[Senate Hearing 117-188]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-188

                   A DIRE SHORTAGE AND GETTING WORSE:
            SOLVING THE CRISIS IN THE HEALTH CARE WORKFORCE

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

                                HEARING

                               BEFORE THE

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                                   ON

       EXAMINING SOLVING THE CRISIS IN THE HEALTH CARE WORKFORCE
                               __________

                              MAY 20, 2021
                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
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                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
46-768 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
                                 ------                                

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                 BERNIE SANDERS (I), Vermont, Chairman
ROBERT P. CASEY, JR., Pennsylvania   SUSAN M. COLLINS, Maine, Ranking 
TAMMY BALDWIN, Wisconsin                 Member
CHRISTOPHER S. MURPHY, Connecticut   RAND PAUL, M.D., Kentucky
TIM KAINE, Virginia                  LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire         ROGER MARSHALL, M.D., Kansas
JACKY ROSEN, Nevada                  TIM SCOTT, South Carolina
BEN RAY LUJAN, New Mexico            JERRY MORAN, Kansas
PATTY MURRAY, Washington (ex         BILL CASSIDY, M.D., Louisiana
    officio)                         MIKE BRAUN, Indiana
                                     RICHARD BURR, North Carolina (ex 
                                         officio)


                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         THURSDAY, MAY 20, 2021

                                                                   Page

                           Committee Members

Sanders, Hon. Bernie, Chairman, Subcommittee on Primary Health 
  and Retirement Security, Opening statement.....................     1
Collins, Hon. Susan, Ranking Member, a U.S. Senator from the 
  State of Maine, Opening statement..............................     3

                               Witnesses

Skorton, David J., M.D., President and Chief Executive Officer, 
  Association of American Medical Colleges, Washington, DC.......     5
    Prepared statement...........................................     7
McDougle, Leon, M.D., MPH, President, National Medical 
  Association, Columbus, OH......................................    14
    Prepared statement...........................................    15
Spires, Shelley, Chief Executive Officer, Albany Area Primary 
  Health Care, Albany, GA........................................    18
    Prepared statement...........................................    20
Herbert, James D., Ph.D., President, University of New England, 
  Biddeford and Portland, ME.....................................    25
    Prepared statement...........................................    27

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Sanders, Hon. Bernie:
    Nine Letters from Healthcare Orginizations...................    48

                         QUESTIONS AND ANSWERS

Response by James Herbert to questions of:
    Senator Casey................................................    78
Response by Leon McDougle to questions of:
    Senator Hassan...............................................    80
    Senator Casey................................................    83
Response by David Skorton to questions of:
    Senator Casey................................................    90

 
                   A DIRE SHORTAGE AND GETTING WORSE:
            SOLVING THE CRISIS IN THE HEALTH CARE WORKFORCE

                              ----------                              


                         Thursday, May 20, 2021

                                       U.S. Senate,
    Subcommittee on Primary Health and Retirement Security,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:37 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Bernie Sanders, 
Chairman of the Committee, presiding.
    Present: Senators Sanders [presiding], Casey, Baldwin, 
Murphy, Kaine, Hassan, Rosen, Collins, Marshall, Cassidy, 
Braun, and Burr.

                  OPENING STATEMENT OF SENATOR SANDERS

    The Chairman. Thank you again for being here. Let me thank 
Senator Collins and her staff for helping us put together this 
hearing on an issue that I consider to be enormously important.
    Let me thank our panelists, two of whom are here with us, 
and two of them, we see you clearly through modern technology. 
Thank you all for being here. We look forward to your 
testimony.
    It is no secret that our Country faces many healthcare 
crises. Too many of our people are uninsured or underinsured. 
We pay, by far, the highest cost for healthcare of any major 
country on earth. The costs of prescription drugs are off the 
wall, and many people cannot afford that.
    In the midst of all of that, for whatever reason, and I 
think we will delve into that today, our Nation, the richest 
country in the history of the world, simply does not have 
enough doctors, nurses, dentists, and other medical 
professionals. And why that is so, I am not sure, but I hope we 
can learn something about that.
    But, the result is that, according to the Association of 
American Medical Colleges, by 2033, the United States will have 
a shortage of up to 139,000 physicians. And primary care 
physicians, we already have a crisis in terms of access to 
primary care for many people throughout this Country. Primary 
care alone will be facing a shortage of up to 55,000 
physicians.
    By the way, as we all know, this does not take into account 
what COVID-19 has done to the health profession. Anecdotally, I 
have heard from hospitals, many nurses just exhausted, leaving 
the profession. Hundreds and hundreds of medical professionals 
have died as heroes and heroines fighting COVID-19 and 
protecting the American people. But, no question that 
healthcare professionals have taken a very big hit as a result 
of COVID-19.
    The Federal Government, as we all know, plays an enormously 
important role in how many physicians we have because, through 
the Medicare Graduate Medical Education program, we fund the 
vast majority of residency slots in this Country. In 2015, the 
most recent data available indicates we spent about $16 billion 
on Graduate Medical Education, providing for roughly 31,000 
residency slots a year. Last year, Congress added 1,000 
additional slots. That is a step forward, but it is nowhere 
near enough, I think, to address the crisis that we face.
    Very importantly, I think--maybe we can discuss this a 
little bit today--in addition to expanding those slots, 
Congress did expand the Teaching Health Center Graduate Medical 
Education program. That is a much smaller program than what 
Medicare does, but it focuses directly on the needs to get 
doctors and others into medically underserved areas.
    Very shortly, I will be introducing legislation to address 
the multiple crises we face, and I just want to very briefly 
touch on what that legislation will look like.
    No. 1--and I hope some of our panelists will speak to this 
issue, as well. I learned--Senator Collins, I learned recently, 
calling up New England medical schools, as a matter of fact, 
that the number of medical students per class is a lot smaller 
than you would think. For example, if you look at Dartmouth or 
UVM Medical School, we are talking about 90 or 100 students per 
class.
    Now, I know that it is an intensive effort to train a 
doctor, but I would think maybe we would want to explore 
whether we can produce more doctors through larger medical 
school classes. Ninety or 100 per class seems a little bit 
small to me.
    Clearly, we also--and there is I think widespread, 
bipartisan support for the understanding that we need to 
increase payments for direct graduate medical education. The 
legislation that I will be introducing picks up on work being 
done by Senators Schumer, Boozman, Menendez, and others, would 
authorize 14,000 new Medicare-supported medical residency 
programs--positions over 7 years. Two thousand a year in 
addition to what we have.
    Further, and very importantly, what our legislation would 
do is to establish new criteria for how the new GME training 
positions would be allotted to qualifying hospitals with a 
minimum of 50 percent of new slots going toward primary care.
    In other words, the crisis we face is not only a shortage 
of doctors; it is where those doctors are. They are not in 
rural Maine, they are not in rural Kansas, and they are not in 
rural Vermont. We have a hard time attracting them. We do not 
necessarily need more dermatologists on Park Avenue in New York 
City. I do not know if we do or not. Probably not. But, we do 
need them in rural areas all over the Country, and we have to 
make sure that Medicare understands that.
    Another issue that maybe panelists can pick up on, I think 
we all know that residents are really underpaid. You go 4 years 
for medical school, you do a year of internship, and the 
average pay for a resident is $63,000 a year. So, you have 
medical debit, right? You have got a few hundred thousand 
dollars in debt.
    Senator Marshall. That is triple since I was in medical 
school.
    The Chairman. Oh, is that right? But costs have gone up a 
little bit, too. But, if you are living in a big city----
    You were making 20,000?
    Senator Marshall. Twenty-five.
    The Chairman. Working long hours, I expect.
    Senator Marshall.
    [Inaudible]
    The Chairman. All right. Well, that is the whole--that is 
another story. But, here is one thing that gets to me. While 
the average resident earns 63,000, which I think is inadequate, 
primary care residents earn 58,000. So, the discrimination 
starts right there in the residency program, not to mention 
what salaries are paid. It does not make a whole lot of sense 
to me. I think we should increase it.
    Our bill will significantly increase funding for the 
Teaching Health Center Graduate Medical Education program. We 
have made progress, I am happy to say. And in the American 
Rescue Plan, some of us worked very hard to double funding for 
community health centers and triple funding for the National 
Health Service Corps, and I think we have to continue that 
effort.
    That says to somebody, if you are going to be graduating 
medical school $300,000 in debt, you are not going to rural 
Maine, frankly, all right, and we are going to help you pay off 
that debt if you do go to rural Maine or rural Vermont or rural 
anyplace.
    That is some of my thoughts, and I look forward to this 
serious discussion.
    Senator Collins.

