[Senate Hearing 117-173]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 117-173
 
                    EXAMINING OUR COVID-19 RESPONSE:
                     AN UPDATE FROM THE FRONTLINES

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                                   ON

    EXAMINING THE COVID-19 RESPONSE, FOCUSING ON AN UPDATE FROM THE 
                               FRONTLINES

                               __________

                             MARCH 9, 2021

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
                                
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        Available via the World Wide Web: http://www.govinfo.gov      
        
  
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             U.S. GOVERNMENT PUBLISHING OFFICE 
46-753 PDF            WASHINGTON : 2022 
 
 
         
        
        
        
        
          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
          
          
                             PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                     TOMMY TUBERVILLE, Alabama
                                     JERRY MORAN, Kansas

                     Evan T. Schatz, Staff Director
               David P. Cleary, Republican Staff Director
                  John Righter, Deputy Staff Director
                  
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         TUESDAY, MARCH 9, 2021

                                                                   Page

                           Committee Members

Murray, Hon. Patty, Chair, Committee on Health, Education, Labor, 
  and Pensions, Opening statement................................     1
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State 
  of North Carolina, Opening statement...........................     3

                               Witnesses

Shah, Umair, A., M.D., MPH, Secretary of Health, State of 
  Washington, Tumwater, WA.......................................     7
    Prepared statement...........................................    10
Jha, Ashish, K., M.D., MPH, Dean, Brown University School of 
  Public Health, Providence, RI..................................    28
    Prepared statement...........................................    29
Abraham, Jerry, P., M.D., MPH, CMQ, Director, Kedren Health 
  Vaccines, Los Angeles, CA......................................    33
    Prepared statement...........................................    35
    Summary statement............................................    39
Fuchs, Mary, Ann, DNP, RN, NEA-BC, FAAN, Vice President of 
  Patient Care & System Chief Nurse Executive, Duke University 
  Health System, Durham, NC......................................    39
    Prepared statement...........................................    41

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
    Statement of The American College of Physicians..............    74
    Letter from The American Academy of Family Physicians........    80


                    EXAMINING OUR COVID-19 RESPONSE:

                     AN UPDATE FROM THE FRONTLINES

                              ----------                              


                         Tuesday, March 9, 2021

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in Room 
106, Dirksen Senate Office Building, Hon. Patty Murray, Chair 
of the Committee, presiding.
    Present: Senators Murray [presiding], Casey, Baldwin, 
Kaine, Hassan, Rosen, Hickenlooper, Burr, Collins, Cassidy, 
Murkowski, Marshall, and Tuberville.

                  OPENING STATEMENT OF SENATOR MURRAY

    The Chair. Good morning. The Senate Health, Education, 
Labor, and Pensions Committee will please come to order.
    Today we are holding a hearing on the ongoing response to 
the COVID-19 pandemic with public health experts and those on 
the frontlines of our fight against this virus.
    Ranking Member Burr and I will each have an opening 
statement, and then I will introduce Dr. Shah, Dr. Jha, and Dr. 
Abraham; and Senator Burr will introduce Dr. Fuchs.
    After the witnesses give their testimony, Senators will 
each have 5 minutes for a round of questions.
    Before we begin, I again want to walk through the COVID-19 
safety protocols in place. We will follow the advice of the 
Attending Physician and the Sergeant at Arms in conducting this 
hearing. Committee Members are seated at least six feet apart, 
and some Senators are participating by video conference. While 
we were unable to have the hearing open to the public or media 
for in-person attendance, live video is available on our 
Committee website at help.senate.gov.
    If you are in need of accommodations, including closed 
captioning, you can reach out to the Committee or the Office of 
Congressional Accessibility Services.
    We are all very grateful to everyone, including our 
Committee Clerks, who have worked so hard to set up a hearing 
like this and help everyone stay safe and healthy during this 
pandemic.
    Life for families across the country has changed a lot over 
the past year, and while we are familiar with the staggering 
number of this pandemic, over 29 million infected, over a half-
million dead, the full toll of that loss and so much else 
families have gone through--missed birthdays, weddings, 
graduations, and even funerals--the fear, the loss, the 
isolation we have gone through individually and as a Nation, 
and the impact that it is causing on mental health and 
substance use, among other issues, cannot be measured.
    The true cost of this pandemic so far is unthinkable, and 
it should be just as unthinkable that we would do anything 
short of everything when it comes to ending this crisis as soon 
as possible and rebuilding our Nation stronger and fairer.
    I'm glad President Biden has put forward a bold, 
comprehensive vision to see our Country through this pandemic, 
and we took a critical step toward making that vision a reality 
by passing in short order the historic American Rescue Plan, 
which provides funding for testing, contact tracing, and 
sequencing so we can identify new variants of COVID and slow 
the spread; funding for vaccines so we can distribute and 
administer them quickly, widely, and equitably, fight 
misinformation, promote vaccine confidence, and engage trusted 
partners in communities we know are hard to reach; funding to 
recruit and train 100,000 new public health workers for these 
efforts, and funding to address inequities that have made this 
pandemic more deadly for communities of color, to address 
mental health, behavioral health, and substance abuse 
challenges this pandemic has worsened; to support home and 
community-based services that help people with disabilities and 
older Americans; and to support community health centers, which 
continue to be a lifeline to so many hard-hit and hard-to-reach 
communities.
    This bill represents important progress, as does President 
Biden's announcement that our Country will have enough vaccines 
for every adult by the end of May. But we are all well aware 
that it is not mission accomplished. We have to roll up our 
sleeves, literally and figuratively, and get vaccines in arms. 
We have to make sure communities that are often overlooked and 
underserved are getting vaccines, and getting answers to 
questions people are asking, like when can I get a vaccine, 
where do I go for my vaccine, and how do I know the vaccines 
are safe and effective.
    We have some promising tools here, but we will also still 
have work to do to make them accessible to people with 
disabilities, people who do not speak English, and people who 
do not have Internet or smart phones. We have skilled experts 
promoting vaccine confidence, but we still have to engage 
trusted community partners as well.
    In my home State of Washington, the Pacific Islander 
community has been hit harder than anyone by this pandemic, and 
while we still don't have good data on the extent of that 
problem, it's clear when it comes to vaccinating this community 
that we're already behind. That's why when Joseph Seia, 
Executive Director of the Pacific Islander Community 
Association of Washington State, saw how online booking for 
vaccines was missing elders in their community, PICA worked to 
set up the first-in-the-nation pop-up vaccination clinic. Seia 
told the Seattle Times, ``It's an equity thing. People don't 
have technology. People don't have the time. It's essentially 
privileged people that are signing up for these appointments, 
and the most impacted folks are not able to do it.''
    The clinic PICA set up kept things intentionally low-tech 
to help prioritize reaching vulnerable seniors. We need to 
continue seeking out community partners like that to make sure 
we are understanding the challenges they face and working 
through them together, because this pandemic will not truly be 
over for anyone until we can vaccinate everyone we can. And 
even when it ends, we need to make sure nothing like this ever 
happens again. So I'll be saying more about how we do that 
later this week when I reintroduce the Public Health 
Infrastructure Saves Lives Act.
    It was hard to imagine when this pandemic began a year ago 
where we would be today, but the question before us in this 
moment is how soon will students be back in the classrooms? How 
soon will those people not already at work be back? How soon 
will we be able to visit safely our friends and family for 
special occasions and greet them with smiles and handshakes and 
hugs?
    We all want to get there as soon as possible, but that 
starts with the work all of our witnesses are here today to 
discuss, and the steps we take right now to support it. I look 
forward to hearing from our witnesses about how we end this 
pandemic and working with them to get all of our communities 
there.
    As Ranking Member Burr and I have been talking about since 
early in January, COVID-19 has defined this Committee's work 
over the last year and in many ways will define it over the 
next 2 years. For all of my Committee Members, hearings like 
this are just the beginning of our effort to look 
comprehensively at the impact of the pandemic we are in the 
middle of. I look forward to working with Ranking Member Burr 
and every Member of this Committee as we continue those efforts 
and work to respond to the COVID-19 pandemic and its aftermath.
    Keys to this work will also be helping American workers and 
families recover from all impacts of the virus and the dire 
economic situation they face, addressing the devastating 
impacts of learning loss so many children are facing, and the 
symptoms long-haulers continue to fight, and ensuring this 
country's response to all the ways this pandemic will stay with 
us for a long time, as well as all the things we should be 
doing to prepare for pandemics in the future.
    I know every single Member of this Committee, no matter how 
different our politics or our states, is unified in feeling the 
deep loss caused by this crisis, deep gratitude to all of those 
on the front lines who are fighting it, and the importance of 
responding to this moment by building a stronger, fairer, 
better Nation for the people we represent.
    I look forward to this hearing and working with all of you 
in the days and months ahead.
    With that, I will turn it over to Ranking Member Senator 
Burr for his opening remarks.

                   OPENING STATEMENT OF SENATOR BURR

    Senator Burr. Thank you, Senator Murray, and good morning 
to our witnesses. Dr. Abraham, good to see you, and to our 
other witnesses who are joining us virtually.
    One year ago today, March 9th, there were 1,020 COVID cases 
in the United States and 35 people had died from complications 
from the disease. This was still at that time not a threat 
based upon what CDC and other agencies said. Since then, 28 
million people have contracted COVID-19 in this country, and 
more than 514,000 Americans have died from it. Globally, 116 
million have contracted COVID and 2.5 million have died from 
this once-in-a-century pandemic.
    The Committee has an awesome responsibility ahead of it. We 
must take stock of lessons learned from the response to the 
COVID pandemic and learn together to see what worked, what 
didn't work, and what needs to be done to be more prepared in 
the future.
    We should be proud of the important laws and programs and 
policies we have worked on together in this Committee to create 
and fund, because so much of it worked exactly as we 
envisioned. FDA used its emergency use authority to get 
vaccines and therapeutics to Americans in record time, while 
maintaining the gold standard of safety and efficacy. The 
Assistant Secretary for Preparedness and Response coordinated 
with health care providers on the ground to ensure the sharing 
of critical information and supplies as quickly as possible 
during the response, and coordinated with the NIH and BARDA to 
kick our countermeasure development into high gear. Using 
BARDA's authorities, Operation Warp Speed developed and scaled 
manufacturing for multiple vaccines in record, life-saving 
time.
    But we should also be humble enough to know that more needs 
to be done to be prepared for the future. I hope now that the 
partisan spending bill is over, that only had 5 percent of its 
funding dedicated to the public health portion of the COVID 
response and 1 percent of their massive spending bill dedicated 
to COVID vaccines, we can shift our attention back to working 
together.
    As we start this thorough review process, it's important 
that we remember that we are still in the midst of our current 
response. But the tools we have today look very different than 
where we started over 1 year ago, largely because of the 
authorities that we have given to the executive branch. In May 
of last year, some experts were predicting that a vaccine could 
take years. In partnership with the private sector, we did it 
in 10 months. Testing is now widely available, with the FDA 
announcing just last week the emergency authorization of 
another test that delivers results at home, thanks to the 
public-private partnership and leadership from the NIH. Our 
doctors and nurses have found new ways to better treat our 
sickest COVID patients, improving outcomes with better clinical 
practice guidelines, and our state and local officials have led 
the charge in tailoring our response to their communities' 
needs, as they should.
    Alongside our successes, we must acknowledge our failures. 
At the beginning of the academic year, just 17 percent of our 
Nation's schools had fully returned to in-person learning, 
jeopardizing the future and potential of an entire generation 
of Americans. Businesses are still closed, with the National 
Restaurant Association estimating that 100,000 restaurants will 
not ever be back to welcome customers. And the tools we have to 
solve these urgent problems, a vaccine, should be reaching more 
Americans faster. The CDC stated that we are averaging 2 
million shots in arms per day, but this Administration has not 
updated its goal to reach 100 million shots in 100 days, which 
was already the trajectory when the President took office in 
January. Instead, we should set aspirational goals, like we did 
with the development of the vaccine, not easily attainable 
ones.
    When we look at where we are in the response today, the 
data shows a significant decline in COVID cases and 
hospitalizations. I share this with my colleagues not because 
we should let up on our response, but because I believe we are 
at the greatest moment, right now, to learn from our progress 
and to learn from our failures. The time to capture the lessons 
we are learning is now, in real time, and not months down the 
road when case levels are low, attention spans are shortened, 
and urgency fades.
    I remind my colleagues, in the life of BARDA as an 
institution, it's been on life support three different times 
because Congress lost interest in funding advanced development.
    To our witnesses, welcome. Each of you spent the last year 
in the thick of the COVID-19 response, 24 hours a day, 7 days a 
week. Thank you for your tireless efforts. I hope we can learn 
from each of you today about what was most important during the 
early days of the pandemic, the strategies that were most 
effective at the height of cases and deaths over the holidays, 
and the ways your response is changing as the vaccine is made 
available to more and more Americans.
    Your input is critical as we begin to consider the next 
phase of the current response, and as we look to the next 
public health threat that we will face. It is not a matter of 
if but of when we will need to turn to the tools and policies 
we are using today for yet another novel or emerging threat to 
our Nation's health and its security. The questions I will 
raise with each of you today are what did we get right, what 
did we get wrong, and what parts of our response were not part 
of the anticipated plan of action originally.
    Throughout this year, the Committee has held many 
bipartisan hearings and bipartisan briefings, and we spent 
countless hours on the phone and in meetings with experts from 
around the country. This was a wise decision despite its 
logistical difficulties because it allowed us to begin to build 
the record necessary to move forward.
    This is our first hearing on the COVID response this 
Congress, and I look forward to working with Senator Murray to 
make these hearings and these conversations a regular practice 
of the Committee. I know that we are in the process of securing 
administration witnesses for a hearing in the near future, and 
I'd like to set the expectation for all of us on this 
Committee, on both sides of the aisle, that we should expect to 
hear from administration officials on a regular basis just like 
we did with the last administration, if not more often. They 
have an obligation to be open and transparent with Congress and 
the American people about what they are doing, in real time, 
and I know all of my colleagues on both sides of the aisle will 
join us in this request.
    Dr. Abraham, to you and the other witnesses today, thank 
you for being here. Please share with us, if you can, those 
personal experiences, those personal decisions that you made 
that may have gone counter to what the Federal guidelines were 
but they were unique to your community in your area, in your 
state, in your community health center, and why that decision 
was so crucial for you to pivot to something you thought would 
work and, in fact, did work.
    With that, Madam Chair, I thank the Chair and I yield the 
floor.
    The Chair. Thank you, Ranking Member Burr.
    We will now introduce today's witnesses.
    I'm very pleased to start by welcoming Dr. Umair Shah from 
my home State of Washington. Dr. Shah was appointed as 
Washington Secretary of Health last year and has been on the 
front lines of our state's efforts to get vaccines into arms 
and to keep families safe. The progress we've seen is 
encouraging, especially as new vaccinations per day now outpace 
new cases, and cases are down 70 percent from the peak this 
winter. I'm grateful to Dr. Shah for the work he's done to help 
get us here, the work he continues to do to help us finally end 
this pandemic for everyone, and for taking the time to join us 
today to share his insights and expertise.
    Before his current role, Dr. Shah served for several years 
as the Executive Director and Local Health Authority for Harris 
County Public Health in Texas, the third largest county in the 
Nation. He served a term as President of the National 
Association of City and County Health Officials, and he served 
as an Emergency Medicine Physician at the Houston VA. Dr. Shah 
received his M.D. from the University of Toledo Health Science 
Center and completed his residency at the University of Texas 
Health Science Center while earning his MPH there.
    Dr. Shah, welcome. Thank you for joining us today.
    Next I will introduce Dr. Ashish Jha. Dr. Jha is the Dean 
of Brown University School of Public Health, and before that he 
taught at the Harvard T.H. Chan School of Public Health and led 
the Harvard Global Health Institute. Dr. Jha is a renowned 
expert on pandemic preparedness whose work has been published 
in over 200 research publications. He has led groundbreaking 
research on Ebola and been a key advisor to policymakers 
looking for thoughtful analysis as they work to respond to 
COVID-19.
    Dr. Jha received his M.D. from Harvard Medical School, 
completed his Internal Medicine training at the University of 
California-San Francisco, and completed his MPH and a 
Fellowship in General Medicine at Harvard. He was also elected 
to the National Academy of Medicine in 2013.
    Dr. Jha, I'm glad to have you with us today.
    Dr. Jerry Abraham is the Director of Kedren Vaccines at 
Kedren Health, a community health center in South Los Angeles, 
California, where he also serves as a family medicine 
physician. Dr. Abraham has publicly championed the importance 
of vaccine equity and how we achieve it, and has worked to make 
it a reality in his role leading vaccination efforts in 
underserved communities that have been hit especially hard by 
this pandemic.
    He's a graduate of the University of Southern California's 
Keck School of Medicine, where he also completed his family 
medicine training. Dr. Abraham, community health centers like 
yours are a lifeline to patients across the country and one 
that has become all the more important during this pandemic. I 
look forward to your testimony about the work happening in your 
community and what we can learn from it, so thank you for 
joining us.
    Now I'll turn it over to Ranking Member Burr to introduce 
Dr. Fuchs.
    Senator Burr. Thank you, Senator Murray, for the 
opportunity to introduce Dr. Mary Ann Fuchs from Durham, North 
Carolina. For almost 20 years, Dr. Fuchs has served as Vice 
President of Patient Care and System Chief Nurse Executive for 
Duke University Health Systems, where she is responsible for 
overseeing the nursing practice and ensuring the high-quality 
care across the health system.
    Dr. Fuchs also serves as the Associate Dean of Clinical 
Affairs for Duke University School of Nursing, and serves on 
the American Hospital Association COVID-19 Pathways to Recovery 
Task Force. In her role as the President of the American 
Organization of Nursing Leadership, Dr. Fuchs advocates for 
nurses in leadership roles across the country, a position that 
has been particularly important during the COVID-19 pandemic, 
highlighting the role nurses have played in caring for patients 
on the front lines.
    Dr. Fuchs earned her doctorate, post-master's certificate, 
and master's degree from Duke University, her Bachelor of 
Science degree in Nursing from the State University of New York 
at Binghamton. Dr. Fuchs is a Fellow in the American Academy of 
Nursing, a Fellow in the Wharton Fellows Program and Management 
for Nurse Executives, and a Robert Wood Johnson Executive Nurse 
Fellow.
    Dr. Fuchs, thank you for all the important work you're 
doing and what you're doing on behalf of North Carolina and the 
country and nurses across the country during this challenging 
time. I look forward to hearing your perspective from the front 
lines of the fight against the COVID pandemic.
    Thank you, Madam Chair.
    The Chair. Thank you.
    We will now move on to testimony. Dr. Shah, you may begin 
your remarks.

  STATEMENT OF UMAIR A. SHAH, M.D., MPH, SECRETARY OF HEALTH, 
               STATE OF WASHINGTON, TUMWATER, WA

    Dr. Shah. Good morning, Chair Murray, Senator Burr, Members 
of the Committee. Thank you for your leadership and for 
inviting me to testify today to share my observations on the 
COVID-19 response to date.
    Let me start by saying it's far from over, and we need to 
stay the course in using every tool available to end it. We're 
all tired of the pandemic, but we cannot forget the more than 
500,000 Americans who have lost their lives to date. In our 
state, in Washington, that means 5,000 Washingtonians whose 
lives have been lost.
    While we still have a long way to go, it is my hope that 
we're on the right road. Let's hope this pandemic is an 
inflection point that results in real and sustained change to 
protect the safety of all Americans.
    My name is Dr. Umair Shah. I have responded to countless 
emergencies over the last 20 years, including hurricanes and 
tropical storms, infectious disease outbreaks, chemical 
incidents, and even global earthquakes. My family and I 
experienced firsthand the massive power outage in Texas just a 
few weeks back.
    I'm a public health professional and medical doctor and 
emergency department physician at UCVA Medical Center, taking 
care of our Nation's veterans for over 20 years. In late 
December, I was honored to be appointed by Governor Jay Inslee 
as the Secretary of Health for the great State of Washington, 
honored because Washington has been a leader in responding to 
this pandemic, and this is a testament to Governor Inslee's 
leadership, as well as the work of our state health agency and 
countless partners on the ground.
    While I'm new to the state role, I've been on the front 
lines fighting this pandemic this past year and leading the 
public health efforts at Harris County Public Health in Texas; 
and as the previous president of HR, I recognize the absolute 
importance of what happens in local communities.
    That said, I am now a proud member of the Association of 
State and Territorial Health Officials, ASTHO, representing the 
state public health agencies across the country who served as a 
key intersection between the Federal Government and local 
communities.
    Over this past year we have all witnessed the loss of life, 
the impact on countless patients and their families and 
communities devastated by COVID-19. Watching this play out, I 
have been frustrated by seeing the strain on our public health 
system to ramp up epidemiology, surveillance, laboratory 
testing, communications, contact tracing, and now getting 
vaccines into arms.
    I'm here today, though, not to just express frustration but 
to work toward solutions. Please refer to my full written 
testimony. Today I will touch on two main points.
    No. 1, we need the state, of course, using public health 
tools to help end this pandemic. And No. 2, public health truly 
matters, and there is a cost to chronic underfunding.
    With the first point about staying the course, from our 
response we remain focused on three things: No. 1, getting 
Americans to continue everyday precautions; No. 2, distributing 
and administering COVID-19 vaccines; and No. 3, safely 
reopening schools and businesses.
    Overall, we may see the light at the end of the tunnel due 
to vaccines, but we must support preventive measures that have 
gotten us to where we are today. We cannot let our guard down 
or this pandemic will make us pay yet again. We must emphasize 
the importance of following public health guidance, including 
wearing masks, watching distance, getting tested, and avoiding 
large gatherings.
    Secondly, the focus around the country is getting COVID-19 
vaccine into the arms of people quickly and equitably. To do 
this, we are balancing three legs of a three-legged stool: No. 
1, vaccine supply; No. 2, logistics and operations; and No. 3, 
vaccine demand.
    Currently, our biggest challenge is limited supply, but we 
expect this to improve, as you know.
    As far as operations go, we are grateful to Congress 
working to get resources to support our efforts on the front 
lines and within states. As we ramp up supply and capacity, we 
must pay attention to the demand as vaccine hesitancy is real, 
whether due to mistrust or misinformation.
    Third, we all want our schools and businesses to reopen for 
in-person learning and get our economy moving ahead, but we 
want to do so safely. If communities continue to control the 
spread of COVID-19, the road ahead is better than the one we 
have been on.
    Public health truly matters, and there's a cost of chronic 
underfunding. Everyone everywhere, in all communities, should 
be able to rely on strong public health systems. This pandemic 
has shown the shortcomings of our current system, including 
from emergency response. This is due to the fact that we have 
not adequately invested in it. We must have a public health 
system ready to protect Americans from all hazards, including 
pandemics, natural disasters, biological, chemical, nuclear, 
and terrorism.
    This pandemic has been horrific in so many ways, yet it is 
a transformational event. Now is the time to make smart, 
strategic, and sustained funding in public health 
infrastructure. Making these investments will also address 
longstanding health inequities. COVID has not started these, 
but it has made them worse. The inequitable distribution of 
death and disease means we have seen communities with 
disproportionate impacts from this pandemic. This is simply 
unacceptable. To reset, reform, and rebuild, Federal 
investments must prioritize resource equity, and now is the 
time for Congress to act.
    We're making progress against COVID-19. We can see the 
light at the end of the tunnel, but leaders must stay the 
course because there are still threats, including the risk from 
COVID-19 variants and COVID-19 fatigue.
    Let me close by saying public health is the offensive line 
of a football team, and we're not doing enough to invest in 
that offensive line. We keep focusing on the quarterback. We 
have had an invisibility crisis in public health for far too 
long. If nothing changes, we'll get more of the same, systems 
without the robust capacity and capabilities to respond to the 
next emergency. We are truly at a crossroads. Either we can act 
now and invest in public health, or we act later and overspend 
dearly to undo that which could have been prevented.
    On behalf of the State of Washington, thank you, Senator 
Murray, for your leadership, from ASTHO and my colleagues 
across the Nation. I appreciate the opportunity to testify 
today. We look forward to working with all of you, all of us in 
public health, in building safe, healthy, and protected 
communities across this great Nation of ours. Thank you.
    [The prepared statement of Dr. Shah follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]     
    
        
    The Chair. Thank you, Dr. Shah.
    Now we'll turn to Dr. Jha.

