engineers, the creators of those technologies, allows us to 
deliver that faster to market.
    The second is, really, it comes down to credibility. We at 
Udacity don't consider ourselves to be the voice of cloud 
computing or artificial intelligence or machine learning. There 
are plenty of technology companies out there who have earned 
their place as the authorities on that.
    What we do is we structure effective programs. We invest in 
pedagogy and research to scope and run these programs. And, 
therefore, by bringing in a technology partner, it adds 
credibility and creates a greater impact.
    Mr. Walberg. Makes all good sense. Again, turf is a key 
issue, but inflexibility with creativity.
    Finally, Mr. Burani, as the economy recovers from the 
COVID-19 pandemic, it is critical that we assist the 
unemployed, underemployed, and dislocated workers succeed in 
transitioning to in-demand full-time employment. How can 
Udacity, through its partnerships with industry and workforce 
boards, help this effort?
    Mr. Burani. Really, it is a complex answer, because there 
are so many resources at our disposal. But just for the sake of 
simplicity, what I will say is that we aspire to make use of 
the infrastructure that is laid out in front of us. We look to 
provide job-ready skills so that there is something of value 
that these individuals carry with them out of their credential, 
and we measure as much as possible to make sure that we 
optimize our programs for maximum lifelong impact.
    Mr. Walberg. Thank you, I appreciate it.
    And, Mr. Chairman, I yield back.
    Chairman DeSaulnier. Thank you, Mr. Walberg.
    We will now recognize the distinguished Member from Oregon, 
Ms. Bonamici.
    Ms. Bonamici. Thank you so much to the Chairs and Ranking 
Members, but truly thank you to the witnesses for being here 
today to discuss this important issue.
    Throughout the pandemic, I have spoken with direct care 
workers who put their lives at risk caring for our loved ones. 
And, unfortunately, despite their heroic efforts, their work is 
far too often underpaid and undervalued. We know most home care 
workers are paid poverty-level wages. They lack access to 
training and support services and do not have access to paid 
sick time or other basic benefits.
    Forty-four percent of direct care workers live in low-
income households and 42 percent need to rely on some form of 
public assistance. These working conditions have a 
disproportionate effect on more than 86 percent of direct care 
workers who are women, nearly two-thirds of whom are women of 
color.
    In Oregon, my home State, home care workers and personal 
support workers gained the right to form a union back in 2000, 
and through successful organizing and collective bargaining 
workers have raised their base pay. They worked with the State 
to provide a new model of healthcare for home care workers that 
provides premium assistance, out-of-pocket expense assistance, 
as well as dental, vision, and employee assistance benefits for 
eligible workers.
    SEIU 503 also recently launched an innovative program to 
provide workforce training opportunities for direct care 
workers. Their Care Works Program is the first registered 
apprenticeship program for certified nursing assistants in the 
State, and it focuses on mentorship and support services to 
strengthen retention in the workforce, which is so critical. 
But fair wages and benefits should be available to direct care 
workers, not just in Oregon but across the country.
    Ms. Torres, you in your testimony noted the barriers you 
face accessing quality training when you started your career as 
a home health aide. So was the training sufficient to provide 
you the skills you needed to succeed, and how would access to 
supportive services like childcare and transportation, how 
would that have changed your experience?
    Ms. Torres. Can you repeat the question?
    Ms. Bonamici. Yes. Ms. Torres, you noted the barriers that 
you faced accessing quality training when you started your 
career, and how would access to supportive services like 
childcare and transportation change the experience, how would 
that have changed the experience for you?
    I could rephrase it and say, would supportive services like 
childcare and transportation be important to people who are 
learning and training how to be a home healthcare worker?
    Chairman DeSaulnier. I don't think she is--there we go.
    Ms. Torres. Sorry, I don't have the answer, but I will give 
you my point of view.
    Ms. Bonamici. OK.
    Ms. Torres. Yes. We had a really great--I had a great 
support team from Cooperative Home Care. Our training was 
intense. They were excellent. They made sure that we knew what 
we were doing. If we missed out on anything then we would have 
to make up the time, because they wanted us to go out there 
knowing exactly what we were doing.
    And at lot of companies, we get a forward training, and it 
is intense. We take two tests. And it is awesome, because we go 
out there prepared, even though we become a little afraid when 
we are in the field, because we don't know where we are going, 
and it could become a little bit stressful. But once we get 
there, we access to the client and we make it comfortable and 
clear, not cluttered for them so they won't fall, and we get to 
know one another, and we build from there.
    Ms. Bonamici. That is wonderful. Thank you so much. I 
really appreciate your being here today to share your story.
    And I want to get a question for Mr. Espinoza. I often 
speak with direct care workers in Oregon about the challenges 
with career development and with employers about retention.
    So how could States better leverage local resources and 
partnerships with community colleges and other programs to 
improve the workforce development pipeline for direct care 
workers, and how can this Committee better incentivize the 
development of career pathways and support services to 
encourage workers to stay in these very important jobs?
    Mr. Espinoza . Thank you for your question, Congresswoman. 
Creating a strong pipeline and addressing retention and 
reducing turnover I think are some of the goals that the 
interventions of the Direct CARE Opportunity Act would 
specifically address. I mean, we know that oftentimes providers 
name caregiver shortages and caregiver turnover as the top 
threats. And the cost is expensive. It is $2,200. It impacts 
quality of care, and it impacts workers.
    We have seen across the country a variety of interventions 
that have improved retention, and this act would specifically 
support those kinds of programs and help us build the evidence 
base.
    Ms. Bonamici. Thank you, Mr. Espinoza.
    And I know my time is about to expire, but just on a 
personal level, I spent a couple of years taking care of my mom 
in the last years of her life in various levels of assisted 
living and skilled nursing facilities. And the turnover is a 
serious, serious issue. It affects the quality of care, it 
affects the continuity of care, and it is expensive for the 
employer.
    So we need to do all we can to improve these positions so 
that people stay in them, and they really are valued for, and 
paid and valued for the very, very important work these direct 
caregivers provide.
    And I yield back the balance of my time. Thank you.
    Chairman DeSaulnier. Thank you, Ms. Bonamici.
    And we will now go on to Mr. Grothman for five minutes.
    Mr. Grothman. OK. Thank you. Can you hear me?
    Chairman DeSaulnier. Yes.
    Mr. Grothman. Mr. Burani, I have a couple of general 
questions for you. First of all, I know a lot of the problem or 
at least when I talk to my local providers, they feel a lot of 
the problem is caused by people right now staying out, because 
of the unemployment.
    Is that what you are seeing? Is this a nationwide thing, or 
is this just in Wisconsin?
    Mr. Burani. So I want to make sure I understand this 
question, Congressman. Is the question about the unemployment 
safety net creating sort of a different environment, which is 
driving decisionmaking?
    Mr. Grothman. Well, yes, decisionmaking of potential 
employees. I mean, I hear, be I talk to home care, be I talk to 
anybody in that field, therapy places, retirement homes, that 
sort of thing, they all tell me the same thing, that they are 
having a bigger problem finding people in the last year because 
of the excessive benefits. Is that so?
    Mr. Burani. So I think that this is probably a topic better 
addressed by a labor economist. I can tell you that from our 
point of view, we have seen pretty steady demand for our 
programs. And whether or not the baseline, you know, has the 
floor been raised, has the ceiling been raised is probably more 
of a macroeconomic discussion.
    But what I can say is that, with respect to skill 
development and that aspect of the unemployment safety net and 
the benefits that are afforded to people that are out of work, 
underemployed, low income, et cetera, especially under the 
guidelines of WIOA, the COVID-19 pandemic has certainly created 
a surge, but we also have seen that there really is a lot of 
baseline demand, which probably reflects conditions that 
predated the pandemic by a long span.
    Mr. Grothman. Do you see people looking for training in 
these fields who already spent time in a traditional 4-year 
university?
    Mr. Burani. Yes, we do. The reality that I believe we are 
all facing at this point is that education is not a one and 
done milestone. We tend to think of, you know, the span or the 
arc of a lifetime, you are born, you graduate, you get married, 
you have kids. This is not a pillar of our lifestyle. Lifelong 
learning really is the new normal, and we are not in an 
environment where a single degree is really appropriate or----
    Mr. Grothman. I guess what I am saying, is it apparent to 
you when someone with a 4-year degree comes there that they 
would have been better off, rather than getting involved in 
your field at age 25 or 30, better off being trained for this 
sort of job when they were 19 or 20?
    Mr. Burani. I would say in some cases, yes, that would be 
the case. However, we also need to realize the fact that this 
journey of educating oneself also has many twists and turns. 
How many people in this meeting knew what they wanted to be 
when they grew up at various ages?
    I think that what we could say is, in hindsight, in some 
cases, it might have been a better investment to go into a 
short-term training program, maybe an apprenticeship, and save 
the tuition, the opportunity cost of a 4-year degree. But to be 
honest, it is a realm of opportunities, and it is a vast 
marketplace.
    Mr. Grothman. I would think so. I mean, do you see people 
going through your programs that have not only a 4-year degree 
perhaps but a student debt associated with that degree?
    Mr. Burani. Absolutely. In fact, one of the drivers for 
entry into one of these programs is that a lot of the 
alternatives involve taking on more debt. And I believe that is 
the individual calculus of any person who decides to join our 
program. They think about that.
    Mr. Grothman. So if they were in your program, first of 
all, if you repeat again, how quickly do you go through your 
program?
    Mr. Burani. Four months.
    Mr. Grothman. OK. So you could be a 19-year-old who already 
went through your program and is helping out in this vital area 
of the American economy, you could be doing that without debt 
as opposed to even graduating from a 4-year, having substantial 
debt, and then entering your program?
    Mr. Burani. That is absolutely right. And I think the 
environment that they are stepping into with this credential 
has become more and more inviting for those sorts of 
nontraditional educational pathways.
    Mr. Grothman. I think certainly we do, on a Federal level, 
have programs that encourage people to take that 4-year degree 
and not use the 4-year degree. Do you think you find that 
accurate from the people you are dealing with?
    Mr. Burani. I think that there are a range of outcomes, and 
I think that in some cases that could be the case, but it's 
become a lot more complex.
    Mr. Grothman. OK. Thank you very much.
    Chairman DeSaulnier. Thank you, Mr. Grothman.
    The Chair will now recognize the distinguished gentleman 
from California, Mr. Takano.
    Mr. Takano. Thank you, Mr. Chairman.
    I want to first begin my question with Ms. Torres. Ms. 
Torres, could you please describe the work you do on a daily 
basis as a home health aide. Just describe a typical day, the 
daily work that you do.
    Is Ms. Torres still here? Ms. Torres?
    Ms. Torres. Yes.
    Mr. Takano. There you are. Just tell us what your day is 
like, just the daily tasks, the work you do. Like when you get 
to a, you know, particular client's home, I mean, just can you 
tell me what that is like.
    Ms. Torres. I do overnights. I make sure I remind them of 
their medication. I assist with meals. I provide companionship. 
I really love my job. It is very rewarding. It is not only the 
necessary tasks. I do the necessary tasks that my clients will 
need to make them happy, to assist them, to see a smile on 
their face, to know that I am there for a reason and it is to 
help them. And they appreciate it, especially those that don't 
have family. So my nights of work is companionship, making sure 
that my patients are OK, reminding them, making sure they have 
eaten their breakfast, giving them a sponge bath, grocery 
shopping for them, if necessary, and making sure they are safe. 
Thank you.
    Mr. Takano. Ms. Torres, I mean, how much physical--I mean, 
are some of your tasks physically, you know, exerting? Do you 
have to exert yourself physically? I mean, is it physically 
challenging at times to be able to----
    Ms. Torres. Yes.
    Mr. Takano. It is.
    Ms. Torres. It is.
    Mr. Takano. I mean, maybe helping lift people or you have 
to move people around, that can require quite a bit of physical 
exertion. So it is physically demanding work is what I am 
trying to say.
    Ms. Torres. Yes, it is. I use a Hoyer lift. I have to use 
my body mechanics to strengthen my body, and I have a lot of 
contact. It is very difficult.
    Mr. Takano. How long are your days, typically? How long 
does your day go?
    Ms. Torres. Well, I do 12-hour shifts.
    Mr. Takano. Twelve-hour shifts?
    Ms. Torres. Yes.
    Mr. Takano. Twelve-hour shifts. And so you will work maybe 
4 days out of the week?
    Ms. Torres. Yes. I work from 8 p.m. to 8 a.m. in the 
morning. I do 12 hours.
    Mr. Takano. And do you have to go--is it just one client 
that you work with, or do you have a number of clients, you go 
different places?
    Ms. Torres. Right now, yes, I have one. But as a home 
health aide I will say my hours vary as needed.
    Mr. Takano. Now, tell me, I wanted to ask what was it like 
during the pandemic, you know, and when the pandemic began, how 
long did it take before you were provided with proper PPE?
    Ms. Torres. They gave us some in the beginning. But we have 
a sister union in North Carolina, and they shipped us out a lot 
of masks and gloves and gowns and shields for us. So we were 
lucky, and we were blessed.