                  OPENING STATEMENT OF SENATOR COLLINS

    Senator Collins. Mr. Chairman, thank you so much for 
holding this very important hearing today.
    Our Country is tremendously grateful to the medical 
community for its colossal efforts during the past year. Many 
healthcare professionals are exhausted by the physical and 
emotional toll of caring for COVID patients, and that burden, I 
think it is important to note, did not fall solely on the 
medical workers themselves, but also on many members of their 
families, who have had to cope with separation, long hours, 
health risks, and stress from closed schools.
    In many areas of the Country, there is a fierce competition 
for nurses, nursing assistants, other medical professionals, 
and physicians. And as the Chairman has mentioned, for those of 
us who represent rural states, the competition is particularly 
stiff. The situation is particularly acute in our nursing homes 
where low Medicaid reimbursement levels often translate into 
low wages.
    This workforce shortage has been with us long before COVID. 
It is frustrating to watch year after year. Tens of thousands 
of qualified nursing school applicants are turned away each 
year due to a lack of a sufficient number of faculty and a 
shortage of clinical sites.
    We need to break that cycle. At a time when our Nation is 
aging, and as more and more people are living longer with 
increasing health needs, these shortages have serious 
consequences.
    Growing up in northern Maine, I know the vital role that 
nurse practitioners and physician assistants, in particular, 
play in our healthcare system in rural areas. That is why one 
of my highest priorities in the Senate has always been to 
increase funding for workforce programs.
    The bipartisan work that the HELP Committee has 
accomplished to support healthcare workforce training has made 
a difference. Both the Title VII health professions training 
and the Title VIII nursing workforce programs were reauthorized 
by the CARES Act last year. We need to make sure that they are 
sufficiently funded.
    While many health professions desperately need to attract 
more students, several disciplines stand out. One is addiction 
medicine, a theme that we heard in the excellent Committee 
hearing on mental health last month. In March, researchers from 
Stamford University wrote in the Journal of the American 
Medical Association Psychiatry that opioid overdoses likely 
reached a record high in 2020 because COVID has exacerbated 
stress and social isolation, and interfered with opioid 
treatment, addiction treatment.
    That is certainly true in the State of Maine. Last year, a 
record 502 Mainers died from overdoses, a tragic toll that 
exceeded even the deaths caused by COVID-19. Senator Hassan and 
I recently reintroduced the Opioid Workforce Act, legislation 
that would create 1,000 new medical residency positions focused 
on addiction medicine at teaching hospitals. And we are 
grateful to the American Association of Medical Colleges, which 
is represented here today, for its endorsement of our 
legislation.
    Another area of unmet need is geriatric medicine. In Maine, 
there are more than a quarter of a million Mainers who are over 
the age of 65, and we only have 40 geriatricians. There is an 
acute need to quickly train more geriatric health professionals 
and direct service workers to meet the growing demand. And I 
agree with the Chairman that we need to provide incentives to 
get them into rural areas through partial forgiveness of their 
medical school debts.
    Last year, the CARES Act included my legislation with 
Senator Casey to formally establish and authorize funding for 
the Geriatrics Workforce Enhancement program, the only Federal 
program designed to increase the number of healthcare 
professionals with the training to care for older people. 
Today, there are 48 Geriatrics Workforce Enhancement programs 
in 35 states, including a terrific program at the University of 
New England. And I am very pleased that UNE's president, Dr. 
James Herbert, is testifying today.
    Increasing the overall number of healthcare professionals 
is just part of the shortage equation. Another, as I have 
mentioned, is making sure that they practice in communities 
across the Country, including in rural areas. And one way we 
can do that is expanding where medical residents train.
    The December Omnibus Appropriations bill contained a three-
year authorization of Teaching Health Centers Graduate Medical 
Education program, a program that I have championed with 
Senator Tester. Teaching Health Centers train medical residents 
in community-based settings, including low-income, underserved 
rural and urban neighborhoods. Why does this matter? It matters 
because we know that people are much more likely to stay where 
they train. And if we can get people out to underserved areas 
to do their residencies, they are much more likely to practice 
there.
    I know that I could go on and on. Let me just end by saying 
that I think telehealth is another avenue to address the 
mismatch in supply and demand, particularly in behavioral 
health. The determination and compassion that leads students to 
choose a career in healthcare are needed now more than ever.
    I very much appreciate this hearing, and I look forward to 
hearing from our excellent witnesses.
    Thank you, Mr. Chairman.
    The Chairman. Well, thank you, Senator Collins. This does 
appear to be an issue where there may be a bipartisan approach 
to a very serious problem.
    We have a great panel, and let me begin with Dr. David 
Skorton. Dr. Skorton is the President and CEO of the 
Association of American Medical Colleges, which represents the 
Nation's medical schools, teaching hospitals, and health 
systems, and academic societies.
    Dr. Skorton, thanks so much for being with us.

   STATEMENT OF DAVID J. SKORTON, M.D., PRESIDENT AND CHIEF 
 EXECUTIVE OFFICER, ASSOCIATION OF AMERICAN MEDICAL COLLEGES, 
                         WASHINGTON, DC

    Dr. Skorton. Thank you, Chairman Sanders and Ranking Member 
Collins for holding this hearing. I am honored to be included 
among this distinguished panel, and I look forward to 
discussing challenges related to the physician workforce.
    I am proud to represent academic physicians who daily teach 
our next generation of doctors, perform life-saving research, 
and care for some of the Nation's most vulnerable and complex 
patients. And just one example: Years of federally funded 
research led to the scientific underpinnings for the mRNA 
COVID-19 vaccines that are now saving so many lives.
    Addressing the Nation's physician workforce shortages and 
related challenges will require a multi-pronged, public-private 
approach, including innovation, such as team-based care and 
better use of technology, in addition to increasing the overall 
number of physicians.
    Our annual workforce report continues to project that 
demand for physicians will outstrip supply, leading, as the 
Chairman mentioned, to a projected total physician shortage 
between 54,100 and 139,000 physicians by 2033, including both 
primary care and non-primary care specialties. The range 
reflects a variety of scenarios that may affect the exact 
future needs, including population shifts, delivery pattern 
changes, and increased use of physician assistants and advanced 
practice registered nurses.
    The fact is, we have a current and projected shortage of 
physicians that is ominous and requires our best efforts and 
your support. Though our report focuses on physicians, I 
underscore the major contributions of other health 
professionals.
    Not surprisingly, the Nation's growing aging population 
continues to be the main driver of increasing demand for 
physicians over the next 15 years, on top of current stressors, 
including behavioral health needs, substance use disorders, 
and, of course, COVID-19.
    Our physician workforce also is aging, and a large 
proportion are nearing the traditional age of retirement, thus 
affecting supply, as do physician well-being and our work hour 
patterns.
    It can take more than a decade for a physician to complete 
medical school and residency training, also known as Graduate 
Medical Education, or GME. This post-graduate training is 
required to become licensed for independent practice. U.S. 
medical schools have increased enrollment by 35 percent and 
opened 30 new schools since 2002. However, this growth will not 
increase the workforce without increasing residency training 
slots, which have not increased enough to address the shortage.
    The AAMC has endorsed the Resident Physician Shortage 
Reduction Act that would raise the cap on Medicare's support 
for GME and help train approximately 3,500 more physicians each 
year. We also believe that Children's Hospital and Teaching 
Health Center GME, as you heard, are critical programs 
complementary to Medicare GME.
    We must also increase private and public efforts to help 
shape the primary care workforce, increase community-based 
training and rural practice, and improve workforce diversity. 
Many successful programs already exist at the Health Resources 
and Services Administration, but in our view, they need 
additional investment to increase their scope and reach.
    The AAMC convenes the Health Professions and Nursing 
Education Coalition, which calls for a doubling of HRSA Title 
VII funding in Fiscal Year 2022.
    Furthermore, public service scholarship and loan repayment 
programs can be effective, targeted incentives for recruiting 
physicians to help specific vulnerable populations. And I thank 
you, Senator Sanders, for championing the recent historic 
investment in the National Health Service Corps.
    Intervention earlier in the education pipeline is necessary 
to increase the number of students from rural, underserved, low 
income, minorities, and other disadvantaged backgrounds. The 
programs I have already mentioned will be more successful if we 
recruit students who are more likely to practice primary care 
in underserved communities, including those from diverse racial 
and ethnic backgrounds.
    I am very concerned there has been minimal progress in 
increasing physician workforce diversity. In 1980, when I began 
my first faculty appointment, Black men made up 3.4 percent of 
entering U.S. medical students. Today, Black males are 3.6 
percent of all U.S. med students. It is inexcusable that we 
have not moved the numbers in 40 years.
    Beyond the efforts of our Nation's medical schools, I would 
encourage this Committee to speak with families and students 
from kindergarten through college to better identify and 
address barriers so that we can work together to expose young 
people to science, particularly those who are currently 
underrepresented in medicine.
    I thank you again for the opportunity to testify. We stand 
ready to work with this Committee, with Congress, and with my 
distinguished colleagues on this panel to improve the Nation's 
healthcare workforce.
    Thank you very much.
    [The prepared statement of Dr. Skorton follows:]
                  prepared statement of david skorton
    I am pleased to testify on behalf of the AAMC (Association of 
American Medical Colleges) on physician workforce challenges and 
primary care access across the United States, including projected 
physician workforce shortages as well as policies and programs that 
seek to improve and diversify our health care workforce and ensure we 
have enough providers in underserved areas.

    The AAMC is a not-for-profit association dedicated to transforming 
health through medical education, health care, medical research, and 
community collaborations. Its members are all 155 accredited U.S. and 
17 accredited Canadian medical schools; more than 400 teaching 
hospitals and health systems, including Department of Veterans Affairs 
medical centers; and more than 70 academic societies. Through these 
institutions and organizations, the AAMC leads and serves America's 
medical schools and teaching hospitals and their more than 179,000 
full-time faculty members, 92,000 medical students, 140,000 resident 
physicians, and 60,000 graduate students and postdoctoral researchers 
in the biomedical sciences. \1\
---------------------------------------------------------------------------
    \1\  For background on physician education and training, see AAMC's 
The Road to Becoming a Doctor.

   KEY FINDINGS FROM THE ANNUAL AAMC PHYSICIAN WORKFORCE PROJECTIONS
    Since 2008, the AAMC has produced reports of national physician 
workforce projections, including annual reports prepared by independent 
experts since 2015 leading up to The Complexities of Physician Supply 
and Demand: Projections from 2018-2033. We expect to release a 2021 
update to this report in June.

    The report's microsimulation model projects the future supply of 
physicians based on the number and characteristics of the current 
physician workforce, new physicians trained each year, hours-worked 
patterns, and retirement patterns. The model projects demand for 
physicians based on current patterns of health care use, population 
growth and changing demographics, potential changes to delivery 
systems--including greater use of managed-care, retail clinics, and 
increased use of advanced practice registered nurses and physician 
assistants--and achieving certain population health goals to illustrate 
the potential impact of improved preventive care. The large projection 
ranges presented in the report and cited below are the result of 
comparing a multitude of scenarios and reflect the data challenges and 
uncertainties of projecting future workforce supply and demand.