 STATEMENT OF ASHISH K. JHA, M.D., MPH, DEAN, BROWN UNIVERSITY 
            SCHOOL OF PUBLIC HEALTH, PROVIDENCE, RI

    Dr. Jha. Good morning, Chair Murray, Ranking Member Burr, 
Members of the Committee. It is indeed an honor to be here.
    As we heard, we mark a grim anniversary this week, one year 
into a global pandemic that has caused unimaginable suffering 
and loss. But we also are seeing the beginning of the end of 
this pandemic. Infections and hospitalizations are down, more 
than 2 million vaccines are going into arms every day, and we 
will have enough vaccines for every American adult by the end 
of May. This is an extraordinary achievement of what has been a 
long and difficult road.
    But as you've heard already this morning, the pandemic is 
not done with us. There is important work ahead to get back to 
a time when Americans feel safe living their daily lives, where 
our economy is thriving again.
    Let's talk about what remains to be done.
    First and foremost, we need to continue to focus on 
equitably expanding national and global vaccine supply and 
distribution. We are at a time when new variants and strains 
pose real risks, and the longer the virus circulates, the more 
it will mutate. Our full efforts and attention must be focused 
on vaccinating as many Americans as quickly as possible.
    We have to do it far more equitably, far more equitably. So 
far, vaccinations for people of color has lagged far behind 
those of white Americans. We need a renewed strategy that 
ensures that those at the highest risk of this pandemic are 
getting vaccinated quickly. And Congress should demand that we 
systematically collect and publicly report data on vaccinations 
by race, ethnicity, age, and income to ensure Americans that 
need vaccinations are getting them.
    Next, we need an aggressive global vaccination strategy, 
because if the pandemic has taught us anything, it's that 
viruses don't respect borders. If we continue a slow global 
rollout of the vaccine, it is entirely possible that strains 
will emerge elsewhere that threaten the efficacy of our current 
vaccines and possibly even render them useless. We will then 
have to reformulate, retest, and redistribute vaccines, and 
revaccinate our population.
    At current global vaccination rates, it will take three to 
four years to reach widespread global immunity. Now, the Biden 
administration has taken important steps, including rejoining 
WHO, and Congress has committed funds to COVAX. These are good 
things, but unfortunately they are not enough. We need a 
strategy that isn't just about more money; it's about 
substantially ramping up production of these vaccines. This 
will require more global collaboration, and it will require 
U.S. leadership.
    Next, closer to home, we need to build up more rapid 
testing. Some Americans will choose not to get vaccinated, and 
vaccines, as good as they are, are not 100 percent effective. 
That means we will continue to see some outbreaks of COVID for 
the foreseeable future. We need a testing and surveillance 
system that can help prevent outbreaks and keep us all safe. In 
a world of low transmission and high vaccine coverage, we need 
cheap, easy-to-administer tests that are widely available. 
These exist today. Now, the FDA should work through the 
regulatory challenges to make many more of these tests 
available to the American people, and Congress should continue 
to make investments to ensure these tests are affordable.
    Even with vaccinations and testing, people will get 
infected, and some people will get very sick, and we need more 
investments in therapeutics, particularly outpatient therapies. 
We have identified several good treatments for critically ill 
patients, but we have very little to offer to people before 
they get very sick. Congress should work with NIH to continue 
to support development of new outpatient treatments that can 
render this disease far less harmful.
    Finally, we need a renewed set of investments in public 
health, as you heard from Dr. Shah. This pandemic has shown us 
the costs of under-investing in our public health 
infrastructure, the economic and human costs, which are not 
borne by all of us equally. They are borne by some of us much 
more than others. We need a new set of investments in public 
health infrastructure that puts equity at the heart of its 
mission.
    Over the long run, we need to remember that we are entering 
an age of pandemics. Infectious diseases caused by pathogens 
jumping from animals to humans will become more common as a 
result of economic development and climate change, and 
globalization means an outbreak anywhere will quickly become an 
outbreak everywhere, and that's the world we are looking at.
    To conclude, we are at a critical moment in this pandemic. 
We can see the time when we get our lives back, but we must do 
a few key things: invest in vaccinations, testing, 
therapeutics, and public health infrastructure to ensure that 
we bring this pandemic to a close, and to ensure that we 
prevent the next one. Thank you.
    [The prepared statement of Dr. Jha follows:]
                  prepared statement of ashish k. jha
    Introduction:

    We mark a grim anniversary this month, one year into a global 
pandemic that has caused unimaginable suffering and loss. But, we also 
are seeing the beginning of the end of this pandemic. Infections are 
down nearly 70 percent since the peak of early January and, while we 
must keep wearing masks, keep social distancing, and keep being 
careful, data from the past two months suggests that we are turning a 
corner in our fight against this deadly pandemic.

    As a Nation, our 7-day case average has plateaued and now rests in 
the same realm as our mid-summer peak, at just under 60,000 new cases 
per day. Accordingly, 7-day average COVID-related hospitalizations and 
deaths have decreased by 66 percent and 77 percent, respectively, from 
the winter peak. These data reflect a combination of the rebound after 
a surge of cases during the holidays, increased national attention to 
masking and social distancing, seasonal trends of the virus, a high 
level of population immunity, and vaccination efforts ramping up across 
the country.

    More than 2.1 million shots are now administered every day. Since 
December, more than 87 million doses of vaccine have become 
vaccinations, and many more are coming. While we began our vaccination 
efforts in late December with an average of 228,000 doses administered 
per day, the most recent data indicates that we are consistently 
administering more than 2 million doses per day, with expected supply 
over the next weeks and months likely to increase this number to more 
than 3 million doses per day.

    Vaccine appointments across the country are scarce and the supply 
remains low in comparison to overwhelming demand, but we expect vaccine 
supply to far outstrip demand over the next month or so. The Biden 
Administration recently announced that all willing American adults will 
be able to receive a COVID-19 vaccine by the end of May. This is an 
extraordinary achievement on what has been a treacherous road. There is 
important work ahead.

    First, we must ramp up vaccine supply and distribution efforts 
across the country. Though cases, deaths, and hospitalizations remain 
at their lowest levels in months, we have entered a plateau phase that, 
with the addition of viral variants, poses the potential for further 
spikes which could outpace vaccine distribution. The longer the SARS-
CoV-2 virus circulates in our Nation and our world, the more it will 
mutate. These mutations are likely to become more dominant over time, 
and pose serious risks of rapidly increasing the number of infections, 
hospitalizations, and deaths. It is imperative that our full efforts 
and attention be focused on vaccinating as many Americans as we can as 
quickly as possible over the coming weeks to avoid yet another spike in 
COVID-19 cases, hospitalizations, and deaths. Vaccinating all willing 
American adults within the timeframe presented by the Biden 
Administration mandates that we immediately shift our focus to expand 
infrastructure for vaccine distribution and administration. Meeting the 
Biden administration goal will require a vaccination rate of 3 million 
doses per day through the end of May.

    Simultaneously, we must ensure that we substantially improve the 
equitable distribution of vaccines. There need not be any tradeoff 
between speed and equity. The United States right now does not have the 
ability for equitable and widespread distribution of vaccines to reach 
all American adults by the end of May--even with expected increases in 
supply. Local and Federal leaders must continue to establish more high-
volume mass vaccination sites across the country, and specifically in 
communities of color that have been hit hardest by the pandemic. Where 
people cannot get to a vaccination site, we must bring the vaccine to 
them, with credible community voices addressing concerns. And we must 
continue to systematically collect and publicly report data on 
vaccinations by race, ethnicity, age, and income to ensure Americans 
who need the vaccinations the most are getting them.

    Global Vaccination Strategy

    Second, there must be an aggressive global vaccination strategy to 
match a rapid, equitable distribution model in the United States. Our 
Federal Government has both a domestic and global responsibility to 
ensure the adequate supply of COVID-19 vaccine. Infectious diseases do 
not respect national boundaries, so we must establish a global 
vaccination strategy that aims to protect people around the world as an 
important mechanism to protect the global economy, global public 
health, and in the process, the economy and health of the American 
people. A failure to equitably distribute global vaccines may result in 
large financial and human costs. Consider the facts: studies suggest an 
inequitable vaccination distribution may ultimately result in almost 
twice the number of deaths. Failure to employ an aggressive global 
strategy will allow more virulent and dangerous strains to emerge. So 
far, our vaccine candidates have withstood the emerging strains, 
maintaining their efficacy against these new variants of concerns. But 
over time, it is possible that strains will emerge that threaten the 
efficacy of our current vaccines and essentially, render them useless. 
We will then have to reformulate, retest, and redistribute vaccines and 
revaccinate our population. Unfortunately, our current global strategy 
is neither rapid nor equitable. At the current global rate of 6.39 
million doses administered per day, it will take nearly 5 years to 
reach widespread global immunity (assuming 75 percent protection with a 
2-dose vaccine). An estimated 90 percent of people in low-income 
countries will not be vaccinated in 2021. Our government has taken 
initial steps to advance an equitable global vaccination process, 
including rejoining the World Health Organization and engaging with 
COVAX (COVID-19 Vaccines Global Access).

    Our government has committed $4 billion to COVAX, with a potential 
new pledge of $2 billion through 2021 and 2022. But while these 
contributions are substantial, this budget falls far short of global 
need. Current estimates suggest that COVAX will secure close to 2 
billion doses by the end of the year, with at least 1.3 billion of 
those directed toward 92 low-and middle-income nations, covering at 
least 20 percent of the participating population. However, this is 
nowhere near the 60 -70 percent (or more) of vaccinated individuals 
required to achieve global immunity. To meet this goal, COVAX should 
instead aim to procure and distribute enough doses to fully vaccinate 
four to five billion people by the end of this year. Scaling up its 
targets to this level will require substantial additional funding but 
money is not the biggest barrier. Limited supplies and manufacturing 
capacity will make ramping up global vaccine production a complex 
endeavor; it will require more than just relaxing intellectual property 
rights or technology transfers. Rather, it will require global 
collaboration and solidarity to address challenges at every step of the 
supply chain. We will need to work closely with our allies and take an 
aggressive approach. It can be done, but we will need U.S. leadership.

    Testing

    In addition to vaccinations, testing must remain a central part of 
our strategy against COVID-19. As vaccinations increase, it is 
important to remember that we should not expect to vaccinate 100 
percent of Americans. We know some Americans will forgo vaccinations 
despite their safety and efficacy.

    That means we will continue to see some outbreaks of COVID for the 
foreseeable future. For example, more than 90 percent of American 
children are vaccinated against measles but the outbreak of over 1,000 
measles cases in NY in 2019 highlights what can happen when a disease 
finds its way to those who are not vaccinated. In recognition of 
imperfect vaccine coverage and the imperfect protection offered by 
vaccines, it is important that we build a sustainable viral 
surveillance and testing system that can help prevent COVID-19 clusters 
and ensure that we can all engage in things we value, such as getting 
back to school and work, getting together in large groups, and living 
our lives in ways that are safe.

    While the United States has substantially ramped up its COVID-19 
testing infrastructure over the past year, we are still heavily reliant 
on slow and expensive PCR testing. The accuracy of these tests offers 
value as we try to curb the pandemic, but in a world of low 
transmission and high vaccine coverage these tests are not the proper 
tool for surveillance. Instead, we should be looking to cheap, rapid 
antigen tests that could be self-administered, cheap, and widely 
available. We could imagine using these before large gatherings. They 
could be used during the school year, especially next year when many 
younger children will not yet be vaccinated. They could be used for 
high-risk endeavors, such as when a community comes together to watch a 
play in a packed auditorium. These tests ideally would be available 
over-the-counter and would make it very easy to continue the simple, 
low-level testing needed in a world that is post-pandemic but where 
COVID-19 has not been fully eradicated.

    Many companies have developed antigen tests that cost less than 
five dollars and can return results in less than 15 minutes. The UK has 
been a leader in distributing and leveraging these tests, and have 
relied largely on Innova Medical Group, a California company who ships 
millions of rapid tests a day to Europe but still does not have FDA 
approval to distribute tests in the United States. The FDA has been 
slow to approve these cheap, rapid antigen tests primarily due to 
concerns about accuracy and lack of thorough data, and maintaining the 
rigor and high standards of FDA approval are important. However, rapid 
tests serve a different role than PCR tests and should be evaluated 
accordingly. Accuracy is undoubtedly important for diagnostic tests, 
particularly ones used by physicians in a clinical setting. But in the 
midst of a pandemic, these rapid tests have shown enough efficacy that, 
in combination with their high speed and low cost, would allow them to 
play a critical role in keeping our economy open and people safe. It 
would be beneficial for the FDA to work through these regulatory 
challenges with the recognition that these tests are different from PCR 
tests, and offer substantial value despite their reduced accuracy.

    Congress, in turn, should make investments to ensure that these 
tests are easily available to Americans and that there is effective 
messaging on how these tests should be used in the coming months and 
years. Doing so would be a valuable step in preparing our Country for 
the post-pandemic world.

    Therapeutics

    Another key element in establishing pandemic resilience is the 
development of safe and effective therapeutics, in both inpatient and 
outpatient settings. As we continue into the Fall and next Winter, we 
can expect to see a rise in cases once more, even as the majority of 
Americans are vaccinated. We must ensure these infections do not result 
in hospitalization or death. A few promising therapeutics appear to 
lower death rates in the inpatient setting, but investment in 
developing effective outpatient treatments has been and remains too 
limited.

    Thus far, in clinical trials, three inpatient therapies have shown 
clear promise: remdesivir (likely given early in the disease course), 
dexamethasone (for advanced disease) and most recently, interleukin--6 
receptor blockers, which are also likely useful in advanced disease. We 
still need more inpatient therapies to save our most critically ill 
patients.

    While effective inpatient therapeutics are important and we are 
making progress here, the therapeutic landscape for early outpatient 
interventions has been disappointing. If we are able to develop such 
therapies, we could dramatically lower the impact of COVID on severe 
illness and prevent hospitalizations. So far, the NIH has recommended 
monoclonal antibodies as protective therapeutics, but clinical trial 
data is still lacking and only a few candidates have presented 
promising preliminary results. The FDA has approved Emergency Use 
Authorization for select monoclonal antibodies in outpatients: 
bamlanivimab (developed by Eli Lilly), casirivimab, and imdevimab (both 
developed by Regeneron). Monoclonal antibodies are potentially 
important but they must be given as infusions and given early in the 
disease course before the patient is hospitalized. These logistics have 
created a strange situation. Despite their development and 
availability, monoclonal antibodies are largely underutilized. More 
concerningly, initial studies suggest the South African and Brazilian 
variants of concern may demonstrate escapability from these monoclonal 
antibodies, and we do not yet have enough data to determine efficacy 
against other new variants. Other companies are developing antivirals 
for mild outpatient cases, including Merck's MK-4482 and Synairgen's 
SNG001. However, these drugs are still in the initial phases of 
clinical trials and we really don't know if they will work.

    Members of President Biden's COVID-19 Advisory Board have argued 
for a three-pronged approach to ending the pandemic, alongside a robust 
vaccination campaign: (1) improve genomic surveillance (2) develop 
multivalent vaccines (vaccines which are protective against more than a 
single strain of the virus) and (3) develop scalable treatment options 
to mitigate severe cases. This last prong is absolutely crucial to 
ensuring a stable recovery. Efforts by the NIH's ACTIV program began 
far too late, and targeted expensive therapies with limited 
applications. We need a renewed focus by the NIH on practical 
outpatient therapies (ideally those administered orally) for COVID-19. 
To achieve this, we must increase funding for research and development, 
scale up recruitment in clinical trials, and rapidly assess which drugs 
are safe and effective for use.

    Building an Equitable Recovery

    As we build robust models of vaccination, testing, and therapeutics 
in our recovery, equity must be at the center of our strategies. So 
far, there have been clear disparities we are still working to repair. 
Investments in our public health infrastructure must be made equitably 
to build a healthier society, and Congress has an important role to 
play in funding these investments. A comprehensive national public 
health system incorporates both disease prevention and health 
education, incorporating state, local, and Federal agencies to promote 
health, surveil and predict emerging threats, and retain the capacity 
to respond to emergencies. The United States Public Health system is 
fragmented across local, state, and Federal jurisdictions and 
consistently underfunded. In 1969, the Federal Government contributed 
almost 50 percent to total public health expenditures. But, by 2013, 
that number had fallen to less than 15 percent. The Prevention and 
Public Health Fund, established by the Affordable Care Act and designed 
to sustain investment in public health at the Federal level, remains at 
50 percent of what should have been funded due to the reappropriation 
of money to other programs.

    This consistent underfunding and underinvestment in public health 
is not without its consequences, consequences too often felt by 
America's most vulnerable populations. For example, analyses by our 
research group show a direct correlation between hospitals where 
Intensive Care Units reached capacity due to a larger number of COVID-
19 patients faster, and the social-vulnerability index (SVI). 
Underinvestment in public health aligns with structural inequalities 
and has left people in these communities, including communities of 
color and rural areas, vulnerable to the disparate impact of the 
pandemic. Additionally, a lack of data infrastructure has led to 
difficulties in collecting data related to cases and deaths by race 
early in the pandemic. This issue continues within the vaccine roll-
out. As the Biden administration has prioritized, key changes must be 
made to improve the Nation's public health data-collection capacity to 
allow us to recognize and improve racial disparities in health.

    Public health funding must anticipate rather than react to public 
health emergencies. We saw an increase in funding in 2009 during the 
H1N1 pandemic, and slight increases in supplementary funding in 2014 
and 2016 in response to Zika and Ebola respectively. After these 
viruses came under control, investments stopped and there has not been 
continued growth in improving our public health systems.

    We have built up our public health infrastructure during the 
pandemic, and now must continue past the COVID-19 crisis and continue 
allocating money and resources to public health agencies. Currently, as 
the vaccine rollout continues, Federal and philanthropic efforts are 
spending money on vaccine education campaigns, and are funding local 
community-based organizations to increase communication and access. We 
cannot let these investments stop after the pandemic is over. Giving 
community-based organizations and local health departments the money 
and resources to continue to engage their constituencies in public 
health education will be necessary to reduce the disparities made clear 
by the pandemic so we emerge from this crisis a healthier, more 
resilient society.

    A New Age of Pandemics

    Investment in public health infrastructure is all the more 
important when we consider that pandemics will start to become 
recurring events in our lives. As a result of climate change, 
deforestation, agricultural intensification, and globalization, 
infectious diseases caused by a pathogen jumping from animal to human 
are spreading throughout global society and are increasing in 
probability as a consequence of continued development destroying or 
diminishing animal habitats. Of all new and emerging human infectious 
diseases, 75 percent can be traced to animals, mostly from wildlife.

    Additionally, as global travel becomes more pervasive, epidemics 
are more likely to turn into pandemics. The number of Chinese 
passengers who traveled by air in 2019 was 7 times higher than in 2003, 
when the original SARS pandemic hit. World Bank data shows that the 
global increase of passengers went from 1.7 billion in 2003 to 4.2 
billion in 2018. Thus, it is imperative that we continue to allocate 
resources to prepare for this future reality.

    Conclusion

    We are at a critical point in our response to the COVID-19 
pandemic. If vaccine supply projections hold and distribution and 
administration efforts are rapidly increased across the country, we 
should be able to begin vaccinating the general population by the end 
of April or early May. If we accomplish this goal with the speed, 
equity, and efficiency required, we should begin to bring the acute 
stage of this pandemic to an end by early summer.

    While there is much work that remains and we will be combatting 
this virus for years, important public health restrictions can begin to 
be eased by late spring into summer. From there, we can begin to build 
a new normal, that can be even better than where we were before this 
pandemic struck. All of this is contingent on vaccinating a vast 
majority of Americans, having an effective testing and surveillance 
infrastructure that lets us monitor and manage the disease, and 
applying some common-sense public health measures that will prevent new 
flare ups.

    Congress must allocate for key investments, both nationally and 
globally, in disease surveillance, stockpiling healthcare supplies, 
equitably increasing the capacity and resilience of our public health 
infrastructure, just to name a few. Only then will we emerge from this 
crisis as an America that is prepared and ready for what the future may 
bring.
                                 ______
                                 
    The Chair. Thank you, Dr. Jha.
    I will now turn to Dr. Abraham.

STATEMENT OF JERRY P. ABRAHAM, M.D., MPH, CMQ, DIRECTOR, KEDREN 
                HEALTH VACCINES, LOS ANGELES, CA

    Dr. Abraham. Madam Chair Senator Patty Murray, Ranking 
Member Senator Richard Burr, Senators, I would like to thank 
the Committee for this opportunity to discuss this paramount 
issue, the COVID-19 pandemic.
    My name is Jerry Abraham, and I'm a family and community 
medicine physician, a global injury epidemiologist, and a 
medical quality specialist practicing in South Los Angeles. I 
provide care to patients at Kedren Health, a federally 
qualified health center and acute psychiatric hospital serving 
low-income patients, diverse patient populations of South Los 
Angeles.
    First, on behalf of Kedren and our President, Dr. John 
Griffith, we extend the warmest thanksgiving and gratitude to 
each of you for inviting us to share our experience and 
perspective on the issue of health care service and public 
health delivery to underserved populations during this time of 
this COVID-19 pandemic.
    Before I begin, we at Kedren want to acknowledge the local 
leaders who make it possible for our measured success, Governor 
Gavin Newsome in the State of California Department of Public 
Health, our Los Angeles County Department Board of Supervisors, 
our Board of Supervisor Holly Mitchell, our local L.A. County 
Board of Supervisors, specifically the city of Los Angeles and 
Mayor Eric Garcetti, our Counselor Karen Price, and, of course, 
our very own Congressional Representative Maxine Waters, who 
represents us here in Washington.
    I would also like to begin by thanking the Biden 
administration for their leadership in working with physicians 
and other providers across the country to address the COVID-19 
pandemic. It has made a tremendous difference to have national 
leadership, transparency, and communication about the pandemic 
and this vaccination effort.
    Across this country, the pandemic has exposed deep-seated 
divides within our communities. Data from the CDC shows that 
Black and Latino populations who contract this disease are 
dying at twice the rate of other populations. Nowhere is this 
felt more deeply than in South Los Angeles, where we work. 
Those living in poorer communities struggle daily with access 
to medical care amongst the worst pandemic in over 100 years.
    This population is more likely to utilize public 
transportation, to struggle with limited access to mental 
health services, to have difficulties related to language and 
insecurity due to the lack of immigration documentation. They 
usually lack medical insurance. Our population suffers from 
higher rates of hypertension and diabetes and obesity.
    The point is that racial and ethnic, economic, lack of 
equitable access to health care and public health, and a whole 
raft of other issues related to disparities result in health 
outcomes that are different. While it is easy to unmask this 
effect related to vaccination rates, the same forces play out 
throughout the entire health care system.
    But really, why I'm here today is to tell you about the 
story of the little Kedren that could, the historically Black 
institution from South Los Angeles that started in the `60's by 
22 Black psychiatrists when African American individuals in 
South L.A. had nowhere to turn when they were in mental health 
crisis. That's the place that I work, and that's the place that 
answered the call of March 2020 when we knew we had to be a 
part of the response of this pandemic.
    We became a resource, a safe haven, safe harbor, truly that 
light for testing right away for our county and our city. We 
knew that testing strategy and contact tracing would be 
critical in ending this epidemic. In December, when the FDA 
approved Pfizer and then shortly thereafter Moderna and the EUA 
was approved, we knew we needed vaccines, and we picked up the 
phone and we did what we do best every day, overcoming health 
disparities and addressing social determinants of health and 
achieving health equity. We called and we asked our department 
of public health where are our vaccines, and we worked in lock 
step with our local public health jurisdiction to make sure 
that we got vaccines.
    Our nurses had COVID, our patients had COVID, and we knew 
we needed to vaccinate our community now. So we ended up 
getting 100 doses. Christmas Eve we started calling. By New 
Year's Eve we put 50 doses into the arms of our staff, and the 
next day 100, then 150, and today over 52,000 doses into the 
arms of people in South Los Angeles.
    We said don't give us enough just for us, give us enough 
for our brothers and sisters to our right and left, other 
health care workers who had nowhere else to turn. And after 
that we said give us enough for all of our frail and our 
elderly and our vulnerable that needed a vaccine today.
    What we do and what we do exceptionally well is we take 
down every barrier that stands in the way of our patients and 
their vaccines: Internet, email, phone, transportation, I can't 
speak English, I cannot walk, I cannot see, hear, talk. None of 
those are reasons not to get vaccinated in this country, and we 
made sure we broke down every one of those barriers.
    What we do exceptionally well, why we're the Center for 
Excellence and the exemplary role model is we vaccinate a high 
volume of individuals as equitably as we can, and we report 
that data back accurately and timely, back to the appropriate 
jurisdictions.
    No barrier stands in the way with our patients. What stands 
in our way is we need more vaccines. We need more hands to 
administer them. We're thankful for every volunteer who comes 
and helps, over 200 volunteers daily. And we need more 
resources, and we're very thankful for the work of Congress and 
this Senate in making sure that's achievable.
    This is our shot. We must end this epidemic. We must engage 
and educate and vaccinate our communities. We can achieve 100 
million vaccines and more, as Senator Burr mentioned, and we 
will and can get back to work, get back to school, loving our 
loved ones and doing all those wonderful things we used to do 
before this pandemic, loving and hugging and kissing everyone.
    That's the story that we have to tell, and thank you so 
much for allowing us this opportunity to be here before you 
today. Thank you.
    [The prepared statement of Dr. Abraham follows:]
                 prepared statement of jerry p abraham
    Madam Chair Senator Patty Murray, Ranking Member Senator Burr, 
Senators, I would like to thank the Committee for this opportunity to 
discuss the paramount issue of the day; the COVID-19 Pandemic.