    It took some time in the beginning, of course, because we 
didn't expect this to happen. And many a times we had to buy 
them ourselves until the shipment came in and they were able to 
give us more. So now, going forward, we are pretty well on 
that.
    Mr. Takano. Great. Well, thank you. Thank you, Ms. Torres, 
for sharing that with us.
    Mr. Burani, I just want to ask a question about the short-
term training program. It is a 4-month program, but would you 
describe the pathways, the training pathway as one that is 
stackable, stackable credentials? You kind of get the first and 
this could lead to a 4-year degree at some point?
    Mr. Burani. So yes, it is a stackable credential. We have 
Nanodegree Programs that are structured at different skill 
levels, and the idea is to create pathways and even to bake in, 
you know, some decisions along the way. It is not identical to 
a 4-year degree, but there are parallels in terms of the 
outcomes and the skills.
    Mr. Takano. But it could lead to one?
    Mr. Burani. We are not an accredited institution, so we 
don't compare our credential to a 4-year institution's 
credential.
    Mr. Takano. OK. I am over time. Thank you, sir. I yield 
back.
    Chairman DeSaulnier. Thank you, Mr. Takano.
    The Chair now recognizes Representative Miller-Meeks for 
five minutes.
    Mrs. Miller-Meeks. Thank you so much, Mr. Chair. And I 
thank our witnesses. And I think it is an interesting 
conversation, because although I am a physician, in my job 
prior to Congress I started out volunteering in a mental health 
facility, in nursing homes, then became a student nurse and 
then a nurse and then a physician. So I have had this spectrum, 
if you will, which interesting that Representative Takano would 
mention stackable degrees or education that builds upon itself. 
And throughout that, I have certainly seen healthcare change 
and also, you know, home care.
    And one of the concerns I have--and I think Mr. Burani, 
this goes to your point--is one of the key problems in our 
workforce development system is that we place too much focus on 
jobs of the past as opposed to the labor market of the future.
    And I think we in government trying to determine what the 
jobs of the future are we're woefully inadequate in doing so. 
For instance, one of the things the pandemic has shown us, it 
is so hard for people to come back into nursing homes after the 
events that had happened, especially in places like New York 
and New Jersey and Michigan. So that there may be a shift in 
the future, even though there was already a shift toward care 
at home, it may be more of a push for care at home rather than 
in a residential care facility.
    And at the same point in time, we are seeing an explosion 
of technology. And so we now have technology that can do blood 
pressure monitoring at home. I am an ophthalmologist so eye 
pressure, glaucoma pressure checking at home. We can do EKGs at 
home. You can monitor and use technology to monitor medication 
boxes if you set up the medication when a patient has removed a 
medication or individual has removed a medication from their 
medication box and whether they have taken it or not. At the 
University of Iowa, in our Aging Centers looking at determining 
falls.
    So there is a variety I think of--I won't necessarily call 
it artificial intelligence, but it is in some ways artificial 
intelligence that is used to help us monitor people without 
someone physically being there.
    So to that end, Mr. Burani, what role does Udacity play in 
preparing people for tomorrow's workforce, which I think is, as 
you have indicated, going to integrate AI and other methods of 
technology?
    Mr. Burani. That is a great question, Congresswoman. Thank 
you. So I think it starts with understanding, being able to 
contextualize the industry. So you could look at, you know, the 
long-term growth of an occupation like a health information 
specialist. They are going to add approximate about 30,000 jobs 
by 2029, and that is valuable context for the direction of the 
industry. Earlier, we heard that it is the fastest growing 
industry.
    Consider on a shorter-term basis that by 2024 more than one 
in three new jobs will be in the healthcare industry. Today, 
that is 2.3 million open jobs, and the top occupations are 
registered nurse or personal care aide. You are looking for 
skills like nursing, CPR, even records management.
    But I think what we need to do is look at the occupations 
within healthcare. So if you were to take an occupation code 
like computer and mathematical, that subset is about 50,000 
open jobs, but the median salary is about 50 percent higher. A 
third of these jobs don't even require a bachelor's degree.
    And so what kind of titles are we talking about: Business 
intelligence analyst within healthcare, clinical informatics 
specialist. And they want computer science. They want 
programming languages likes Sequel or Python. They want, you 
know, agile methodology in some of those sort of project 
management skill sets.
    So whether it is AI or some other technology that is being 
applied to the healthcare industry, what we are really trying 
to do is just solve analog problems, problems from the 
nondigital world, like physician shortage and the burnout 
associated with that, all of the data that has been collected 
for eons in this industry through a clipboard and a ballpoint 
pen.
    If we can manage these things at scale, through 
telemedicine, through data science and machine learning, we can 
get better at removing outliers from our diagnoses. We can get 
better at trend spotting, so that if there is another pandemic 
around the corner maybe we spot it a bit sooner.
    It is very abstract and certainly warrants a longer 
conversation, but hopefully that helps to answer your question.
    Mrs. Miller-Meeks. I agree it absolutely does warrant a 
longer conversation. I would love to talk with you more about 
the data acquisition, the amount of data out, how that goes 
into population health and public health, but my time has run 
out, so perhaps in another conversation we can continue this. 
Thank you so much.
    And thank you, Madam Chair. I yield back my time.
    Chairwoman Wilson of Florida.
    [Presiding.] The co-Chair of the Committee had to step away 
to another Committee to vote, so I am assuming the gavel.
    And I now recognize Chairman Scott.
    Mr. Scott. Thank you and thank you for the recognition.
    I would like to ask Representative Fay a couple of 
questions. Thank you for your service. I served in the State 
legislature and I know the sacrifices that are made by State 
legislators.
    I think you have heard a number of people comment on the 
disappointment that people feel when they think a CNA is a 
dead-end position because somebody moving up to a CNA was just 
the first step in a long tradition, because you can go from CNA 
to an LPN to an RN and then to advanced practice, midwife, 
nurse anesthetist or even an independent clinical practice, and 
you would be amongst some of the best paid professions in the 
country. So considering that a dead end was certainly a 
disappointment.
    But you served on the Committee that studied this issue. 
Did you issue a publicly available Committee report?
    Ms. Fay. We did. We did. Thank you.
    Mr. Scott. We will try to get that, because I am sure you 
have got some nice recommendations that we can take advantage 
of.
    I was also intrigued when you said that sometimes there is 
no place to discharge people, because they don't have access to 
direct care. Did you make any attempt to quantify this, how 
many people were staying in an expensive hospital for the lack 
of direct care at home?
    Ms. Fay. Thank you, Congressman. We didn't have access to 
that data at the time we were doing this. And I think the issue 
has really become exacerbated because of COVID, but it has also 
really shone a light on concerns.
    So what I can do is check with our Department of Health and 
Human Services and see if there is any specific data available 
on that, and I can submit that in my comments later.
    Mr. Scott. Good. Thank you.
    I am not sure who this question, maybe Mr. Espinoza: Within 
just direct care--we have got different levels of certification 
within nursing. Would there be different levels of 
certification within direct care?
    Mr. Espinoza. Thank you for the question, Chairman. You 
know, we would look at the opportunities. There would be 
advanced roles that would fulfill different roles, so there 
would be peer mentor roles, there would be care coordinator 
roles, et cetera. However, the occupations would be within you 
know personal care aide, home health aide, and nursing 
assistant.
    We have seen some States adopt advanced home health aide 
occupations that do represent an elevation in title and 
compensation and responsibilities. So there are ways in which 
policymakers can create these advancement opportunities and 
different certifications, for example.
    Mr. Scott. And what can be done to make training more 
available and consistent?
    Mr. Espinoza. It is a great question. I think there are a 
variety of approaches. I mean, one is making sure that training 
requirements are as strong as possible for all occupations 
within direct care. Right now only home health aides and 
personal care aides have a Federal training requirement, but 
personal care aides do not. And so the State requirements for 
personal care aides vary considerably across States.
    I mean, certainly we would also argue for the importance of 
routing training in core competencies, making sure that 
programs are training workers across occupations. The potential 
of universal worker roles, for example, that could be funded 
through the Direct CARE Opportunity Act would be an opportunity 
to think about what are the core competencies and training 
approaches that these workers need across occupations so that 
they could be more portable across settings and in an ideal 
world across States. So those are the kind of opportunities 
that this act could support.
    Mr. Scott. A direct care worker has, just for logistical 
reasons, a limit to the kind of caseload that they can handle. 
If they are properly trained and getting more money, how would 
they get paid? Medicaid, obviously, could increase pay. Does 
insurance, private insurance pay for these services?
    Mr. Espinoza. It does, but in most instances the primary 
payer for Medicaid--the primary payer for long-term care is 
Medicaid. And this is part of the challenge is that too often 
what we hear is that providers do not receive a sufficient 
level of Medicaid funding or reimbursement rates to deliver the 
services that they need to deliver and much less to----
    Mr. Scott. Well, we can fix that by just doing it, but you 
can't just do it to tell private insurance or self-pay, the 
self-pay, you just can't tell them to pay more. Would people be 
able to afford the services?
    Mr. Espinoza. No. Unfortunately, these services are very 
expensive, and most people spend down their assets or income 
just to qualify for Medicaid.
    Mr. Scott. Thank you, and I yield back.
    Chairwoman Wilson. Thank you, Mr. Chair.
    And now, Mr. Fulcher, Representative Fulcher.
    Mr. Fulcher. Thank you. Thank you, Madam Chairwoman.
    A question for Mr. Burani, if I may, please: Mr. Burani, I 
personally have the belief that a one-size-fits-all model in 
higher education is preventing more individuals from successful 
careers. And it seems to me that too often we hear the only 
pathway to success is through a bachelor's degree and a 
traditional 4-year college path, but companies like yours seem 
to prove that notion wrong.
    Could you describe for me, first of all, do you agree? 
Second, if so, what are the types of learners, what is the 
profile of that learner that participates in Udacity's 
programs?
    Mr. Burani. Thank you, Congressman. I could not agree more. 
And I think that that is emblematic of the environment in which 
we find ourselves in 2021.
    So, to your second question, the types of learners in our 
program, I would say there is not a specific type. It is a vast 
diverse spectrum of learners. So I'll give you some examples. 
We have some fascinating case studies we have been tracking 
over the years. A trucker who was sort of dissatisfied with the 
direction of his career and decided in his spare time on the 
road to start learning how to code and gained access to a 
scholarship program to nanodegree in programming from Udacity 
and ended up in a front-end web development career and has 
completely reinvented himself.
    Another example I can give you is very different. So this 
earlier gentleman I believe was in his late forties. And we 
have got a kid who is no more than 18, 19 years old working two 
retail jobs at minimum wage to try and make ends meet and 
actually got accepted to a 4-year university, decided not to 
take that opportunity, and instead gained access to a 
Nanodegree Program through a partnership we had with Google, 
landed an internship with NASA, and now is gainfully employed 
by GitHub, which is a Microsoft subsidiary.
    We work with learners who are incumbents in corporations, 
some of those that I mentioned in my opening statement. They 
are looking to us to drive big capacity building initiatives. 
So these are employees that are just looking for a way to move 
up.
    But we work with distressed communities, dislocated workers 
from the pandemic, partnering with workforce development boards 
at a local level in order to find people that maybe don't fit 
any particular profile other than they are hungry for change. 
So we try to provide them with a platform to take control of 
their careers and come out with job-ready skills.
    Mr. Fulcher. You also mentioned, Mr. Burani, in your 
testimony that the processes for providers to maintain their 
catalogs of programs is different in every State. I know that 
we have got some differences in my home State of Idaho, which 
creates a number of administrative burdens for new providers.
    Would you talk to me about that process, the 
cumbersomeness, if that's a word, of the process for providers 
to be added to an eligible training provider list and what 
changes you might recommend to that process.
    Mr. Burani. Absolutely. This is an important topic, 
Congressman. So when we think about the structural 
underpinnings of WIOA, the system needs to know who is 
training, what they offer, what their performance is, because 
it needs to maintain accountability. So that is important.
    However, what we find is that if you choose to engage in 
one State versus another, one workforce area versus another, 
some things are consistent, and some are not. Some States will 
require different types of records. They may ask for financial 
records for a private institution. That can get a little 
thorny. They may ask for certified documentation from a company 
officer.
    There is a lot of inconsistency in this sort of structural 
blueprint for the system. And I would say a solution, I would 
liken it similar to the common application that a lot of people 
use to get into higher ed, right? You fill out one application, 
it gives you access to a lot of different institutions. Maybe 
that is a model we can look at with the reauthorization of 
WIOA.
    Mr. Fulcher. Just very quickly, because I am just about out 
of time, but I am going to shift gears right quick. We have 
this tendency in Congress to throw money at things, and 
sometimes money is not always the answer.
    How do we take a reform and tie the connection better 
between the learner and the taxpayer?
    Mr. Burani. This goes back to my opening statement. No. 1, 
have a more clear-minded, modernized view of what the labor 
markets of today need. No. 2 is to create some of the 
structural reforms, and No. 3 is to invest in channels and 
facilitate the collaboration between entities.