    AAMC continues to project that physician demand will grow faster 
than supply, leading to a projected total physician shortage between 
54,100 and 139,000 physicians by 2033. We also project:

          A shortage of primary care physicians between 21,400 
        and 55,200 by 2033.

          A shortage of non-primary care specialty physicians 
        between 33,700 and 86,700 by 2033, including:

                Y  Between 17,100 and 28,700 for surgical specialties.

                Y  Between 9,300 and 17,800 for medical specialties. 
                Between 17,100 and 41,900 for the other specialties 
                category.

    Demographics--specifically, population growth and aging--continue 
to be the primary driver of increasing demand for physicians from 2018 
to 2033. During this period, the U.S. population is projected to grow 
by 10.4 percent from about 327 million to 361 million. The U.S. 
population under age 18 is projected to grow by 3.9 percent, while the 
population aged 65 and over is projected to grow by 45.1 percent by 
2033. Therefore, demand for physician specialties that predominantly 
care for older Americans will continue to increase. This projected 
increase in demand for physicians is on top of current stressors that 
we see driving demand today, such as increased behavioral health needs, 
substance use disorder, and of course, COVID-19.

    On the supply side, a large portion of the physician workforce is 
nearing traditional retirement age, and supply projections are 
sensitive to the workforce decisions of older physicians. More than 2 
of 5 currently active physicians will be 65 or older within the next 
decade. Shifts in retirement patterns over that time could have large 
implications for the supply of physicians to meet health care demands. 
Also, growing concerns about physician burnout suggest physicians may 
be more likely to accelerate, rather than delay, retirement.

    While the AAMC annual report projects future shortages, the 
association also includes a separate ``Health Care Utilization Equity'' 
scenario that provides additional context to current physician shortage 
estimates. In 2018, the Health Resources and Services Administration 
(HRSA) estimated that the Nation requires about 14,900 more primary 
care practitioners and 6,894 mental health practitioners to eliminate 
all federally designated Health Professional Shortage Areas (HPSAs). 
The HPSA designation identifies an area, population, or facility 
experiencing a shortage of primary care or mental health care services, 
but does not consider non-primary care physician specialty shortages 
also projected by HRSA, such as cardiology, \2\ neurology, \3\ and 
orthopedic surgery. \4\
---------------------------------------------------------------------------
    \2\  U.S. Department of Health and Human Services, Health Resources 
and Services Administration, National Center for Health Workforce 
Analysis. 2016. Supply and Demand Projections for Internal Medicine 
Subspecialties: 2013-2025.
    \3\  U.S. Department of Health and Human Services, Health Resources 
and Services Administration, National Center for Health Workforce 
Analysis. 2017. Health Workforce Projections: Neurology Physicians and 
Physician Assistants.
    \4\  U.S. Department of Health and Human Services, Health Resources 
and Services Administration, National Center for Health Workforce 
Analysis. 2016. National and Regional Projections of Supply and Demand 
for Surgical Specialty Practitioners: 2013-2025.

    The ``Health Care Utilization Equity'' scenario finds that if 
underserved populations were to experience the same health care use 
patterns as populations with fewer barriers to access, the US would 
need an additional 74,100 to 145,500 physicians just to meet current 
demand. This analysis underscores the systematic differences in annual 
use of health care services by insured and uninsured individuals, 
individuals in urban and rural locations, and individuals of differing 
races and ethnicities. These estimates, which are separate from the 
2033 shortage-projection ranges, help illuminate the magnitude of 
current barriers to care and provide an additional reference point when 
gauging the adequacy of physician workforce supply.
APPROACHES TO ADDRESSING OR EVEN SOLVING PHYSICIAN WORKFORCE SHORTAGES 
                             AND CHALLENGES
    Addressing or solving the Nation's physician workforce shortages 
and challenges requires a multipronged private-public approach, 
including innovations such as team-based care and better use of 
technology in addition to increasing the overall number of physicians. 
Below are physician workforce policies, programs, and actions the AAMC, 
its member medical schools and teaching hospitals, our Federal 
partners, and the Nation can build on to improve access to health care 
for all and help address gaping health inequities.
                      Overall Physician Shortages
    Over the last two decades, the worsening physician shortage has 
demonstrated the need to increase the number of physicians to help 
ensure access to care for people, including during the COVID-19 
pandemic and into the future. Academic medicine has responded and, 
since 2002, the number of first-year students in medical schools has 
grown by nearly 35 percent as schools have expanded class sizes and 30 
new schools have opened. \5\ While medical schools continue to increase 
enrollment, this will not be sufficient. To be licensed to practice 
independently, graduate physicians must undergo further, graduate 
medical education (GME).
---------------------------------------------------------------------------
    \5\  AAMC Medical School Enrollment Survey: 2019 Results, September 
2020. https://www.aamc.org/media/47726/download.

    Currently, Medicare caps the number of GME positions it supports at 
each teaching hospital. One key element of addressing the physician 
shortage is increasing Medicare support for GME, which will help boost 
access to high-quality care, particularly for underserved populations 
in rural communities and urban areas that have been disproportionately 
---------------------------------------------------------------------------
affected by the pandemic.

    A broad bipartisan coalition of Members of Congress worked together 
to provide 1,000 new Medicare-supported GME positions--the first 
increase of its kind in nearly 25 years--in the Consolidated 
Appropriations Act, 2021 (P.L. 116-260), which the AAMC estimates will 
add approximately 1,600 new physicians by 2033. This increase was an 
important initial investment, but more still needs to be done to help 
ensure everyone can access the primary and specialty care they need.

    To meet this need, Senators Robert Menendez (D-NJ) and John Boozman 
(R-AR) and Majority Leader Charles Schumer (D-NY) introduced the AAMC-
endorsed bipartisan Resident Physician Shortage Reduction Act of 2021 
(S. 834), which would gradually raise the number of Medicare-supported 
GME positions by 2,000 per year for 7 years, for a total of 14,000 new 
slots. Much like the year-end package, these positions would be 
targeted to hospitals with diverse needs, including hospitals in rural 
areas, hospitals serving patients from federally designated HPSAs, 
hospitals in states with new medical schools or branch campuses, and 
hospitals already training over their caps. The legislation has broad 
stakeholder support and has been endorsed by over seventy members of 
the GME Advocacy Coalition representing the broad range of disciplines. 
Many of these stakeholder groups also recommend the bill's inclusion in 
upcoming efforts to rebuild and improve the Nation's infrastructure.

    The Opioid Workforce Act (S. 1483), introduced by Senators Maggie 
Hassan (D-NH) and Susan Collins (R-ME) would similarly increase the 
number of Medicare-supported GME positions, but would target those 
positions to increase the number of residents training in addiction 
medicine, addiction psychiatry, and pain medicine. As the Nation 
continues to fight the opioid epidemic, it is crucial that we increase 
access to physicians with focused expertise in treating substance use 
disorders.

    GME programs administered by HRSA, including Children's Hospitals 
GME (CHGME), Teaching Health Center GME (THCGME), and the Rural 
Residency Program, help increase the number of residents training in 
children's hospitals, federally Qualified Health Centers (FQHC), and 
rural areas, respectively. The AAMC continues to urge Congress to 
increase annual appropriations for these GME programs in fiscal year 
2022, including $485 million for CHGME. We also appreciate the $330 
million in supplemental funding for THCGME included in the American 
Rescue Plan (P.L. 117-2).
                              Primary Care
    While the country still faces primary care physician shortages, the 
AAMC is encouraged to see increases over the last several years in the 
number of residents matching to primary care residency programs, the 
number of primary care resident positions offered in the Match, and the 
percentage of primary care positions as a proportion of total matches. 
\6\ The National Residency Matching Program (NRMP) \7\ reports, ``In 
2020, primary care specialties offered record-high numbers of positions 
and had high position fill rates,'' and ``Family Medicine has 
experienced position increases every year since 2009. In 2020, Family 
Medicine offered 4,662 positions and filled 4,313 (92.5 percent).'' \8\
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    \6\  Results and Data: 2020 Main Residency Match, Table 9, All 
Applicants Matched to PGY-1 Positions by Specialty, 2016-2020, NRMP, 
May 2020.
    \7\  For additional background on NRMP and the Match see: https://
www.nrmp.org/intro-to-main-residency-match/.
    \8\  Results and Data: 2020 Main Residency Match, NRMP, May 2020.

    To help shape the physician workforce, and specifically primary 
care, the AAMC recommends doubling funding for the HRSA workforce 
development programs under Title VII and Title VIII of the Public 
Health Service Act. Under Title VII, the AAMC supports increased 
Federal funding for the HRSA Title VII Primary Care Training and 
Enhancement (PCTE) and Medical Student Education programs. PCTE 
supports training programs for physicians and physician assistants to 
encourage practice in primary care, promote leadership in health care 
transformation, and enhance teaching in community-based settings. In AY 
2018-19, PCTE grantees trained over 13,000 individuals at nearly 1,000 
sites, with 61 percent in medically underserved communities and 30 
percent in rural areas. \9\
---------------------------------------------------------------------------
    \9\  Health Resources and Services Administration. Department of 
Health and Human Services Fiscal Year 2021 Justification of Estimates 
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.

    The HRSA Title VII Medical Student Education is a new program that 
supports the primary care pipeline by expanding training for medical 
students to become primary care clinicians, targeting institutions of 
higher education in states with the highest primary care workforce 
shortages. Through grants, the program develops partnerships among 
institutions, federally recognized tribes, and community-based 
organizations to train medical students to provide care that improves 
health outcomes for those living on tribal reservations or in rural and 
underserved communities. AAMC believes earlier intervention in the 
educational continuum is also necessary to support additional medical 
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school applicants that are more likely to enter primary care.