    My name is Jerry Abraham, and I am a Family & Community Medicine 
Physician, a Global Injury Epidemiologist, and a Medical Quality 
Specialist practicing in South Los Angeles. I provide care to patients 
at Kedren Health, a FQHC community health center and acute psychiatric 
hospital serving low-income, diverse patient populations of South Los 
Angeles.

    First, on behalf of Kedren Community Health Center and our 
President and CEO Dr. John Griffith, we extend the warmest thanksgiving 
and gratitude to each of you for inviting us to share our experience 
and perspective on the issue of healthcare service and public health 
delivery to underserved populations in this time of COVID-19.

    Before I begin, we at Kedren want to acknowledge those local 
leaders who make it possible for our measured success. Governor Gavin 
Newsom and the State of California Department of Public Health, our Los 
Angeles County Board of Supervisors, specifically Supervisor Holly 
Mitchell, our local LA County Department of Public Health, and many 
city of Los Angeles officials including Mayor Eric Garcetti and 
Councilor Curren Price and of course our very own Congressional 
Representative Maxine Waters who represents us here in Washington, DC.

    I would also like to begin by thanking the Biden Administration for 
their leadership in working with physicians and other providers across 
the country to address the COVID-19 pandemic. It has made a tremendous 
difference to have national leadership, transparency, and communication 
about the pandemic and the vaccination effort.

    Across this country, the pandemic has exposed deep seated divides 
within our communities. Data from the Centers for Disease Control and 
Prevention (CDC) shows that Black and Latino populations who contract 
this disease, are dying at twice the rate of other populations.

    Nowhere is this fact more deeply felt than in Los Angeles where 
those living in poorer communities in South Los Angeles struggle daily 
with access to medical care amid the worst Pandemic in more than 100 
years. This population is more likely to utilize public transportation, 
to struggle with limited access to mental health services, to have 
difficulties related to language and insecurity due to the lack of 
immigration documentation, and last, they usually lack medical 
insurance. These populations also suffers from higher rates of 
hypertension diabetes, and obesity. For example, South Los Angeles has 
a rate of diabetes that is three times higher than the rate of diabetes 
in other parts of the state. All of these challenges are contributing 
to the unequal and uniquely adverse medical outcomes from the Pandemic. 
According to recent data released in mid-February by the Los Angeles 
County Department of Public Health showed that among those who were 
vaccinated with at least one dose, only 5 percent were Black, while 33 
percent were white and 23 percent were Latino and 19.1 percent were 
Asian. Among Black residents in Los Angeles 65 and above, only 24 
percent of Black residents had received at least one dose of the 
vaccine compared to 42 percent of white residents 65 and up.

    The point is that racial and ethnic, economic, lack of equitable 
access to healthcare and public health, and a whole raft of issues 
related to disparities have conspired to result in health outcomes that 
are different. While it is easy to unmask this effect related to 
vaccination rates, the same forces play out throughout the entire 
health care system. As the Nation approached 500,000 deaths and 
mortality numbers were exceeding 3000 deaths per day, the community in 
South Los Angeles had to do something to ensure no one was left behind. 
At a time when many had lost hope, Kedren Community Health Center 
decided something had to be done to change this dynamic. We needed 
action at the local level where people live and work with the full 
participation and empowerment of the population. I call this the 
``Kedren Miracle'' where a disenfranchised community pulled together 
under Kedren Community Health Center to build one of the most effective 
vaccination units in this Pandemic which continues to this day to serve 
as a model throughout the USA.

    Over the last several months, we have been able to transform Kedren 
into a COVID-19 vaccination center serving the people of South Los 
Angeles. We have worked with the Los Angeles County of Public Health 
and received tremendous support from California Governor Newsom's 
Administration, including the CalVolunteers program, which has provided 
dozens of volunteers to help staff the clinic. We have also received 
support from the Americorps, American Red Cross, International Medical 
Corps, Salvation Army, Americares, among other official channels for 
volunteerism and service--they help us serve over 15,000 members of the 
community every week.

    During this phase of the vaccination effort, the limiting factor in 
our efforts has been vaccine supply. Like many parts of the country, 
the demand for vaccine has outpaced supply since the first vaccines 
were distributed in December. This has been particularly true in 
communities that look like our community, with an overwhelming majority 
of people of color, and those who get their health insurance from 
Medicaid. Studies have shown that Black and Brown communities have 
simply not gotten their fair share of COVID vaccines.

    Through our advocacy efforts and by being loud, we at Kedren have 
been able to secure vaccines to serve over 15,000 people every week. 
That number is increasing, but we still have the capacity to do more. 
We stand ready to serve our community, and to help ensure Black and 
Brown people in particular don't get left behind when it comes to 
getting vaccinated.

    Communities like ours are the ones that have been hit hardest by 
this pandemic. Residents in the communities around Kedren are far more 
likely to have been hospitalized or die from COVID-19 than in most 
other parts of the state. We will continue to be more exposed to risk 
if we cannot get enough people vaccinated against this deadly disease.

    In recent days, the Newsom Administration has adopted new guidance 
that will allocate a disproportionate share of the state's vaccine 
supply to communities that have higher concentration of high-risk 
patients. Using the Health Equity Index to guide vaccine allocations 
makes sense. When you fight a fire, you don't just sprinkle a little 
water around the entire fire. You aggressively attack the parts that 
are burning the hottest and pose the most immediate risk.

    That same principle is now driving the Newsom Administration's 
approach to vaccine distribution. But it is not enough to just have 
vaccine in these areas. We need to make sure we have the people power, 
the communications outreach and the infrastructure necessary to get the 
shots into arms.

    This can't be done by just using apps to make appointments at mass 
vaccination sites. While thousands of people have gotten their shots at 
mass vaccination clinics like the one at Dodger Stadium in Los Angeles, 
if we rely only on these mass sites, we will have distorted and 
inequitable distribution of shots. The technology needed to navigate 
the state's vaccine appointment system can be confusing in particular 
to older patients. The ability to get to these sites requires the 
ability to take hours out of your day to be able to sit in line, 
limiting opportunities for those who have to work or single parents who 
have to care for their children. And of course, it requires use of a 
car. Even in Los Angeles, thousands of low-income people do not have 
their own car to be able to access a drive-thru mass vaccination site.

    Over the next several weeks, it will be essential to build a 
network of community-based vaccine administrators. It will be important 
to involve physicians and other providers in every single community. 
The California Medical Association is working with the state's Third 
Party Vaccine Administrator to help build a network of community 
physicians and other providers to help the state achieve its goal of 
vaccine equity. As vaccine supply becomes less of an issue, it will be 
important to make the vaccine available for people in the community 
where they live through their local providers.

    We also know there are high levels of vaccine hesitancy in our 
Black and immigrant communities. There are many historic reasons for 
this skepticism which we do not have to go into here. But it does 
underscore the added importance of getting vaccine into the hands of 
community providers. Many people have a personal relationship with 
their local physician or community clinic. When people utilize other 
health care services, we need to be able to vaccinate people as well. 
If people are in a place they know with a health care professional they 
trust, they are more likely to be able to talk through their vaccine 
hesitancy issues. Local physicians and others can help advocate for 
their patients to be vaccinated, and hear their concerns, while 
addressing them with science and compassion.

    By late April, we fully anticipate going from a vaccine supply 
problem to a vaccine demand problem. If we truly want to bring an end 
to this pandemic, we will need a robust, and community-specific 
communications and persuasion strategy. Physicians will be an important 
part of that outreach, but we cannot do it alone. We need to build 
partnerships with trusted community leaders and create a high-touch, 
multi-faceted strategy to promote vaccine acceptance.

    We have had our share of hiccups over the last several months. It 
is no small thing to create a statewide vaccination program for roughly 
30 million adults. We know that many of the same problems we've seen in 
California are plaguing other parts of the country. Some of this is to 
be expected, but that does not mean we should be silent or accepting. 
We must continue to push for a faster and more equitable vaccine 
distribution at every turn.

    We have learned a great deal since vaccinations began in December, 
and we share the Biden administration's optimism that we can get 
vaccines to those who want and need them by late spring/early summer. 
But we are also clear eyed about the challenges that lie ahead. With 
continued transparency and cooperation between Federal, state and local 
governments, along with health care providers and community leaders, we 
can meet those challenges head on and bring an end to this pandemic.
                   The Kedren Model--The Secret Sauce
    Kedren Community Health Center is a federally qualified health 
center (FQHC) that provides quality, integrated health and behavioral 
health services to children, youth, adults and families irrespective of 
immigration status, residency, language, culture, gender, ethnicity, 
religion, sexual orientation or one's ability to pay. Annually, KCHC 
provides care for more than 100,000 patients. Kedren Community Health 
Center is a trusted care provider in South Los Angeles and has worked 
to exemplify some of the best practices for distributing the COVID-19 
vaccine and breaking down barriers to accessing the COVID-19 vaccine 
for vulnerable individuals in South Los Angeles.

    For example, one of the biggest barriers cited by patients 
attempting to become vaccinated has been the appointment registration 
process. Many seniors have had to rely on children, nieces, nephews or 
other friends who are more comfortable using the internet to schedule 
an appointment. In addition, many vulnerable residents lack access to 
reliable broadband or simply do not have the time to wait for 
appointments to become available. Kedren Community Health Center. 
Adding to the problem and due to the digital divide, many of the local 
residents do not have internet access, or own a computer, or even have 
access to a smartphone. We worked to develop a simplified system that 
allowed both appointed and walk ins, a system that used a combination 
of paper and ``point of care'' information collection that could be 
entered into the county's online data base later. As a consequence, 
Kendren Community Health Center became one of only a handful of country 
affiliated vaccination facilities where walk ins are welcome.

    Additionally, interpreters for almost every language spoken in 
South Los Angeles are available onsite. As of March 5, 2021, more than 
12,000 people are vaccinated at our facility each week. One immediate 
outcome was that many--many of them Black and Latino healthcare workers 
who worked independently or in small practices that were excluded from 
that vaccination efforts of the larger hospital system have received 
their vaccine doses at Kendren Community Health Center. I would like to 
add that although our federally Qualified Health Center accounts for 
only a small fraction of the 100's of vaccinating organization in 
greater Los Angeles, we routinely account for nearly 10 percent of the 
COVID-19 vaccinations given within the county. It doesn't seem possible 
that so few can do so much for so many.

    We have been relentless in this effort to save lives, much like 
Noah gathering people and animals before the great flood, Kendren 
Community Health Center has become a beacon for those trying to address 
the COVID-19 flood. Organizations such as the Los Angeles County 
Department of Public Health, International Medical Corps, AmeriCorps, 
the faith-based community, and myriad of other organizations and 
donors, many from the community have come to our aid and are providing 
surge support and human resources to enhance this vaccination effort. 
The result is a small city of vaccinators, with temporary shelters, 
stockrooms, endless deliveries of vaccine, needles and medical 
commodities. We have been so successful in promoting vaccination 
efforts in our community model that we routinely send a fleet of trucks 
to other vaccine sites throughout the city to take their unused 
vaccines!
               Kedren Community Health Center's Framework
    Kendren Community Health Center has a robust framework for 
distributing COVID-19 vaccine effectively and efficiently to vulnerable 
populations, the aged and the disabled. It is a model built on trust at 
the most local level of the health system.

        Phase 1: Increase vaccination at fixed sites within the 
        community

        Phase 2: Expanding services and recruit additional vaccination 
        sites

        Phase 3: Develop Academic Partners to improve options for 
        access and quality

        Phase 4: Develop mobile vaccination teams for those hardest to 
        reach

        Phase 5: Conduct mass vaccination events uniquely tailored to 
        the population

    I would like to speak to Kedren Community Health Center's Vision 
for a future where inequality in medical services doesn't force people 
in my community to wait at the end of the vaccine line to ensure their 
survival. We are on a mission to get as many people in the life boat as 
possible. We are targeting support to drive up vaccinations to over 1 
million people in South Los Angeles and beyond this year in an 
equitable and culturally focused program able to reach those most at-
risk. Second, we will not let this experience fade. We also have a 
dream that we have been able to work in a manner that will contribute 
to expanded healthcare infrastructure in our community when the 
pandemic subsides. Last, we hope that the heroic work of Kedren 
Community Health Center, and the work of our partners, will serve as an 
example of others seeking to address the problem of unequal access to 
health services in underserved, vulnerable, disabled, minority and at-
risk populations during this Pandemic and beyond.

    Thank you for this opportunity to testify before each of you today 
on this very important subject. I humbly respect your time and admire 
your service to our Nation. I am happy to answer any questions you may 
have.
                                 ______
                                 
                      summary of jerry p. abraham
    Across this country, the pandemic has exposed deep seated divides 
within our communities. Data from the Centers for Disease Control and 
Prevention (CDC) shows that Black and Latino populations who contract 
this disease, are dying at twice the rate of other populations.

    Nowhere is this fact more deeply felt than in Los Angeles where 
those living in poorer communities in South Los Angeles struggle daily 
with access to medical care amid the worst Pandemic in more than 100 
years. This population is more likely to utilize public transportation, 
to struggle with limited access to mental health services, to have 
difficulties related to language and insecurity due to the lack of 
immigration documentation, and last, they usually lack medical 
insurance. These populations also suffer from higher rates of 
hypertension, diabetes, and obesity.

    The point is that racial and ethnic, economic, lack of equitable 
access to healthcare and public health, and a whole raft of issues 
related to disparities have conspired to result in health outcomes that 
are different. While it is easy to unmask this effect related to 
vaccination rates, the same forces play out throughout the entire 
health care system. As the Nation approached 500,000 deaths and 
mortality numbers were exceeding 3000 deaths per day, the community in 
South Los Angeles had to do something to ensure no one was left behind. 
At a time when many had lost hope, Kedren Community Health Center 
decided something had to be done to change this dynamic. We needed 
action at the local level where people live and work with the full 
participation and empowerment of the population. I call this the 
``Kedren Miracle'' where a disenfranchised community pulled together 
under Kedren Community Health Center to build one of the most effective 
vaccination units in this Pandemic which continues to this day to serve 
as a model throughout the USA.

    Over the last several months, we have been able to transform Kedren 
into a COVID-19 vaccination center serving the people of South Los 
Angeles. We have worked with the Los Angeles County of Public Health 
and received tremendous support from California Governor Newsom's 
Administration, including the CalVolunteers program, which has provided 
dozens of volunteers to help staff the clinic. We have also received 
support from the Americorps, American Red Cross, International Medical 
Corps, Salvation Army, Americares, among other official channels for 
volunteerism and service--hundreds of servicemembers help us serve over 
15,000 members of the community every week--over 52,000 individuals 
have been vaccinated at Kedren thus far.
                   The Kedren Model--The Secret Sauce
    Kedren Community Health Center is a federally qualified health 
center (FQHC) that provides quality, integrated health and behavioral 
health services to children, youth, adults and families irrespective of 
immigration status, residency, language, culture, gender, ethnicity, 
religion, sexual orientation or one's ability to pay. Annually, KCHC 
provides care for more than 100,000 patients. Kedren Community Health 
Center is a trusted care provider in South Los Angeles and has worked 
to exemplify some of the best practices for distributing the COVID-19 
vaccine and breaking down barriers to accessing the COVID-19 vaccine 
for vulnerable individuals in South Los Angeles.
               Kedren Community Health Center's Framework
    Kendren Community Health Center has a robust framework for 
distributing COVID-19 vaccine effectively and efficiently to vulnerable 
populations, the aged and the disabled. It is a model built on trust at 
the most local level of the health system.
                                 ______
                                 
    The Chair. Thank you, Dr. Abraham.
    We will turn to Dr. Fuchs.

   STATEMENT OF MARY ANN FUCHS, DNP, RN, NEA-BC, FAAN, VICE 
 PRESIDENT OF PATIENT CARE AND SYSTEM, CHIEF NURSE EXECUTIVE, 
           DUKE UNIVERSITY HEALTH SYSTEM, DURHAM, NC

    Ms. Fuchs. Thank you, Chair Murray, Ranking Member Burr, 
and Members of the Committee. I'm honored to represent our many 
frontline staff who have worked tirelessly to care for all of 
our patients, including those suffering with COVID-19.
    Duke University Health System is comprised of a hospital 
and health care network that spans the care continuum, and 
we're dedicated to providing high-quality patient care, 
educating tomorrow's health care leaders, discovering new and 
better ways to treat disease, and partnering with our community 
to improve health. We appreciate the Committee's leadership in 
addressing the current pandemic, and on behalf of Duke Health, 
thank you for the critical support Congress has provided over 
the last year, including through the CARES Act and subsequent 
legislation.
    Over the last year, COVID-19 has posed persistent 
challenges for the communities we serve, our patients, and our 
team members. And as Chief Nurse of our health system, I know 
these issues firsthand.
    As COVID-19 persisted, I worked with multiple teams to 
create new strategies to meet patient care needs, reallocated 
internal resources to adapt to influxes of patients, and 
quickly pivoted when circumstances changed. We set up new 
delivery models and care practices, established testing and 
treatment sites, and stood up vaccination sites for employees 
and patients. We served our community as a major transfer 
center for the sickest patients and provided resources to 
skilled nursing facilities in the form of testing, staffing, 
and training.
    We responded to the ever-changing information by regularly 
updating our care, holding town halls and virtual forums for 
our employees in the community; and like many health systems, 
we were the hub of the COVID-19 response in our community.
    This past year has offered us many lessons learned which I 
hope can inform the future actions of this Committee. We are 
committed to protecting our workforce. We were impacted by a 
real and global shortage of N95 masks and other PPE, as well as 
stockpiles that contained expired PPE. Our supply chain team 
worked around the clock sourcing from around the globe to 
ensure we had adequate and effective PPE.
    Our workforce must be cared for and offered respite. Caring 
for critically ill patients, comforting families with loved 
ones suffering in isolation, and fearing bringing the virus 
home to our families has taken a significant toll on the mental 
well-being of our workforce. We are seeing their exhaustion 
compounded by pandemic-related anxieties and increased 
responsibilities at home.
    In my role as President of AONL, we continue to advocate 
for resources to protect the physical and mental health of the 
workforce, and we know through a recent national AONL study 
that the inability of health care workers is still a major 
issue, along with addressing burnout and building resilience.
    Duke Health also joins other organizations, including the 
AHA and AONL, in supporting the Dr. Lorna Breen Health Care 
Provider Protection Act. And before the pandemic, our nursing 
workforce needs outpaced our supply. Thus, we continue to 
support increased funding for Title 8 Nursing Workforce 
Development Programs and support the Future Advancement of 
Academic Nursing Act, which would make critical investments in 
nursing infrastructure.
    COVID-19 has also served as a blunt reminder that we cannot 
afford to overlook our public health infrastructure and 
workforce. Thanks to a grant from our state, Duke Health's 
COVID-19 Support Services Program has been able to assist 
community members requiring to isolate or quarantine. Over 
30,000 people have been provided relief payments, meals, 
supplies, transportation, and medication delivery.
    We established a Vaccine Equitable Distribution Committee 
to better understand our data and reach marginalized 
populations, including those who are disproportionately 
impacted by the virus. We have dedicated appointments and 
vaccines, and we partner intentionally with community 
organizations. This work has improved the rate of African 
Americans vaccinated in our community from 8.8 to more than 15 
percent today.
    The impact of the expansion of telehealth services has 
facilitated connection to our communities and demonstrated the 
efficacy in delivering care. We want to ensure that telehealth 
will remain accessible to more patients on the other side of 
this current crisis.
    The substantial financial impacts of COVID-19 on hospital 
and health systems will also have lasting effects. Systems now 
face difficult decisions to reduce cost. Additional support is 
needed, including eliminating further reductions in payments 
through Federal programs, including Medicare and Medicaid, to 
maintain access to care.
    In closing, as the number of vaccinations increase, in 
combination with continued infection prevention measures, we 
need to acknowledge pandemic fatigue, be patient with each 
other, and work together to continue to provide the highest 
quality care in the safest manner.
    Thank you for the opportunity to serve on the witness panel 
for this important conversation.
    [The prepared statement of Ms. Fuchs follows:]
                  prepared statement of mary ann fuchs
    Chair Murray, Ranking Member Burr, and Members of the Committee, I 
am honored to represent our many frontline staff and other team members 
who have worked tirelessly to care for all of our patients, including 
those suffering from COVID-19. I am Mary Ann Fuchs, Vice President of 
Patient Care & System Chief Nurse Executive at Duke University Health 
System and Associate Dean of Clinical Affairs at the Duke University 
School of Nursing. I also serve as the current president of the 
American Organization for Nursing Leadership (AONL), which is the 
national professional association of more than 10,000 nurse leaders who 
manage and facilitate patient care in all settings across the care 
continuum. AONL is the voice of nursing leadership and a subsidiary of 
the American Hospital Association (AHA). Thank you for the opportunity 
to testify.

    Duke University Health System is comprised of a hospital and health 
care network supported by outstanding and renowned clinical faculty, 
nurses, and care teams. This network is dedicated to providing high-
quality patient care, educating tomorrow's health care leaders, 
discovering new and better ways to treat disease through biomedical 
research, and partnering with our community to improve health 
everywhere. Duke's services span the full continuum of care, from 
primary care to medical and surgical specialties and subspecialties, 
all dedicated to putting our patients at the forefront of everything we 
do.

    Founded in 1998 to provide efficient, responsive care, the health 
system includes three hospitals--Duke University Hospital on our Duke 
University Medical Center campus in Durham, North Carolina, Duke 
Regional Hospital, and Duke Raleigh Hospital. In addition to our 
hospitals, Duke Health has an extensive, geographically dispersed 
network of outpatient facilities that include primary care offices, 
urgent care centers, multi-specialty clinics, and outpatient surgery 
centers. Duke Primary Care is the largest primary care network in the 
greater Triangle, North Carolina area with family and internal medicine 
providers and pediatricians in more than 40 locations throughout the 
region. Duke Connected Care, a community-based, physician-led network, 
includes a group of physicians, hospitals, and other health care 
providers who work together to deliver high-quality care to Medicare 
Fee-for-Service patients in Durham and its surrounding areas.

    The Private Diagnostic Clinic (PDC) is the faculty physician 
practice for Duke Health. It is one of the first and largest academic 
multi-specialty group practices in the United States. The PDC owns and 
operates more than 140 primary and specialty care clinics throughout 
central and eastern North Carolina. Through a diverse and integrated 
network of Duke providers, patients have convenient, accessible, and 
high-quality primary and specialty care close to home.

    Duke HomeCare & Hospice offers hospice, home health, and infusion 
services. Hospice care is offered to terminally ill patients in their 
home, skilled-nursing facilities, assisted-living facilities, and at 
our two inpatient facilities located in Hillsborough and Durham, North 
Carolina. Home health services are available to patients who are 
homebound and in need of nursing services, physical therapy, speech 
therapy, or occupational therapy. Infusion services are provided at 
home or at work for individuals who need intravenous therapy.

    We appreciate the Committee's leadership in addressing the current 
COVID-19 pandemic. On behalf of Duke Health, thank you for the support 
Congress has provided to hospitals, health systems, and all providers 
over the last year. The CARES Act and subsequent legislation 
established and added to the Provider Relief Fund, which provided 
critical resources to better prevent, prepare for, and treat COVID-19.

    As a tertiary and quaternary care center, we put the person who 
needs our care at the center of everything we do. Since well before the 
arrival of the COVID-19 pandemic, the safety of our patients is and 
always has been our first priority. Our hospitals safely manage 
infectious diseases every day. And we will continue to provide safe, 
effective, patient-centered care in our facilities.