    Mr. Fulcher. Thank you, Mr. Burani.
    Miss Madam Chair, I yield back.
    Chairwoman Wilson. Now Representative McBath. 
Representative McBath. Representative Jayapal. Representative 
Manning.
    Ms. Manning. Thank you, Madam Chair. And thank you for 
holding this very important hearing.
    Representative Fay, I found your testimony, your written 
testimony to be informative and thought-provoking in framing 
the ways we need to professionalize and refer to caregivers. I 
have also found that so many people lack any real appreciation 
of caregivers until they need assistance for their own family 
Members. And then it is like an epiphany and suddenly they 
realize the importance of having trained professional people in 
those positions.
    So I wonder if you could tell us how direct care workers 
are trained in your State and whether you have any 
recommendations regarding the importance of having statewide 
programs that are focused on providing training to this 
workforce, both in terms of ensuring quality and also the 
impact of training on retention and the development of career 
ladders for this workforce.
    Ms. Fay. Thank you, Congresswoman. That's a big question. 
And in a big State that is both geographically large and also, 
we have significant rural populations, I think the answer 
depends on where you are.
    So for--to answer the first part, the training happens 
depending on I think where you are, whether you have access to 
a vocational program or it's something that you are called to 
do, the work is work that you are called to do, or whether you 
are working for a provider or need a job. So our private 
providers will train personal care attendants. Anecdotally, I 
have heard that sometimes the training is short and not 
particularly comprehensive, and I think that's part of the 
professionalizing of the workforce.
    So, you know, I am not trying to give a nonanswer answer, 
but it really does depend on where you are and what resources 
you have access to and what your motivation is.
    Ms. Manning. Thank you.
    Mr. Espinoza, one goal of the Direct CARE Opportunity Act 
is to spur investment in new recruitment efforts for direct 
care workers. And in your written testimony, you describe some 
examples of promising recruitment initiatives.
    Can you talk a little bit more about the elements of a 
successful recruitment program. How can recruitment efforts 
bring untapped labor pools into the direct care workforce?
    Mr. Espinoza. Thank you for that question. Recruitment is a 
major challenge for us in the direct care workforce. Generally, 
we think about the various strategies that employers can use to 
recruit more workers, from improving the hiring process to 
strengthening entry-level training, providing employment 
supports, the kind of wraparound supports that Zulma testified 
to earlier, promoting peer support so that workers are getting 
that attention of other workers and learning about the job from 
other workers. Also ensuring effective supervision, developing 
advancement opportunities, recognizing and rewarding staff and 
measuring progress.
    Typically, in a recruitment approach, the approach first 
looks at how do you attract and select the candidates that are 
best suited for providing quality services and support, and 
then they help employers establish the kind of partnerships or 
boost the kind of partnerships that will help them reach a 
broader pool of candidates. And really, how do you strengthen 
an employer's brand.
    We have seen a variety of retention recruitment projects 
throughout the country that have really focused on bringing 
more workers into the sector, from a program in Wisconsin that 
brings more nursing assistants by training them and then 
connecting them to employers through partnerships in the field 
to an intervention in Minnesota where an assisted living 
facility in the rural part of the State partnered with a social 
media firm to develop paid ads to target key markets and drive 
them to apply online through their mobile devices.
    So there are a range of recruitment processes that can be 
used to bring more workers into this sector and, of course, 
strengthen the retention once those workers are--take on these 
jobs.
    Ms. Manning. Thank you. My time has expired. I yield back.
    Chairwoman Wilson. Thank you so much.
    And now we have Ranking Member Foxx from North Carolina.
    Ms. Foxx. Thank you, Madam Chairwoman.
    My comments and questions will be for Mr. Burani. A well-
skilled direct care workforce is critical for serving our most 
vulnerable populations but adding more Federal programs is 
often duplicative of broader efforts and creates an inflexible 
system that does not meet the needs of local employers.
    Rather, Congress should work to reform our existing 
workforce development system to ensure all workers, including 
those in health-related fields, have the skills they need for a 
successful career path.
    Mr. Burani, programs like WIOA have the potential to be a 
flexible and robust workforce pipeline for millions of 
Americans. In your view, what are the top three things in 
current law preventing this from occurring?
    Mr. Burani. Thank you, Congresswoman. That is a compelling 
question and narrowing it down to three is my challenge. I 
would say there is, in no particular order, one important 
priority is creating opportunities for distressed communities 
to thrive within this system. So what that means is effectively 
looking at the outcomes and the standards to which we hold 
these, appreciating that these populations may be structurally 
disadvantaged from thriving within the system simply because 
the way workforce boards are measured works against them and, 
therefore, leaves them cut out of the mix. How to do this is 
another conversation, but one that I think is very compelling 
and happy to always explore further.
    The second is the host of structural reforms that I have 
discussed in my opening statement as well as in response to 
some of these other questions. And what I would say is that it 
goes beyond simply the mechanisms for managing training 
providers. We also want transparency into the performance data. 
It is hard to just take a pulse on WIOA and understand what is 
working and what is not, in which geography, for which learner, 
et cetera. And so I would propose expanding structural reforms 
to also include more free access to that data.
    And then if I had to pick a third and exclude others as a 
result, what I would do is I would think about how we can look 
at maintaining individual accountability while also broadening 
service delivery to a more aggregate level.
    American Job Centers, for example, are tasked with liaising 
one on one with individuals and really taking a case management 
approach to letting people into these programs. As the training 
provider in this equation, we have observed countless times 
that that becomes the biggest bottleneck. It is not a job that 
can be approached with shortcuts. It simply needs to be 
modernized in such a way that service delivery can be a 
smoother process. Hopefully, that helps answer your question.
    Ms. Foxx. That helps a little bit. And I think making the 
language a little simpler--you use a lot of big words that I 
think don't need to be used and we could use simpler ones.
    But from your testimony and the answers you provide today, 
it is clear Udacity serves learners much more efficiently than 
the Federal Government does. While our time is limited today, I 
want to followup with you after this to better understand how 
we can focus taxpayer dollars to enhance our workforce 
development system and help the individuals gain the skills 
they need for a successful career.
    And I appreciate Udacity's focus on producing lifelong 
learners. That is certainly an interest of mine. Our economy is 
rapidly evolving, as we have talked about, and it is important 
that individuals have the ability to upskill and reskill. That 
is very clear in this hearing today.
    So how can individuals advance their career development 
with your company? If an individual learns one skill and then 
desires to learn additional skills in the chosen field, what 
avenues are there for the person to pursue that goal?
    Mr. Burani. That is an excellent question. I appreciate 
your compliment and your earlier feedback as well, 
Congresswoman Foxx. I think that it starts with understanding 
the multitude of options available. Udacity is but one training 
provider, and we are reaching a point where there are more 
specialists.
    People need career guidance. They need to understand what 
is out there before they can begin to make decisions. We 
provide career services, and on occasions our programs also 
include soft skills, so they learn teamwork, collaboration, 
leadership and so on. And we feel like this helps to create 
more opportunities for lifelong learning.
    Ms. Foxx. Well, thank you very much. And I hope you will 
put more of a focus on education than on the T word, because I 
think when you use that you are limiting, very seriously 
limiting people's options. Thank you very much.
    And thank you, Madam Chair.
    Chairwoman Wilson. Thank you.
    And now Representative Morelle of New York.
    Mr. Morelle. Good morning. Thank you, Madam Chair. And 
thank you to both our Chairs for holding what I think is a 
very, very important hearing to discuss this topic, and 
certainly to all of our witnesses for being here today and 
sharing their expertise. And I will say also that many of the 
questions that I had thought about asking, have been asked by 
my colleagues, so I want to thank them. I think this has been a 
really enlightened conversation.
    You know, each year the nearly 20 million adults in the 
country who need assistance with self-care deserve the dignity 
of receiving these services in the comfort of their own home. 
But obviously, as the witnesses have testified, you can't 
ensure that those services will be provided in the appropriate 
way unless we have a robust direct care workforce, each of whom 
receives appropriate pay and has the opportunity to grow 
professionally within the healthcare system.
    Just parenthetically, I note I was proud last year to 
introduce the Senior and Disability Home Modification 
Initiative, which would have helped support independent living 
for older individuals living with disabilities.
    And I was proud to see some of the provisions related to 
older individuals become law with the passage of Supporting 
Older Americans Act, but I know we still have a lot to do when 
it comes to recruiting an effective workforce and retraining 
them with proper wages, improved working conditions, and 
advancement opportunities.
    I just wanted to make note of a program. It is a Federal 
program, the Health Profession Opportunity Grant Program, also 
known as H-POG, or HPOG, which I think is a pretty effective 
healthcare training program that helps address workforce 
shortages for in-demand jobs.
    And the program creates career pathways, such as 
apprenticeships and ongoing training, to empower advocates, 
many of whom are low income, to take on new jobs as nurses and 
technicians. It also supports many indirect aspects that people 
must consider and which you have talked about here this morning 
when working in those settings, including childcare, 
transportation, work supplies, application fees, et cetera.
    So the program stands out because it has helped advance the 
careers of people who have been disproportionately left behind 
in workforce training programs, especially low-income single 
women of color, and it is more likely to result in a person 
being employed in a health program upon graduation. The 
availability of this program has been particularly an asset to 
my community.
    Action for a Better Community is an organization that 
receives money from the program, and I have been blessed to be 
in contact with them, meet with the folks who have gone through 
the program. I think it is something we should continue to work 
on.
    I wanted to just, if I can, ask a question of 
Representative Fay. I am a proud former Member of the New York 
State Legislature, so I have great appreciation, as many of my 
closing who served in State government, for that role.
    I wonder how we might be able to utilize programs and how 
the States might be able to utilize programs like this Health 
Professions Opportunity Grant Program to leverage funds to 
improve recruitment and develop defined pathways for career 
advancement for the direct care workforce. You might be able to 
comment on that, not simply HPOG, but as I have described it, 
perhaps other programs as well.
    Ms. Fay. Thank you. Yes. And so I am thinking about that as 
we adjourned sine die last night fairly late. So I might be 
just a little foggier than I would be normally.
    I would say it depends on the State. So in Maine, our 
workforce is really kind of disparate. And while our Department 
of Health and Human Services and MaineCare does the funding, at 
a level where we are talking about home healthcare, they don't 
necessarily have a jurisdiction over all of that. I mean, we 
have credentials and training. So I think--yes.
    Mr. Morelle. Yes, let me ask this, Representative: Would it 
be helpful, in terms of thinking of it, and do you think about 
it in terms of creating rungs on a career ladder. So that 
people come in--in terms of skill set--having relatively few 
skills but continue to work up and have a more defined? Would 
that be helpful, and is that something you think about in your 
responsibilities?
    Ms. Fay. Oh, absolutely. I mean, we definitely--that was 
definitely one of the recommendations of the commission that I 
Chaired. And any assistance and guidance in making that happen 
I think would be helpful.
    Mr. Morelle. Very good.
    Well, Madam Chair, I will have additional questions, and I 
appreciate the hearing very much. I see my time is up, so I 
will yield back. Thank you.
    Chairwoman Wilson. You may submit them for the record if 
you want answers.
    Mr. Morelle. And we will do that. Thank you.
    Chairwoman Wilson. So ordered.
    Chairwoman Wilson. And now Representative Banks of Indiana.
    Mr. Banks. Thank you, Madam Chair.
    Mr. Burani, Udacity has educated over 15.4 million learners 
since its founding in 2011.
    Can you tell us, in what ways do you believe an effective 
reauthorization of WIOA can help Udacity further expand 
learning opportunities for even more individuals?
    And are there reforms to the Higher Education Act, such as 
allowing Pell grant recipients to enroll in short-term 
workforce development programs that would allow you to 
successfully help more learners?
    Mr. Burani. Thank you, Congressman, for the question.
    So, while we have had good success, to the tune of 15 
million learners, the reality is that metric reflects our 
business around the world. And so we have run programs in a 
variety of contexts, direct to consumer, working with 
corporations, you know, at an enterprise level, as well as 
through the public sector, and that 15 million encompasses all 
of it.
    We are in the early days of WIOA at Udacity, and to be 
honest, I think I can speak for, you know, the broader world of 
short-term credentials.
    So, when we think about reauthorization, going back to my 
opening statement, certainly there are a lot of reasons to be 
encouraged by what this potential, you know, reauthorization 
actually signifies. Anything that helps bring more dynamic 
options and choice to the learners' and employers' marketplace, 
we are in support of. If that helps students have a better 
range of options and if that helps employers have a more robust 
talent pipeline, we support it.
    To your second question around the Higher Education Act, 
this is an area in which, generally speaking, what we can say 
is, as short-term credentials start to get their moment in the 
spotlight next to additional 2-year and 4-year degrees, we 
think that these programs should be open to accepting more 
learners from different backgrounds. And, if, you know, 
different grant eligibility becomes a topic for discussion, we 
support that.