    Medical education costs can be a significant burden for individuals 
interested in medicine. While non-financial factors appear to have a 
greater impact on the specialty choice of medical students, \10\ the 
AAMC is concerned about the impact these costs may have on the 
physician pipeline. Medical schools and their leadership across the 
country are committed to reducing this burden and have increased 
institutional aid, some committing to eliminate debt or tuition 
altogether in the hopes of increasing interest in primary care. \11\ 
The AAMC also supports Federal efforts to ensure financial stability of 
primary care providers, including the HRSA Title VII Primary Care Loan, 
which provides low interest loans to medical students planning to enter 
primary care. Additionally, the AAMC applauds the recent historic 
investment of $800 million in the National Health Service Corps (NHSC) 
under the American Rescue Plan (P.L. 117-2) to help recruit primary 
care providers to underserved communities through scholarship and loan 
repayment.
---------------------------------------------------------------------------
    \10\  Physician Education Debt and the Cost to Attend Medical 
School: 2020 Update, Section Six: Debt and Specialty Choice, AAMC, 
October 2020. https://store.aamc.org/downloadable/download/sample/
sample-id/368/.
    \11\  Will free medical school lead to more primary care 
physicians? Ken Budd, Special to AAMCNews, December 2019. https://
www.aamc.org/news-insights/will-free-medical-school-lead-more-primary-
care-physicians.

                          Workforce Diversity
    A diverse health workforce contributes to culturally responsive 
care, helps to mitigate bias, and improves access and quality of care 
to reduce health disparities, such as those seen during COVID-19. It 
also improves primary care and access as underrepresented students are 
more likely to choose primary care specialties.

    A common theme across several physician workforce challenges is the 
need to diversify the population of students entering medical school. 
According to the AAMC Medical School Enrollment Survey, \12\ virtually 
all medical schools have specific programs or policies designed to 
recruit a more diverse student body. The majority of respondents to 
that survey had established or expected to establish programs/policies 
geared toward minorities underrepresented in medicine, students from 
disadvantaged backgrounds, and students from underserved communities. 
Schools also reported a variety of approaches, with a focus on outreach 
at high schools and local 4-year colleges and admission strategies such 
as holistic review. In addition to these efforts, AAMC believes earlier 
and greater intervention is necessary to diversify the physician 
workforce.
---------------------------------------------------------------------------
    \12\  Results of the AAMC Medical School Enrollment Survey: 2017, 
May 2018. https://www.aamc.org/media/8276/download.

    For myriad reasons, there has been minimal progress in increasing 
the number of physicians from diverse racial and ethnic backgrounds. We 
need more assertive efforts to cultivate a more diverse and culturally 
prepared workforce. We need to better understand how systemic barriers 
such as racism and inconsistent access to quality education, beginning 
with pre-K, negatively affect diversity in academic medicine. And we 
must design bolder interventions to address the growing absence of 
Black men and the near-invisibility of American Indians and Alaska 
Natives in medical school and the physician workforce, which are 
---------------------------------------------------------------------------
national crises.

    The AAMC is committed to increasing significantly the number of 
diverse medical school applicants and matriculants, and last year 
launched a new strategic plan that will take a multitiered approach 
with sustained investment, collaboration, and attention over time to 
significantly increase the diversity of medical students. Our goal is 
to keep increasing the number of students from underrepresented groups 
until they are no longer underrepresented in medicine. While AAMC 
enrollment data show we are moving slowly in the right direction to 
recruit more students from underrepresented groups entering medical 
school, there is still much work to be done across academic medicine to 
ensure our diverse nation is reflected in a diverse physician 
workforce.

    In 2020, the total number of first-year students identifying as 
Black or African American, Hispanic, Latino, or of Spanish origin, and 
American Indian or Alaska Native increased. However, this growth was 
concentrated at a small number of medical schools, reflecting the 
important contributions historically Black colleges and universities 
and Hispanic-serving institutions make to the diversity of the 
physician workforce. In recent years, the AAMC released two reports, 
Altering the Course: Black Males in Medicine \13\ (2015) and Reshaping 
the Journey: American Indians and Alaska Natives in Medicine \14\ 
(2018), to further explore why diversity efforts have not been more 
successful. As discussed in these reports, not all racial and ethnic 
groups saw notable increases in medical school applicants and 
matriculants. In particular, the reports demonstrated that the numbers 
of Black or African American medical school applicants and American 
Indian or Alaska Native medical school applicants had remained 
relatively stagnant. Even more concerning was the finding reported in 
the Altering the Course report that the number of Black or African 
American male medical school applicants and matriculants had actually 
decreased since 1978. While there have been some increases in the 
number of Black or African American male medical school applicants and 
matriculants in the six-years since that report was published, Black or 
African American male students continue to be woefully underrepresented 
compared with other medical student groups.
---------------------------------------------------------------------------
    \13\  https://store.aamc.org/downloadable/download/sample/sample-
id/84/.
    \14\  https://store.aamc.org/downloadable/download/sample/sample-
id/243/.

    The HRSA Title VII health professions and Title VIII nursing 
programs play an important role in improving the diversity of the 
health workforce and connecting students to health careers by enhancing 
recruitment, education, training, and mentorship opportunities. 
Inclusive and diverse education and training experiences expose 
students and providers to backgrounds and perspectives other than their 
own and heighten cultural awareness in health care, resulting in 
benefits for all patients and providers. Studies also show that 
underrepresented students are more likely to serve patients from those 
backgrounds. \15\
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    \15\  Stewart, K., Brown, S. L., Wrensford, G., & Hurley, M. M. 
(2020). Creating a Comprehensive Approach to Exposing Underrepresented 
Pre-health Professions Students to Clinical Medicine and Health 
Research. Journal of the National Medical Association, 112(1), 36-43. 
doi:10.1016/j.jnma.2019.12.003.

---------------------------------------------------------------------------
    Title VII's health professions diversity programs include:

          Health Careers Opportunity Program (HCOP), which 
        invests in K-16 health outreach and education programs through 
        partnerships between health professions schools and local 
        community-based organizations;

          Centers of Excellence (COE) program, which provides 
        grants for higher education mentorship and training programs 
        for underrepresented health professions students and faculty;

          Faculty Loan Repayment, which provides loan repayment 
        awards to retain minority health professions faculty in 
        academic settings to serve as mentors to the next generation of 
        providers; and

          Scholarships for Disadvantaged Students (SDS), which 
        grants scholarships for health professions students from 
        minority and/or socioeconomically disadvantaged backgrounds.

    Studies have demonstrated the effectiveness of such pipeline 
programs in strengthening students' academic records, improving test 
scores, and helping racial and ethnic minority and students who are 
economically disadvantaged pursue careers in the health professions. 
\16\ Title VII diversity pipeline programs reached over 10,000 students 
in the 2018-2019 academic year (AY), with HCOP reaching more than 4,000 
disadvantaged trainees, SDS graduating nearly 1,400 students and COE 
reaching more than 5,600 health professionals; 56 percent of whom were 
located in medically underserved communities. \17\ This success is even 
more impressive considering that only 20 schools have HCOP grants and 
only 17 have COE grants--down from 80 HCOP programs and 34 COE programs 
in 2005 before the programs' funding was cut substantially.
---------------------------------------------------------------------------
    \16\  Ojo, K. (2020). Preparing Minority Students For Careers in 
Health: A Case Study Investigation of a Health Careers Opportunity 
Program (HCOP) (Temple University Press). Temple University. 
doi:https://scholarshare.temple.edu/handle/20.500.12613/287.
    \17\  Health Resources and Services Administration. Department of 
Health and Human Services Fiscal Year 2021 Justification of Estimates 
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.

    Title VIII's Nursing Workforce Diversity Program increases nursing 
education opportunities for individuals from disadvantaged backgrounds, 
through stipends and scholarships, and a variety of pre-entry and 
advanced education preparation. In AY 2018-19, the program supported 
more than 11,000 students, with approximately 46 percent of the 
training sites located in underserved communities. \18\
---------------------------------------------------------------------------
    \18\  Id.

    The AAMC appreciates that Congress reauthorized the HRSA Title VII 
and Title VIII programs in the Coronavirus Aid, Relief, and Economic 
Security (CARES) Act (P.L. 116-136). However, increased funding is 
necessary for these programs to reach their full potential. For fiscal 
year 2022, AAMC joined an alliance of over 90 national organizations, 
the Health Professions and Nursing Education Coalition (HPNEC), in 
recommending $1.51 billion for Title VII and Title VIII, which includes 
doubling funding for the HRSA diversity pipeline programs.
                              Rural Access
    Access issues persist in rural communities. While 20 percent of the 
U.S. population lives in rural communities, only 11 percent of 
physicians practice in such areas. The Centers for Disease Control and 
Prevention (CDC) reports that Americans living in rural areas are more 
likely to die from health issues like cardiovascular disease, 
unintentional injury requiring emergency services, and chronic lung 
disease than city-dwellers. \19\ People living in rural communities 
also tend to be diagnosed with cancer at later stages and have worse 
outcomes.
---------------------------------------------------------------------------
    \19\  Rural Americans at higher risk of death from five leading 
causes. CDC, January 2017, https://www.cdc.gov/media/releases/2017/
p0112-rural-death-risk.html.

    We know that medical students who grow up in rural communities are 
much more likely to return to them, and physicians who train in rural 
areas are ten times more likely to practice full time in those 
communities. \20\ As previously discussed, many medical schools aim to 
identify potential candidates from rural communities and encourage them 
to take up medicine; \21\ however, in 2016 and 2017, students from 
rural backgrounds made up less than 5 percent of the incoming medical 
student body. \22\
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    \20\  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007145/.
    \21\  Attracting the next generation of physicians to rural 
medicine, Peter Jaret, special to AAMCNews, February 2020. https://
www.aamc.org/news-insights/attracting-next-generation-physicians-rural-
medicine.
    \22\  The Decline In Rural Medical Students: A Growing Gap In 
Geographic Diversity Threatens The Rural Physician Workforce, Health 
Affairs, December 2019, https://www.healthaffairs.org/doi/abs/10.1377/
hlthaff.2019.00924 (Note--this study does not include osteopathic 
medical school matriculation and enrollment).