    Over the last year, COVID-19 has posed persistent challenges for 
the communities we serve, our patients, and our team members on the 
frontlines. Below, I address the many ways in which we adapted care for 
our community and our patients, many of whom are very sick and require 
complex, coordinated care. I will also share our experience standing up 
a robust testing program and rolling out a successful vaccine campaign. 
I also share some perspectives on the challenges ahead and how to apply 
lessons learned to future public health threats.
         A View From the Frontlines: Provider Care and COVID-19
    As the chief nurse of our health system, and on behalf of the many 
nurse leaders on the frontlines of this pandemic, I know firsthand the 
issues facing our patients, our nurses and other provider colleagues, 
and our health care organizations. At Duke, we provide tertiary and 
quaternary services and serve the highest acuity patients. In order to 
meet our mission, we need appropriate staffing (nurses, respiratory 
therapists, physician staff, others) and equipment (personal protective 
equipment (PPE) and other intensive equipment) to best care for our 
patients, their loved ones, and each other.

    I worked with multiple teams comprised of nurse, physician, and 
administrative leaders to create new strategies to meet patient care 
needs; reallocated internal resources to adapt to influxes of patients; 
and quickly pivoted when circumstances changed. Specifically, our team 
developed appropriate staffing models; new policies and procedures in 
support of infection prevention for patients, visitors, and staff and 
appropriate use and reuse of PPE and supplies; new care models and 
patient care practices; established new testing and treatment sites; 
and stood up multiple vaccination sites for employees and patients, 
among many other things. We also worked in our community in a variety 
of ways, including serving as a major transfer center for the sickest 
patients, and providing resources to skilled nursing facilities in the 
form of COVID testing, staffing, and training to care for that patient 
population.

    As a team, we responded to the ever-changing information by 
regularly updating our policies and procedures, holding weekly town 
halls for employees, convening virtual community forums with our 
experts to learn more about testing and vaccines, and providing other 
outreach--including through print materials and online communications--
to inform our workforce and community about our pandemic response. Like 
many health systems, we were the hub of the COVID-19 response in the 
community. The vital role health systems played in the response is 
something I hope this Committee will consider when drafting future 
policy.

    At Duke, we are extremely committed to protecting all of our 
workforce and have learned so much about this coronavirus since it 
first emerged in the United States in early 2020. In the beginning, we 
had too little information about the virus and how it is transmitted, 
uncertainty that was compounded by a real and global shortage of N95 
masks and other PPE, as well as stockpiles that contained expired PPE. 
We know that the same challenges were impacting hospitals all over the 
country, including those facing additional resource challenges and 
workforce shortages.

    Very early in the pandemic, we made a commitment at Duke to 
universal masking for all our team members, and we later expanded that 
to require masks for patients and visitors. Our Supply Chain team 
worked around the clock sourcing from around the globe to ensure we had 
adequate safe and effective PPE--including surgical masks, gloves, and 
gowns--for our teams. Given these challenges, I am proud of our Duke 
community and the partnerships across both the health system and 
university to help address some of our most pressing needs.

    Over a year ago, facing a critical shortage of N95 face masks of 
our own, Duke Health research and clinical teams confirmed a way to use 
existing vaporized hydrogen peroxide methods to decontaminate the masks 
so they can be reused. The process uses specialized equipment to 
aerosolize hydrogen peroxide, which permeates the layers of the mask to 
kills germs, including viruses, without degrading the mask material. As 
a result, the decontamination process allowed for thousands of N95 
masks to be reused at all three of our hospitals, easing some of the 
shortage and curbing the need for other alternatives using unproven 
decontamination techniques. Our experts also provided guidance to other 
hospitals and health systems across the country so that they could 
develop and implement such procedures.
    Recognizing the Mental Health Needs of the Front-Line Workforce 
    The impact

    The pandemic has profoundly affected our health care teams and 
clinician leaders, emotionally and physically. Caring for critically 
ill patients, comforting families of loved ones suffering in isolation, 
and fearing bringing the virus to our families has taken a significant 
toll on the mental well-being of our workforce. The unfortunate reality 
is physicians and nurses already suffered from high rates of 
depression, burnout, addiction, and suicide before the COVID-19 
pandemic.

    Early on in the pandemic, in my role as president of AONL, we 
joined leadership from other national nursing organizations to meet 
with the Coronavirus Task Force to collectively advocate for three 
priorities: keep our nurses safe; allocate nurses so we have enough 
staff to care for our patients and communities; and ensure nurses have 
the supplies and equipment they need to treat patients. While we 
continue to advocate for resources to protect the physical health of 
clinicians and staff, we are also advocating for resources to support 
their mental health.

    To help shed light on nurse leaders' primary challenges, leading 
practices, and areas of support during this pandemic, AONL fielded a 
pulse check study of more than 1,800 nurse leaders in July 2020. 
Participants included nurses at all leadership levels, mainly in the 
hospital and health system setting. The primary challenges identified 
were access to PPE and other supplies, communicating and implementing 
changing policies, surge staffing, reallocation and training, and 
emotional health and well-being. AONL fielded a follow-up study last 
month, and while the report is still in development, we do know that 
the availability of health care workers is still a major issue along 
with addressing burnout and building resilience. These issues are not 
specific to nursing and also extend to physicians, respiratory 
therapists, transport specialists, and environmental service staff.

    I am proud of all our Duke Health team members for their commitment 
to our patients and support of their colleagues during unthinkably 
challenging professional circumstances, but none of us are immune to 
the burdens the pandemic has placed on our mental health. We are seeing 
the exhaustion among nurses, first and foremost, followed by the 
feelings of being overwhelmed and anxious and having difficulty 
sleeping, as many nurses also face challenges of managing other 
responsibilities for their families and conducting virtual school at 
home. This fatigue and strain, which at times presents as post-
traumatic stress disorder, has been dramatically exacerbated over the 
last year.

    As a result, we are starting to see more of our skilled workforce 
leave or planning to leave, which is also being reported in recent 
surveys conducted nationally. This kind of high turnover will have a 
significant impact on the future of delivering health care. Compassion 
fatigue is just as real and consequential as physical exhaustion, and 
while the COVID vaccines bring hope, we are seeing the respect for 
frontline workers dwindle as the public tires of this pandemic. 
Unfortunately, we also are starting to see an increase in inappropriate 
and violent behaviors as a result of the incredible toll this pandemic 
is taking on those seeking care in our hospitals and clinics, which is 
another complicating factor for our workforce.

    Our response and proposed solutions

    The constant challenge of caring for COVID patients--by serving as 
their family and managing death and dying in addition to intensive 
care--means our workforce must be cared for and offered respite. We 
provide mental health resources through Duke's Personal Assistance 
Service (PAS), which provides assessment, short-term counseling, and 
referrals by a staff of licensed professionals to help resolve a range 
of personal, work, and family problems. PAS services are available at 
no charge to benefit-eligible Duke faculty, staff, and their family 
members. Duke also sponsors an emotional support and well-being hotline 
and online resources conveniently available to staff, faculty, and our 
broader community. In addition, our chaplains provide needed support to 
frontline staff in their care settings across the health system.

    In addition to supporting the National Academy of Medicine's Action 
Collaborative on Clinician Well-Being and Resilience, the AHA and AONL 
have developed a number of resources to address burnout and promote 
resilience, especially during the COVID-19 pandemic. These include 
guides on grieving when there is no time to grieve, embracing 
mindfulness, and addressing moral distress. The AHA also created the 
Caring for Our Health Care Heroes During COVID-19 resource, which 
outlines the ways hospitals and health systems are helping to care for 
and support the health care workforce during this crisis. The document 
focuses on three areas--mental health, food, and housing--and features 
case examples from across the country. It also provides a list of 
national well-being programs and resources developed for healthcare 
workers.

    Further, Duke Health joins other organizations, including the AHA 
and AONL, in supporting the Dr. Lorna Breen Health Care Provider 
Protection Act, which aims to reduce and prevent suicide, burnout, and 
behavioral health disorders among health care professionals. Named for 
a physician who led the emergency department at New York-Presbyterian 
Allen Hospital, the bill would authorize grants for providers to 
establish programs that offer behavioral health services for front-line 
workers. In addition, the bill would require the Department of Health 
and Human Services to study and develop recommendations on strategies 
to address provider burnout and facilitate resiliency, and it would 
direct the Centers for Disease Control and Prevention to launch a 
campaign encouraging health care workers to seek assistance when 
needed. Thank you to Senator Kaine and Senator Cassidy for leading this 
effort. I hope this Committee will give the legislation swift 
consideration.

    Moving forward: Planning for the future from lessons learned 

    This past year has offered us many lessons learned to better care 
for our patients during and after public health crises. We continue to 
treat patients who suffer from chronic conditions as a result of COVID-
19 and who will need long-term care in the community. From the early 
phases of COVID-19 through recent surges and into the future, we will 
continue to see adaptation in the care we provide our patients and the 
safety we ensure for our workforce.

    The pandemic created regional collaboration between (historically) 
competitor health systems, who pulled together above and beyond the 
connections that exist in NC, and the state emergency management 
collaboratives (RACs) that are in place to address natural disasters 
and other emergencies. Health systems like ours began weekly 
coordination of our response, sharing supplies and resources and 
ensuring access to care and an equal sharing of the burden of COVID 
cases. Lessons learned through these efforts could be translated into 
mutual aid expectations for any future similar public health crises.

    The Hospital at Home program allows us to care for patients at 
home. We recently launched this initiative at Duke Raleigh Hospital and 
have seen firsthand the benefit of allowing acute healthcare services 
to be provided outside of a hospital setting in response to the surging 
COVID-19 pandemic. At Duke University Hospital, we are providing 
enhanced home care services to COVID-19 positive patients who can be 
treated at home and thus provide better access to hospitalization for 
more acutely ill patients.

    Thanks to a $7.4 million grant from the North Carolina Department 
of Health and Human Services (NC DHHS), Duke Health's COVID-19 Support 
Services Program has been able to assist individuals and families 
required to isolate or quarantine due to COVID-19. The program, which 
initially covered three counties and has expanded to nine, has served 
approximately 30,000 people through relief payments, food boxes, meals, 
COVID supplies, transportation, and medication delivery. Duke has 
partnered with 15 minority-led community-based organizations to provide 
these much needed services in our community.

    At Duke Health, our top priority remains the health and safety of 
our patients, their loved ones, and each other. Our planning team has 
been diligently coordinating with our state leadership and developing 
the proper preparations for administering all three COVID vaccines now 
currently available. At Duke Health, we see the vaccine working to 
protect our team--with over 70 percent of our team members having been 
vaccinated--and in recent weeks we have not seen any COVID-19 
infections in vaccinated team members.

    As part of our commitment to getting vaccine to those most impacted 
by COVID-19, we have established a system-wide Vaccine Equitable 
Distribution Committee to better understand our data and reach 
historically marginalized populations, including those who are 
disproportionately impacted by COVID-19. We have dedicated appointment 
blocks and allocation for these populations, and we partner 
intentionally with community organizations.

    We continue to partner with the community to pilot ``pop-up'' 
vaccine clinics. Recently, we joined with the Latino Community Credit 
Union, La Semilla, El Centro Hispano, Greenlight, and Immaculate 
Conception Church through the LATIN-19 initiative to create a vaccine 
clinic geared toward the Latino community. We also have partnered with 
the Durham Recovery & Renewal Task Force's Faith Leaders Round Table to 
hold an event at Nehemiah Christian Center in downtown Durham. We 
continue to collaborate with the African American Covid-19 Task Force 
and Community Health Coalition, Meals on Wheels, Lincoln Community 
Health Center, and additional faith communities to provide vaccine 
allocation and transportation for vulnerable communities.

    As supply increases and eligibility categories expand, we will 
continue to build on the above efforts and develop additional 
strategies with the communities we serve. Through this work, the health 
system has improved the rate of African Americans vaccinated from 8.8 
percent on February 1, 2021, to more than 15 percent today. While we 
are still not where we need or want to be, we are making progress and 
will continue to do so. All combined, this outreach is just one way to 
address the enormous health equity gaps that COVID-19 has exposed. Our 
nation's health policies must prioritize addressing these health 
disparities so that they are no longer systemic impediments to patient 
care and access.

    We are following the guidance and direction of our public health 
experts, including our infectious disease and infection prevention 
colleagues, closely monitoring and adopting new findings, and following 
clinical protocols developed by expert scientists and clinicians in 
every discipline of care. We will continue to manage the pandemic's 
impact on everything we do, while also seeing to the important 
challenge of maintaining resilience within our workforce.

    Preparing for future health emergencies now means doing all that we 
can to ensure a strong, deep, and viable health care workforce in the 
future, including our physicians, physician assistants, and especially 
our nurses. Even before the COVID-19 pandemic, our nursing workforce 
needs outpaced our supply. We are grateful for the leadership of 
Senator Burr and Senator Merkley in advancing the reauthorization of 
Title VIII Nursing Workforce Development Programs. We were pleased its 
reauthorization was included in the CARES Act enacted last March and 
thank Congress for supporting legislation to update and improve 
programs that help to grow and support the nursing workforce in the 
United States.

    We continue to advocate for increased funding to the Title VIII 
Nursing Workforce Development programs to increase the nursing and 
nursing educator workforce. Each year, nursing schools must deny 
admission to thousands of potential students because they do not have 
enough faculty to teach these aspiring nurses. The Title VIII programs 
support nursing schools but also seek to add diversity to the nursing 
profession and improve access in health shortage areas. Along with the 
broader nursing community, we support the Future Advancement of 
Academic Nursing (FAAN) Act, which would make critical investments in 
our nursing infrastructure, including underserved areas by supporting 
the needs of nursing students, helping retain and hire diverse faculty, 
providing resources to modernize nursing education infrastructure, and 
creating and expanding clinical education opportunities. These 
legislative efforts are essential and will help prepare nursing 
students as they transition from the classroom to the frontlines of 
patient care. Thank you to Senator Merkley for his leadership 
introducing the FAAN Act.

    COVID-19 has served as a blunt reminder that we cannot afford to 
overlook our public health infrastructure and workforce. At a state 
level, and in the absence of a coordinated and consistent public health 
infrastructure with sufficient resources, communities, long-term care 
facilities, and public health officials turned to health systems and 
hospitals to support testing, case identification and contact tracing, 
facility interventions in long-term care and communal living 
facilities, assistance for historically marginalized communities, and 
most recently vaccination at scale in our communities. While health 
systems including Duke Health have stepped forward to do this work, 
these additional responsibilities have substantially added to the 
burden and burnout of our teams and increased financial losses and 
challenges. Further ongoing investment in public health infrastructure 
is critical.

    We appreciate the tremendous and ongoing coordination with our 
Governor's Office and NC DHHS to develop a statewide plan to respond in 
lockstep to the current pandemic. But because our public health 
infrastructure is resourced differently in every county, the local-
level capacity to respond to public health threats varies significantly 
across our state. The pandemic has highlighted a critical need to 
narrow these gaps in pursuit of a stronger and more coordinated public 
health system. In follow-up to legislation enacted by Congress in 
December, we are grateful the North Carolina General Assembly approved 
a bill last week that will provide $84 million to local health 
departments across our state.

    As the Trust for America's Health notes, \1\ public health 
departments must respond quickly to emergencies while maintaining the 
day-to-day work they already do to support healthy communities, 
including managing chronic disease and substance misuse. We echo the 
TFAH's call for robust funding ``to ensure that all communities are 
served by health departments with comprehensive capabilities'' and to 
minimize the vulnerabilities recently exposed. We are grateful for 
Chair Murray's leadership on legislation that would strengthen the 
state and local public health infrastructure. Thank you to this 
Committee for its attention to these issues and for seeking policy 
solutions that will address workforce needs and provide access to care 
for all patients.
---------------------------------------------------------------------------
    \1\ https://www.tfah.org/wp-content/uploads/2021/03/Public-Health-
Infrastructure-Fact-Sheet-3-1-21-1.pdf.

    As president of the AONL, I served on an AHA task force that 
developed a Pathways to Recovery compendium of resources to help inform 
hospitals and health systems' work to respond to and recover from the 
pandemic. It spans 11 areas, including workforce, testing/contact 
tracing, communications (both internal and external), supply chain, 
ancillary/support services, plant operations, financial management, 
governance, patient experience, transitions in care, and risk 
management. It is intended to help hospitals align with where their own 
---------------------------------------------------------------------------
communities are in the pandemic.

    COVID-19 highlighted the disparities in care and the need for 
health equity. In addition to addressing systemic racism within health 
care, we recognize the importance of recruiting and retaining a diverse 
health care workforce, reflective of the communities we serve. The AHA 
and AONL developed resources to help health leaders implement and 
foster workforce diversity and inclusion within their organizations. 
These tools also address bias and examine how institutionalized and 
systemic racism result in inequities in care.

    I must also note the impact of the unprecedented expansion of 
telehealth services and access to telehealth resources since the start 
of the pandemic that has helped us stay connected to our communities. 
Our experience, and that of fellow health systems across the country, 
has demonstrated the efficacy of telehealth in delivering care in a 
public health emergency, and we want to ensure that it will remain 
beneficial, acceptable, and accessible to more patients when applied in 
the appropriate ways on the other side of the current crisis.

    We are grateful that the Centers for Medicare and Medicaid Services 
(CMS), through emergency waiver authority, have provided numerous 
telehealth flexibilities, and we urge further action by Congress and 
CMS to make many of these flexibilities permanent after the pandemic. 
In the near term, we support the Temporary Reciprocity to Ensure Access 
to Treatment (TREAT) Act (S. 168), introduced by Senator Chris Murphy 
and Senator Roy Blunt, that would create Federal uniform licensing for 
the duration of the COVID-19 pandemic. We also support changes to 
Section 1834m of the Social Security Act to allow more medical 
professionals, including, occupational therapists, physical therapists, 
and speech-language pathologists, to be able to be reimbursed by 
Medicare for their services after the public health emergency ends. 
Finally, we urge Congress to address technological, broadband, and 
other gaps to access along with any further telehealth expansion 
efforts so that the digital divide is not a barrier to quality care.

    The substantial financial impacts of COVID-19 on hospitals and 
health systems will also have lasting impacts. Systems now face 
difficult decisions to reduce costs, potentially limiting support to 
health care professionals, further development of needed 
infrastructure, and support for their communities. The economic impacts 
for patients and those who have lost health care insurance or cannot 
afford patient financial responsibilities are further impacting 
providers facing financial challenges now due to the COVID-19 pandemic. 
Additional support is needed, including eliminating further reductions 
in payments through Federal programs including Medicare and Medicaid to 
maintain access to care for patients.

    In closing, nursing has been ranked the most trusted profession by 
Americans for decades, with a large majority of survey respondents 
rating the honesty and ethical standards of nurses as high or very 
high. Nurses have the skills, expertise, creativity, and unique ability 
to problem solve and lead while putting the patient's whole health at 
the middle of everything we do. As the spring and summer bring an 
increasing number of vaccinations per day, in combination with 
continuing to mask and practicing healthy behaviors after receiving the 
vaccine, we need to acknowledge pandemic fatigue, be patient with each 
other, and work together in being innovative to provide highest quality 
care in the safest manner possible. In my role at the AONL and with the 
AHA, we will continue to support state efforts to expand scope of 
practice laws, allowing non-physicians to practice at the top of their 
licenses.

    Thank you for the opportunity to serve on the witness panel for 
this important conversation. At a recent HELP Committee hearing, 
Ranking Member Burr, who has been a great partner for Duke Health and 
health systems across North Carolina throughout the challenges of 
COVID-19, commented that it would be ``devastating'' if we do not learn 
from the lessons of the current pandemic. I wholeheartedly agree. Our 
collective weaknesses and failures have rarely been so important to 
understand or on such public display--but we have also seen our nearly 
unlimited capacity for resilience, innovation, and responsiveness. We 
look forward to working with you to apply those lessons, cement our 
strengths, and create an even more robust health care infrastructure to 
address future challenges.
                                 ______
                                 