    Mr. Banks. Good. Appreciate that.
    You also mentioned in your testimony that Udacity offers 
over 60 Nanodegree programs. Can you describe what these--what 
that means? What do these programs entail?
    Mr. Burani. Yes. So a Nanodegree program is effectively a 
combination of technical learning and hands-on project work. So 
earlier, we spoke about industry partnerships for curriculum 
development.
    If you were to enroll in a program to learn the fundamental 
skills of cloud computing, you would have an expert in cloud 
computing, potentially someone, you know, employed or connected 
to that industry who is effectively delivering this content 
through sort of bite-sized learning modules. And this 
experience is augmented by a series of supports, just 
interventions.
    We have session leaders who effectively work not unlike 
graduate students in a higher-ed context, facilitating 
discussion and lab work and project submissions. We have got 
tutors and mentorship resources available. We have got 
community resources, because we acknowledge that a lot of our 
best learning comes from observing our peers.
    And this also includes--I could go on and on, but there is 
career resources. There is an employer platform to help 
motivate students and remind them that there are interviews 
waiting on the other end.
    The--these two components, the project work and the 
technical instruction, come together. And, over time, what we 
have done is we have optimized a lot of these interventions in 
pursuit of the best completion rates, the best career outcomes 
that we can find.
    Mr. Banks. How many--how many Nanodegree courses would it 
take for me to get--for me to receive a degree, let's say, in 
business?
    Mr. Burani. So a Nanodegree credential can be done with a 
single program, and it would be 4 weeks, roughly 10 to 15--I am 
sorry--4 months, 10 to 15 hours a week is the type of 
commitment we are looking for.
    Mr. Banks. And, for the purposes of this education for my 
colleagues on this Committee, how much would that cost?
    Mr. Burani. So, to the learner, we typically have--you 
know--what we do is, especially in the public sector, is we 
orchestrate funding through different entities in order to 
effectively grant a full ride. So, we position these as 
scholarships.
    The reality is that there is a wide range of, sort of, 
commercial schemes in which we have kind of positioned our 
programs on a consumer level. If you were to come in through 
the website, you would pay $3.99 a month, and you would have 
access until you are complete, and $3.99 a month is sort of 
like all you can eat.
    Mr. Banks. Well, this is fascinating and revolutionary. I 
appreciate that feedback.
    My time has expired. I yield back.
    Chairwoman Wilson. Representative Wild of Pennsylvania. 
Thank you.
    Ms. Wild. Thank you, Madam Chairman.
    I would like to direct my question to Ms. Torres. Good 
morning, Ms. Torres. Thank you for being here and thank you for 
the work that you do every day to care for people who are in 
need of extra help.
    In my own family, we have experienced the need for direct 
care to my mother, who, in 2014, was diagnosed with brain 
cancer and came to live in my house using home hospice. And, 
because we--this came out like a bolt out of the blue, we had 
no warning that that was going to happen. We hadn't made 
arrangements, and I had no choice but to hire somebody to come 
in and take care of my mother while I went to work for a few 
hours a day. And she was very well cared for in the few months 
that she had left in her life, and I thank you and all who do 
this kind of work. It is so important.
    Unfortunately, we know that the industry is known for its 
low pay and high turnover rates. The median wage for direct 
care workers is $12.27 an hour. And, during the year 2018, the 
direct care workforce experienced a turnover rate of 82 
percent.
    So, I guess my question to you is: Do you see career 
advancement as something that you desire? And, if so, do you 
believe that there is any possibility for career advancement 
for you in your field? Do you have any kind of pathway to jobs 
with greater responsibilities and higher pay?
    Ms. Torres. Yes. I do believe that I can go forward with my 
job. I can build--they have opportunities--through the 
Cooperative, we have opportunities to get involved with office 
work, or through our union, if you want to become a nurse. 
There are opportunities. We just need more funding.
    Ms. Wild. Uh-huh. And so you have--I assume you have 
experienced coworkers who have left their job because of the 
low pay. Is that true?
    Ms. Torres. Yes.
    Ms. Wild. And have you considered doing that? Have you 
considered looking for other kinds of work because you just 
weren't making enough money?
    Ms. Torres. No, because I found a love for my job.
    Ms. Wild. Well, thank you for that.
    How do you believe that you could be affected if you were--
what would it mean for your family if you were able to make 
more money?
    Ms. Torres. That would be awesome. That would be----
    Ms. Wild. How many hours a week do you work?
    Ms. Torres. I work 36 hours a week. I am a night worker. I 
do overnights. I used to do a CVPAC [inaudible] but now I do 
overnights.
    Ms. Wild. Do you receive any kind of benefits in your job, 
healthcare----
    Ms. Torres. Yes. Yes, I do.
    Ms. Wild. Do you get vacation pay?
    Ms. Torres. I have--yes. I have PTO. I have 401(k). I am a 
worker-owner to the company. I have life insurance through my 
union, 1199.
    Ms. Wild. OK.
    Ms. Torres. Health insurance, which is very important, 
because I have my son with me. So I do have benefits. And 
sometimes benefits are better than the pay in certain 
situations, because we need those for when we get sick.
    Ms. Wild. So have--so, in your case, you feel that the work 
that you are doing is satisfying enough that you don't aspire 
to leave and go into another line of work?
    Ms. Torres. Uh-huh.
    Ms. Wild. I believe that that is what you said.
    What about the people that you work with? Do you know 
others who leave the job, which is such an important job, 
simply because they want a job that pays more?
    Ms. Torres. Yes, because we need raises. We need the money. 
And not everyone wants to stay on board knowing that they could 
make more money somewhere else. And it is difficult, because 
even though I love my job, my wages, I live check to check. I 
do transportation back and forth. I reside in Connecticut and 
work in New York. So that is also money, going back and forth.
    Ms. Wild. Sure. Costs money.
    Ms. Torres. It would be great if it--paid my bills, right. 
You know, like everyone else. So, if we were to get a raise, it 
would be awesome for every home health aide? Why? Because they 
will find interest in wanting to go out to work. We could 
recruit more home health aides and give them the benefits that 
we are--that Cooperative and our union is offering. So that 
would be awesome.
    Ms. Wild. And which union do you belong to?
    Ms. Torres. 1199 SEIU.
    Ms. Wild. OK. Thank you so much. I appreciate your 
testimony.
    And I yield back, Madam Chair.
    Chairwoman Wilson. Thank you so much. Thank you.
    And now Representative Good of Virginia.
    Representative Good?
    You have to unmute, sir. We can't hear you.
    Mr. Good. There we go. Thank--sorry about that. Trying to 
hit it, and it wasn't working for me.
    Thank you, Madam Chairman, and thank you to all of our 
witnesses, and I appreciate your time with us today.
    Mr. Burani, last Congress, the Republican Study Committee 
proposed the establishment of an E-Verify Program that would 
require all individuals to be confirmed through the Department 
of Homeland Security before being eligible for Federal jobs 
programs. This would mean that only people who are legal, 
eligible to work in the United States would be able to take 
advantage of Federal jobs programs.
    Would you recommend that Congress implement this proposal?
    Mr. Burani. So, at Udacity, where we have typically focused 
our energy is on getting people through the system once they 
are allowed in. We haven't traditionally taken positions on 
eligibility of that nature.
    Mr. Good. Well, I--the question of E-Verify--mandatory E-
Verify for the Federal workforce is one that my office has been 
discussing for some time now, and a policy like this would be a 
simple fix to ensure that American workers are prioritized, and 
the rule of law is followed and upheld. So I certainly continue 
to strongly urge my colleagues to consider policies that would 
institute mandatory E-Verify for the Federal workforce.
    But, Mr. Burani, I appreciate your focus on working within 
the existing framework that we have instead of adding to an 
already bloated welfare State like some on this Committee would 
seek to do.
    Under current law, there are--and this relates to a 
previous questioner, but there are social welfare benefits that 
are reduced if a beneficiary increases their income. And the 
consequence of this can be a difficult tradeoff scenario where 
lower-wage workers must choose whether or not to continue 
receiving welfare benefits as they potentially increase their 
income. And this has--can have the effect of disincentivizing 
work or advancement for many lower-wage workers.
    How would you suggest that be addressed?
    Mr. Burani. That is a good question, Mr. Congressman, and I 
think, you know, it takes a lot of analysis to understand the 
benefit cliff and how it is actually changing behavior. People 
who are entering programs such as ours are making an 
investment.
    To the earlier question, you know, this is not necessarily 
a financial investment. However, the opportunity cost of 
stretching their lives even thinner, making sacrifices, 
potentially even taking themselves out of the labor market, 
need to be considered.
    I think that the important thing is to look at the outcomes 
of these programs and to understand, as WIOA has stipulated 
since its enactment 7 years ago, that not only is credential 
attainment and job placement important, but also, we are 
looking at median salary. We are looking at it--the system 
looks at it after 6 months and after 12 months, because we want 
to see retention, and we want to see effectively a standard of 
living that has been sustained.
    In our particular programs, the sort of archetype of a 
learner who upskills through a Udacity Nanodegree program has 
set themselves up for, in many cases, a much higher standard of 
living because they are entering high-growth pathways in which 
the supply and demand in the labor market has supported that.
    So we believe that accountability and transparency into 
those outcomes, certainly in our world, helps to keep that 
momentum moving forward.
    Mr. Good. I agree. And that is what we all aspire to do, is 
to help people get to those higher-wage situations.
    In your testimony, Mr. Burani, you emphasized the 
importance of creating effective mechanisms that encourage 
individuals to invest in their own career transformations. What 
are some ways that you have seen individuals set themselves up 
for success by creatively developing their long-term skill 
sets?
    Mr. Burani. That is an excellent question, and I think that 
there are--there are so many paths to the finish line. But as 
is probably no secret to anyone in this discussion, they get 
what they put in, and, so, people that look for the path of 
least resistance might succeed, but, on balance, generally will 
not succeed as much as the people who look for ways to augment 
their learning experience.
    Earlier, I mentioned career services that we offer. Some of 
them are mandatory project submissions. Some of them are 
discretionary. You can choose to have your resume reviewed, and 
you can choose to do the work to polish it up, ditto your 
LinkedIn profile.
    You can hone your interview skills. You can also--you know, 
there is the variety of free courses that we offer as well as, 
you know, the marketplace in general. And, so, that is the best 
answer, is the more you can invest, likely the more you stand 
to benefit.
    Mr. Good. Great answer. There is no substitute for hard 
work or being the CEO of your own career and taking 
responsibility. So thank you so much for your time.
    And I yield back, Miss Madam Chairman.
    Chairwoman Wilson. Thank you. Thank you so much.
    Ms. McClain--I am sorry. Ms. McBath of Georgia, welcome. 
Welcome back.
    Mrs. McBath. Thank you, Madam Chair, and thank you so much 
for convening this panel today and thank you to all of our 
panelists.
    And everyone, thank you for sharing your testimonies with 
us. And I know that this is a vitally important topic, and I 
appreciate the focus of this Committee on continuing to serve 
all of our workers in America.
    And I know that we have all experienced a time when an 
aging apparent, or a disabled family Member, really needed 
additional care in the home. I myself, as many of our 
colleagues have expressed earlier, had the responsibility to 
care for my ailing mother during the last years of her life, 
and finding a good, loving care provider was extremely 
important to our family.
    And we know that nearly 20 million Americans need 
assistance with self-care and daily living, and that number 
just continues to grow as our population ages.
    This is an issue that touches the lives of almost every 
American. And, when the time comes, we all want to leave our 
loved ones in the care of a compassionate and very capable 
individual. And we should treat those caretakers with the same 
compassion and the same respect that we expect them to treat 
our loved ones.
    And, despite the essential nature of their work, you know, 
as we have been expressing, direct care workers face an 
extremely high turnover rate of about 80 percent. And these 
high rates of burnout, low pay, and limited benefits, and a 
feeling of being just so undervalued are all central to the 
challenges facing the direct care workforce.
    However, we know that, you know, there are solutions for 
these problems. We have been talking about this today, and 
President Biden and this Committee have proposed bold action to 
address the direct care workforce shortage and ensure that 
these are good-paying, middle-class, high-quality jobs.
    So my question is for Representative Fay. One of the 
elements that you touched on in your testimony is the need to 
raise the perception of direct care as a viable, meaningful 
career pathway.
    Can you talk about proposals that your State is considering 
helping implement and achieve these goals?
    Ms. Fay. Yes. Thank you, Congresswoman, for that question.
    So I think the No. 1 issue is pay, is wage rates. And so, 
if we sort of set that aside, which is something that our 
commission did, because I think everyone on the commission was 
in consensus agreement that--that the pay was not commensurate 
with the work. And, if we value work by the amount of money 
that we pay people, then we are not doing justice to the value 
that this work provides to our loved ones, but also to our 
economy.
    There is a parallel between the childcare workforce issue 
and the caregiving workforce issue as well.
    So I think I will just--I will just stop there with the 
pay. You know--yes. That is where I will stop. Thanks. Sorry.