    As Congress considers improving the Nation's health infrastructure, 
there is an opportunity to invest in the rural workforce pipeline. AAMC 
supports The Expanding Medical Education Act (H.R. 801), which would 
authorize grants to enhance current and establish new regional medical 
campuses (RMCs), thereby helping expose more future providers to rural 
and other underserved settings. RMCs are important settings for medical 
schools to expand their reach and help fulfill their unique missions. 
Approximately 30 percent of medical schools already have at least one 
branch campus. \23\ RMCs often have targeted missions, such as training 
future providers in primary care and in rural settings. The funds 
authorized in this bill would help with the construction of new branch 
campuses and assist current RMCs in enhancing their facilities, 
expanding their enrollment, recruiting new faculty, developing 
curriculum, and planning for accreditation.
---------------------------------------------------------------------------
    \23\  Association of American Medical Colleges. Regional Campuses 
at US Medical Schools. Liaison Committee on Medical Education (LCME) 
Annual Questionnaire Part II, https://www.aamc.org/data-reports/
curriculum-reports/interactive-data/regional-campuses-us-medical-
schools.

    To facilitate new rural residency programs, the HRSA Office of 
Rural Health Policy provides technical assistance and startup funding 
to rural hospitals under the Rural Residency Planning and Development 
(RRPD) programs. Specifically, the Rural Training Track required in the 
RRPD program places residents in rural locations for greater than 50 
percent of their GME training and focuses on producing physicians who 
will practice in rural communities. In fiscal year 2019, the RRPD 
program provided 27 rural health facilities with funding for graduate 
medical education. \24\ The AAMC supports increasing the $10.5 million 
Federal investment in the HRSA RRPD.
---------------------------------------------------------------------------
    \24\  Health Resources and Services Administration. Department of 
Health and Human Services Fiscal Year 2021 Justification of Estimates 
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.

    The HRSA Title VII health professions programs have also proven to 
be successful in guiding students toward careers in rural and 
underserved areas. Area Health Education Centers (AHECs) specifically 
focus on recruiting and training future physicians in rural areas, as 
well as providing interdisciplinary health care delivery sites. In AY 
2018-19, AHEC grantees partnered with community health centers, 
hospitals, and ambulatory practice sites to train future physicians, 
with 44 percent of the training sites located in rural areas. \25\ AHEC 
training sites focused on interprofessional networks that address 
social determinants of health and incorporate field placement programs 
for rural and medically underserved populations. With over 2,700 AHEC 
scholars in 2018-2019, 36 percent of the scholars came from rural 
backgrounds, and over half of the scholars received training in rural 
settings. \26\ The AAMC supports doubling AHECs in fiscal year 22 as 
part of our recommendation for HRSA Title VII funding.
---------------------------------------------------------------------------
    \25\  Id.
    \26\  Id.

                        Underserved Communities
    Additionally, public service loan repayment programs offered by 
HRSA, the National Institutes of Health, the Department of Education, 
the Department of Veterans Affairs, the Department of Defense, and the 
Indian Health Service are effective, targeted incentives for recruiting 
physicians and other health professionals to serve specific vulnerable 
populations. Increasing Federal investment in these programs is a 
proven way to increase the supply of health professionals serving 
HPSAs, nonprofit facilities, and other underserved communities. For 
example, the Public Service Loan Forgiveness (PSLF) program 
administered by the Department of Education encourages physicians to 
pursue careers that benefit communities in need. In an annual AAMC 
survey of graduating medical students, over one-third of 2020 medical 
school graduates indicate an interest in pursuing PSLF. \27\ The AAMC 
supports preserving physician eligibility for PSLF to help vulnerable 
patients and nonprofit medical facilities that use the program as a 
provider recruitment incentive.
---------------------------------------------------------------------------
    \27\  Medical School Graduation Questionnaire: 2020 All Schools 
Summary Report (Rep.). (2020). https://www.aamc.org/media/46851/
download.

    The NHSC in particular has played a significant role in recruiting 
primary care physicians to federally designated HPSAs through 
scholarship and loan repayment options. With a field strength of 13,053 
in 2019, including 2,418 physicians, more than 13 million patients 
relied on NHSC providers for health care. \28\ Despite the NHSC's 
success, it still falls far short of fulfilling the health care needs 
of all HPSAs due to growing demand for health professionals across the 
country. Again, we are pleased Congress recognized the vital role the 
NHSC has in caring for our Nation's most vulnerable patients by 
providing the program with $800 million in supplemental funding in the 
American Rescue Plan. The AAMC supports continued growth for the NHSC 
in fiscal year 2022 appropriations, and we urge Congress to provide a 
level of funding for the NHSC that would fulfill the needs of all 
current HPSAs.
---------------------------------------------------------------------------
    \28\  Health Resources and Services Administration. Department of 
Health and Human Services Fiscal Year 2021 Justification of Estimates 
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.

    Similar to the NHSC, the State Conrad 30 J-1 visa waiver program 
has been a highly successful program for underserved communities to 
recruit both primary care and specialty physicians after they complete 
their medical residency training. Conrad 30 allows physicians to remain 
in the U.S. in an underserved community after completing medical 
residency on a J-1 ``exchange visitor'' visa (the most common visa for 
GME), which otherwise requires physicians to return to their home 
country for at least 2 years. Over the last 15 years, the Conrad 30 
program has brought more than 15,000 physicians to underserved areas--
comparable to (if not more than) the NHSC, at no cost to the Federal 
---------------------------------------------------------------------------
Government.

    As the 117th Congress considers immigration reform, the AAMC 
endorses the bipartisan Conrad State 30 and Physician Access 
Reauthorization Act (S. 948 in the 116th Congress), which among other 
improvements would allow Conrad 30 to expand beyond 30 slots per state 
if certain nationwide thresholds are met. We applaud this bipartisan 
reauthorization proposal for recognizing immigrating physicians as a 
critical element of our Nation's health care infrastructure, and we 
support the expansion of Conrad 30 to help overcome hurdles that have 
stymied growth of the physician workforce.
                          Physician Well-being
    Physicians and other health professionals dedicate their careers to 
keeping people healthy, but too often they do not receive the care they 
need to address their own well-being. AAMC data show that, like the 
overall U.S. physician population, a large percentage of medical school 
faculty have experienced higher levels of stress (particularly 
underrepresented minorities), and nearly a third of medical faculty 
face one or more symptoms of burnout. \29\ In addition to their 
detrimental effect on health professionals and their families, burnout, 
stress, and other behavioral health issues negatively affect patient 
care, patient experience, and overall health outcomes.
---------------------------------------------------------------------------
    \29\  https://www.aamc.org/system/files/reports/1/
february2019burnoutamongusmedicalschoolfaculty.pdf.

    There are numerous systemic and other sources for the high levels 
of stress and burnout that have long plagued health professionals, and 
the COVID-19 pandemic is only exacerbating the problem. Yet, stigma, 
bias, and other barriers can hinder health professionals from seeking 
and receiving care for new or ongoing mental and behavioral health 
---------------------------------------------------------------------------
challenges.

    The AAMC has endorsed the Dr. Lorna Breen Health Care Provider 
Protection Act (S. 610), which would take steps to reverse these 
troubling trends through investments to prevent suicide, reduce 
burnout, and promote care for mental and behavioral health conditions 
among health care professionals. While the ability of any single 
educational intervention on its own to overcome pervasive systemic 
challenges is limited, we believe that the bill's grants to help train 
health professionals in strategies to reduce stress and burnout would 
represent an important effort to raise awareness among health care 
professionals about the need to prioritize their well-being, 
particularly if teaching hospitals also are eligible for such awards. 
We also appreciate the inclusion of grants to promote use of mental and 
behavioral health care services among health professionals and the 
bill's two studies to identify the factors contributing to such 
challenges and evidence-based best practices for reducing and 
preventing self-harm and burnout.

    In addition to support for this important legislation, the AAMC is 
also part of the National Academies of Medicine's Action Collaborative 
on Clinician Well-being and Resilience, which aims to expand our 
understanding of the factors affecting clinician well-being and promote 
evidence-based solutions to address clinician stress and burnout.
                               CONCLUSION
    The AAMC appreciates the subcommittee's attention to the important 
topic of physician workforce shortages and the challenges the country 
faces. We believe there must be a private-public, multipronged approach 
to bolstering the physician workforce and the diversity of the 
physician workforce. Academic medicine is committed to working to 
address the challenges and has made significant investment in both 
these areas. At the same time, we believe there must be a corresponding 
increase in the Federal Government's investments for a variety of 
Federal programs that are already working. The cost of inaction today 
will result in higher costs and a less healthy population tomorrow. We 
look forward to continuing to work with you and the Senate HELP 
Committee to achieve this goal. If you have any further questions 
please contact me or Matthew Shick, Senior Director, AAMC Government 
Relations.
                                 ______
                                 
    The Chairman. Dr. Skorton, thank you very much.
    Our next witness is Dr. Leon McDougle. Dr. McDougle is the 
121st President of the National Medical Association, and the 
first African American professor with tenure in the Ohio State 
University Department of Family Medicine.
    Dr. McDougle, thanks so much for being with us.