    The Chair. Thank you, Dr. Fuchs. And thank you to all of 
our witnesses today. We look forward to your responses to our 
questions.
    We will now begin a round of 5-minute questions, and I ask 
my colleagues to please keep track of your clock and stay 
within those 5 minutes.
    Dr. Shah, for over a year we have been responding to the 
greatest public health crisis in over a century. COVID-19 has 
pushed our public health system to the brink and underscored a 
lack of desperately needed resources. That's why Democrats 
included robust funding for vaccines and awareness campaigns, 
testing, and public health workforce in the American Rescue 
Plan, among other critical public health priorities.
    In the all-hands-on-deck effort to end the pandemic, we 
must center our response on equity and reach every community. 
Populations hardest hit by COVID-19, including communities of 
color, tribes, and other underserved populations, must be 
prioritized, and outreach efforts and websites and information 
tools must be accessible to people with disabilities and 
English language learners.
    Dr. Shah, can you tell us what is Washington State doing to 
make sure things like testing and vaccines are accessible to 
everyone?
    Dr. Shah. Thank you, Senator Murray, and thank you again to 
all of you for your leadership on this issue.
    I would say that there are a number of things that we've 
been doing, and it starts not just today but starts way back in 
the fall. It was really around a number of dialogs and sessions 
where we reached 20,000 Washingtonians to also work with them 
and learn from them what their prioritization thoughts were.
    In addition to that, we have put together, as is in my 
written testimony, the Vax Center, which is a public-private 
partnership coming together to help with really efficiencies 
and numbers, but also a fix, which is really a combination of 
dialog sessions and feedback sessions with stakeholders for 
equity.
    I think the key message is that COVID-19 did not start 
these inequities, it has only made them worse. So we have 
really an incredible amount of work ahead of us to make sure 
that we're really underscoring all the feedback from these 
communities and all the people that are impacted 
disproportionately by COVID-19, but also addressing them by 
giving them a voice in the work that we're doing, and I think 
that's critical as well.
    The Chair. Okay, thank you very much.
    Dr. Abraham, we do have a long history of health inequities 
in this country which have only been exacerbated by the 
pandemic, as Dr. Shah just said. It is completely unacceptable 
that Black people are dying from COVID-19 at 1.4 times the rate 
of white people, and that native Hawaiian and Pacific Islander 
populations are contracting COVID-19 at over 3 times the rate 
of white populations. Despite this, in nearly all states, Black 
and Latino people have received a lower share of vaccinations 
compared to their share of cases, deaths, and population.
    We know vaccinations are an essential tool to end this 
pandemic, and they need to reach communities that are hurting 
the most. I am impressed with your health center's success in 
vaccinating communities of color you serve. Tell us how we can 
make sure vaccines and information about them are reaching 
communities of color.
    Dr. Abraham. Sure. Thank you for that question, Senator 
Murray. As Dr. Shah and Dr. Jha mentioned, we have to build 
this public health infrastructure yesterday, and we really 
needed those networks, and what we have really strong in South 
L.A. are networks of Black and brown physicians who knew we had 
to work together to race to get our patients vaccinated. So 
we've been in close collaboration with the physician community 
in South L.A. to figure out how we can better coordinate our 
response. We work in lock step.
    This whole rollout has been a series of marriages, a series 
of marriages between Kedren and our local Department of Public 
Health. It has been working in lock step with our state 
government and making sure that the supply chain reached 
community health centers, FQHCs, to make sure that we get 
clinicians and providers access to the essential medicines 
because this is what we do every day. We vaccinate our 
patients, we care for them, and we educate them. So trust us to 
continue to do our job and we will get more of America 
vaccinated.
    But what we built today really is a revolutionized health 
care delivery system. There is an opportunity in this crisis, 
and that really is to bring a public health infrastructure that 
has been lacking, and we must wed public health and the health 
care delivery system together.
    The Chair. Thank you very much.
    Senator Burr, I'll turn it over to you.
    Senator Burr. Thank you, Madam Chair.
    All of you have talked about inequities. Let me just put 
another one on the table: rural versus urban. It hasn't been 
mentioned, and I think you leave out a lot of America when you 
don't talk about rural America and how difficult it is to 
reach.
    Dr. Abraham, it is unbelievably refreshing to hear you say 
we just built our system, what we needed. Regardless of what 
Washington said, we built what works, and that's what's so 
unique about the local communities and the empowerment of those 
communities.
    Dr. Shah, as I mentioned in my opening statement, we're 
closely examining the first year of our response to the novel 
coronavirus, and we've seen things we didn't expect. One of the 
most obvious recent things, partnership between pharma 
companies with each other, an innovator or discoverer and now a 
big pharma company that takes on a contract manufacturing role 
to finish and fill.
    We never dreamed that these things would happen, but 
they're happening. Our successes are due in large part to the 
ability of state and local public health officials to identify 
and address the unique needs of their community during the 
pandemic. The way that Raleigh handles COVID-19 in North 
Carolina is not the same as Seattle, and we need to address it.
    Let me ask you, Dr. Shah, do you agree that state and local 
officials should be the leading voices for the needs of their 
community as we continue to respond to COVID-19?
    Dr. Shah. Senator, thank you for that. Absolutely, state 
and local officials have an incredible role to play, and we do 
need to lead because we do know our states, we do know our 
localities, so absolutely.
    That said, we also have a responsibility to make sure that 
our Federal partners are also at the table and also leading. 
There are certain things that the CDC can do, that the guidance 
that allows for consistency across the country is also 
incredibly helpful.
    I will tell you on the front lines, it has been so 
challenging this entire year of up and down, back and forth, 
left and right, this and that, to try to fight a pandemic. So 
all the tools that we can have, there are roles of government 
at the Federal level, the state level and the local level that 
all work together so ultimately we are protecting the community 
member, and that consistency of either policy or communications 
is absolutely critical to the success not just for this 
pandemic but in future emergencies.
    Senator Burr. Dr. Jha, we have spent millions over the last 
decade to set up a surveillance system in the United States as 
an early warning system to detect things like this. Hopefully 
it would have seen the pandemic earlier, responded to it 
faster. Did our surveillance system fail, and what should we 
do?
    Dr. Jha. Yes. So, Senator, thank you for that question. A 
year ago, in January 2020, actually, I wrote a piece in which I 
said that I thought the U.S. would have a relatively robust 
response to the pandemic because we had such a good 
surveillance system. We had great laboratories, great doctors, 
great nurses, great hospitals. We do.
    It obviously did not work. I think our surveillance systems 
are not as robust as we need them to be. We don't do enough 
surveillance out in the community. One of the things that we've 
learned, for instance, is wastewater surveillance is a very 
good way of finding diseases before we start detecting them in 
humans. We haven't really made a national effort to do that 
kind of surveillance.
    There's a whole series of things that are much more public 
health and not so much who comes into the doctor's office that 
we need to be investing in. And then the other part that really 
failed us was the data infrastructure. Even if you could 
identify cases or diseases, we could not aggregate it and look 
at the broader pattern in individual states, let alone across 
the country.
    Just yesterday COVID tracking, which was an effort by a 
group of journalists, packed up after a year of pulling 
together data and making it widely available. That's the data 
that we all use as a Nation, was data coming from a group of 
journalists.
    We need the government to be able to pull together data 
across states, do surveillance, and make it available for 
policymakers and academics. None of that worked as well as it 
needed to.
    Senator Burr. Dr. Jha, how can the private sector be better 
leveraged and incorporated into biosurveillance systems to 
support Federal, state, and local public health decision-
making?
    Dr. Jha. Well, the private sector has the tools, right? I 
mean, if you think about genomic surveillance, for instance, 
there are some fabulous American companies that have that 
technology, and the U.S. Government has to partner with them. I 
completely agree with the premise of this and your other 
question, that so much of the success of this pandemic has come 
from the Federal Government, and sometimes state governments, 
partnering with the private sector. That's how we have beaten 
this thing. And when we think about future investments, that's 
the mindset we're going to have to use.
    Senator Burr. Thank you, Doctor. Thank you, witnesses.
    The Chair. Senator Casey.
    Senator Casey. I want to thank Chair Murray, and I want to 
start as well by thanking the witnesses for the focus on public 
health infrastructure. I want to thank Chair Murray for her 
dedication to this issue over time, because we don't talk about 
it enough and, frankly, have not moved forward in a manner that 
would prepare us for the next pandemic.
    I'll start with Dr. Shah. You talked about the need to 
build resilience in the public health system, and about the 
relationship between both public health infrastructure and 
public health preparedness. So I've got a couple of questions.
    Do you think it's possible to be as prepared as possible 
for a public health emergency without investing in public 
health infrastructure?
    Dr. Shah. Well, thank you, Senator, for that question. I 
will say that it becomes extremely difficult. It's really about 
building the capacity not in the middle of the crisis, or not 
reactively trying to throw dollars at it, but in advance to 
build that capacity so public health can respond. So what Dr. 
Jha just mentioned about the surveillance systems, the data 
systems, he's absolutely right. These are systems that in 
advance of COVID-19, if we had this investment in public health 
infrastructure, would have been robust, would have been strong.
    Now, we can look back, that's fantastic, but we really need 
to be looking forward, and that's really about investing in 
systems in a very smart, strategic, and sustainable way.
    Senator Casey. Part of that, I guess, is at the local 
level, and I guess the follow-up to that is who are the people 
you would hire and the other investments you'd make, and what 
other resources would be used when we're not in the middle of a 
public health emergency, as you suggest, to be prepared for 
what's ahead of us?
    Dr. Shah. Well, I think we need to be thinking--look, our 
department of health in Washington has been stood up for 400-
plus days. I mean, that's remarkable. The same thing in Harris 
County down in Texas. The same thing for 300-plus days. We're 
talking about a year-plus of response. Public health systems 
are fatigued both physically and, honestly, emotionally.
    I think the key message is that we need to be thinking 
about how do we make smart investments in that workforce so we 
support the workforce, we make sure that workforce is both 
physically and emotionally and behaviorally supported, but we 
should also think about bringing into the workforce the 
technology, the logistics, folks that have the cost-
effectiveness, who understand process flow, who have 
efficiencies in that. And also, we in public health have to do 
a better job of communications. We have to do a better job of 
really making sure that we can engage with our communities so 
people recognize that we are part of the solution, not part of 
the problem.
    Senator Casey. Doctor, thanks very much.
    I want to move to Dr. Jha regarding children, and I want to 
start by thanking him for being such a great communicator at a 
time when we needed clear and science-based communication 
across the country.
    The one issue that relates to our children that has gotten 
some attention but probably not enough, that while children are 
less likely to become seriously ill from COVID-19 by way of 
comparison to adults, they still can spread the virus, and you 
and others have spoken about MISC, the multi-system 
inflammatory syndrome in children, a very serious condition.
    After we prioritized the high-risk populations and are 
immunizing now tens of millions of people, once we get to the 
immunization of children and teens to reduce community 
transmission in cases of this MISC, and we know that all of the 
major drug companies are running or plan to run pediatric 
vaccine trials, can you speak to the process that's underway 
and assess the safety and efficacy of these vaccines for 
children and teens as you see it right now?
    Dr. Jha. Yes. Senator Casey, thank you. It's a critically 
important question because it will make--it's going to be very 
hard to reach population herd immunity if everybody under 18 is 
not vaccinated. And while the disease does have a much milder 
effect on most kids, there are high-risk children with chronic 
diseases for whom this can be quite substantial; and then, of 
course, we do ultimately want to get kids vaccinated.
    I think we can, and I think the question is when are we 
going to have the data to feel comfortable about the safety of 
these vaccines in children? I do believe we have trials running 
by Moderna and some of the others also, for kids 12 and older, 
and I expect a lot of that data to be available by mid to late 
summer.
    The problem will be the younger children and looking for 
efficacy, looking to see does the vaccine actually work. When 
infection numbers get very, very low, you're going to need very 
large trials to prove that the vaccines are effective. We may 
need to think about this a bit differently. We may need to say 
we want to make sure these things are safe in children and use 
that as a bar. But there's a lot of work to be done. We do have 
to get our kids vaccinated, and I worry, especially for younger 
ones, that it may take a while to have the data to feel 
comfortable doing it.
    Senator Casey. Doctor, thank you very much.
    Thanks, Chair Murray.
    The Chair. Thank you.
    We'll turn to Senator Cassidy.
    Senator Cassidy. Thank you, Madam Chair.
    Dr. Jha, there was just an article in the MMWR about the 
strong relationship between obesity, even that which people 
would think not being very obese but nonetheless is obese, and 
its risk factor for hospitalization and death. Now, Dr. Abraham 
and I did our training in the same area in South Los Angeles, 
and my own medical practice was with the poorly insured in 
Louisiana. And as we know, there is more of a risk factor for 
obesity in those who are lower socioeconomic regardless of 
race.
    To what degree do you think we can explain the 
disproportionate impact upon some sub-populations relative to 
their associated increased risk of having obesity?
    Dr. Jha. Senator Cassidy, it's a really good question, and 
I think you're absolutely right that we're still really 
learning about the impact of obesity on this disease. But no 
doubt about it, based on all the data that I've seen, obesity 
is a meaningful risk factor for having poor outcomes.
    I think if you look at the broader picture of the fact 
that, for instance, African Americans have died at much higher 
rates of this disease, or Latinos, a lot of it is much higher 
rates of infection, which is I think driven by work conditions 
and----
    Senator Cassidy. That is increased rates of infection, but 
we know that there are a lot of folks who are infected and we 
don't know that they're infected, correct?
    Dr. Jha. Absolutely.
    Senator Cassidy. Do you have surveillance testing to 
establish that point, or is that intuition?
    Dr. Jha. Well, we have very good data that they're 
certainly identified far more often as having been infected, 
and given that testing rates have often been lower in African 
American communities, you'd have to--it stands to reason that 
the level of infections in these communities are much, much 
higher as well.
    Senator Cassidy. That's more of an intuition than actually 
having data on that. Everybody respects your intuition, but 
it's still an issue there.
    Secondly, we are looking at an outcome of prevention of 
infection, but it does seem as if there are surrogates for 
prevention of infection, specifically the development of 
antibody response to vaccination than perhaps the height of the 
antibody response. Cannot these surrogate measures be used to 
measure vaccine efficacy in children? Obviously, their immune 
systems are robust. They typically respond to vaccines better 
than those who are older, and yet this vaccine produces good 
immunologic response in those who are older. What are your 
feelings about using a surrogate as a marker of immunity?
    Dr. Jha. It's a great question, Senator Cassidy. As a 
physician, you know that the science here is evolving but 
getting better. I think the key question you're asking is how 
confident are we about the correlates of immunity? How 
confident are we that antibody response, or T cells, which we 
can also measure, really reflect somebody's immune status? And 
my sense is that we're pretty close to that point, but we 
haven't really nailed it down.
    I can easily imagine, especially as infection numbers get 
very, very low into the summer, if we want to measure efficacy 
in children or in other populations, we may need to get to 
using correlates of immunity as opposed to direct infections, 
and that seems to me to be reasonable as long as we've 
established that, in fact, those correlates are right.
    Senator Cassidy. Dr. Jha, we'll stay with you once more. 
Obviously, there's been a lot of concern regarding schools not 
reopening.
    [Inaudible] heavily favored by teachers' unions than not, 
even though CDC continually said that you could safely reopen 
taking normal precautions. I am actually associated, or at 
least my wife is, with a school that did testing, and we found 
that the teachers and the students who were infected typically 
brought the infection--in fact, they always brought the 
infection into the school. It did not spread within the school.
    What are your feelings about the ability of schools to 
safely reopen now?
    Dr. Jha. Senator Cassidy, I believe, and I've been pretty 
vocal in the last several months, that I think most schools in 
America can open safely as long as we put in important 
mitigation efforts--universal masking, reasonable ventilation, 
and I believe testing does add a layer of protection. I have at 
this point believed, given how much vaccines we have, that I 
think we should go ahead and vaccinate teachers and staff. It 
would certainly add a very important layer of protection. But 
there's no doubt in my mind that we can get schools open in a 
way that will keep kids and teachers and staff safe.
    Senator Cassidy. Two more things. Dr. Fuchs, let me just 
say thank you for giving a shout out to the Lorna Breen Act. 
That is something which I am sponsoring with Tim Kaine, so 
thank you for the shout out. We want to take care of our health 
care providers.
    Dr. Abraham, I did do my training at L.A. County USC, and 
the patients you see are my patients as well, and in a sense I 
feel as if we're brothers in kind of cheering for the less 
fortunate. So thank you for all the work you do.
    With that, I yield back.
    The Chair. Thank you very much.
    We'll turn to Senator Baldwin.
    Senator Baldwin. Thank you, Chair Murray. And thank you to 
our expert panel today.
    Public health experts have warned that the coronavirus 
continues to adapt, mutate, and change, and I'm increasingly 
concerned about the rise of new and potentially more harmful 
variants. This is why I authored the Tracking COVID-19 Variants 
Act. It would provide resources necessary to dramatically scale 
up our Country's sequencing, surveillance, and outbreak 
analytics capacity.
    I was proud to see a version of my bill included as part of 
the Senate-passed American Rescue Plan, and I look forward to 
seeing the President sign that bill into law, hopefully very 
soon.
    Dr. Shah, many experts have noted that we could see another 
spike of new infections due to a rise of variants. What can 
states do to respond to these emerging variants, and how will 
scaling up our surveillance efforts and our ability to do 
genomic sequencing for coronavirus make us better prepared for 
the future of this pandemic and future pandemics?
    Dr. Shah. Senator Baldwin, thank you for that set of 
questions. Let me say that the number-one thing that states can 
do is what I said, stay the course. We have to make sure that 
those mitigation efforts for prevention, which is really the 
robust measures around wearing of masks and making sure that 
we're careful as we reopen, that we do so based on evidence and 
the best we can for not dialing up too quickly because, as you 
know, that can also be challenging when you have to dial back 
or if there's another surge.
    But the other thing in the State of Washington and one of 
the things that I'm really proud of from the Department of 
Health standpoint is that we are in the top five in states when 
it comes to genomic sequencing when it comes to the variants, 
and we have discovered variants in the State of Washington. The 
other piece of it is that we've actually invested in more 
laboratory capacity in the public health lab at the state level 
and working in partnership with the University of Washington.
    I think there is something we can do to invest in our own 
state public health systems from a laboratory surveillance 
standpoint, but also working with our partners in the academic 
centers. We need to do a better job and more of genomic 
sequencing because, remember, as you said, viruses, this is 
what they do. They love to mutate. They love to change. They're 
trying to get the next human being to try to figure out how to 
infect. So this is what variants do, but our job is to make 
sure those public health measures are robust and strong, while 
we're also searching and seeking out so we can get data to 
individuals, policymakers, and obviously to public health 
officials so we can continue to monitor what's happening.
    Senator Baldwin. Ideally and pragmatically, what percent of 
positive COVID tests should receive genomic sequencing to 
really keep on top of or keep close track of emerging variants?
    Dr. Shah. This is a tough one, because across the globe 
there are certain countries that are doing a better job, in 
Europe, for example, the United Kingdom, where it's somewhere 
in that 5 to 7 percent range. We're not there. We're obviously 
markedly lower than that.
    I think it's really about continuing to make sure that we 
make progress on it, but we do need to be working with CDC and 
many of our partners like APHL, the Association of Public 
Health Laboratories, to really learn what exactly the optimal 
percentage is.
    But it's really not about just a percentage. It's about 
making sure it's distributed throughout the country so we have 
strong surveillance systems, and then we're also looking and 
using those surveillance systems to really discover pockets of 
where things are happening across the country.
    Senator Baldwin. Thank you.
    I know my time is running out, but I did want to ask a 
question to Dr. Abraham. Community health centers like the one 
you lead play a critical role in providing health services to 
underserved populations. In my home State of Wisconsin, there 
are nearly 20 federally qualified health centers providing 
really important care around the state.
    Now, last month the Biden administration established a 
partnership with community health centers to expand their role 
in COVID-19 vaccinations, and in Wisconsin the 16th Street 
Community Health Center in Milwaukee was named one of the 
participating sites.
    I'm curious to hear from you, are the successes that you're 
having at Kedren being replicated at community health centers 
across the country, or do you think your experience is unique, 
and do you think more needs to be done to help community health 
centers in their vital mission in serving the underserved, 
especially as it concerns vaccines?
    Dr. Abraham. Thank you so much, Senator Baldwin. It also 
reminds me of the question that Senator Burr had mentioned 
about rural populations, as well.
    Community health centers and AFQCs really play a critical 
role, whether it's urban underserved Los Angeles, or whether 
it's rural parts of this Nation. What we've learned is that the 
heroic work at Kedren and the work of partners and public-
private partnerships really is an example for other community 
health centers throughout this country, especially where there 
is unequal access within those communities, whether they are 
rural or urban, anyone who is underserved or vulnerable, those 
that are differently abled, minority, or at high risk for any 
disease during this pandemic.
    What we do is no secret. It's not a magic trick. We just 
need more vaccines, more hands, and more resources, and the 
more of those that go to the places where we receive our care, 
whether those are AFQCs, whether those are small and solo 
physician practices, that's how we're going to get everyone 
vaccinated. That's what we do every day, COVID or no COVID.
    The Chair. Thank you.
    Senator Collins.
    Senator Collins. Thank you, Chair Murray.
    Dr. Jha, I would like to talk with you about the critical 
issue of reopening our schools. I've been very concerned about 
the fact that so many of our students, particularly in the more 
urban areas of the country, still are not back in school. 
Maine, I'm pleased to say, is doing a good job in this regard.
    Just last week I talked to the head of Maine CDC who made 
the point that children are actually safer in schools in many 
cases than they would be in their community or in their home 
doing remote learning. I have tremendous respect for the CDC, 
but I'm very disappointed in its latest guidance on school 
reopenings. You have talked about that for some people in 
public health, that it did not appear to be particularly well-
grounded in the evidence and science. Similarly, Dr. Allen from 
Harvard has questioned the advice on distancing, suggesting 
that for children 3 feet might be adequate as long as they're 
wearing masks. You've talked also about the need and important 
role for ventilation.
    Could you please give us your views on schools reopening 
and what could be done to expedite reopening of virtually all 
schools so that we don't have more and more children falling 
behind, additional mental health problems, social development 
not progressing, and all of the adverse side effects from 
children not being in school?
    Dr. Jha. Senator Collins, it's a really good question. It's 
a really important question. The effects of children not being 
in school over the last year I think have been very 
substantial. They have not been borne by everyone equally. I 
think children from poorer backgrounds have borne 
disproportionately the impact of this. And then let's also be 
honest that when kids are at home, the caretaker is often the 
mother and therefore has had very negative effects and very 
negative labor market effects on women and their ability to 
work.
    The societal effects here are very, very large, and I think 
we need to think about how do we get kids back to school 
safely. One of the things I've been frustrated by is we've set 
up what I think has been a false dichotomy. We've set up kids' 
education versus teacher safety. And the truth is we need both. 
We need both if we're going to do this over the long run.
    I believe there is a way to get kids back into school full 
time now and certainly into the future that keeps teachers and 
staff safe and kids learning. And the principles of that in my 
mind are--and this is really based on where we are today--right 
now you need to have universal masking in school, and you've 
got to have pretty high levels of adherence, 90-plus percent. 
You're not going to get 100, but you've got to have most people 
adhering to that.
    Second is ventilation. I really do think that having 
reasonable ventilation in schools is critical, and I think most 
schools can get that.
    Third is I have argued that testing is an important 
component of keeping schools safe. You catch outbreaks early. 
You offer a level of assurance to everybody that you can do 
this.
    Last but not least is vaccinations, and I said this to 
Senator Cassidy. Given how much vaccines we now have, I believe 
it is important to prioritize teachers, and when I say teachers 
I also mean other staff in schools.
    I did not mention 3 feet versus 6 feet. I did not mention 
deep cleaning of surfaces. I think there's a lot that's gotten 
us distracted. I think if we focus on these things we can keep 
teachers safe, we can keep kids safe and open schools, and I 
think we have the ability to do all of this now, not 6 months 
or a year from now. That's what we need to focus on.
    Senator Collins. I could not agree with you more, and I 
hope that school officials, teachers, parents and others will 
follow the advice that you just gave. Thank you so much.
    The Chair. Senator Kaine.
    Senator Kaine. Thank you, Chair Murray and Ranking Member 
Burr, and thank you to the witnesses for this important 
hearing.
    Dr. Fuchs, I want to thank you for your testimony about the 
challenges--it's hard to say thank you--about the challenges 
that our nursing workforce is facing, mental health challenges. 
And you indicated in your testimony that as a result we're 
starting to see more of our skilled workforce leave or planning 
to leave, which is also being reported in recent surveys. This 
kind of high turnover will have a significant impact on the 
future of delivering health care.
    I want to thank Chair Murray and others. Senator Cassidy 
mentioned the Breen Act. You helped put funding into the COVID 
bill to start to deal with the mental health needs of our 
frontline health care workers and public safety professionals.
    But, Dr. Fuchs, what would you suggest to the Committee 
that we might want to consider going forward to make sure we 
provide resources so that we don't see the kind of high 
turnover that you are concerned about?
    Ms. Fuchs. Thank you for that question, Senator Kaine. This 
actually is a complex issue because, indeed, some of the 
factors for individuals may very well be different depending 
upon individual situations. But one I would say is that clearly 
providing consistent support and education and access to 
services I think is extremely important for not just the 
nursing workforce but for others. So the acts that you have 
sponsored I think will be very helpful.
    I think there is a direct need to really study the impacts 
of the pandemic on the workforce to be able to really look at 
different strategies that may be helpful in addition, and I 
think we have to continue to support our workforce. But we're 
starting to see now, with patients reentering care facilities, 
that the public is stressed, and the public is now acting out 
more in addition, and placing largely nurses and those in the 
direct care environments in a position to be disrespected and 
in more violent situations.
    I think that we're going to have to place emphasis on the 
support of workplace violence initiatives to be able to support 
our staff, amongst other initiatives.
    Senator Kaine. Let me ask a question, Dr. Jha, about long 
COVID and how we should be thinking about that as we're 
thinking about what we need to do. I had COVID in March and 
April nearly a year ago, and it was a mild case, thank 
goodness. But one of the effects of it was nerve tingling 24/7, 
every nerve ending in my body, and a heating pad sensation that 
happens about four or five times a day where it just feels like 
somebody has turned a heating pad on. It heats up, and then 15 
minutes later it goes, then it crops up somewhere else.
    These are mild symptoms that don't stop me from working, 
and the tingling thing actually helps keep me awake in long 
hearings.
    [Laughter.]
    Senator Kaine. My Governor in Virginia had COVID. Six 
months later, no sense of smell. Obviously, there's nothing 
wrong with my skin, and there's nothing wrong with his nose. 
It's a neurological issue, probably just altered the thalamus 
or something like that. But these are not debilitating 
symptoms, but many have debilitating symptoms: fatigue, heart 
impairment, respiratory problems, brain fog. I did get asked if 
I had that and I said no, but my friend said, well, how would 
anyone know?
    [Laughter.]
    Senator Kaine. But as we're thinking about going forward 
and the way we look at the health magnitude of this crisis, 
there will be a day when the President will declare that the 
emergency is over, but there's this huge category of these long 
COVID consequences that we still don't completely understand.
    Maybe for Dr. Jha, how should we be thinking about that as 
we are trying to put together the right plan to take care of 
the Nation's health needs going forward?
    Dr. Jha. Senator, it's a fabulous question. First of all, 
I'm happy to hear that your symptoms are mild. But as you 
pointed out, there are people who struggle with substantial 
symptoms. I think one of the things that I found most 
frustrating over the last year, for people who like to focus on 
mortality rates and essentially argued for let Americans get 
infected, is that we did not appreciate the effects for the 
large number of people who got infected and recovered, didn't 
die, thankfully, but had substantial debilitating symptoms.
    I would say two or three things. One is, first of all, we 
need to really study this much more carefully. We have to apply 
science to it the way we do everything else, and NIH I think 
has been doing some really good work on building cohorts and 
really trying to figure out what are the predictors, how long 
do these things last.
    Obviously, we need to work on therapeutics to try to 
resolve some of these symptoms, address some of these symptoms. 
There's some preliminary data that actually vaccinations can 
potentially be helpful for long COVID. I don't want to 
overstate how good the science on that is, but there is some 
preliminary data that it might be the case. I'm hoping that as 
more people get vaccinated, that will show up.
    The last point I'll say is when our President declares the 
public health emergency over, we are going to find a large 
number of Americans with substantial disability from this 
virus, from this infection, and the cost of that, human and 
financial, is going to be long term, and we're going to have to 
manage that as a country.
    Senator Kaine. Thank you, Dr. Jha.
    Thank you, Chair Murray.
    The Chair. Thank you.
    Senator Murkowski.
    Senator Murkowski. Thank you, Madam Chair.
    Thank you to all of our witnesses. I really appreciate this 
discussion about the mental health side of what we're dealing 
with this COVID.
    I think last year at this time we were all very keenly 
focused on the health impact, what was happening to people who 
were coming down with the virus. And then shortly after that we 
saw the economic crisis that came following the health. And now 
I think we are into this third wave of a crisis, and I think 
it's the mental health and behavioral health side of it. You 
want to talk about long haul and those long-lasting impacts, 
whether it's the impacts on kids, the societal impact that has 
been referenced here today, as we think about our providers and 
what we need to do to ensure that they have the help and 
support, and also recognizing the stigma that attaches.
    If you are the mental health provider that says I need 
mental health help now--there was an article in the Sunday News 
about the doctor who took her own life after dealing with COVID 
and then coming back with the stress of handling it all. So I 
think we need to be very cognizant of what we're doing to 
address the behavioral and the mental health needs of not only 
our medical professionals, our children, but at all levels now.
    I was looking at a full-page--it was an advertisement but 
not really an advertisement. It was an informational piece that 
was put out by the Alaska Mental Health Trust Authority, full 
page in our newspaper yesterday. But they are partnering with 
the State Department of Health and Social Services. They're 
bringing together a coalition of health care organizations, 
government agencies, social service providers, and community 
members, and they call it Crisis Now, and it's a framework for 
expanding the behavioral health crisis response. They're doing 
it in our larger communities. The big components of it are a 
mobile crisis team, a 23-hour and short-term crisis 
stabilization center, where those who are experiencing mental 
health or substance use emergencies can go for safe care.
    The question--and I don't know, maybe this is to Dr. Jha or 
to Dr. Shah, maybe any of you--I understand that this Crisis 
Now framework is based off SAMHA's National Guidelines for 
Behavioral Health Crisis Care model. So the question is whether 
or not folks are familiar with these guidelines or if there are 
similar models that are being implemented to address the 
behavioral needs that we're seeing within the hospitals, and 
more particularly in the emergency rooms, because it's in the 
emergency rooms that you get them first, and the ability to be 
able to respond is perhaps limited.
    I throw that out as a jump ball to whomever would receive 
it.
    Dr. Abraham. Senator, this is Dr. Abraham. I work at an 
acute psychiatric hospital. Kedren is a federally qualified 
health center that has an outpatient mental health outfit, as 
well. One of the things, if you come and visit us in South 
L.A., that you'll visibly see is there is joy. There is music, 
there is dancing. We're turning the story around. We're at war 
with COVID, and we are winning, and that is part of improving 
people's mental health.
    I'm hoping that with our strategies to really combat this 
pandemic, we do get back to work, back to school, back to 
loving our loved ones, and I think that has a significant 
impact on the burden of mental health both for our workforce 
and also the patients and the public that receives the care 
that we provide them.
    What I've noticed about the over 200 volunteers that come 
and show up every day from AmeriCorps and the American Red 
Cross and the Salvation Army, they are happy, and they now feel 
part of the solution. We are solutions oriented at Kedren, and 
we've seen how that has directly impacted people who have been 
morally injured by this pandemic, those that are dealing with 
the realities of burnout. For health care providers, mental 
health care providers who are suffering, this is the antidote, 
this is the cure, this is the shot. We say let's get everybody 
vaccinated, and we've seen how positively it has impacted our 
community.
    Senator Murkowski. Thank you, Doctor.
    Dr. Shah. This is Umair Shah in Washington. I want to also 
give a shout out to Dr. Zink, who is the state health official 
in Alaska, and she does a fantastic job.
    Senator Murkowski. She's a rock star, really.
    Dr. Shah. She is, she absolutely is.
    I'm not familiar with that program, but I think one of the 
biggest concerns from a patient standpoint is that across the 
country we had, prior to the pandemic, some 1 in 10 Americans 
had some sort of anxiety disorder or anxiety symptoms, and 
during the pandemic that has increased to 4 out of 10. So we've 
had an increase in that. And on the provider side we've had 
compassion fatigue as well, where there's also been the concern 
that even psychiatrists or responders have not been able to 
cope with their own challenges from a mental health and 
behavioral health standpoint as they're now addressing the 
person in front of them.
    I will agree with Dr. Abraham that there are moments that 
we need to--first of all, we need to support our health care 
and public health workforce, absolutely. But there are also 
moments that we need to champion. So, for example, in the State 
of Washington, we celebrated several weeks ago our millionth 
dose. Governor Inslee recognized the millionth dose, which is 
Ruby T., a 90-year-old from Eastern Washington who was the 
symbolic millionth dose who had received a vaccine, and there 
was a big celebration, confetti and things like that. It 
brought such an incredible positive uplifting to our own team 
at the Department of Health.
    I will say that now, as we're closing in on our 2 millionth 
dose, actually, this week, in fact we just passed it yesterday, 
there are moments of celebration in the midst of this horrific 
pandemic. But we do need to not just celebrate. We also need to 
support. We need to put the resources in not just for physical 
health but really for emotional behavioral health. As you know 
just as well as I do that this is what providers are least 
likely to come forward and say I've got a problem, I've got an 
issue, I've got a challenge, I am burned out, and this is why 
we need to be really careful, methodical and forthright in 
supporting our health care and public health professionals with 
emotional health support.
    Senator Murkowski. Thank you.
    The Chair. Thank you.
    We'll turn to Senator Hassan.
    Senator Hassan. Well, thank you, Chair Murray and Ranking 
Member Senator Burr. And thank you to all of our witnesses for 
your testimony today and for the optimism that you have been 
expressing as well. I think it's much needed.
    I want to start with the issue of long-term care 
facilities. I want to start with a question first to Dr. Shah 
and then to Dr. Jha.
    In New Hampshire, more than 70 percent of COVID-19-related 
deaths occurred within our long-term care facilities. Despite 
consistent pressure from me and many of my colleagues, the 
previous administration failed to provide the clear and 
consistent guidance and resources that these facilities needed 
to protect their residents and their staff.
    Secretary Shah, moving forward, what steps should we be 
taking to better support long-term care facilities and ensure 
that they are protecting their residents against COVID-19 and 
other infectious diseases?
    Dr. Shah. Senator, thank you for that question. I will say 
one thing that is absolutely critical, which is that as we are 
continuing to prioritize populations for vaccines across the 
country, we cannot forget the absolutely critical importance of 