    Mrs. McBath. OK.
    Ms. Fay. I don't want to take too much time.
    Mrs. McBath. Thank you so much for that.
    And, Mr. Espinoza, individuals who are receiving consumer-
directed care are often responsible for finding and hiring 
their own direct care workers, as my family and I had to do as 
well. And, while these--this gives these individuals, really, a 
great deal of individual choice--you know, we had a large 
choice of care providers regarding who provides, you know, 
services for families and, you know, we had to do the same for 
my mother.
    Can you talk about some of those strategies that PHI 
actually recommends that helps connect people like us, families 
like us, with workers who can provide those kinds of services?
    Mr. Espinoza. Yes. Absolutely. Thank you for the question, 
Congresswoman.
    One of the best strategies I think that we have been seeing 
in the field are matching service registries or caregiver 
registries. These are online platforms that help home care 
consumers and workers find one another.
    In California, there are four centers for independent 
living that offer matching service registries, and they include 
features for consumers and workers. They include the option for 
workers to record short messages. There are a variety of 
technological features that make that interaction more 
possible, and it allows them to connect based on preference, 
based on their needs, and based on their availability.
    However, there are only matching service registries in 10 
States. Many of them are chronically underfunded and do not 
embody the best of technological processes. And, so, certainly 
the Direct CARE Opportunity Act could make a big dent in this 
issue. It could ensure that all States have matching service 
registries, or that we find other viable ways to connect 
consumers and consumer-directed programs to workers.
    Mrs. McBath. Thank you so much.
    And, Ms. Torres, I just want to say in my last few seconds, 
thank you so much for everything that you do. The work that you 
provide and the care that you provide the residents that are 
depending on you is truly, truly vital, and we just really 
appreciate everything that you do for this industry.
    Ms. Torres. Thank you.
    Mrs. McBath. And I yield back.
    Ms. Torres. Thank you.
    Chairwoman Wilson. Thank you, Ms. McBath.
    And now Ms. McClain of Michigan.
    When she finishes, the gavel will go back to Mr. 
DeSaulnier, who has returned to the meeting as co-Chair.
    Ms. McClain of Michigan.
    Mrs. McClain. Thank you, Madam Chair.
    Mr. Burani--thanks--sorry about that--your work involves 
upskilling individuals with vital skill sets that leads to 
promising careers.
    Some of my colleagues across the aisle often argue that 
throwing more and more funding on new Federal programs is the 
answer for workforce development. This is simply not true, and, 
actually, could detract from existing workforce development 
efforts that already work.
    I intend to actually introduce legislation addressing ways 
to promote awareness and information on these incredible 
programs and their beneficial role in shaping our next 
generation's workforce. I believe we need to focus on helping 
all workers, including those in direct care sectors, by 
strengthening really existing programs that will further help 
address the skills gap.
    Can you speak about the current success and employment 
outcomes--the actual outcomes that these programs, such as 
Udacity, can lead to, you know, as well as any structural 
changes or reforms that could be better serve both prospective 
students and actually taxpayers?
    Mr. Burani. Yes. Thank you, Congresswoman, for this 
question.
    I think that, you know, the way that we look at a 
successful program is largely within the context of the systems 
that support it. So WIOA's standard of performance is based on 
credential attainment. It is based on job placement, retention 
of that job for 6 and 12 months. It is based on the median 
salary coming out of that program.
    So we look at all of these things, but we also use a 
broader definition of positive career outcomes. We have run 
programs around the world in which what we have done is 
measured the impact for a learner coming out of our program not 
only on the ability to attain the job offer, because that may 
or may not have been their goal. It may or may not have been 
the goal of the funders and the sponsors of this program.
    We have run a program in Egypt, for example, where we are 
working with tens of thousands of graduates to put them in 
gainful freelancing work, and the attainment of a freelancing 
gig or a series of them would be a positive career outcome. So 
would a promotion, either in title or pay or both. So would the 
launch of a successful venture. It could even simply be that 
you self-report yourself as being happier on the job.
    So we look at these positive career outcomes, and they are 
broadly defined. It gives us a basis on which to optimize our 
programs and really make sure that this technical curriculum 
paired with the projects also is supported with the right 
wraparound services to maximize those outcomes.
    Mrs. McClain. Sure. Thank you.
    And then, workforce shortages in the healthcare industry 
have long been an issue but have only been really exacerbated 
by this pandemic. As our next-generation workforce takes shape, 
there will likely be advancements in technology in the 
healthcare industry, which will require, obviously, a robust 
workforce.
    Can you speak to how programs and platforms, such as 
Udacity, can help address some of these shortages, and the 
skill sets they can provide for future healthcare and jobs?
    Mr. Burani. Yes. It is a fascinating topic, and we are in 
the early days at Udacity of looking at, sort of, sector-
specific solutions of this sort. But I will give you one 
example.
    We offer a program for artificial intelligence in 
healthcare, and this really provides what we see as a, you 
know, a very modern skill set, which is a bit of a lead pass 
for where we see the industry going.
    Now, you will recall earlier, I spoke to the 2.3 million 
open jobs in healthcare, and the very small subset of those 
today that represent these types of technology, sort of, 
related skills. But we do see that changing over time, and that 
is due to all of the investment in digital transformation.
    So our AI for healthcare Nanodegree will--you know, here is 
an interesting application. Using the data that comes from 
wearable devices to understand the context around some of these 
indicators, something as simple as your heart rate or pulse, 
right? If we understand the context, we understand the--you 
know, the altitude, or the accelerometer tells us that this 
person was actually moving quickly, right. This can now add 
important metadata for a practitioner to understand, I can rule 
out explanations A, B, and C, and focus my diagnosis on X, Y, 
and Z. So we hope to use that technology in a productive way.
    Mrs. McClain. Thank you, sir. And thank you for all the 
guests today.
    I yield back my time. Thank you.
    Mr. DeSaulnier.
    [Presiding.] Thank you, Chairwoman Wilson. Wonderful to 
partner with you.
    And now, I would like to recognize the distinguished 
gentlelady from Michigan, Representative Stevens, for five 
minutes.
    Ms. Stevens. Well, thank you, Mr. Chair, and thank you 
for--to our witnesses for today's very important hearing on 
caring for our communities and supporting and investing in the 
direct care workforce.
    Let me just couch this in the Michigan sense really 
quickly. Michigan has about 60,000 direct care workers who take 
care of our elderly peoples and peoples with disabilities in 
their own homes.
    In addition to our current shortage of direct care workers, 
State officials estimate that Michigan is going to need an 
additional 178,000 direct care workers in the next 10 years to 
meet growing demand. That is more than twice the current 
workforce.
    Currently, there are not any Federal or Michigan State 
training initiatives or certification requirements to work as a 
direct care worker in someone's home. We all know, and we have 
talked about today the pay being low, the benefits being 
virtually nonexistent. And, over time, it is becoming more and 
more common that the work is obviously--grows to be physically 
and emotionally demanding. Michigan home care workers are paid 
somewhere between $9.50 and $12.00 an hour without a lot of 
benefits.
    So, Mr. Espinoza, you had mentioned in your testimony that 
COVID-19--that the COVID-19 pandemic worsened existing 
challenges for the direct care workforce. Could you just talk a 
little bit more about that specifically and the impacts that 
the pandemic had on our home care workforce and the people they 
support?
    Mr. Espinoza. Yes. Thank you for that question, 
Congresswoman.
    What we saw in our experience and through our research was 
that, in the early stages of the pandemic, direct care workers 
were on the front line, but they were often there without 
enough PPE, without enough supplies, without childcare or paid 
sick days, and without proper compensation. In fact, we heard 
some horror stories in New York City, for example, where PHI's 
headquarters are based, of workers using garbage bags as gowns 
and purchasing their own protective equipment.
    And many workers were being made--asked to make the 
impossible choice: Do I go to work and risk getting infected or 
infecting my families and clients without paid sick days, or do 
I stay home and collapse financially?
    And employers and industry groups also sounded the alarm. 
Our research would show that about 280,000 workers left the 
direct care sector in the first 3 months.
    Now, that said, over time, we have seen that these numbers 
have begun to settle and return back to normal, but there are 
still a variety of questions that I think the direct care 
workforce and the long-term care sector needs to address, 
really to strengthen jobs and to protect ourselves during the 
next healthcare crisis.
    What has been--the mental health impact, for example, on 
workers who saw clients and family Members die, how does this 
affect turnover? What does it mean that this sector often lacks 
grief support and bereavement leave for workers? How should 
this sector improve safety standards, infection control and 
prevention, emergency preparedness? How do we recruit 
effectively when so many workers saw how dangerous and 
unprotected these jobs are, especially in nursing homes?
    And how do we learn from the short-term measures that were 
adopted, from hazard pay to paid leave, to childcare centers in 
certain cities, or virtual trainings, to think long-term, to 
modernize the job, and to transform this sector in the long-
term?
    I mean, certainly we would ask for a Federal report on the 
lessons learned of this workforce and how to prepare for 
ourselves in the future.
    Ms. Stevens. Great. Thank you so much for that really, 
really thorough explanation, and just all of your background.
    And with my remaining time, Representative Fay, in your 
testimony, you talk about individuals who are eligible for home 
care and community-based services going unstaffed because there 
is simply a shortage of workers to provide the services that 
the individual is eligible for.
    Could you just tell us what is at stake when an individual 
is not able to access the care they need?
    Ms. Fay. In some circumstances, people will die, because 
they can't access care. And that is part of what really keeps 
me doing this work. You know, making sure that there is a 
workforce there to care for folks that need it so that they can 
live their best lives is, I feel like, one of the most 
important things that I can do as a Representative.
    So not being able to do the things that bring people joy or 
simply live with dignity is what is at stake here.
    Ms. Stevens. Thank you for that.
    And, with that, Mr. Chairman, I yield back.
    Chairwoman Wilson of Florida.
    [Presiding.] Thank you, Ms. Stevens. I am back.
    This hearing is impacting each and every one of us 
personally, and it has really just impacted our constituents, 
and this is very moving.
    And now, we will hear from Mrs. Harshbarger of Tennessee.
    Mrs. Harshbarger. Thank you, Madam Chairman.
    My question is for Mr. Burani. I have been in the 
healthcare industry for 35 years, and I have absolutely 
serviced and worked right alongside with these direct 
healthcare workers as a pharmacist in making sure that we work 
with home health and hospice at the agencies as well as the 
healthcare providers in that. And I absolutely know there is a 
shortage of direct healthcare workers. You know, there is a 
shortage of registered nursing, especially in rural 
communities.
    And, from Representative Fay's comment of what they saw 
from some research that this is a dead-end job, I absolutely 
agree with the Chairman that there--that is a marketing failure 
in my opinion, because this is just a springboard to so many 
other areas in healthcare as far as the nursing industry goes.
    And, from the business component, more money does not equal 
better outcomes, and I can tell you that from my profession and 
being a business owner, too.
    I looked at your testimony, though, and there are so many 
things that you recommended for the WIOA program as far as 
structural changes. And, just like you created more scalable 
registered providers, every State is different. Make that easy 
for them to, you know, compile that information.
    I am looking at the facilitating the mobility of dollars 
across labor markets. I am a border State right at the tip of 
Virginia. So a lot of those people that may live in Virginia 
work in Tennessee or vice versa. That is a huge problem.
    Increase the accessibility and transparency for all 
programs. You know, make a single source--single source where 
they can record that data. That is a no-brainer as well.
    There is just--you have got a ton of good recommendations 
in here.
    Incentivizing community colleges to work with employers. 
You know, we have community colleges in my district that do CNA 
programs or LPN programs. We have workforce development 
agencies who do the same. We have a hospital system who will 
train at no charge, do the CNA program to where they can go get 
certified.
    You know, some of the things--you talk here about fostering 
a more dynamic relationship between the workforce board and 
learners, about the marketing operations. People don't know 
what they don't know, and marketing is a huge part of that. 
And, in your industry, with all the AI and things you have, 
this should incentivize people to come look at this.
    But what I want you to talk about is to incentivize 
distribution of funding toward distressed communities. I have 
two distressed counties in my district, and, like I said, 
people don't know what they don't know. How do you get the word 
out to those people that there are opportunities out there, and 
how do we do that? How do we bring them into the fold and keep 
them there by giving them that opportunity, sir?
    Mr. Burani. Thank you, Congresswoman. I appreciate the 
feedback, and I appreciate your taking time to think through 
all that goes into these reforms.
    So, when we consider this critical point of view around 
facilitating a relationship between workforce and the general 
public, you hit on exactly the problem. What do they know about 
the system that is designed to serve them?
    The workforce board of any given county or metropolitan 
region or State is not a consumer brand. The closest thing to a 
consumer brand is the job center, which has a retail presence, 
and is where you go to get coaching and to look at the job 
board and maybe attend a career fair.
    But what we need to do is--and I used this word 
``modernize'' a lot today--we need to sort of 10X the 
sophistication of the relationship between the server and the 
recipient of that service. So understanding the range of 
programs, understanding the range of conditions or, you know, 
sort of status quo that these----
    Ms. Harshbarger. Uh-huh.