  STATEMENT OF LEON MCDOUGLE, M.D., MPH, PRESIDENT, NATIONAL 
              MEDICAL ASSOCIATION, COLUMBUS, OHIO

    Dr. McDougle. Hello. I want to thank the Chairman, Senator 
Bernie Sanders, and Ranking Member, Senator Susan Collins, and 
other Members of the Subcommittee for the opportunity to 
discuss the healthcare workforce crisis facing U.S. 
communities.
    The COVID-19 pandemic has served as a stress test for 
communities made vulnerable by racism, bias, geography, 
disability, and socioeconomics. Improving social determinants 
of health, primary care access, and workforce diversity are 
central to any solutions that enable communities to overcome a 
failed stress test and barriers to health equity.
    We know that primary care access results in cost savings 
and improved health disparities and outcomes. Well, why is 
that? Primary care physicians take a person-focused, as opposed 
to disease-focused, approach to healthcare. Rural and urban 
populations with higher ratios of primary care physicians have 
lower rates of mortality for all causes.
    The supply of primary care physicians also improves 
disparities and health outcomes related to income inequality. 
In addition, after controlling poor income, inequality, and 
socioeconomic characteristics, a higher supply of primary care 
physicians is associated with a four-times greater lowering of 
total mortality among African Americans.
    In regards to specialty selection and healthcare access, we 
know that African American, Hispanic/Latino, and American 
Indian physicians are more likely to become primary care 
physicians and provide care in underserved communities.
    Ranked No. 1, No. 2, and No. 3, Morehouse School of 
Medicine, Meharry Medical College, and Howard University 
College of Medicine have the highest social mission scores for 
medical schools. The combined composite, taking into account 
the percentage of graduates who practice primary care, work in 
health professional shortage areas, and who are 
underrepresented in medicine.
    Proposed remedies. Yes, I am in agreement with everyone 
here. Priority should be given to funding more primary care GME 
positions for hospitals within rural and urban health 
professional shortage areas, or medically underserved areas.
    Yes, priority should also be given to funding more primary 
care GME positions for hospitals affiliated with medical 
schools with higher social mission scores.
    In addition, I want to focus on a program that the National 
Medical Association and the Association of American Medical 
Colleges have collaborated on. It is the Action Collaborative 
for Black Men in Medicine. A recent study revealed that the 
percentage of Black men who were physicians has remained at 
about 2.6 percent for the past 80 years.
    In closing, thank you for providing me the opportunity to 
offer my thoughts and suggestions to improve the healthcare 
crisis in this Country so that all of our communities can 
benefit from accessible and empathetic healthcare. The National 
Medical Association stands ready to assist you in any way that 
we can to achieve this goal.
    [The prepared statement of Dr. McDougle follows:]
                  prepared statement of leon mcdougle
    My name is Dr Leon McDougle. I am the 121st President of the 
National Medical Association, Professor of Family Medicine and Chief 
Diversity Officer for the Ohio State University Wexner Medical Center. 
The views I express in this testimony are my own and should not be 
construed as representing any official positon of the National Medical 
Association or the Ohio State University.

    I want to thank the Chairman, Senator Bernie Sanders, and Ranking 
Member, Senator Susan Collins, and other Members of the Subcommittee 
for the opportunity to discuss the health care workforce crisis facing 
U.S. communities.

    The COVID-19 pandemic has served as a stress test for communities 
made vulnerable by racism, bias, geography, disability, and 
socioeconomics. Improving social determinants of health, primary care 
access and workforce diversity are central to any solutions that enable 
communities to overcome a failed stress test and barriers to health 
equity.

        1. Primary care cost savings and improved health disparities 
        and outcomes:

                (A) Primary care physicians take a person-focused, as 
                opposed to disease-focused approach to health care. \1\ 
                Communities with higher ratios of primary care 
                physicians have much lower total health care costs, 
                partly because of better preventive care and lower 
                hospitalization rates. \2\
---------------------------------------------------------------------------
    \1\  Starfield B. Family Medicine Should Shape Reform, Not Vice 
Versa. Fam Pract Manag. 2009 Jul-Aug;16(4):6-7. https://www.aafp.org/
fpm/2009/0700/p6.html.
    \2\  Starfield B, Shi L, Macinko J. Contribution of Primary Care to 
Health Systems and Health. Milbank Q. 2005 Sep; 83(3): 457-502. https:/
/www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/.

                (B) Rural and urban populations with higher ratios of 
                primary care physicians (defined as family physicians, 
                general internists, and general pediatricians) have 
                better health outcomes, including lower rates of 
                mortality for all causes, heart disease, cancer, 
                stroke, infant mortality, low birth weight, and poor 
---------------------------------------------------------------------------
                self-reported health.

                (C) The supply of primary care physicians also improves 
                disparities in health outcomes related to income 
                inequality. In addition, after controlling for income 
                inequality and socioeconomic characteristics 
                (metropolitan area, education level, and percent 
                unemployed) a higher supply of primary care physicians 
                is associated with a four times greater lowering of 
                total mortality among African Americans as compared to 
                the white majority population.

                (D) In regard to specialty selection, 45 percent of 
                Black physicians, 43 percent of Hispanic/Latino 
                physicians, 46 percent of American Indian physicians, 
                and 41 percent of Asian physicians were practicing 
                primary care as compared to 35 percent of White 
                physicians. \3\
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    \3\  AAMC Analysis in Brief. Analyzing Physician Workforce Racial 
and Ethnic Composition Associations: Physician Specialties (Part I). 
Volume 14, Number 8. August 2014. https://www.aamc.org/media/7616/
download.

                3(E) In regard to health care access, nearly 50 percent 
                of Black, Hispanic/Latino, and American Indian 
                physicians were practicing in primary care Health 
                Professional Shortage Areas or Medically Underserved 
                Areas as compared to 33 percent of Asian physicians and 
                38 percent of White physicians. \4\
---------------------------------------------------------------------------
    \4\  AAMC Analysis in Brief. Analyzing Physician Workforce Racial 
and Ethnic Composition Associations: Geographic Distribution (Part II). 
Volume 14, Number 9. August 2014. https://www.aamc.org/media/7621/
download.

                (F) Ranked number 1, 2 and 3, Morehouse School of 
                Medicine, Meharry Medical College and Howard University 
                College of Medicine, have the highest social mission 
                scores for medical schools. The combined composite 
                taking into account the percentage of graduates who 
                practice primary care, work in Health Professional 
                Shortage Areas, and who are underrepresented in 
                medicine, form the social mission score. \5\
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    \5\  Mullen F, Chen C, Peterson S, Kolsky G, Spagnola M. The Social 
Mission of Medical Education: Ranking the Schools. Ann Intern Med. 
2010;152:804-811.

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        2. Proposed remedies for primary care crisis:

                (A) Increase access to primary care, mental health and 
                dental services by establishing more federally 
                Qualified Health Centers in rural and urban health 
                professional shortage areas and medically underserved 
                areas and populations.

                (B) Fund additional Graduate Medical Education (GME) 
                residency positions to support training of primary care 
                residents/fellows who agree to a service obligation in 
                a Health Professional Shortage Areas or Medically 
                Underserved Areas or Populations after completion of 
                residency/fellowship training.

                Priority should be given to funding more primary care 
                GME positions for hospitals within rural and urban 
                health professional shortage areas or medically 
                underserved areas and populations.

                Priority should also be given to funding more primary 
                care GME positions for hospitals affiliated with 
                medical schools with higher social mission scores.

                Require all persons involved with GME selection of 
                residents and fellows, along with medical school 
                admissions committee members and application screeners 
                to undergo implicit bias awareness and mitigation 
                training and adopt holistic review best practices.

                (C) Support HRSA programs such as the Health Career 
                Opportunity Program and Center of Excellence grants and 
                Scholarships for Disadvantaged Students to ensure 
                sustainability and growth of a diverse health care 
                workforce.

                (D) Incentivize universities and medical schools to 
                partner with under-resourced urban and rural school 
                systems to establish K-12 health sciences academies to 
                increase the number students from disadvantaged 
                backgrounds, (e.g. homeless, in foster care, or qualify 
                for a free or reduced-priced lunch in elementary or 
                high school, whose parents never graduated from 
                college, persons with a disability) entering physician, 
                biomedical science, and other health professions 
                careers.

                (E) Involve residents of HPSA and MUA/P neighborhoods 
                in decisions about those who best provide needed 
                resources or attributes in their communities when 
                determining recipients of National Health Service Corps 
                Scholarships.

                (F) Expand the number of National Health Service Corps 
                Scholarships and provide additional incentives for 
                physicians to remain in the community once their 
                obligated service time has expired.

                (G) Expand National Health Service Corps loan repayment 
                availability as an additional incentive for physicians 
                to remain in the community once their obligated service 
                time has expired.

                (H) Establish HRSA funding to support the Association 
                of American Medical Colleges (AAMC) and National 
                Medical Association (NMA) Action Collaborative for 
                Black Men in Medicine. A recent study of the historical 
                trends of African American physicians from 1900 to 
                2018, revealed that the percentage of physicians who 
                were African American has increased by only 4 percent 
                in 120 years, from 1.3 percent in 1900, 2.8 percent in 
                1940 to 5.4 percent in 2018. \6\
---------------------------------------------------------------------------
    \6\  Ly DP. Historical Trends in the Representativeness and Incomes 
of Black Physicians, 1900-2018. J Gen Intern Med. 2021 Apr 19. doi: 
10.1007/s11606-21-06745-1. https://www.newswise.com/pdf-docs/
161860566877749-LyJGIM-4-19-21.pdf.

        In addition, the percentage of African American men who were 
        physicians has remained about 2.6 percent for the past 80 
        years. https://www.aamc.org/what-we-do/diversity-inclusion/
---------------------------------------------------------------------------
        action-collaborative-black-men-medicine.

                (I) Support THE ANTI-RACISM IN PUBLIC HEALTH ACT OF 
                2021

                        Y  Create a ``National Center for Anti-Racism'' 
                        at the Centers for Disease Control and 
                        Prevention (CDC).