vaccinating seniors, those who are older in our communities, 
especially in long-term care facilities.
    As you remember, in the State of Washington very early on 
in this pandemic, we had a long-term care facility where there 
were real issues, and that was the first focus across the 
country of what we needed to do as a system to respond to the 
needs within those long-term care facilities.
    I think it's really three-fold. First of all, we have to 
continue with the process of vaccinations, and we need to make 
sure that the staff and the persons who are within those 
facilities are vaccinated. We have to prioritize that. 
Fortunately, we have been, but we need to continue to 
prioritize that, especially as we have turnover in either staff 
or people.
    No. 2 is we need to make sure that we have those resources 
within those facilities so they also can continue to have all 
the protective measures, the personal protective equipment, 
masks and hand sanitizers, et cetera, and they have enough room 
to be able to cordon off individuals who are sick or have 
symptoms, to be able to get them out of that facility, or at 
least away from others.
    No. 3, which is back to that additional question that I 
answered previously around behavioral health, we also have to 
be really thinking about the impact on seniors, on those who 
are in long-term care facilities by isolation away from 
families, away from others who they normally would be relying 
on to be able to touch and feel and be a part of a family, and 
that is absolutely critical for us to be doing, to make sure 
that those resources are also there from a behavioral health 
standpoint as we also continue to fight the pandemic.
    Senator Hassan. Thank you.
    Now I want to turn to Dr. Jha, because outside of 
congregate care settings, home health workers face unique 
challenges accessing paid sick leave and personal protective 
equipment, and many individuals who receive home-based care are 
struggling to access vaccines.
    Dr. Jha, what steps can we take to improve vaccine 
availability for workers and patients across all types of care 
settings, including for those who are unable to travel to 
centralized vaccine sites?
    Dr. Jha. Yes, Senator, it's such an important question, and 
there are a couple of components to that. First of all, I want 
to talk about home health workers. These are some of the least 
well paid people in our society. A lot of them are hourly in 
their wages, and the idea that a lot of them have turned down 
the opportunity to get the vaccine and we say they're vaccine 
deniers or they're being hesitant, we fail to understand that 
these people have lives where they can't take time off if they 
end up having side effects in a way that I could when I had my 
vaccine shot. I could take a day off if I needed it. Many 
people cannot.
    I think there are some really important issues about 
understanding the context in which people are turning down 
vaccinations and finding policies as well as really having the 
organizations themselves being able to pay people to take that 
time off or help them get vaccinated, I think that's a really 
important area that has not gotten enough attention, and we've 
been quick to dismiss these individuals who work incredibly 
hard, often multiple jobs, and get paid so very little.
    More broadly, I think right now in terms of getting people 
vaccinated across the country, my take is we really need an 
all-of-the-above strategy, and I think the Administration has 
largely been doing this right. They have large sites, FEMA 
sites, that will attract a lot of people and will get a lot of 
people through, but there are a lot of home-bound individuals 
who can't get to these sites. So that's why we need things like 
mobile vans, or we need community-based organizations that know 
where these people are and can reach out and connect with them.
    My overall thinking on this has been we've got to let 
states do a lot of this, and then states have to push this out 
to community-based organizations who actually understand the 
community at large and can implement a lot of these vaccination 
strategies.
    Senator Hassan. Thank you very much.
    I see that I'm over time, Chair Murray, so I will submit 
the rest of my questions for the record. Thank you.
    The Chair. Thank you.
    Senator Marshall.
    Senator Marshall. Thank you, Madam Chair, I appreciate it.
    My first question will be for Dr. Abraham. Dr. Abraham, 
like you, I'm a physician, oversaw three county health 
departments. I volunteered in federally qualified health 
clinics. We have 21 in Kansas, very proud of them. And I'm used 
to dealing with finite resources, and you are too. I just want 
to talk for a second--I wrote an op-ed for the Wall Street 
Journal published last night and just kind of talk to you about 
how do we save the most lives.
    Are you familiar with some of the new studies coming out 
saying the effectiveness of one shot of the vaccines? Have you 
been following those stories? Well, good.
    I think what we're seeing is that one shot of either the 
Moderna or the Pfizer vaccine is 75 to 90 percent effective for 
one shot. And the other big news is that you can still get the 
second shot 12 weeks later and be just as effective and raise 
it.
    If you have a finite set of number of shots and you're 
trying to get to herd immunity as quickly as possible, after 
you get the high-risk people who get two shots, let's say 
seniors and everybody with diabetes and heart disease--you know 
your clinic better than I do--if we would give you the 
flexibility of giving everybody one shot now and then coming 
back in the next 3 months and picking up that second shot, does 
it make sense to you that we could impact a greater number of 
folks?
    Just a quick example. If I gave you 200 vaccinations and 
you had your choice to give 100 people two shots or 200 people 
one shot, which would result in the greater number of people 
that are effectively vaccinated? And the answer is the latter, 
150 people in the latter scenario, the first scenario maybe 90.
    What would your thoughts be that you could do with that, if 
I could give you the flexibility to do that?
    Dr. Abraham. Thank you so much for that question, Senator. 
I would gladly take those 200 vaccines and I will make sure 
they get into the arms of Americans, and that's what we have to 
do. We've got a race against time right now. We don't have a 
moment to waste, not a drop to waste of this vaccine. Whichever 
vaccine you are offered, whether it's Pfizer, Moderna, or now 
Johnson & Johnson, and I'm sure there are many in the pipeline, 
we'll see what the technologies bring in terms of updated 
versions as we continue to combat variants.
    However, I too believe that we must get this vaccine out. 
As previously stated, it is not either/or, it is all. My 
second-dose patients need their second dose, and they're lining 
up outside my gate, and if you get your first dose, we'll do 
everything in our power to get you your second dose. But we are 
dealing with a rationed, limited supply of these vaccines. But 
I do believe achieving that herd immunity as quick as we can is 
critical.
    To some of the points made earlier about mobile units, 
getting those vaccines out to the home-bound, homeless 
encampments, to jail populations, there is clearly a critical 
use for single-dose vaccines. It is all, not either/or.
    Senator Marshall. I visited a federally qualified health 
clinic last week in Wichita that has the mobile center, and 
we're out there doing it.
    I want to turn now and just talk a little bit about the 
disparity, about the lack of equality of opportunity for the 
vaccines. In Kansas, I'm ashamed to tell you, as of about a 
week ago, 10 percent of white Americans already had the vaccine 
and 5 percent of African Americans or minorities were 
vaccinated, and this was so predictable. I could just bang my 
head against the wall what happened. What did we do wrong? We 
knew this was going to be the case, that it would be a 
challenge, and I knew the places to cure the problems were 
federally qualified health clinics and the county health 
departments. Those are the ones that can get the vaccines to 
those people. Was it that you didn't get the vaccines, or that 
people didn't want to get them? I just can't imagine you didn't 
give everything you had out.
    Did our Governors not make the right choices on where to 
distribute the vaccines? Maybe, Dr. Shah, you can tell me. We 
know it's been a bad deal. What did we do wrong?
    Dr. Shah. Well, Senator, thanks for that question. I will 
tell you one of the things that we have to recognize is that 
we've also been moving throughout every, if not all, 50 states, 
that the vaccines have been going not just in general to the 
communities but they're going to specific priority populations. 
So health workers, long-term care facilities, and seniors, and 
then essential workers. We have to make sure that our 
denominator is correct, that we're looking and comparing it not 
just to the general population of a percentage of certain 
populations within our states but really those who are eligible 
for the vaccine.
    The reason I bring up that comment is that this is not an 
excuse; it's an explanation. We need to be thinking about all 
of this information. But as we move into populations, you are 
absolutely correct, we need to continue to prioritize equity, 
we need to continue to be thinking throughout the system what 
can we be doing. And we've been doing that for months.
    But I will tell you the challenge has been that these 
public health systems and health care delivery systems, whether 
it's county health departments, whether it's what's happening 
within the health care facilities or community health centers 
or pharmacies, that all are ramping up with limited supply. So 
as we get more vaccine, we are going to see more logistics and 
more operations, but then we've got to shift into vaccine 
hesitancy.
    This is just continuing to follow and move and evolve as 
the vaccine process evolves, as well as the pandemic itself.
    Senator Marshall. My time has expired, but I think we got 
something wrong. And until we identify what we got wrong, it's 
going to be hard to correct. Thank you.
    I yield back.
    The Chair. Thank you.
    Senator Hickenlooper.
    Senator Hickenlooper. I appreciate all of your service and 
your time on this issue. I mean, COVID and the distribution of 
the vaccines has been one of the greatest public health 
challenges this country has faced, and it did obviously start 
with a lot of bumps in the road, but I for one have been very 
impressed that the resolution of a lot of these issues--
obviously, there are 50 different Governors in this country. I 
know that too well. I think that the responses and the 
evolution of the effort has really been dramatically improved.
    Yesterday--you guys have discussed this, the new guidelines 
and allowing the fully vaccinated a little more freedom with 
still some constraints. I spent a lot of time in small business 
and was curious what rays of hope you see for small businesses 
and what kind of timeline that looks like, and I'm thinking 
specifically of the retail small businesses like cafes, beauty 
salons, places where they in many cases have less than 10 and 
sometimes have only 2 or 3 employees. What kind of guidelines 
and what kind of support do you see helping facilitate them 
coming out of this as quickly as possible?
    Dr. Shah. Senator, I'm not sure if that question is for me 
or for someone else, but I can take a quick stab at it and then 
maybe turn it over to my colleagues.
    I would just say from the standpoint of what we had been 
very, very interested in throughout and supportive of 
throughout is to be able to reopen and to reopen safely. 
Vaccines provide us that glimpse of hope. And why does it do 
that? Because now you have patrons in restaurants and in bars 
and throughout different establishments, retail establishments, 
who are vaccinated, who have little chance or markedly lower 
chance of transmitting to the person next to them in the cafe 
or next to them somewhere else.
    As we continue to see increases in vaccine rates, we are 
going to start to see decrease in transmission, and that's what 
vaccines really promise us.
    However, we have to continue to be thinking about all those 
mitigation efforts that Dr. Fuchs, Dr. Abraham, Dr. Jha 
mentioned throughout, that these public health measures cannot 
just go away. We have to continue to dial up while we're also 
thinking about very carefully what we can dial down. But unless 
we do that carefully, unfortunately we can see another surge, 
and that's what this virus has taught me this entire year. It 
is a super-slick virus that has broken every rule in the 
playbook, and if we are not super-smart in response, then 
exactly what will happen will be another potential surge.
    Dr. Abraham. Senator Hickenlooper, this is Dr. Abraham. I 
just wanted to add to that it's critical that we get the 
vaccines to where people live, work, and play. And for smaller 
businesses, it's impossible to close your doors. How are you 
going to send everyone to a vaccination site? How are you going 
to wait in line for hours? You may not have PTO or child care 
or transportation. Those are all barriers to small businesses 
getting their workforce vaccinated. So it's critical that we 
take those mobile units, we partner with our roots in the 
ground, the network of our business leaders, and let's get to 
your business and vaccinate your staff so they can safely 
continue the services they provide.
    Senator Hickenlooper. I couldn't agree more. I think that, 
and being willing to work on weekends, which I see you guys 
have made that evolution.
    The last thing I'll throw out there just as a concern. 
Years and years and years ago, I was a scientist. I got a 
master's in geology, did my master's, published a couple of 
papers, but I can't ever remember seeing so much distrust of 
science. And at a time where it's so important, have you guys--
again, I won't direct this to any one of you; feel free to 
chime in. But how do we go about rebuilding trust in science, 
especially in terms of rebuilding our public health 
departments?
    Dr. Abraham. Really quickly, this is Dr. Abraham. I'll just 
say we deal with this every day on the front lines. We're 
vaccinating over 2,500 people a day. Whether you're Black or 
brown, white or yellow, you legitimately have every reason to 
have questions. It is your body, your health. What is mRNA? 
What is an mRNA vaccine? These are real questions, and you have 
every right to ask them. There are questions around health 
literacy. There is sometimes a lack of basic science 
understanding, and we must meet people where they are.
    It's critical to take the time to engage them. We answer 
their questions and educate them, and those that are medically 
eligible, we've seen that they roll up their sleeves, and let's 
not confuse a lack of access for hesitancy, and let's not 
confuse not finding parking in South L.A. as I don't have time 
for a vaccine or I don't want a vaccine. So those are all 
critical issues that we look at, Black and brown vaccination 
rates. You've got to start teasing a lot of those things out.
    But take time, answer people's questions. Let's be honest 
with them. And those who choose to get vaccinated, we will 
vaccinate you.
    Senator Hickenlooper. Great. Thank you.
    I'm out of time. I have more questions, but thank you so 
much.
    The Chair. Thank you.
    Senator Tuberville.
    Senator Tuberville. Thank you, Madam Chair. Thank you very 
much.
    Thanks for all of your service and what you're going 
through, a very tough time. What a tough time for the world and 
our Country.
    I worked in education for the last 40 years, and the last 
20 years I saw a huge uptick in mental health problems with our 
kids. I don't know whether it has anything to do with drugs--
I'm sure it does--lack of family. But we have a huge uptick.
    Now, the question I've got for all of you, if anybody wants 
to answer this, we're getting ready, just watching our doctors 
and our first responders work for the last year, overworked, 
stress, which can cause a lot of problems. Do we have a plan to 
help these people that are first responders once, hopefully, we 
see the light at the end of the tunnel in this pandemic? Are we 
preparing for what we can do for these people who have done so 
much for us, and then at the end of the day it's going to hit 
us right between the eyes of what the problems they're going to 
have?
    Dr. Abraham. Dr. Abraham here. I'll answer really quickly. 
Thank you for that question, Senator.
    As I say, the mantra that we have is more vaccines, more 
hands to administer them, and more resources and funding. When 
it comes to the hands, there are just not enough health care 
workers in our communities. We don't have enough nurses and 
doctors and every other health care worker that helps us 
deliver essential medicines and health care delivery and public 
health in this country.
    Part of it is we've got to buildup the workforce because, 
myself included, has not taken a day off since the day before 
Christmas, and that just can't keep happening. That's not 
sustainable. But my colleagues are racing against time in ICUs, 
keeping ventilators operating and keeping people from dying. 
The least we can do in public health and community health 
centers is race against time to get this vaccine out, but it's 
not sustainable and we need more health care infrastructure and 
more public health and more hands, and that means we do need to 
train people to do health work well.
    Senator Tuberville. Would anybody else like to answer that?
    Dr. Jha. One thing I would just quickly add is during this 
last year, what we saw was a pretty unmitigated attack on 
health care professionals, people accusing doctors and nurses 
of lying about how many cases of COVID there were, a real 
turning on these heroes who I think have saved so many lives 
across the country.
    One of the things we've got to do moving forward is make 
sure that we are not doing that moving ahead, that we're not 
attacking frontline health care providers as somehow being 
dishonest, when I think they have been anything but that.
    Then the second is that as we come out of this pandemic, we 
really do need to, from a policy point of view, look at our 
payment systems that have made it very, very difficult for 
primary care practices and independent practices to survive in 
this pandemic. We need to find new ways of paying doctors and 
nurses and health care providers.
    There's a lot of work ahead, but it certainly begins, I 
think, by showing people respect and understanding what health 
care workers have gone through, and not questioning their 
motivations.
    Senator Tuberville. Thank you.
    Dr. Shah. Senator Tuberville, first of all, I'm from 
Cincinnati originally, so I just want to give a little shout-
out to you from that previous job with your career there.
    I will say that, in addition to what Dr. Abraham and Dr. 
Jha just mentioned, I do think there is an incredible need for 
us to invest in that health care and public health workforce 
both for more of them and training and support, but also 
behavioral health-wise. Your question was are we ready for that 
for the future, and my answer is I don't think so. I don't 
think we are. I don't think we've done enough. I don't think we 
have done enough. I don't think we did enough prior to this 
pandemic, I don't think we've done enough during this pandemic, 
and I don't think we're doing enough moving forward to make 
sure that the health and the health care needs and the mental 
health and behavioral health needs of our health care workers 
and our public health workers are addressed.
    We have not done enough to support it. We've got to do 
more. And if we do not get this right, we are going to lose 
more people from the health care system and the public health 
system, and it's going to be a terrible loss for this country.
    Ms. Fuchs. I can't agree enough with my colleagues on the 
panel today. This is a big issue, and we are not prepared for 
the future workforce for health care. I recently had the 
opportunity to speak with both Rear Admiral Mix and Orsega 
about the public health workforce and the large gaps in the 
numbers of people, in the numbers of nurses that we have 
prepared either in the whole workforce or in the Reserves.
    This is an extreme area and opportunity for us moving 
forward, and then back to the concept of how we're caring for 
people within our organizations. Wherever they're delivering 
care, we have to have flexible services that meet individual 
needs in a place where they can accept and be comfortable with 
those resources. That will take a very broad approach that will 
require additional sources of resources to be able to impact 
our workforce.
    Senator Tuberville. Thank you very much.
    If I could just make one statement, Madam Chair? I told 
this to General Pierre last week, who is over at Operation Warp 
Speed. I've been in sales and recruiting all my life. I've 
watched how things work. We've got a lot of people that's not 
taking this vaccine, and we've got to have a lot more take it, 
even when there's more vaccines to be given. We need to come up 
with a marketing plan. At the end of the day, when we've got 
vaccines and 30, 40, 50 percent of the people will not take it, 
we've got to have a marketing plan, television and radio, to go 
in and say this is why you've got to take it. We can't just set 
back and expect people to take it. It's not going to happen.
    I think at the end of the day, probably here in a month or 
so, we're going to be at a point where we've got to make a 
statement of marketing and getting this thing out to get this 
thing behind us.
    Thank you very much. Thank you for your service.
    Thank you, Madam Chair.
    The Chair. Thank you.
    Ms. Fuchs. Can I make a comment, please? We need a 
sensitive approach to how we educate the American people. We 
need to meet them where they're at, as Dr. Abraham has said. We 
need to recognize that we have a great opportunity here. As a 
nurse on this panel on the front lines of our Country, nurses 
are the most trusted professionals as rated by our public for 
years, and I don't believe we've taken the opportunity to 
really maximize the potential that we have in order to impact 
vaccinations. So I look forward to partnering with many to be 
able to help in this work in the future.
    The Chair. Great. Thank you.
    Senator Rosen.
    Senator Rosen. Thank you, Madam Chair and Ranking Member 
Burr, for holding this really important hearing today.
    I just want to thank all of the doctors here for your 
compassion during the pandemic, not just you but all of our 
health care workforce, all of our first responders who have 
gone above and beyond to serve our Nation. We are eternally 
grateful for what you have done for those 500,000-plus families 
who have lost loved ones alone and just all of it. I'm just so 
grateful and I thank you on behalf of our Nation.
    It is encouraging to see that 92 million Americans have 
been getting vaccinated, about 856,000 so far in Nevada. But 
greater access to the vaccine can't come soon enough. Far more 
needs to be done. So despite our progress, there have been 
challenges with appointment scheduling systems, long lines, too 
many individuals in underserved areas and rural communities 
being left out, and many Americans still waiting for their 
first or second shot as we know that the virus variants 
continue to mutate. It's critical that we rapidly review what's 
working and make changes to ensure that no one is left behind.
    Dr. Jha, from a broad systemic perspective, what do you see 
as the long-term changes we need to do to improve vaccine 
delivery, especially to our most vulnerable communities? And 
then I think part of this would be to address our public health 
infrastructure, our data systems, creative ways to meet people 
where they're at regardless of their communities. What else can 
we do to help you with this?
    Dr. Jha. Great. So let me kind of lay out what we know 
nationally, and then obviously folks like Dr. Shah can talk 
much more about the individual state-level experience.
    When we look across the country, we see a lot of variation, 
some people doing very well, some states doing very well, and 
other states struggling. If you look at what differentiates 
states that are doing well from those that are struggling, 
keeping things very simple is probably the most important. A 
lot of states I think have made this far too complicated and 
have made it very difficult for people to sign up, to arrive at 
a vaccination place, and the more difficult we make it, the 
harder we make it for people with fewer resources, fewer 
capabilities, fewer support systems to actually make it through 
the system.
    We really have to have a ground game where we go out to 
people and make this incredibly easy. We've heard some of this 
from Dr. Abraham, what he's doing in L.A., but it has got to be 
much more about getting out into the communities, and I worry a 
lot about the rural areas of the United States because I just 
feel like we have not paid enough attention to how we're going 
to get vaccines out there.
    The problem here is that we're trying to recreate a public 
health system that we have hollowed out over the last decade, 
and now we find ourselves saying, boy, it would really be 
useful if we had a system that had good data, that had a really 
terrific workforce that we could plug into, but we don't. And 
so we've got to build it for the short run, because vaccines 
are a short-term problem and we've got to get people vaccinated 
quickly. But then we've got to make sure we don't pull all 
those investments away once people are vaccinated and say, 
Okay, we're done, we're leaving. We've got to leave a lot of 
those resources and infrastructure behind not just for future 
pandemics but all the other health crises, opioids and other 
things that continue to plague our Nation. We've got to 
continue to make investments in those.
    I'm hoping that vaccines become really the step that we 
need to leave a public health infrastructure that helps us 
address all sorts of other public health challenges.
    Dr. Abraham. Senator Rosen, I just wanted to add really 
quickly--Dr. Abraham here--the digital divide in America, the 
digital fortress we've created as barriers to people and their 
vaccines, we really need to transform some of the digital 
demons that have stalled grandma's shot and train them and 
teach them and empower them to be digital angels that actually 
help us use these systems. These technologies are supposed to 
help us, not harm us, not stand in the way between people and 
their vaccines. And we need to understand why we need this 
data, and there may be more creative ways to capture it than 
having a 65-plus senior in our community fighting with their 
computer so that they can get a vaccine.
    Senator Rosen. I couldn't agree more.
    I just have a few seconds left, so I want to talk quickly 
about therapeutics research and access. We know that we're 
going to have vaccines, but people will still become ill. So 
quickly, I just really want to ask what suggestions do you have 
to improve access for COVID-19 therapeutics for our vulnerable 
patients, maybe particularly in rural areas or in areas that 
are underserved and folks not able to get to a Tier 1 hospital, 
perhaps. That's going to be our challenge now as people become 
vaccinated.
    Dr. Jha. Let me start by quickly saying I think this is an 
area--look, we've done a lot of things well. The scientific 
community has been extraordinary. The NIH has been 
extraordinary. But I would say that therapeutics is one area 
where we probably have under-invested. I think there are a 
variety of issues. We've done pretty well with inpatient 
therapies. We've got monoclonal antibodies, but they need 
outpatient infusion, which is very difficult in a lot of 
contexts. We actually are under-using them.
    I think given the billions of dollars appropriately 
invested in vaccines, I would like to see a similar effort for 
therapeutics. The virus is not going away, even when most of us 
have gotten vaccinated. We'd like to get to a point where if 
you got infected, you could take a 5-or 7-day oral course of 
something which would dramatically reduce your chances of 
getting sick. We don't have that. We got distracted with things 
like hydroxychloroquine and all that stuff. We've got to let 
science drive this, and we've got to let NIH really--give them 
a lot more resources to push new therapies. We don't know which 
ones will work, but we've really got to try and put a lot more 
effort into this area.
    Dr. Shah. The other thing I would just say is we have to 
also support our rural systems, to Dr. Jha's point, rural 
hospitals, rural health care providers, rural health 
departments that are doing an incredible amount of work, both 
on the vaccine side but also on the therapeutic side. We need 
to make sure we continue to support them because they have 
challenges that are quite different than what's happening in 
the urban areas. We need to make sure that we're also thinking 
about those in a very methodical way.
    Ms. Fuchs. I would also add that different innovative 
models of care delivery are really important. So the work 
that's gone on about hospital-at-home programs or being able to 
deliver services from an enhanced home care perspective is some 
of the work that we have done in our health system, and we have 
seen the ability to treat people at home versus bringing them 
into the hospital. So these therapeutics I think have to be 
available to be able to be delivered in multiple places.
    For example, we believe we can deliver remdesivir in the 
patient's home. We're not able to do that right now because of 
the restrictions around it. So we have to think innovatively 
about how we can deliver care differently to be able to touch 
the people wherever they are, and especially in our rural 
communities.
    The Chair. Thank you.
    Senator Rosen. Thank you. I yield back. Sorry, Madam Chair.
    The Chair. Thank you very much.
    I will turn to Senator Burr.
    Senator Burr. Thank you, Senator Murray.
    I have one question, and then some comments. And on the 
comments, any of you that want to refute what I say, feel free 
to do it.
    Dr. Jha, some COVID-19 models have started to incorporate 
weather patterns into their predictors for the trajectory of 
pandemics. Are there other data points or sources of 
information that we should be including in our surveillance and 
predictive models to provide a better picture of the virus 
pathway?
    Dr. Jha. Oh, Senator, this is a fabulous question. And let 
me say, throughout this entire pandemic, as I have tracked this 
pandemic in our Nation, sometimes I look at public health data, 
but a large chunk of what I look at is not traditional public 
health data at all. I look at Google mobility data. I look at 
open-table reservations data, not because I'm trying to get a 
restaurant reservation but because it tells us something about 
how people are behaving.
    We have in the public health world--and this is a broader 
societal problem--a not-thought-through how this incredible 
proliferation of data that is out there is getting incorporated 
and used for public health modeling.
    Of course, we need basic laboratory data and all of that, 
the standard stuff, but we need a new approach. And it raises a 
whole series of questions, Senator, because countries like 
China, for instance, use incredible amounts of social-generated 
data, but they do it in a way that I think is not consistent 
with our values. It's not the way we would want to do it in a 
democracy with privacy and security.
    We need to find ways--these are policy issues, these are 
regulatory issues--where we can access and use these kinds of 
data in a way that people feel that their privacy is still 
being conserved. We have barely begun to scratch the surface of 
this issue.
    Senator Burr. Well, I'm delighted to hear you say that 
because I think we do have to think outside the box as we talk 
about in the future a layered surveillance system, one that 
leverages technology, and we've proven in medical research that 
you can de-identify data and it can be used and used very 
successfully.
    A few comments. With the flu every year we flood the zone, 
to use a football analogy, as the coach would say. We flood the 
zone with vaccines, and we make it as easy as possible, in 
large part because we've got unlimited vaccine production. We 
never thought about the multi-use manufacturing needs that we 
were going to have, and we've got to re-think that, and we've 
got to incorporate that into our architecture of the future.
    When airlines adopted a mask policy and put HEPA filters in 
every airplane, and people started flying with a mandatory mask 
and with filtration but no social distancing, we never had an 
instance of super-spreader on an airline from the time they 
restarted that new system.
    I'm not sure why we're so scared on schools. If we've got a 
mask and we've got filtration and we've got distancing, which 
is the third thing, and the fourth thing is we've got a 
population of kids that we have the data that shows they're 
less likely to contract, it's just amazing to me that we have 
put off so long putting these kids back to school and letting 
mothers and fathers go back to work and to resume some normalcy 
in their lives.
    Three, the vaccine process--I agree with Dr. Jha--we've 
made it way too difficult, and I think, Dr. Abraham, you 
simplified it where you are. I remember I was in a hospital 1 
day that is known for heart bypass surgery. And when they 
explained to me what a typical day was like and the first two 
operations, they required them to stay inpatient the night 
before. My question was why? There's an added expense. And they 
made it clear that any missed operation the next day broke 
their model of how they reduce cost in health care but make 
money at the end of the day.
    If you can't assure that your first two people wake up and 
show up on time for their pre-op, you've messed up the entire 
day of bypass surgery.
    Well, any time we have an interruption in the line of 
people that are sticking in arms when we've got a limited 
number of stickers--Dr. Abraham, I think you alluded to it--we 
have missed an opportunity. So we've got to simplify this, as 
was said. We've got to make sure that our focus is on sticking 
as many arms as we possibly can in a given day with the number 
of vaccines that we have, and the system today was not set up 
to do it.
    We have a limited number of health care professionals that 
can do it. This is not new. We identified this in the early 
2000's when we started the pandemic legislation with PAHPA and 
other things. We identified that we needed a parallel effort to 
try to identify a world delivery system, because sticking 
people in arms is a very difficult thing in a national and 
global picture.
    Well, thank God we've had health care professionals that 
were retired that have come back to the front lines and 
volunteered pro bono to come out and stick people because 
they're already trained, and we've got to tap into that supply 
even greater.
    Either Dr. Jha or Dr. Shah alluded to the fact that we 
can't get there if we've got 147 million Americans that aren't 
going to be vaccinated because they're under the age of 18. And 
I agree totally, as this infection begins to decline, the 
pediatric indications that are needed for historical 
determination to make safety and efficacy pass the test is 
going to be impossible. It will take years, and we really need 
to do that population, at least down to an 8-year-old, before 
school goes back next year.
    I hope that some of the words that you go out and preach 
are words that accept the standard that we're going to have to 
use technology to close the gap on making those determinations, 
which is not the historical model that FDA and others have 
used. We're asking Federal agencies, quite frankly, to do 
things they haven't done historically, in large measure because 
technology gives us the ability to gap that now.
    But let me assure all of our witnesses, government is the 
last one that will take advantage of it unless it's the medical 
community that pushes Congress to make the changes, that pushes 
the Federal agencies to make those changes. Partnering with the 
private sector is absolutely essential to mapping out the way 
to address pandemics of the future, and we are the worst 
partner for the private sector, we the government, that exists 
in the marketplace. We've got to change that. It can no longer 
be that the CDC is in charge of all testing, which is where we 
were 1 year ago on March the 9th, and not until we created RadX 
over at NIH with Dr. Collins' leadership did they start to 
partner with the private sector to bring all sorts of new 
testing capabilities both in office and in home, and we're 
going to continue to expand on that. But we've got to get 
outside of the historical paradigms that exist. Technology, 
innovation, and investment are the only way that we will 
improve the future, and that's in all aspects of pandemics.
    The heroes in this story are the individuals on the front 
line. Without them, we'd fail. With them, we have accomplished 
something that 12 months ago most people believed we couldn't 
do. We've developed three vaccines, and hopefully a fourth very 
soon. We have immunized now millions of Americans. And I agree 
with the comments that were made, we can't stop looking at 
America and saying when are we going to be immunized? Until we 
find a way to be the driver of global immunization, then we 
will not feel comfortable about where we are.
    America needs to open up our schools, we need to open up 
our businesses, we need commerce outside of the United States, 
and until we find a way to immunize globally, that is not going 
to happen at the levels that we've got to get it to. So it's 
not just about how do we buy 600 million doses for the United 
States which can vaccinate every American. It's how can we use 
American assets to leverage manufacturing capabilities, both 
here and globally, to where we manufacture cost-effective 
vaccines, maybe with U.S. technology, maybe with U.S. 
companies, and we leverage the rest of the world to do it. 
You'll never get them to do it if we don't display a 
willingness to partner between the Federal Government and the 
private sector going forward.
    Chair Murray, I thank you for this hearing. I thank our 
witnesses for their expertise. I'm willing to take any 
criticism about my observations from any of you.
    The Chair. Well, thank you very much, Ranking Member Burr.
    I just have a couple more questions, and I want to again 
thank all of our witnesses.
    Dr. Jha, if you can just answer me. In December the U.S. 
ranked 43rd worldwide in sequencing of coronavirus variants, 
which is why I pushed to include $1.75 billion for genomic 
sequencing and surveillance activities at the CDC in the 
American Rescue Plan. But, Dr. Jha, what do you see as the 
biggest challenges ahead in terms of identifying, tracking, and 
stopping these emerging variants?
    Dr. Jha. Two things, Senator. First, I think your push for 
more sequencing was exactly right. It's what we need. I do 
believe--look, there's no reason why the U.K. has to be the 
global leader in sequencing. We have so much sequencing 
capacity in our Country and we just need to be doing a lot more 
of it, even a lot more than we have right now.
    I remain, as I said in my opening remarks, pretty worried 
that we are not taking these variants seriously enough. Within 
a year of this disease outbreak, we have seen multiple variants 
that challenge our vaccines. None of them will defeat our 
vaccines yet. We are on a track for three or four more years 
until the world is vaccinated, and the question is how lucky do 
we feel that we will not see the rise of a variant that will 
make all of our vaccines ineffective.
    We need a surveillance program certainly in the United 
States that's far more robust. We need a surveillance program 
globally that's far more robust. But identifying these variants 
isn't enough. We've got to get the world vaccinated, as Senator 
Burr said. It is absolutely in our national interest, in our 
economic, political, and health interest, to get the entire 
world vaccinated as quickly as possible, and we are not on 
track to keep the American people safe, but we need to in terms 
of getting the whole world vaccinated.
    The Chair. Thank you. I'm not for relying on luck myself.
    Dr. Abraham, the health care safety net has never been more 
important. Millions of people rely on our community health 
centers for primary care services. They are really a lifeline 
for our families, as you so know, and I was really glad we were 
able to secure billions in the American Rescue Plan. That 
investment will really help our health centers continue caring 
for COVID-19 patients, but we have been solely centered on 
COVID-19.
    I wanted to ask you, in addition to your work addressing 
COVID-19, how have you been able to manage the other primary 
care needs of your community throughout this pandemic?
    Dr. Abraham. The short answer is it has not been easy. It 
has required an all-hands-on-deck approach. Whether you are the 
receptionist in our clinic or the medical assistant, every 
single person, including the person that wears that business 
hat, we've all had to race to help every patient because 
despite COVID, our patients still have their needs, their 
diabetes, their hypertension, their heart disease, and they 
need their refills, and they need access to diagnostics and to 
treatments, and we can't delay that because of this pandemic. 
That creates a whole other storm.
    What we do definitely is we need to have more hands on 
deck, more team-based health care delivery. We need more of all 
of it, so every dollar that you send from this Act to a 
community health center really helps us better care for our 
community. It gets more hands hired. It gets more resources, 
whether it's getting out into the community, a mobile mammogram 
unit, all of those things are required. But they do take 
resources, and with more resources we can really do more for 
our communities.
    The Chair. Thank you, and I think that's one of the things 
we have not focused on, that the other cost of this pandemic 
has really been all of those other health care needs that we 
have not been focused on that have been neglected for a variety 
of reasons, including people not going in to get their care, 
but also because of the lack of access. So we need to really be 
aware of that focus.
    I want to thank all of our witnesses today and all of our 
colleagues for a really thoughtful discussion. Again, I 
especially want to thank Dr. Shah, Dr. Jha, Dr. Fuchs, and Dr. 
Abraham for sharing your time and knowledge with all of us and 
for the work you are doing on the front lines and for so many 
who are working their way through this.
    For any Senators who wish to ask additional questions, 
questions for the record will be due in 10 business days, 
Tuesday, March 23rd at 5 p.m.
    This hearing record will also remain open until then for 
Members who wish to submit additional materials for the record.
    This Committee will next meet on Tuesday, March 15th, in 
Dirksen 106 at 10 a.m. for a hearing on the nomination of Julie 
Su to be Deputy Secretary of Labor.
    The Committee stands adjourned.