    Mr. Burani [continuing]. programs are designed to serve.
    And, to your point about distressed communities, 
structuring programs in such a way that we provide the 
supports. I will give you a very simple example. Our programs 
don't work if you don't have a laptop and a broadband 
connection.
    Now, penetration of broadband is quite high at an 
aggregated level. But, when you go into distressed communities, 
those numbers plunge. So that requires us to broker those 
partnerships on the side. Sometimes we will work with community 
partners, sometimes the workforce board can nominate someone, 
or we have got to do the work to find those connections to get 
people to donate laptops.
    And, so, I know there are always good ideas in the mix for 
how to make these provisions for distressed communities, but it 
needs to be more endemic to the workforce system versus a box 
that we check and something we pursue separately.
    Mrs. Harshbarger. We will continue our conversation, sir, 
and great ideas.
    And I yield back.
    Mr. Burani. Thank you.
    Chairwoman Wilson. Thank you so much.
    And now Mr. Levin of Michigan.
    Mr. Levin. All right. Thank you so much, Chairwoman Wilson, 
and also to Chairman DeSaulnier for putting together this vital 
hearing on the direct care workforce.
    You know, direct care professionals do the challenging work 
of taking care of the most vulnerable populations in our 
country, our young, our old, our folks who are sick. And, as 
our Nation ages over the coming decades, this direct care work 
will become ever more essential. And so, we will need more 
direct care professionals. But, if you look at the obstacles 
they face, it is no wonder that we see such high turnover in 
this field.
    Direct care workers must contend with low pay, a lack of 
resources, lack of benefits, lower job agency and inadequate 
training options. And it is not due to marketing of workforce 
agencies.
    I would--in Michigan, actually, our workforce investment 
boards are very strongly branded as Michigan Works, and the 
public knows about them. But these are just not jobs that 
enough people are able or willing to do, because they are so 
low paid, and they have so low--you know, low status in 
society, which is all of our faults--the fault of policy.
    So, we have got to invest more in direct care to ensure 
that direct care workers are valued and have the resources and 
respect fitting this essential, complicated, and dangerous work 
that they do.
    Mr. Espinoza, you mentioned in your testimony that, in all 
50 States and D.C., the direct care worker median wage is lower 
than the median wage for other occupations with similar entry 
level requirements due in large part to the limited funds 
available through Medicaid.
    So, as you know, the American Rescue Plan increased Federal 
funding for home-and community-based services by 10 percent. 
Can you talk about how these funds have enabled States or will 
enable States to improve wages for these workers? Will the 
money really get through to the workers?
    Mr. Espinoza. Thank you, Congressman.
    I think the American Rescue Plan can make a big difference 
in improving jobs and improving supports for people who need 
this level of support.
    What it does specifically is it increases the Federal 
matching rate by 10 percentage points. It encourages States to 
use that additional funding to both expand home and community 
services, but also, in many instances, improve jobs.
    Several States have put forth their spending plans, and we 
have seen a number of measures in those plans that would do a 
great deal for workers in those States.
    So, for example, North Carolina recently introduced its 
spending plan, and some of its measures include $210 million a 
year for recruiting, retaining, and building the network of 
HCBS direct care workers, also money for employment training 
for direct care workers, and money for a direct care workforce 
survey to better understand what the driving factors are for so 
many workers to come into the sector and leave the sector. And 
this would, of course, not just address marketing, but it would 
address how do you transform the overall quality of the job.
    New York has also put forth its spending proposal, and it 
includes about $2.1 million for direct care workforce issues, 
including the long-term care workforce and the value-based 
payment readiness, improving jobs for direct support 
professionals, which are a segment of the worker--workforce 
that supports people with intellectual and developmental 
disabilities, but, also, issues like transportation, Medicaid 
rehabilitation rates, training and supports, and building 
evidence-based practices, and more.
    So it shows, I think, both the possibilities that increased 
Medicaid funding can have on improving jobs and improving 
services, but, also, the incredible need that is needed in this 
sector in every State to strengthen recruitment and retention.
    Mr. Levin. Does PHI have specific recommendations regarding 
increasing Federal Medicaid funding on a going-forward basis 
after, you know--after we have--what we have already done?
    Mr. Espinoza. Yes, absolutely. I mean, we would argue for 
many of the items that we--that I mentioned just right now. But 
we would include how do you improve wages for direct care 
workers? How do you strengthen the training infrastructure for 
employers, including virtual, but also in-person and hybrid 
approaches? How do you create career advancement opportunities? 
Can this money be used to strengthen the data collection 
infrastructure so that employers and policymakers can better 
track workforce capacity and job quality? And how do you 
improve research and surveys on these workers?
    Those are a handful of recommendations that we would issue, 
yes.
    Mr. Levin. Well, thanks.
    You know, Madam Chairwoman, I started working with 
healthcare workers who wanted to organize in the early 1980's, 
and I have--throughout this whole--all these decades, this 
workforce has never really been changed in terms of being paid 
adequately, having real career tracks, real opportunities for 
advancement, and the training and supports they need. It is 
high time we get that done. They need it, and the people they 
care for need it.
    And, with that, I yield back.
    Chairwoman Wilson. Thank you, Representative Levin. I agree 
with you 100 percent. It is our responsibility to change that 
scenario.
    Mr. Levin. Yes, ma'am.
    Chairwoman Wilson. Representative Fitzgerald, and then, 
after Representative Fitzgerald is recognized and speaks, I 
will pass the gavel back over to co-Chair, Mr. DeSaulnier.
    Representative Fitzgerald, you are on mute.
    Mr. Fitzgerald. Madam Chair, our--I am here. Are you ready?
    Chairwoman Wilson. Ready.
    Mr. Fitzgerald. OK. Thank you.
    Mr. Burani, you know, in Wisconsin, over the last, and 
obviously, unique circumstances where a lot of these caretakers 
and the workers that are doing this very difficult job, their 
challenges have been increased significantly. You know, we are 
still working on the steady pipeline of individuals that are 
willing to take this type of work on in the direct care space.
    In those discussions, I mean, is there any relationship 
that you feel is being developed? And I would say probably more 
of a--in the traditional educational institutions, like tech 
colleges, or, you know, there are some instances, I would 
think, in which hospitals or clinics would provide OJT for some 
of these individuals. That would be kind of the first question 
I would have.
    Mr. Burani. So I want to make sure I understood your 
question, Congressman, so we are asking do we see entities in 
this ecosystem, the industry and the training providers 
actually moving closer together and working more closely in 
partnership?
    Mr. Fitzgerald. That is right, yes. Yes.
    Mr. Burani. So I think that it is--yes. In--broadly 
speaking, absolutely. I think that you--there is a lot of 
evidence of it. On one extreme, you have got tech companies 
that are actually launching their own, quote/unquote, 
``universities,'' their own upscaling programs, because the 
adoption of their products and services in many ways is 
bottlenecked by skill shortage. No surprise there. That goes 
back to, you know, the narrative we have been talking about all 
day long.
    But I think that there is, you know, another aspect of 
this, which is--it is what the system is demanding. We have a--
I think an increasing--the reality and the mandate for these 
educational providers of all stripes is to show these outcomes. 
I have been beating a dead horse today with that word, 
``outcomes.''
    But the reality is, if you zoom out and you think about the 
student debt crisis, right. At the end of 2020, the first 
year--the first wave of graduates who came out during the 
pandemic, the joblessness rate of those graduates was 3.5 times 
what it was the year prior.
    So, when you look at the average amount of debt, about 
$36,000, 45 million Americans having that debt, you are 
measuring the impact to American GDP in the trillions, and it 
is literally becoming a bigger part of that pie. So I do think 
that organically, just basic supply and demand is pushing us in 
that direction.
    Mr. Fitzgerald. Very good. And let me just followup with: 
So, if there is a reauthorization of WIOA, is there one thing 
that really--and I know you probably touched on this more times 
today, but is there one thing that really stands out that we 
should maybe make adjustments to or make changes to that could 
actually, you know, help us in determining whether or not the 
full reauthorization is warranted, or is there something that 
should be tweaked, I guess?
    Mr. Burani. That is an excellent question.
    In preparation for today, I narrowed it down to about 15 
for the purposes of brevity. I think that, you know, if we had 
to narrow it down to one, I would say we need to have a free 
flow of ideas and a free flow of awareness for all stakeholders 
in this ecosystem. What is it we are trying to do, and how do 
we make the most of the system that we have?
    And that means learners of all archetypes. It means, you 
know, educational institutions of all--you know, traditional, 
nontraditional, long-term, short-term. It means employers 
representing all industries.
    There would need to be some sort of a forum, or some sort 
of a sort of consistent vehicle for all needs to be put out in 
the open for us to then realize that, actually, we are all more 
or less going for the same thing.
    Mr. Fitzgerald. Got it. Very good. Very good. Thank you 
very much.
    Madam Chair, I would--I would yield back.
    Mr. DeSaulnier.
    [Presiding.] Thank you, Mr. Fitzgerald. I will now 
recognize Mr. Bowman for five minutes.
    Mr. Bowman. Thank you, Mr. Chairman.
    Mr. Espinoza, thank you for all the work you do at PHI in 
the Bronx. As you know, part of my district includes the Bronx 
and is home to many caregivers.
    As we emerge from the pandemic, we have an historic 
opportunity to build an America that works for all people by 
centering the care that all people need. So often, the very 
people who provide critical caregiving work in our communities 
are not able to care for their own loved ones, like an ill 
family Member or a young child.
    Earlier this year, I introduced my Care for All agenda 
resolution, because we need to dramatically expand and 
strengthen the care economy and improve conditions and 
compensations for care workers nationwide.
    In addition to better wages, can you talk about specific 
conditions, such as pathways to unionizing and free or low-cost 
childcare for care workers, that we need to consider in the 
face of rising demand for care work?
    Mr. Espinoza. Yes. Thank you for the question, Congressman.
    There are a variety of strategies that are needed to really 
strengthen the direct care workforce and ensure supports for 
the people they support. As you mentioned, I think unionizing, 
collective bargaining has been used as a strategy in many 
States to elevate wages, to provide benefits and a wide range 
of employment supports, to provide career advancement 
opportunities, and to create a collective voice that can 
advocate for change on the job and in their sector.
    We have also seen in New York--we are affiliated with 
Cooperative Home Care Associates, and Zulma is speaking here 
from CHCA. Opportunities for worker-owned cooperatives, or 
other ways in which workers can have a voice in defining the 
quality of a job and ensuring that those supports are as strong 
as possible.
    When you look at the research on direct care workers, what 
you see is these incredible challenges. I mean, certainly, we 
often point to poverty level wages, which forces about 45 
percent of direct care workers into in or near poverty. But, 
because of that poverty, so many workers then rely on public 
assistance to survive, and, in many instances, it is low-wage 
jobs and the ability to access higher-paying jobs in fast food 
or retail in most States that are driving these workers out of 
the sector and are destabilizing the workforce.
    So, as we think about strategies to strengthen this sector, 
certainly any of the interventions that the Direct CARE 
Opportunity Act support, from training to advancement 
opportunities, to recruitment and retention innovation, to 
technology and other kinds of supports are critically needed, 
but so is the evidence base. How do we make sure that the 
Federal Government is investing in those interventions that are 
most effective that improve employment, that improve care, and 
that improve cost savings,
    So, I think this is a critical opportunity for this 
country.
    Mr. Bowman. Thank you, Mr. Espinoza.
    PHI has a powerful resource that shows, in New York, 57 
percent of home care workers are accessing some form of public 
assistance, which is a clear demonstration of underinvestment. 
President Biden's American Jobs Plan----
    Mr. Murphy. No it isn't, people----
    Mr. Bowman. Excuse me. President Biden's American Jobs and 
Families Plan would make a significant investment in Medicaid's 
home-and community-based services, which is a necessary step in 
the right direction.
    In addition to funding, what do you think needs to change 
about the way we talk and think about care work? How can that 
translate to Federal policy?
    Mr. Espinoza. Yes. Thank you for the question, Congressman.
    I think there are a number of representations about direct 
care workers that are inaccurate. One of them is that it is 
unskilled or low-skilled labor when, in fact, what we know 
through our work and what many people in this field know is 
that direct care requires a range of skills and knowledge.
    The National Academy of Medicine encourages that direct 
care training include at least 75 hours of training, which 
acknowledges the level of skill, knowledge, and confidence that 
these workers need to succeed in these roles.
    Another representation is that these workers aren't dealing 
with life challenges, or job-related challenges that are 
threatening their stability on the job, and yet what we know 
and what employers can show is that there are a wide range of 
challenges that they are facing both in their jobs and in their 
communities.
    In the job, it includes everything from safety and 
workforce violence. It includes a lack of training, a lack of 
career advancement opportunities, often challenging situations 
with consumers, but also family Members, and, in general, a 
lack of recognition and respect for the critical role that they 
play.