                        Y  Create a Law Enforcement Violence Prevention 
                        Program within the National Center for Injury 
                        Prevention and Control at the CDC.

    In closing, thank you for providing me the opportunity to offer my 
thoughts and suggestions to improve the health care crisis in this 
country so that all of our communities can benefit from accessible and 
empathetic health care. The National Medical Association stands ready 
to assist you in any way that we can to achieve this goal.
                                 ______
                                 
    The Chairman. Well, Dr. McDougle, thanks very much for your 
comments.
    Now I would like to welcome our next witness, Ms. Shelley 
Spires.
    Ms. Spires.
    [Brief silence]
    The Chairman. Ms. Spires, we cannot hear you. You are on 
mute.
    Ms. Spires. Sorry.
    The Chairman. Okay.

 STATEMENT OF SHELLEY SPIRES, CHIEF EXECUTIVE OFFICER, ALBANY 
              AREA PRIMARY HEALTH CARE, ALBANY, GA

    Ms. Spires. Good morning, Chairman Sanders, Ranking Member 
Collins, and Members of the Subcommittee. Thank you for 
inviting me to speak to you today on this very important topic.
    I am here today on behalf of the Association of Clinicians 
for the Underserved, known as the ACU, as a member of its board 
of directors. The ACU is a non-profit, transdisciplinary 
organization of clinicians, advocates, and healthcare 
organizations united in common mission to improve the health of 
America's underserved populations, and to enhance the 
development and support of the healthcare clinicians serving 
these same populations.
    I am the CEO for Albany Area Primary Health Care in Albany, 
Georgia. We serve over 45,000 patients.
    Prior to serving as CEO, I spent most of my career in human 
resources, which has allowed me to have experience at 
delivering care to the underserved and recruiting and retaining 
the workforce to support these needs.
    Three things that I would like to talk about today that can 
work as a foundation to my experience is, one, the people who 
do this work are committed, they are mission-driven, and they 
are dedicated. The patients who receive the care, they are 
resilient, smart, and inspiring. Federal support for these 
people are critical and pays huge dividends.
    Let me give you a little more detail about each of these.
    I tell you about the people that are committed, mission-
driven, and dedicated. It makes more sense to kind of give you 
some ideas about the realities of working in an underserved 
population.
    Many patients have a chronic condition, sometimes untreated 
and neglected. This makes for a more intense and long, ongoing 
complex care given to this complexity of patients.
    High numbers of our patients are low income and living in 
poverty. Ninety-one percent of health center patients are at or 
below 200 percent of the Federal poverty level.
    Most of our patients are members of ethnic and racial 
minority groups. This supports the fact that culturally 
competent care is vital to effectively care for their specific 
needs.
    Working in systems of high quality, patient-centered work 
surrounded by colleagues that share the same goals and mission 
has defined the Association of Clinicians for the Underserved. 
Being a board member, that is one of the things that drove me 
to providing a service under the board based on the fact that 
we spearhead advocacy for the National Service Corps and 
support the workforce retention and recruitment efforts.
    The term ``burnout'' among healthcare providers was a huge 
topic prior to COVID. It did not go away. Unfortunately, those 
new demands placed on providers as a result of the pandemic 
have only exasperated the impact of burnout.
    While burnout is important overall with a real impact on 
staff retention, the other side of the human capital coin is 
recruitment. Recruiting staff to work in underserved areas is, 
in a word, tough. This goes for all staff, and particular 
focusing on clinical staff.
    The good news is we have existing programs that help with 
these challenges, but these systems could always have some 
additional investment. Among the programs that can always 
benefit from more investment that can provide a substantial 
return are your National Service Corps and your Nurse Corps 
programs. Since its inception in 1972, the NHSC has expanded 
not only in numbers of clinicians, but the types of clinicians, 
which shows we continue to adapt to the needs of the healthcare 
system, which is reflected in its workforce.
    While there are countless examples of the National Service 
Corps and what it has done for addressing the workforce 
shortages, it is vital to recognize that the health equity and 
health equality are key components of Federal health policy. 
The NHSC is an important vehicle to achieve these goals by 
delivering services to our underserved areas and through the 
workforce that delivers these services.
    Ensuring greater racial and ethnic diversity of the 
healthcare workforce is essential for increasing access to 
culturally competent care for all of our Nation's communities. 
Just to give a better context or better picture, the latest 
data shows African Americans make up 6 percent of the U.S. 
physicians; 4.4 percent Hispanic and Latino. This data in 
contrast to the Corps' demographics is 7.2 percent African 
Americans; 18.2 percent Hispanic and Latino.
    Unfortunately, historically, there has been insufficient 
funding to support all clinicians who are interested in the 
National Service Corps. In recent years, 10 percent were 
awarded the scholarship. Forty percent were awarded loan 
repayment programs. The result aided in not being able to fund 
applicants in some of America's most neediest communities.
    While the current field strength of the NHSC is greater 
than 16,000, serving more than 16 million people, there is 
still a shortage. Statistics indicate that nearly 33,000 
additional clinicians across disciplines are needed to care for 
hundreds of millions of people who reside in these shortage 
areas.
    Another component is our THCs, our teaching health centers. 
They are located in community-based, ambulatory care settings 
and serve a large number of Medicaid patients. It has been 
stated many times before, people who train in these underserved 
areas are likely to remain in practice in the same similar 
setting, remembering that residency often trains individuals 
and predicts the practice style regarding quality and cost.
    I would also like to call your attention to barriers to 
some of the other issues that we face in recruiting healthcare 
professionals--behavioral health. Most FQHCs and RHCs are not 
positioned financially to take on such large salaries. This 
salary is very hard to offset when you are serving underserved, 
uninsured, and an underinsured population. These are the people 
in most need.
    I happened to have at least four psychiatrists to interview 
and decline due to salary. The interest is there because of the 
mission of what we do, but the salary is the barrier. 
Colleagues across the Country continue to collaborate on ideas 
how to share resources to meet these needs.
    I would like to leave you with just a few concrete 
suggestions and actions for Congress.
    Increase funding for National Service Corps and Nurse 
Corps. We estimate total annual program costs for the NHSC to 
be $1.5 billion, taking into account existing funding and 
minimum of 400 million in Fiscal Year 2022. Annual 
appropriations is needed in order to address the need.
    Support the creation of state loan repayment and increase 
funding or re-appropriate funding for teaching health centers. 
The NHSC program has proven time and time again to be an 
effective program.
    I appreciate the opportunity to testify before you today, 
and thank you for recognizing the urgent need that we face 
amongst our workforce.
    [The prepared statement of Ms. Spires follows:]
                  prepared statement of shelley spires
    Chairman Sanders, Ranking Member Collins, and Members of the 
Committee.

    Thank you for inviting me to speak to you today on this very 
important topic. My name is Shelley Spires, I am here today on behalf 
of the Association of Clinicians for the Underserved--the ACU--as a 
member of its Board of Directors. The ACU is a non-profit, 
transdisciplinary organization of clinicians, advocates and health care 
organizations united in a common mission to improve the health of 
America's underserved populations and to enhance the development and 
support of the health care clinicians serving these populations. I am 
also the Chief Executive Officer of Albany Area Primary Health Care, 
Inc., a rural federally Qualified Health Center serving over 45,000 
patients in Albany, Georgia. Prior to serving as CEO, I spent most of 
my career in human resources at the same institution. My professional 
experience has made me an expert at delivering care to the underserved 
and recruiting and retaining the workforce to support these efforts.

    To begin, I'd like to share three important things that are 
foundational to my experience serving the underserved:

        The people who do this work are committed, mission driven and 
        dedicated.

        The patients they care for are resilient, smart, and inspiring.

        Federal support for all of these people is critical and pays 
        huge dividends.

        Let me give you a little more detail about each of these.

    The people who do this work are committed, mission driven and 
dedicated. In my experience working at the health center, I've 
witnessed this more times than I can count, but most recently with the 
pandemic. While the Albany area had numerous private outpatient 
practices close their doors due to the risk of the pandemic, AAPHC kept 
our doors open to continue serving patients. One of the critical 
resources that enabled us to continue to do that successfully is our 
providers. Our providers understand what it means to address a 
situation head on instead of running from it. They were troopers and 
were standing strong on the front lines of this pandemic battle we were 
fighting and continue to fight to this day.

    When I tell you that the people who do this work are committed, 
mission driven and dedicated, it may be helpful for me share a more 
about the realities of working in and with underserved populations. 
Many patients live with chronic conditions, sometimes long untreated or 
neglected, making their initial care more intensive and their ongoing 
care more complex. High numbers of our patients are low income or 
living in poverty. Nationally more than 91 percent of health center 
patients are at or below 200 percent of the Federal poverty level. Most 
of our patients are members of ethnic and racial minority groups. This, 
along with many other factors, makes culturally competent care 
absolutely vital to understanding and effectively caring for their 
specific needs. In my own community, we witness these and other 
realities on a daily basis. In fact, during a vicious COVID outbreak 
early on in the pandemic, our community faced incredible hardship. 
People were dying every day, we had an employee and spouses of 
employees die, and yet we stood strong. My team pulled together to 
eliminate barriers, use innovative ideas to continue caring for our 
patients, and made sure that the quality of care never deteriorated. At 
the end of the day, it was our team, our model of patient centered 
care, and our commitment to our collective mission to care for those in 
need that carried us through one of the worst challenges we have faced.

    Working in systems that support high quality, patient-centered 
work--surrounded by a network of colleagues with shared ideals and 
goals--has defined the Association of Clinicians for the Underserved 
since its inception. This is part of what drew me to join the Board of 
ACU and it is these shared ideas and goals have driven ACU to lead and 
spearhead advocacy for the National Health Service Corps (NHSC), to 
support workforce retention and recruitment. The NHSC has always been 
an invaluable tool for recruitment and retention of clinicians to 
underserved areas. However, it is worth noting that as the health care 
system has evolved, so too have the demands placed on clinicians. These 
demands are evident in the needs of the patients and the requirements 
in the way that they provide care.