                          ADDITIONAL MATERIAL

  Statement from the American College of Physicians

                                                      March 9, 2021

    The American College of Physicians (ACP) is pleased to submit this 
statement and offer our views regarding the response to the public 
health emergency (PHE) caused by Coronavirus (COVID-19). We greatly 
appreciate that Chair Murray, Ranking Member Burr, and the Health, 
Education, Labor, and Pensions (HELP) Committee has convened this 
hearing, ``Examining Our COVID-19 Response: An Update from the 
Frontlines'', held on March 9, 2021. Thank you for your shared 
commitment to ensuring that clinicians have the opportunity to share 
their views about the response to the PHE caused by COVID-19. Through 
the experiences of its physicians on the frontlines of furnishing 
primary care during the COVID-19 pandemic, ACP has consistently 
provided input and recommendations to lawmakers surrounding the ongoing 
need for personal protective equipment (PPE), increased support for the 
frontline physician workforce, adequate funding for COVID-19 testing, 
contract tracing, and vaccine distribution, and continued telehealth 
expansion. Support for these policies is vital to the pandemic response 
effort now after the national PHE comes to an end.

    The American College of Physicians is the largest medical specialty 
organization and the second-largest physician membership society in the 
United States. ACP members include 163,000 internal medicine physicians 
(internists), related subspecialists, and medical students. Internal 
medicine physicians are specialists who apply scientific knowledge and 
clinical expertise to the diagnosis, treatment, and compassionate care 
of adults across the spectrum from health to complex illness. Internal 
medicine specialists treat many of the patients at greatest risk from 
COVID-19, including the elderly and patients with pre-existing 
conditions like diabetes, heart disease and asthma.
                     Personal Protective Equipment
    The various coronavirus relief packages, including the recently 
enacted American Rescue Plan Act (ARP), H.R. 1319, began and now 
continue to provide desperately needed personal protective equipment 
(PPE) to frontline physicians, nurses and other health care workers. 
The ARP included possible PPE funding in several provisions, including 
the use of the Defense Production Act (DPA) for procurement of supplies 
and services including PPE. However, ACP members and internists and 
other frontline health care workers are still experiencing difficulty 
in obtaining some types of PPE. Accordingly, ACP has continued its 
financial contributions that will help Project N95 to secure 
appropriate inventory levels for PPE, particularly for hard-to-obtain 
items such as nitrile gloves.

    ACP has partnered with Project N95 since June 2020 to provide PPE 
for internal medicine physicians, filling an urgent need for frontline 
ACP member physicians during the COVID-19 pandemic. Since the beginning 
of the pandemic ACP has been vigorously advocating for the need for 
adequate PPE, calling on suppliers and the Federal Government to ensure 
the availability of essential PPE to protect frontline physicians. Many 
individual physicians, especially those outside of hospitals, had been 
closed out of ordering PPE through distributors at reasonable prices 
and quantities.

    Despite recent reports that U.S. suppliers of N95 respirators have 
inventory available, the distribution system in the U.S. is still not 
working effectively enough to allow individual physicians to order 
high-quality PPE to meet their needs. ACP is continuing to see members 
needing to order PPE through our distribution partnership with Project 
N95, which is why we continue to provide financial support to Project 
N95. The demand crunch has shifted from N95 respirators to nitrile 
patient exam gloves, with gloves being the latest example of a product 
where the minimum order quantities are so high that only the largest 
distributors can easily compete for inventory supplies.

    The need still exists for ACP to offer an alternative buying 
channel for our members, which we are doing through Project N95, but 
the need has declined significantly since last summer. Sales of N95 
respirators through ACP declined 50 percent from August to December, 
and declined 34 percent from December to January and February. However, 
we still have hundreds of members buying through ACP and Project N95.
                 Support Frontline Physician Workforce
    Primary care physicians, including internal medicine specialists, 
continue to serve on the frontlines of patient care during this 
pandemic with increasing demands placed on them. During the pandemic's 
worst months, there was an increasing reliance on medical graduates, 
both U.S. and international, to serve on the frontlines in this fight 
against COVID-19. Many residents and medical students played a critical 
role in responding to the COVID-19 crisis and providing care to 
patients on the frontlines. For residents, COVID-19 has inflicted 
additional strain on them as they were redeployed from their primary 
training programs and put onto the frontlines to care for the sickest 
patients, often putting their own health at risk, and many without 
appropriate PPE at the time. ACP recommends the following legislation 
from the previous, 116th Congress, that should be reintroduced and 
passed in the current 117th Congress to assist medical graduates and 
the overall physician workforce:

          Conrad State 30 and Physician Access Reauthorization 
        Act, H.R. 2895, S. 948, (116th Congress): This bill allows 
        states to sponsor foreign-trained physicians to work in 
        medically underserved areas in exchange for a waiver of the 
        physicians' two-year foreign residence requirement. It 
        increases the base number of annual Conrad waivers available to 
        each state from 30 to 35, with a demand-based sliding scale to 
        determine the number of available waivers in future years, and 
        includes a provision to address the current backlog in the 
        system for physicians on J-1 visas who wish to acquire 
        permanent residency status (green card).

          Healthcare Workforce Resilience Act, H.R. 6788, S. 
        3599, (116th Congress): This bill would authorize immigrant 
        visas for health care clinicians, including up to 15,000 
        physicians who are eligible to practice in the United States or 
        are already in the country on temporary work visas. The visas 
        would provide a pathway to employment based green cards. View 
        ACP's letter of support to Congress for S. 3599 in the 116th 
        Congress.

          The Student Loan Forgiveness for Frontline Health 
        Workers Act, H.R. 6720, (116th Congress): This bill would 
        forgive student loans for physicians and other clinicians who 
        are on the frontlines of providing care to COVID-19 patients or 
        helping the health care system cope with the COVID-19 public 
        health emergency.
         COVID Testing, Contact Tracing, Treatment and Vaccines
    ACP strongly supported several provisions in the American Rescue 
Plan (ARP) Act of 2021, H.R. 1319, that directly will help to contain 
the COVID-19 pandemic. ACP supported the provisions in the ARP to 
provide $49 billion to HHS to detect, diagnose, trace, and monitor 
COVID-19 infections, and for other activities necessary to mitigate the 
spread of COVID-19. ACP also supported the ARP provisions to require 
Medicaid coverage of COVID-19 vaccines and treatment without 
beneficiary cost sharing with vaccines matched at a 100 percent Federal 
medical assistance percentage (FMAP) through one year after the end of 
the PHE. It also gives states the option to provide coverage to the 
uninsured for COVID-19 vaccines and treatment without cost sharing at 
100 percent FMAP. ACP is pleased that these provisions help cover 
vulnerable populations during the PHE caused by COVID-19.

    To address current and looming pharmaceutical therapies and vaccine 
shortages during a pandemic, ACP recommends that the Federal Government 
should work with pharmaceutical companies to ensure that there is an 
adequate supply of pharmaceutical therapies and vaccines to protect and 
treat the U.S. population. ACP also supports measures to increase 
pandemic influenza vaccine and antiviral medications in the Strategic 
National Stockpile (SNS) as discussed below to prepare for a future 
pandemic. ACP also supports measures to increase domestic production of 
vaccines and antiviral medications, including providing liability 
protections to decrease barriers to manufacturing while maintaining 
protections for individuals injured from the use of vaccines and 
antiviral medications.

    Accordingly, ACP strongly supported the provisions in the ARP to 
provide $7.5 billion in funding for the Centers for Disease Control and 
Prevention (CDC) to prepare, promote, administer, monitor, and track 
COVID-19 vaccines, and $6 billion to the Department of Health and Human 
Services (HHS) to support advanced research, development, 
manufacturing, production and purchase of vaccines, therapeutics, and 
ancillary medical products utilized for treatment and prevention of 
COVID-19. ACP is also appreciative of the $1 billion in the ARP for 
vaccine confidence activities to promote education and increase 
vaccination rates.