    And, for many of these workers who are women, people of 
color, and immigrants, they are facing challenges in their 
communities that make it that much harder to succeed on the 
role.
    So I do think that challenging those misconceptions and 
valuing workers for the critical role they play by funding 
something like the Direct CARE Opportunity Act could do a great 
service for these workers and all of us who need this level of 
support.
    Mr. Bowman. Thank you so much.
    Mr. Chairman, I yield back.
    Chairman DeSaulnier. Thank you, Mr. Bowman.
    I will now recognize Representative Letlow for five 
minutes.
    Ms. Letlow. For all the witnesses, thank you for taking the 
time to testify before the Committee today.
    After the past year we have had, it is clear just how 
important it is for our country to have qualified, trained 
professionals in the healthcare sectors. Our doctors, nurses, 
and healthcare workers across all fields are vital in providing 
essential services and helping patients and families through 
some of their most difficult times.
    While I understand the motive is good, I have serious 
hesitations with authorizing another massive new grant program 
for $1.5 billion to address only one sector of the healthcare 
field. I believe we should be utilizing existing funding 
streams under the Workforce Innovation and Opportunity Act and 
the Registered Apprenticeship system to prioritize high-demand 
fields, such as direct care workers.
    Additionally, having employers more involved in workforce 
education curriculum will help future employees come out of 
school prepared to handle the latest challenges and trends and 
ready to enter the workforce.
    My question is for Mr. Burani. In your testimony, you 
emphasized the importance of facilitating the mobility of 
dollars across labor markets and incentives to collaborate with 
neighboring workforce areas. What specific reforms should be 
made to promote greater coordination across communities, and 
what benefits are there to incentivizing collaboration?
    Mr. Burani. Thank you, Congresswoman, for the question.
    I think this is important. Let's just consider a 
hypothetical case study. You are in a specific county. You live 
there and are a contributing Member of that society, and you 
happen to be interested in upskilling yourself.
    It could be that most of the career opportunities happen to 
be in the next county over. And, as a resident of one county, 
with employers buying into a program that is headquartered, for 
all intents and purposes, in another county, we encounter 
difficulties where that money does not flow freely unless there 
are partnerships established within those two distinct 
workforce areas.
    Now, there is nothing holding back those workforce areas 
from collaborating, but that takes time and attention and 
energy and resource, and that is immediately creating drag on 
the process.
    So there needs to be--it starts with a fundamental 
understanding of how the labor markets in this economy have 
evolved over time. There is more breadth--look at commute 
times. That is a perfect example of how geography has changed 
this dialog.
    But also consider the growing--the rise of remote work. 
What we need to do is make provisions for these circumstances, 
and create abilities, either with a--you know, a--sort of a 
parallel hierarchy in which that particular type of partnership 
is facilitated, or some other workaround, some other carve-out 
that allows me in county No. 1 the ability to go with 
confidence and try to get involved in a workforce program that 
might not be in my backyard.
    Ms. Letlow. Thank you so much. I appreciate it.
    I yield back my time.
    Chairman DeSaulnier. Thank you.
    We will now recognize Representative from New Mexico, 
Representative Leger Fernandez.
    Ms. Leger Fernandez. I want to thank both Chairs and 
Ranking Members. And I want to thank the witnesses for their 
excellent description about what--how important this care is to 
each of our families, to each of our communities, to our 
country as a whole, how difficult the work is.
    I really did appreciate Ms. Torres' description of the 
number of hours she works, the--you know, how heavy the work 
is, how hard the work is. But also, how much care she puts in 
that work. It truly came through. And so, for your testimony, I 
am extremely grateful, Ms. Torres.
    I want to address my questions to two types of direct care 
workers: those working in rural communities, and those who are 
immigrants. I represent the Third District of New Mexico, a 
beautiful district, but it is the size of Pennsylvania. It is 
beautiful. It has got wide open landscapes and lots and lots of 
small rural communities, some in a sense that we were listening 
to Mr. Burani talk about. It is like multiple counties.
    Representative Fay, you represent Maine, a State that is 
also very rural. Can you describe the specific challenges 
direct care workers face in rural communities and ways--maybe I 
will combine it--ways in which Congress can incentivize 
individuals to work in those rural communities?
    Ms. Fay. That is a fantastic question.
    So in our commission hearings we heard from rural direct 
care workers, and one of the primary barriers for them was 
travel time. So they are not reimbursed, home care workers are 
not reimbursed for their travel time. And if you are working in 
Penobscot County or Piscataquis County, it might take you an 
hour to get to your client and then an hour back. If you have 
more than one client, then you are doing an awful lot of 
travel.
    So I think we can think of other things. Broadband access. 
We have electronic visit verification now, which is required. 
In some of those places, there is no internet access. You are 
required to have some sort of electronic device. And that can 
be a challenge, and providers don't have necessarily the 
funding available to them to pay for those devices.
    So I think we could play that out in many different ways. 
But those are two of the most significant barriers that we 
discussed.
    Ms. Leger Fernandez. Well, thank you very much. And I think 
that this testimony also highlights to us that in Congress we 
must address all of these complex issues, recognizing the 
interconnectedness, so that we work on broadband at the same 
time that we work on properly valuing our home care workers and 
our direct care workers.
    Mr. Espinoza, you know, New Mexico has got a long history, 
culture, and economy based in valuing our immigrant and our 
immigrant workers. Although New Mexico, the border changed on 
us, we have always welcomed and honored our immigrant workers.
    You mentioned in your written testimony that 27 percent of 
the direct care workforce are immigrants. And I know there has 
been discussion about the disparities immigrant direct care 
workers face compared to their colleagues.
    You know, in another place where there is this 
interconnection, could you describe how offering undocumented 
immigrants a path to citizenship might help stabilize the 
workforce and eliminate disparities? Is that something you can 
speak to?
    Mr. Espinoza. Yes, absolutely. Thank you for the question, 
Congresswoman. Just as background, our research shows that 
about one in four direct care workers is an immigrant, and that 
totals about 1.2 million immigrants. Our research also shows 
that that segment of the workforce, immigrants in direct care, 
is growing faster than U.S.-born workers. So it is part of the 
future of this sector.
    Our research doesn't capture undocumented workers and it 
doesn't capture workers who are hired in the gray market. But 
certainly, we can assume that being an undocumented worker who 
is working in home care most likely runs a variety of 
challenges, right? They often fear retaliation from their 
employers. They often struggle with the challenges of 
navigating an immigration system and the rise of anti-immigrant 
hostility.
    And a pathway to citizenship in particular would stabilize 
the job for those workers, but it would as importantly 
stabilize the workforce for consumers who need those workers, 
right, especially recognizing that immigrants are a big part of 
the future.
    Ms. Leger Fernandez. Thank you for that. I would note that 
if we actually did the American Citizenship Act, it would 
provide a $1.4 trillion benefit to our economy, as well as 
provide the workers in this industry we need.
    My time is expired. I yield back.
    Chairman DeSaulnier. Thank you, Representative.
    Next would be Representative Spartz if she is interested in 
speaking. I don't see her. She was on. Give her a second. If 
not, we will go to Representative Sherrill.
    Representative Sherrill, you are recognized.
    Ms. Sherrill. Thank you so much, and it is great to be 
here.
    Representative Fay, your State and Nation have been 
struggling for years to develop a strong pipeline of direct 
care workers to meet the needs of our residents. You have said 
the shortage of direct care workers has become a real crisis in 
your State. Can you say more about why this is a crisis, and 
what have the impacts been on older and disabled residents, 
based on this?
    Ms. Fay. I think the crisis was laid bare by the pandemic 
for reasons that we have talked about a little bit today. There 
are some problems for workers going into folks' homes I will 
say specifically.
    In Maine there are some personal care attendants who are 
not characterized as healthcare workers and they didn't, for 
instance, early on have access to vaccines. So that was 
problematic for them and problematic for their clients and the 
people that they care for, because if you rely on someone else 
to help you cook meals then your nutrition suffers. If you 
require someone else to help you get to doctor's appointments, 
then your health suffers. And we also know that isolation has a 
significant impact on mental health.
    So I think those are some specific impacts that we saw of 
the growing crisis in the workforce shortage. And that 
continues. We have a workforce crisis across the State in most 
sectors.
    So we are now having the challenge of having to try to 
attract workers into this particular low-wage work, and then 
for reasons which I mentioned before the healthcare impacts to 
their clients is really negative.
    Ms. Sherrill. So is any of what you are discussing a 
funding need directed toward job training and recruitment of 
direct care workers, or it sounds as if it is not necessarily 
on the training end, that it is just that the actual payment, 
the low payment? I am just wondering if this is a recruitment 
and training problem or if it is simply wages need to be higher 
in this industry.
    Ms. Fay. It is both. I think necessary to increase wages, 
but not sufficient. One of the things I mention in my testimony 
is the way we value the work. And if we are having folks whose 
work isn't valued caring for people who maybe have less of a 
voice, who are less visible, people with disabilities and older 
folks, then we have a system that is sort of a negative 
feedback loop. So we need to raise the wages, but we also need 
to raise the visibility and the way that we value these jobs.
    Ms. Sherrill. So given this, what would the effect of the 
American Jobs Plan's $100 billion investment in workforce 
development on the long-term ability of the home care industry 
to recruit the level of staff it needs, what would that impact 
be?
    Ms. Fay. I think the impact would be significant. In Maine, 
much of the work is funded--much of our direct care needs are 
funded through MaineCare, which is our Medicaid. And while the 
State matches, that is a significant impact on our State 
budget. And having ongoing funding and the ongoing ability to 
do workforce development through additional funding coming into 
the State would just be huge.
    Ms. Sherrill. Well, thank you so much. I really appreciate 
your testimony today.
    Thanks, Mr. Chairman. I yield back.
    Chairman DeSaulnier. Thank you, Representative.
    I have got Representative Mrvan next. I don't see him on 
the camera, but if you are ready, please proceed.
    Mr. Mrvan. Mr. Espinoza, in your testimony you note the 
astronomical turnover rate among home care workers of 65 
percent. Can you tell us more about the impact of the high 
turnover on the continuity and quality of care and also 
outcomes for older people and people with disabilities who rely 
on long-term services and supports.
    Mr. Espinoza. Yes. Thank you for the question, Congressman. 
As I mentioned earlier, turnover is one of the top threats that 
providers specifically named facing their agencies. They name 
caregiver shortages and caregiver turnover.
    And two recent studies did show that the turnover rate for 
nursing staff and home care workers are about 99 percent and 65 
percent respectively, and it often happens within the first 90 
days.
    Turnover has a huge impact on everyone in the system. It 
creates job instability and financial challenges for workers 
who must move from one job to another. It disrupts continuity 
of care for consumers. And oftentimes a worker will have quite 
a bit of valuable information on someone's health, someone's 
preferences, someone's experiences, and a lot of that can get 
lost when a worker turns over to another worker. And it affects 
employers. The estimated direct cost of replacing a nursing 
assistant or home care worker is about $2,200, and that affects 
employers, and it affects the system.
    There are ways in which interventions can dramatically 
address turnover and retention. We launched an initiative in 
2013 that provided a 120-hour adult learner-centered home 
health aide training curriculum with about 500 trainees in New 
York City. And it led to a variety of improvements.
    And, most importantly, in addition to the ways in which it 
improved patient-centered care or cultural competence, we found 
that 90 percent of participants completed the course and that 
trainees were more than twice as likely to be on the job at 3 
months and 64 percent more likely to be on the job at 6 months.
    So there are ways in which workforce interventions, if 
well-designed and evaluated in different parts of the country 
to allow for the local context, can make a big dent in 
addressing turnover and retention.
    Chairman DeSaulnier. You are muted, Congressman.
    Mr. Mrvan. I just wanted to give a quick narrative. I was 
able to join a symposium where it was long-term workers, and 
there was a family who had an individual who was disabled, a 
daughter, and ultimately the continuity of care was their most 
important aspect of what was going on in their life. And the 
continuity of care actually did play a role in the quality of 
care and the outcomes.
    With that, I was just going to ask Ms. Torres if you could 
briefly just touch base on the value of continuity of care as 
you do this job.
    Ms. Torres. Could I have the question again?
    Mr. Mrvan. Just if you would touch base on the continuity 
of care, how valuable it is to have a long-term employee with 
someone who needs long-term care.
    Ms. Torres. It is really important. It is really important 
because they need us. They need us. Some of them don't even 
have family Members. And without us, they can't take their 
medication, take a shower, have something to eat. So we are so 
important to them, and they need us that much. So it is 
absolutely important to be there.
    Mr. Mrvan. Well, I thank you for what you do.
    And, again, I yield back my time. And thank you both for 
your answers.
    Chairman DeSaulnier. Thank you, Representative.
    The Chair will now recognize Representative Castro for five 
minutes.
    Mr. Castro. Thank you, Chairman.
    Immigrants make up over a quarter of the direct care 
workforce yet are largely unprotected and provide essential 
support for so many Americans.
    And this is why I introduced the Citizenship for Essential 
Workers Act, to ensure that these workers who are risking their 
lives during COVID are now provided the protection that they 
deserve. We must ensure protections and support for our care 
workers, and we cannot overlook them any longer.
    And so I had a question for Mr. Espinoza: Can you talk 
about the importance of immigrant direct care workers in the 
healthcare workforce and what challenges they face in this 
workforce, such as isolation and the risk of contracting COVID-
19?
    Mr. Espinoza. Yes, absolutely. Thank you, Congressman. I 
mentioned earlier that about one in four direct care workers is 
an immigrant, and we can assume that immigrants are also a big 
part of the gray market where many consumers, out of financial 
need, hire workers off the books, so to speak, and create those 
employment arrangements.
    Our research shows that they are a vibrant part and a 
growing part of this sector. They come from 124 countries. They 
speak 157 languages. And yet we know that we are at a time in 
our country where anti-immigrant hostility is on the rise, and 
many workers feel unstable, not just in their jobs but in their 
communities.
    So all of the challenges that all direct care workers face, 
like inadequate compensation, limited training and advancement 
opportunities, a lack of workplace benefits or general 
recognition and support, immigrants face as well, but they face 
it within a heightened context, because so often the 
instability they are facing doesn't end at the job. It 
continues on in their lives, in their homes and in their 
communities.
    I do think there are a wide range of interventions that 
could be used to bolster supports for immigrants in this 
sector. Certainly, we would advocate for pipeline approaches 
that would bring more immigrants or foreign-born workers into 
this sector. We would also argue for interventions that support 
immigrants who are already here and working in direct care.
    In New Mexico, an organization called Encuentro developed a 
really amazing home care training program that it delivers in 
Spanish and English for immigrants in home care. And it 
prepares them and employs them once they undergo the training, 
but it also helps them navigate life challenges and employment 
challenges.
    So I do think, as our country becomes more diverse, that 
there are great opportunities for innovators in the field to 
think about how do we capitalize on a rich and diverse country? 
How do we draw on the strengths that immigrants bring to this 
sector?
    Mr. Castro. Sure. And you touched upon some of the things 
that, as a Congress, as an American government, we can do to 
support them.
    I want to ask you specifically about a few more things. 
First, with respect to workforce training, what can we do to 
provide better workforce training for this group of folks? And 
also, support that is available in their language and in their 
communities as well.
    Mr. Espinoza. Thank you for the question, Congressman. In 
general, to improve training for these workers, we need a few 
strategies. One is we need to strengthen training requirements 
for all direct care workers, but especially personal care 
aides, which are a growing--probably the largest segment of the 
direct care workforce, yet there is no Federal requirement. And 
no State goes past 40 hours a week of training, right? So--40 
hours training total for entry-level workers.
    So we certainly need to strengthen training requirements. 
We need to standardize training and make them portable and 
stackable so that workers can work across occupations, but 
also, they can work across settings and across States. Too 
often workers need to be retrained again when they move jobs or 
when they move States, for example, right?
    And we certainly need training that is culturally and 
linguistically competent, recognizing that so many workers are 
people of color and women and might benefit from training that 
is more appropriate for the kinds of challenges or learning 
styles that they have.
    There are opportunities I think in the Direct CARE 
Opportunity Act to test and bring to scale those kinds of 
training interventions so that we can make sure that all 
workers have the knowledge and the skills and confidence to 
succeed in the jobs.
    And we need more research specifically on the gray market. 
What does that sector look like? What are the experiences of 
workers, specifically immigrants, in that sector? And what are 
the experiences of consumers who, out of financial need, are 
turning to the gray market? And that is another place where I 
think Federal leadership can really make a dent in this 
workforce.
    Mr. Castro. Well, thank you very much for those responses.
    And I yield back, Chairman.
    Chairman DeSaulnier. Thank you, Mr. Castro. I don't see 
anyone else. If there is anyone else, any Members who would 
like to speak, now is the time. If not, I am going to go to a 
little housekeeping work before we go to closing comments. And, 
again, thank you to all the witnesses for being here. Really 
great testimony, very helpful.
    So, with that, I want to remind my colleagues that, 
pursuant to Committee practice, materials for submission for 
the hearing record must be submitted to the Committee Clerk 
within 14 working days following the last day of the hearing, 
so by close of business on August 3rd, preferably in Microsoft 
Word format. The material submitted must address the subject 
matter of the hearing.
    Only a Member of the joint Subcommittees or an invited 
witness may submit materials for inclusion in the hearing 
record. Documents are limited to 50 pages each. Documents 
longer than 50 pages will be incorporated into the record via 
an internet link that you must provide to the Committee Clerk 
within the required timeframe, but please recognize that in the 
future that link may no longer work.
    Pursuant to House rules and regulations, items for the 
record should be submitted to the clerk electronically by 
emailing submissions to [email protected].
    Witness questions for the hearing record--I just want to 
mention again I want to thank the witnesses for their terrific 
participation today and your obvious interest and passion for 
this subject matter and expertise. Members of the joint 
Subcommittee may have some additional questions for you, and we 
ask the witnesses to please respond to those questions in 
writing. The hearing record will be held open for 14 days in 
order to receive those responses.
    Again, I want to remind my colleagues that, pursuant to 
Committee practice, witness questions for the record must be 
submitted to the Majority Committee Staff or Committee Clerk 
within seven days. The questions submitted must address the 
subject matter of the hearing.
    Now we will go to closing statements. And I want to 
recognize the distinguished Ranking Member of the Higher 
Education and Workforce Investment Subcommittee, Dr. Murphy, 
for a closing statement. Dr. Murphy.
    Mr. Murphy. Thank you, Mr. Chairman.
    I understand the difficult work--I want to thank all the 
Committee Members and the witnesses. I appreciate your counsel 
and a lot of good discussions today.
    I understand the difficult work environment that direct 
care workers can find themselves in, because I have worked 
alongside them, as I have said previously, as a physician for 
over 30 years. Their contributions are meaningful. They make a 
difference in so many, many lives, especially toward the end of 
life. We are going to rely on these important individuals as 
our populations grow and as our population ages.
    Our witnesses did a wonderful job today of illuminating 
some of the challenges that these and other healthcare workers 
face. I look forward to working with my colleagues on both 
sides of the aisle to consider how public policy can foster an 
environment where more people will consider the healthcare 
workforce as a valuable and rewarding career path.
    The best way to do this is to strengthen WIOA. Healthcare 
occupations must be examined within the context of all 
professions to make sure that job seekers are fully informed. 
WIOA can help direct care workers gain the skills that they 
need to succeed in the long term, no matter which career path 
they can pursue.
    Thanks again to all the witnesses. This was a very good 
Committee meeting.
    Thank you, Mr. Chairman. I yield back.
    Chairman DeSaulnier. Thank you, Representative Murphy, 
appreciate your comments.
    And now I would like to recognize my co-Chair and thank her 
again for being able to step in for me. I had a couple other 
hearings going on at the same time, and one of them requires a 
little nimbleness, the Oversight Committee.
    So Chair Wilson, thanks again, and happy to have you have 
any closing comments.
    Chairwoman Wilson. Thank you, Representative DeSaulnier.
    I want to thank our amazing witnesses for sharing their in-
depth expertise and moving experiences. This has been a very 
insightful hearing. There are people in our country doing God's 
work. Thanks to all of the direct care employees in the Nation 
who help our families and our constituents every single day. We 
appreciate you.
    As we all heard throughout our discussions, direct care is 
physically and emotionally taxing work. It is hard. Yet, while 
the demand for direct care services is surging, workers today 
aren't earning living wages or even receiving the necessary 
training to safely do their jobs. They need our help, and it is 
our responsibility to help them.
    People are living longer and longer and desire to live in 
their own homes. That is why we need to secure significant 
resources for direct workers by passing the American Jobs Plan 
and the Direct CARE Opportunity Act.
    These proposals would take significant steps toward 
recruiting and reinforcing the direct care workforce pipeline, 
and they would help create millions of good-paying jobs as our 
economy recovers from the pandemic.
    Most importantly, investing in our direct care workers 
would increase our capacity to help aging Americans and 
individuals with disabilities live with independence. We have 
to pay these employees what they are worth. As a matter of 
fact, their job description is priceless.
    I am grateful for our discussions today, and I yield to the 
Ranking Member--and I yield to the Ranking Member for his 
closing statement.
    Chairman DeSaulnier. We will go to the good son, Mr. Allen.
    Mr. Allen. Thank you. It is great to be with you today. And 
I thank the witnesses for their helpful testimony.
    COVID-19 brought attention to the immense sacrifices 
frontline workers make every day. They deserve our recognition 
and thanks. In fact, all of our medical professionals do.
    As Republican leader of the Subcommittee tasked with 
developing healthcare and labor policies, I am particularly 
interested in supporting individuals who may be interested in 
entering the direct care workforce. In my mind, Congress must 
clear the way for State and local workforce boards to leverage 
private sector innovations occurring in their communities.
    Mr. Burani's testimony shows us how critical it is to set 
folks up for long-term success. Creating additional single-
interest government programs is short-sighted. Our Committee 
can do better than spending additional taxpayer dollars on 
short-term Band-Aids. We need to heal the root cause of our 
problem.
    As this Committee considers a bipartisan reauthorization of 
WIOA, we must consider how we can address all workforce 
challenges facing our Nation, and they are many.
    Thank you, Mr. Chairman, for the hearing today, and I yield 
back.
    Chairman DeSaulnier. Thank you, Mr. Allen. It is always a 
pleasure.
    I would now like to recognize myself for the purpose of 
making a closing statement. Again, thank you all, all of the 
witnesses, for participating. Really terrific. Ms. Torres, 
thank you, always most important to hear from the people 
actually providing the services, not to diminish the 
contributions of the other witnesses as well.
    And to the Ranking Members and Chair Wilson, thank you so 
much. Certainly, I think if we can't agree on helping seniors, 
our moms and dads, our uncles and aunts, gosh, I don't know 
what we could agree with. And knowing and respecting that there 
will be some challenges with that, I do want to mention Ranking 
Member Murphy's comments about being good stewards of 
taxpayers' funding. I completely agree.
    One of the interesting things that we talked about a little 
bit is just the effective and efficient role for the Federal 
Government and our partners at the State and local level and 
being client-based on their needs and listening to them and the 
workers like Ms. Torres.
    So that is a real challenge, and I really appreciate all of 
the comments from the witnesses. You clearly see this in 
delivering these services in a very different social model. I 
always think of growing up in a rural community in New England, 
not far from Representative Fay, in Massachusetts that was 
changing into a suburban community outside of Boston, where all 
of my uncles and aunts and my grandparents were all within 15, 
20 minutes, and we all shared. It was a really remarkable bond. 
But that time, for better or worse, is not the world we live in 
now. So you all know that, and how we adapt to that is so 
important.
    And then last, just the urgency I feel, having been in this 
field for a while at the State, local, and now Federal level. 
People are suffering now and, indeed, people are losing their 
lives that could be extended and the quality of life could be 
extended if we acted with urgency collectively.
    And I think of my own mom, and I really appreciate all the 
comments from Members about their personal experiences as well 
as their professional, but the issues around transfer trauma as 
she moved out of independence, but also the trauma of workers 
coming in and having to establish a relationship in a new 
environment when they came into her home.
    So all of these things, I think there is a real opportunity 
for us to work together to really improve the system. And I 
would say, when we look at internationally and nationally, 
there are really good models. And as we look at workforce 
investment, a conversation I have had with Ranking Member Foxx 
for years, sometimes comical from our perspectives, but the 
importance of incentivizing best practices at Workforce 
Investment Boards at the State and local level so we can learn 
from one another, as Representative Fay has indicated, but not 
just accepting the status quo.
    So, with that, as we reflect on the critical role that 
direct care workers play in ensuring that aging Americans and 
Americans with disabilities can live independently, I just want 
to thank everyone again.
    Unfortunately, the challenge is real, as we discussed. 
Direct care workers are still not being provided the basic 
tools to make them successful for their clients: Fair pay, good 
working conditions, and continuing training that would allow 
them to join and stay in these professions and change the 
really horrible 82 percent turnover. And that is prepandemic. 
So some of the comments by some of my colleagues, the pandemic 
has clarified and made it worse, but we had a real problem 
before the pandemic.
    So this chronic lack of investment in direct care workers 
must change if we are to secure the future of direct care 
workers and the clients that they serve. To that end, I am 
pleased we discussed how the investments in the American Jobs 
Plan, drawing from the Direct CARE Opportunity Act, would 
strengthen the direct care workforce pipeline.
    I look forward to drawing from our conversations today and 
working with all of my colleagues to secure the support that 
our direct care workers need to provide long-term care for our 
communities and for our country.
    Thanks again so much. And if there is no further business, 
without objection, the Joint Subcommittees will now stand 
adjourned. Thanks again so much.
    [Questions submitted for the record and the response by 
Representative Fay follow:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    [Whereupon, at 1:43 p.m., the Subcommittees were 
adjourned.]

                                 [all]