    ACP supports requirements that COVID-19 vaccines be provided at no 
cost to all patients, regardless of coverage status. ACP supports an 
all-hands-on deck approach to administer COVID vaccines, which includes 
primary care offices. We urge Congress to work with the administration, 
state and local governments, and vaccine distributors to support 
physicians who wish to administer the COVID-19 vaccine by ensuring 
community-based practices are included in distribution plans. In a 
January 2021 survey, 71 percent of medical practices reported being 
unable to obtain COVID-19 vaccine for their patients, and independent 
medical groups were significantly less likely to have access than those 
owned by hospitals or health systems. It is vital that vaccinators 
record the vaccine administration data within the patient's medical 
record and promptly report to the state's immunization information 
system (IIS) or other designated CDC system. Ideally, health IT systems 
would automate vaccination data sharing with minimal additional effort 
required, including reporting to state IISs and notifying the patient's 
primary care team of their vaccination status and other relevant 
information.
                    Continuing Telehealth Expansion
    ACP strongly supports the expanded role of telehealth as a method 
of health care delivery that may enhance patient-physician 
collaborations, improve health outcomes, increase access to care and 
members of a patient's health care team, and reduce medical costs when 
used as a component of a patient's longitudinal care. Telehealth can be 
most efficient and beneficial between a patient and physician with an 
established, ongoing relationship and can serve as a reasonable 
alternative for patients who lack regular access to relevant medical 
expertise in their geographic area. Primary care physicians have had to 
convert in-person visits to virtual ones in response to the COVID-19 
PHE, and practices are experiencing huge reductions in revenue while 
still having to pay rent, meet payroll, and meet other expenses without 
patients coming into their practices.

    During the Coronavirus pandemic, internal medicine specialists 
continue to deliver care to their patients with the expanded 
utilization of telehealth made possible by new policies either enacted 
by Congress, the U.S. Department of Health and Human Services (HHS), as 
well as private payers. However, many of the telehealth flexibilities 
and policy changes made by Congress and HHS are due to expire at the 
conclusion of the PHE, wherein patients and physician practices would 
be expected to revert back to primarily face-to-face services without 
any type of risk-based assessment for gradually reopening medical 
practices and health systems to care for non-COVID and non-acute 
patients. \1\ This quick reversal in policy does not take into account 
patients' comfort level in returning to physician offices to seek 
necessary care, as well as changes in office workflow and scheduling 
practices to mitigate spread of the virus within practices resulting in 
substantially lower volume of in-person visits for as long as the 
pandemic is with us. Therefore, the quick reversal in policy is not an 
effective way to recover from the PHE, nor prepare for possible future 
outbreaks.
---------------------------------------------------------------------------
    \1\ Doherty R., Erickson S., Smith C., Qaseem A. ``Partial 
Resumption of Economic, Health Care and Other Activities While 
Mitigating COVID-19 Risk and Expanding System Capacity.'' American 
College of Physicians, May 6, 2020: https://www.acponline.org/acp-
policy/policies/acp-guidance-on-resuming-economic-and-social-
activities-2020.pdf.

    The College believes that the patient care and revenue 
opportunities afforded by telehealth functionality will continue to 
play a significant role within the U.S. healthcare system and care 
delivery models, even after the PHE is lifted. Please see ACP's 
response to the HELP Committee for the Committee's June 17, 2020, 
hearing, ``Telehealth: Lessons from the COVID-19 Pandemic'' and more 
recently ACP's statement to the House Committee on Energy and 
Commerce's March 2, 2021, hearing, ``The Future of Telehealth: How 
Covid-19 is Changing the Delivery of Virtual Care''. In order to 
address the many barriers to patient access and physician adoption and 
use of telehealth prior to the COVID-19 pandemic, and properly assess 
how to foster and strengthen longitudinal, patient-centered care 
delivery, ACP believes that the following existing PHE flexibilities 
and waivers should be continued--and not allowed to expire--to support 
making telehealth an ongoing and continued part of medical care now and 
in the future, allowing time for further evaluation on which ones 
---------------------------------------------------------------------------
should be maintained as is, revised or expanded:

          Pay Parity for Audio-Only and Telehealth Services: 
        The College wholeheartedly supports the Centers for Medicare 
        and Medicaid Services' (CMS) actions to provide additional 
        flexibilities for patients and their doctors by providing 
        payment for telephone services. These changes in payment policy 
        address some of the biggest issues facing physicians as they 
        struggle to make up for lost revenue and provide appropriate 
        care to patients. Primary care services delivered via telephone 
        have become essential to a sizable portion of Medicare 
        beneficiaries who lack access to the technology necessary to 
        conduct video visits. ACP is discouraged to learn that CMS will 
        not continue coverage of telephone evaluation and management 
        (E/M) services beyond the PHE, despite mounting evidence about 
        the effectiveness of expanding coverage for these services. 
        While ACP has supported the Agency's actions to provide 
        coverage and payment parity for such telephone services, the 
        College is very concerned about the impact of reversing these 
        changes at the conclusion of the PHE. ACP believes that 
        existing PHE flexibilities and waivers should be continued, and 
        not be allowed to expire--including pay parity for audio-only 
        phone calls--to support making telehealth an ongoing and 
        continued part of medical care now and in the future, allowing 
        time for further evaluation on which ones should be maintained 
        as is, revised or expanded. We also urge removal of the 
        requirement for the use of two-way, audio/video 
        telecommunications technology so that telephone E/M services 
        can continue to be provided to Medicare beneficiaries.

          COVID-19 Vaccine Counseling: Although most community-
        based physician practices are not yet administering COVID-19 
        vaccinations, many report providing significant counseling and 
        risk factor reduction services to patients who are concerned 
        about COVID-19 or who are trying to get vaccinated against the 
        virus. However, coding and payment has not been made available 
        to allow physicians to bill for these services. While office 
        visit E/M visits, telephone E/M, virtual check-ins, and e-
        visits have been made available by CMS during the pandemic to 
        provide for virtual care, these coding options are not 
        sufficient to meet the current needs. Specifically, the E/M 
        visits are not available for billing as no diagnoses have been 
        established to necessitate an E/M visit. Patients are calling 
        for advice from their doctors, not to set up a visit for a 
        medical problem/issue they are experiencing. Additionally, 
        virtual check-ins are an ineligible option as they are for 
        patients seeking to determine whether an E/M visit is 
        necessary. In the case of COVID-19 vaccinations, patients are 
        seeking to understand the risks associated with getting a 
        COVID-19 vaccine, and where to find a vaccine. These are not 
        examples of patients checking in with their physician to 
        understand whether an office visit is necessary. It is merely 
        for advice and counseling. ACP recommends that Congress urge, 
        or if necessary, require CMS to make coding and payment 
        available for time spent by physicians providing counseling 
        services to patients who are seeking to mitigate their risk for 
        COVID-19 infection. Specifically, ACP encourages CMS to make 
        payment and coverage available for CPT code 99401 (Preventive 
        medicine counseling and/or risk factor reduction 
        intervention(s) provided to an individual (separate procedure); 
        approximately 15 minutes), wRVU 0.48. The College believes that 
        this code adequately describes the resources and physician work 
        involved in providing counseling and risk factor reduction 
        services to patients with inquiries about COVID-19. We 
        encourage CMS to temporarily make payment available for this 
        code through at least December 31, 2021 and waive the face to 
        face requirement associated with this service.

          Geographical Site Restriction Waivers: ACP strongly 
        supported CMS' policy changes to pay for services furnished to 
        Medicare beneficiaries in any healthcare facility and in their 
        home--allowing services to be provided in patients' homes and 
        outside rural areas. ACP has long-standing policy in support of 
        lifting these geographic site restrictions that limit 
        reimbursement of telehealth services by CMS to those that 
        originate outside of metropolitan statistical areas or for 
        patients who live in or receive service in health professional 
        shortage areas. \2\ While limited access to care is prevalent 
        in rural communities, it is not an issue specific to rural 
        communities alone. Underserved patients in urban areas have the 
        same risks as rural patients if they lack access to in-person 
        primary or specialty care due to various social determinants of 
        health such as lack of transportation or paid sick leave, or 
        sufficient work schedule flexibility to seek in-person care 
        during the day, among many others. \3\ Accordingly, it is 
        essential to maintain expanded access to and use of telehealth 
        services for these communities, as well as rural communities, 
        and ACP recommends that Congress permanently extend the policy 
        to waive geographical and originating-site restrictions after 
        the conclusion of the PHE.
---------------------------------------------------------------------------
    \2\ Daniel H, Snyder Sulmasy L. ``Policy Recommendations to Guide 
the Use of Telemedicine in Primary Care Settings.'' American College of 
Physicians, November 17, 2015: https://www.acpjournals.org/doi/full/
10.7326/M15-0498.
    \3\ Webb Hooper M, Napoles AM, Perez-Stable EJ. ``COVID-19 and 
Racial/Ethnic Disparities.'' JAMA. Published online May 11, 2020. 
doi:10.1001/jama.2020.8598.

          Telehealth Cost-Sharing Waivers: ACP appreciated the 
        flexibility provided by CMS to allow clinicians to reduce or 
        waive cost-sharing for telehealth and audio-only telephone 
        visits for the duration of the PHE. At the same time, we call 
        on CMS or preferably Congress to ensure that they make up the 
        difference between these waived copays and the Medicare allowed 
        amount of the service. Many practices are struggling or 
        closing. It is critical that CMS and other payers not add to 
        the financial uncertainties already surrounding these 
        physicians. Given the enormity of the COVID-19 pandemic, cost 
        should not be a prohibitive factor for patients in attaining 
        treatment. This critical action has led to increased uptake of 
        telehealth visits by patients. At the conclusion of the COVID-
        19 PHE, ACP recommends that Congress urge, or if necessary 
        require, CMS to continue to provide flexibility in the Medicare 
        and Medicaid programs for physician practices to reduce or 
        waive cost-sharing requirements for telehealth services, while 
        also making up the difference between these waived copays and 
        the Medicare allowed amount of the service. This action in 
        concert with others has the potential to be transformative for 
        practices while allowing them to innovate and continue to meet 
        patients where they are. ACP believes that existing 
        flexibilities and waivers should be continued, and not be 
        allowed to expire, to support making telehealth an ongoing and 
        continued part of medical care now and in the future, allowing 
        time for further evaluation on which ones should be maintained 
---------------------------------------------------------------------------
        as is, revised or expanded.

          Flexibilities in Direct Supervision by Physicians at 
        Teaching Hospitals: CMS has noted that in instances where 
        direct supervision is required by physicians and at teaching 
        hospitals, the agency will allow supervision to be provided 
        using real-time interactive audio and video technology through 
        the calendar year 2021. The College welcomes this decision by 
        the agency to allow attending physicians and residents/fellows 
        the ability to communicate over interactive systems 
        asynchronously by waiving the in-person supervision 
        requirement. This important step promotes efficient patient 
        care and allows physicians and supervisees to work together 
        unencumbered by social distancing restrictions. We encourage 
        Congress to urge, or if necessary require, CMS to maintain 
        these modifications, and not allow them to expire.

          Revised Policies for Remote Patient Monitoring 
        Services: CMS finalized policy stating that following 
        expiration of the COVID-19 PHE, there must be an established 
        patient-physician relationship for RPM services to be 
        furnished--ending its interim policy permitting RPM services to 
        be furnished to new patients. The Agency also finalized 
        policies allowing consent to receive RPM services to be 
        obtained at the time RPM services are furnished and noted that 
        practitioners may furnish RPM services to patients with acute 
        conditions as well as patients with chronic conditions. RPM 
        services have been a critical component of care, especially 
        during the COVID-19 pandemic. ACP is pleased to see the Agency 
        finalized a number of policies that will be beneficial to both 
        patients and their care teams. These changes expand access to 
        services at an important time, as patients and their care teams 
        need additional resources to meet current challenges. These 
        changes will help relieve physician burden and allow physicians 
        more time to treat complex patient issues that require more 
        than remote monitoring. We continue to believe that Congress 
        should urge, and if necessary, require, CMS to extend the 
        interim policy to allow RPM services to be furnished to 
        patients without an established relationship.

          Interstate Licensure Flexibility for Telehealth and 
        Promotion of State-Level Action: ACP supports a streamlined 
        approach to obtaining several medical licenses that would 
        facilitate telehealth services across state lines while 
        allowing states to retain individual licensing and regulatory 
        authority. \4\ We appreciated CMS' temporary waiver allowing 
        physicians to provide telehealth services across state lines, 
        as long as physicians meet specific licensure requirements and 
        conditions. These waivers offer an opportunity to assess the 
        benefits and risks to patient care in addressing the pandemic 
        as well as the ability to maintain longitudinal care for 
        patients who move across state lines. While these waivers do 
        not supersede any state or local licensure requirements, they 
        provide the opportunity to promote state-level action that may 
        further promote more streamlined licensure requirements across 
        the country. ACP also supports the Temporary Reciprocity to 
        Ensure Access to Treatment (TREAT) Act, S. 168, H.R. 708, which 
        would provide temporary licensing reciprocity for telehealth 
        and interstate health care treatment.
---------------------------------------------------------------------------
    \4\ Daniel H, Snyder Sulmasy L. ``Policy Recommendations to Guide 
the Use of Telemedicine in Primary Care Settings.'' American College of 
Physicians, November 17, 2015: https://www.acpjournals.org/doi/full/
10.7326/M15-0498.
---------------------------------------------------------------------------
                               Conclusion
    We commend you and your colleagues for working in a bipartisan 
fashion to develop legislative proposals to combat the ongoing 
Coronavirus crisis--as well as future pandemics--through continuing 
innovative policies. We wish to assist in the HELP Committee's efforts 
in this area by offering our input and suggestions about ways that 
Congress and Federal health departments and agencies can intervene 
through evidence-based policies both now and beyond the PHE. Thank you 
for consideration of our recommendations that are offered in the spirit 
of providing the necessary support to physicians and their patients 
going forward. Please contact Jared Frost, Senior Associate, 
Legislative Affairs, with any further questions or if you need 
additional information.
                                 ______
                                 
              American Academy of Family Physicians

                                                      March 9, 2021
Hon. Patty Murray, Madam Chair,
Hon. Richard Burr, Ranking Member,
Senate Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.

    Dear Madam Chair Murray and Ranking Member Burr:

    On behalf of the American Academy of Family Physicians (AAFP) and 
the 136,700 family physicians and medical students we represent, I 
applaud the Health, Education, Labor, and Pensions Committee for its 
continued focus on COVID-19 response. I write in response to the 
hearing: ``Examining Our COVID-19 Response: An Update from the 
Frontlines'' to share the family physician perspective and the AAFP's 
policy recommendations for ensuring that our health care system can 
make a complete recovery from the ongoing COVID-19 pandemic.

    Family physicians are on the frontlines of the COVID-19 pandemic 
screening, diagnosing, triaging and treating patients who are fighting 
the virus while continuing to provide comprehensive care to their 
patients with ongoing health care needs, including management of 
chronic conditions. They are keeping patients healthy and keeping them 
out of the hospital and emergency room while many of them have also 
provided surge staffing when hospitals have been overwhelmed. The COVID 
relief legislation that the Senate passed last week placed a heavy 
emphasis on testing, treatment and vaccines to control COVID-19--
primary care is the gateway to all three.

    COVID-19 has highlighted the inefficiencies and inequities that 
already existed in our health care system. As the pandemic continues, 
individuals are struggling more than ever to access the essential 
primary health care services they need to stay healthy. Family 
physicians are committed to doing everything possible to prevent and 
slow the spread of COVID-19 while ensuring that patients get the care 
they need. However, they can't do it alone; there are specific actions 
that the Federal Government should take now to support access to and 
coverage for COVID-19 treatment and prevention.

    Recommendations

          Equitable Vaccine Distribution--According to a recent 
        survey, nearly nine in ten primary care clinicians want their 
        practice to be a COVID-19 vaccination site, only 22 percent are 
        considered as such by their health department, local hospital, 
        or health system. \1\ Additionally, independent practices have 
        had a more difficult time obtaining COVID-19 vaccines for their 
        patients than those affiliated with a hospital or large health 
        system. \2\ It is frustrating that primary care has been 
        overlooked as an outlet for equitable vaccine distribution even 
        though it is equipped to target those most vulnerable and in 
        need.
---------------------------------------------------------------------------
    \1\  Larry A. Green Center. ``Quick COVID-19 Primary Care Survey.'' 
Series 26 Fielded February 12-16, 2021. https://
static1.squarespace.com/static/5d7ff8184cf0e01e4566cb02/t/
60368efc6f135d069645fa93/1614188285446/
C19+Series+26+National+Executive+Summary.pdf.
    \2\  Medical Group Management Association. https://www.mgma.com/
news-insights/press/nation%E2%80%99s-physician-practicesleft-out-of-
covid-19?utm-source=ga-organic-st-01.26.21&utm-medium=social&utm-
campaign=ga-vaccine-press-release.

    While we do not believe legislation is needed to address this 
problem, we call on Congress to support Federal, state, and local 
efforts to prioritize primary care practices in COVID-19 vaccine 
---------------------------------------------------------------------------
distribution.

          Disparities in Vaccination Rates--Data indicate that 
        Black and Hispanic adults under 50, as well as rural residents, 
        are more likely to report vaccine hesitancy or indicate that 
        they will not get the COVID-19 vaccine. \3\ However, 85 percent 
        of individuals across demographic groups report that their 
        primary care physician or other clinician is the most trusted 
        source of information about COVID-19 vaccines and they will 
        rely on them when deciding whether to get the vaccine. \4\, \5\ 
        As trusted members of their communities and the primary source 
        of comprehensive health services in rural and under resourced 
        areas, community primary care physicians play an integral role 
        in ensuring equitable vaccination rates across the state. 
        According to data from the Medical Expenditure Panel Survey, 
        primary care physicians provided 54 percent of all clinical 
        visits for vaccinations, which made them more likely to 
        administer vaccines than other stakeholders, such as pharmacies 
        or grocery stores. \6\ As Congress considers policies to reduce 
        the disparities in COVID-19 vaccine uptake, including investing 
        in a national vaccine promotion campaign, it is important to 
        recognize the role of primary care physicians in combating 
        vaccine hesitancy.
---------------------------------------------------------------------------
    \3\  Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor. 
February 2021. Available at: https://www.kff.org/coronavirus-covid-19/
poll-finding/kff-covid-19-vaccine-monitor-february-2021/.
    \4\  Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor. 
December 2020. Available at: https://www.kff.org/coronavirus-covid-19/
report/kff-covid-19-vaccine-monitor-december-2020/.
    \5\  Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor. 
January 2021. Available at: https://www.kff.org/report-section/kff-
covid-19-vaccine-monitor-january-2021-vaccine-hesitancy/.
    \6\  Analysis conducted by the Robert Graham Center. Publication 
forthcoming.

          Telehealth--Family physicians have rapidly changed 
        the way they practice to meet the needs of their patients 
        during the COVID-19 pandemic. About 70 percent report that they 
        want to continue providing more telehealth services in the 
        future. Telehealth can enhance patient-physician collaboration, 
        increase access to care, improve health outcomes by enabling 
        timely care interventions, and decrease costs when utilized as 
        a component of, and coordinated with, continuous care. Given 
        these benefits, patients and physicians alike have indicated 
        that current telehealth flexibilities should continue beyond 
        the public health emergency. Congress should act to extend 
        Medicare telehealth flexibilities and ensure telehealth is 
        permanently recognized across payers as a valuable modality of 
        providing primary care services beyond the public health 
---------------------------------------------------------------------------
        emergency.

          Primary Care Workforce--COVID-19 has both highlighted 
        and exacerbated the physician workforce shortages facing 
        communities throughout the Nation. It has demonstrated the 
        urgency of building and financing a robust, well-trained, and 
        accessible primary care system in our Country. According to the 
        American Association of Medical Colleges, we will need 52,000 
        additional primary care physicians by 2025 in order to meet the 
        health care needs of our growing and aging population and be 
        prepared to respond to future crises. \7\ Congress should 
        address the primary care physician shortage by increasing 
        investments in the Teaching Health Center Graduate Medical 
        Education (THCGME) program and the National Health Service 
        Corps, which train and place primary care physicians in 
        underserved and rural communities.
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    \7\  Petterson, S. M., Liaw, W. R., Phillips, R. L., Jr, Rabin, D. 
L., Meyers, D. S., & Bazemore, A. W. (2012). Projecting US primary care 
physician workforce needs: 2010-2025. Annals of family medicine, 10(6), 
503-509. https://doi.org/10.1370/afm.1431

          Mental Health of Physicians--Even prior to the 
        pandemic, burnout among health providers was a pervasive public 
        health concern, with some studies reporting burnout in more 
        than 50 percent of clinicians. According to the American Board 
        of Family Medicine, primary care physicians have experienced 
        the highest rate of death (26.9 percent) among health provider 
        specialties during COVID-19. \8\ Physician burn out during the 
        COVID-19 pandemic has become worse, negatively impacting 
        happiness, relationships, career satisfaction, and patient 
        care. A January 2021 report showed that 47 percent of family 
        physicians are burnt out, and 20 percent of all physicians are 
        clinically depressed. \9\ Congress should invest in the mental 
        health needs of our Nation's doctors, particularly during the 
        pandemic, and fight the stigma around seeking necessary 
        treatment by passing the Dr. Lorna Breen Health Care Provider 
        Protection Act.
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    \8\  Gouda D, Singh PM, Gouda P, Goudra B. An Overview of Health 
Care Worker Reported Deaths During the COVID-19 Pandemic. J Am Board 
Fam Med. 2021 Feb;34(Suppl):S244-S246. doi: 10.3122/
jabfm.2021.S1.200248. PMID: 33622846.
    \9\  Kane, L. (2021, January 22). `Death by 1000 CUTS': Medscape 
National Physician Burnout and Suicide Report 2021. Retrieved March 05, 
2021, from https://www.medscape.com/slideshow/2021-lifestyle-burnout-
6013456?faf=1#28.

          Personal Protective Equipment (PPE)--Access to PPE 
        has been a continual challenge for primary care providers 
        during the pandemic. Survey data shows that 1 in 3 primary care 
        practices are consistently having trouble getting PPE. \10\ 
        Family physicians are on the front lines screening, testing, 
        and treating patients for COVID-19 in outpatient and inpatient 
        settings, often at great personal risk. It is imperative during 
        public health emergencies that health care workers have 
        adequate protection to decrease personal harm and the spread of 
        disease. Congress should increase PPE production and stabilize 
        the supply chain by passing legislation, such as the Protect 
        our Heroes Act of 2020 and ensure that community-based primary 
        care physicians are not excluded from PPE distributions from 
        the Strategic National Stockpile.
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    \10\  Larry A. Green Center. ``Quick COVID-19 Primary Care 
Survey.'' Series 20 Fielded September 4-8, 2020. https://
static1.squarespace.com/static/5d7ff8184cf0e01e4566cb02/t/
5f6510dc99d76d706832ba29/1600458973290/
C19+Series+20+National+Executive+Summary.pdf.

          Inadequate Reimbursement for Testing--Some primary 
        care physicians report that payment rates for COVID-19 testing 
        have dropped so significantly that they do not cover the cost 
        of the COVID-19 testing supplies, and therefore jeopardizing 
        access to a tool that is crucial to stopping the spread of 
        COVID-19. \11\ With new variants of coronavirus emerging, 
        testing will be especially important. Congress should address 
        the inadequate reimbursement by clarifying that public and 
        private payers must reimburse the complete cost of a COVID 
        test.
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    \11\  Kliff, S. (2021, February 03). Burned by Low Reimbursements, 
some doctors stop testing for COVID. Retrieved March 08, 2021, from 
https://www.nytimes.com/2021/02/03/upshot/covid-testing-children-
pediatricians.html.

          Medicaid Parity--Recent data show that Medicaid 
        enrollment has increased by more than 6 million since the start 
        of the COVID-19 pandemic, and trends suggest that enrollment 
        will continue to increase a result of pandemic-related job 
        losses. \12\ The demand for primary care physicians in the 
        Medicaid program is more acute than ever. Inadequate Medicaid 
        payment threatens access to primary care services in areas 
        hardest hit by COVID-19, and without proper support during this 
        public health emergency and beyond, family physician practices 
        could be forced to close. Congress should ensure Medicaid 
        beneficiaries have timely access to primary care by raising 
        Medicaid payments to at least Medicare payment levels.
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    \12\  Corallo, B., Rudowitz, R. (2021, January 21). Analysis of 
recent national trends in Medicaid and CHIP Enrollment. Retrieved March 
5, 2021, from https://www.kff.org/coronavirus-covid-19/issue-brief/
analysis-of-recent-national-trends-in-Medicaid-and-chip-enrollment/.

    We thank you for your leadership and actions to date to help our 
Nation combat COVID-19. The AAFP stands ready to partner with you on 
additional legislation to recover from the pandemic and improve our 
public health preparedness. Should you have any questions, please 
contact Erica Cischke, Senior Manager of Legislative and Regulatory 
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Affairs or John Aguilar, Manager of Legislative Affairs.

            Sincerely,
                                              Gary L. LeRoy
                                                  MD, FAAFP
                                                Board Chair
                              American Academy of Family Physicians
                                 ______
                                 
    [Whereupon, at 12:14 p.m., the hearing was adjourned.]

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