    The term ``burnout'' among healthcare providers was a huge topic of 
discussion prior to COVID. It did not go away during the pandemic. 
While health care providers may have forced the burnout that existed 
prior to COVID into the background as the pandemic provided a big shot 
of adrenaline, the longstanding burnout problem lingered, and the new 
demands placed on providers as a result of the pandemic exacerbated the 
impact of burnout. While the light at the end of the tunnel *may* be in 
sight for COVID, the pandemic of provider burnout continues and is 
likely to strike our health care workforce with a vengeance. We are 
already seeing this and in fact, burnout is now a bona fide medical 
diagnosis. The World Health Organization has noted that the syndrome of 
burnout is characterized by three dimensions: (1) feelings of energy 
depletion or exhaustion; (2) increased mental distance from one's job, 
or feelings of negativism or cynicism related to one's job; and (3) 
reduced professional efficacy.

    Burnout has an impact on patient care: it not only produces less 
engaged employees, but also is linked to reduced patient satisfaction, 
reduced quality and value of care that is delivered--and it increases 
the risk for a healthcare error or mistake. Burnout costs our 
healthcare system millions of dollars, a cost that is well beyond the 
loss of organizational knowledge that results from employee change. We 
need serious efforts to measure--and perhaps mitigate--burnout 
recognizing all of these impacts. Patients are also beginning to demand 
that the problem be addressed. They simply want safe more engaged care, 
delivered by more empathetic care teams, something all of us should 
want.

    While burnout is important overall, with a real impact on staff 
retention, the other side of the human capital coin--recruitment--is 
also difficult in the underserved setting. Recruiting staff to work in 
underserved areas is, in a word: tough! This goes for all staff, with a 
particular focus on our clinical staff. New graduate family practice, 
internal medicine or pediatric physicians, many with an average of 
125,000 dollars in debt, can work in a hospital and make 30-40 thousand 
dollars a year more compared to what we can offer in a community health 
center. Market forces, in general, don't lift up the underserved.

    I can speak to the challenges of recruitment and retention, both in 
my current capacity as CEO and in my experience in my former position 
with HR. Challenges that come with rural areas include the geographic 
location, a lack of many services and amenities that new, younger 
providers are looking for, the burden of student debt, and the need to 
understand our population. I make a conscious effort to pay attention 
to my providers and what they are telling me about ``burnout''. I have 
spent time over the last couple of years trying to develop systems that 
allow us to work smarter and not harder. Trying to research ways to 
make patient care, patient flow, and the clinic environment a place 
that my staff enjoy coming to work. There is a lot of stress associated 
with the underserved population--high risk patients, managing multiple 
chronic illnesses with limited resources, and documenting in an 
Electronic Medical Record.

    The good news is that we have existing, functional programs that 
can help with recruitment, retention, and workforce shortages, but 
these systems need additional investment.

    Among the programs that can always benefit from more investment and 
can provide a substantial return on that investment are the National 
Health Service Corps (NHSC) and Nurse Corps programs. Since its 
inception in 1972, the NHSC has expanded not only in numbers of 
clinicians but also in types of clinicians. Notably, the Corps--which 
initially counted physicians as its dominant workforce component--now 
counts behavioral health clinicians as its largest workforce component. 
In 2009, a majority of the Corps was physicians (35 percent); in 2017, 
behavioral health providers made up the majority of clinicians in the 
NHSC (30 percent), with nurse practitioners taking second place at 23 
percent and physician participation down to 20 percent. The NHSC 
continues to adapt to the needs of the U.S. healthcare system and 
reflects that in its workforce.

    Over the past several years the program has expanded to respond to 
national crises such as the Zika outbreak (in 2017) and the substance 
abuse disorder crisis (in 2019). What began as one program--a 
scholarship program--now encompasses six complementary but distinct 
opportunities to serve under the NHSC: The scholarship program and 
multiple loan repayment programs including the students to service 
program.

    While there are countless examples within the NHSC that can be 
cited to highlight its long-standing record of success in addressing 
workforce shortages in medically underserved areas, it's vital to 
recognize that health equity and health equality are key components of 
Federal health policy. To this end, the NHSC is an important vehicle to 
achieve these goals: both by delivering services to underserved areas, 
and through the workforce that delivers these services. A study by the 
Robert Graham Center documenting the impact that the NHSC has had on 
health equality during its first 30 years showed that the NHSC has 
assigned its resources preferentially--and delivered its most 
consistent service--to counties with large minority populations.

    Ensuring greater racial and ethnic diversity of the health care 
workforce is essential for increasing access to culturally competent 
care for all of our Nation's communities. A more diverse workforce 
delivers better results in many settings, including healthcare 
settings, and is better suited to meeting the overall needs of our 
Nation's diverse population, particularly in the most underserved 
areas. Historically and currently, many racial and ethnic and minority 
groups are underrepresented nationally within the major health 
professions. As a result, the NHSC is a success story and is deliberate 
in continuing its work to increase the number of minority clinicians.

    To provide greater context to the present statistics on clinical 
workforce diversity, the latest data available shows that African 
Americans make up 13 percent of the U.S. population but they comprise 
only 6.9 percent of U.S. advanced practice nurses (nurse practitioners 
and nurse midwives) and 4 percent of U.S. physicians. Of actively 
practicing advanced practice nurses in the US in 2018, 81.8 percent 
were white, 7.9 percent were Asian and 0.2 percent were American Indian 
or Alaska Native. Data on practicing physicians in the United States in 
2013 showed that 48.9 percent were white, 11.7 percent were Asian, 4.4 
percent were Hispanic or Latino, and 0.4 percent were American Indian 
or Alaska Native. These statistics are in contrast to the composition 
of the NHSC: 13 percent are African American, 10 percent are Hispanic, 
7 percent are Asian or Pacific Islander, and 2 percent are American 
Indian or Alaska Native.

    In the Corps' physician workforce, in 2016, African American 
physicians accounted for 17.2 percent and Hispanic or Latino physicians 
18.2 percent. Unfortunately, there are no currently available workforce 
data on national estimates of LGBTQ+ or other under-represented 
minority groups. Historically there has been insufficient funding to 
support all clinicians interested in participating in the NHSC. In 
recent years an average of just 10 percent of Scholarship Program 
applicants 40 percent of Loan Repayment Program applicants have been 
funded. There remains a large gap in terms demand versus opportunity. 
The result is that with large numbers of applicants not being funded, 
thousands of positions needed to provide clinical care to America's 
neediest communities remain unfilled. In 2018, there were nearly 5,000 
open NHSC-approved positions in Health Profession Shortage Areas across 
the country that remained unfilled due to inadequate field strength--
this has been a persistent problem each year since.

    While the current field strength of the NHSC is greater than 
16,000, which serves more than 16 million people, severe workforce 
shortages persist in every corner of the Nation. The most recent 
Designated Health Profession Shortage Area Statistics indicate that 
nearly 33,000 additional clinicians across disciplines are needed to 
care for hundreds of millions of people who reside in health profession 
shortage areas. While we are incredibly grateful for the infusion of 
funding invested into the NHSC through the American Recovery Act, much 
more needs to be done to truly address the clinical workforce shortages 
that remain.

    In addition to the NHSC, there are other programs worth considering 
as a part of the solution in addressing workforce shortage issues 
across the Nation. For example, the Federal Government also oversees 
graduate physician training--so called Graduate Medical Education, or 
GME. A Government Accountability Office report in 2017 showed that 
training of residents remains concentrated in urban areas, which 
continued to account for 99 percent of residents, despite some growth 
in rural areas from, 2005 through 2015. Given that many residents stay 
in the same communities where they train, investment of GME dollars 
both for rural hospitals, but also for primary care training, is 
critical. But investing in hospital-based training programs--where many 
hospitals train residents in traditionally primary care specialties 
like internal medicine or pediatrics--is not a complete solution to 
this problem. Most of these residents go on to specialize, and 
hospitals are not required to track and report on career paths of 
graduates who work in primary care or underserved settings.

    Another component needed to create a workforce dedicated to the 
underserved is further investment in teaching health centers (THCs). 
Initially supported under the ACA, the Teaching Health Centers program 
began development and evaluation in 2011, and now exist in a majority 
of states and train close to 1,000 residents a year.

    THC programs are located in community-based ambulatory care 
settings and serve a large number of Medicaid patients. From a 
workforce perspective, those who train in these underserved areas are 
likely to remain in practice in the same or similar settings, with 
location of residency training often predicting practice style 
regarding quality and cost. If additional Medicare GME funding was 
unavailable, reallocating approximately 5 percent of the current $6.5 
billion per year that funds Centers for Medicaid and Medicare Services 
indirect medical education would achieve budget neutrality to expand 
THCs significantly. There is a real opportunity to impact CMS deciding 
on GME slots that benefit the national need, and not just slots that 
generate higher incomes for academic medical centers.

    I would also call to your attention to some state laws that provide 
barriers to care, especially behavioral health care, at a time in our 
Nation when the behavioral health crisis is worsening every day. In 
many states, laws or regulations require organizations to employ a 
psychiatrist to oversee behavioral health programs. This needs to 
change and no longer be a requirement in any state. While it is true 
that all behavioral health clinics would benefit from psychiatrist 
oversight, recruiting one and retaining one even for several hours a 
week is a barrier to care. We have seen, during the COVID public health 
emergency, that overdoses have increased, and mental health has 
worsened. There is a national psychiatric prescriber shortage. When 
these providers can--and often do--make $200 an hour in private 
practice, it is all but impossible for a community health center to 
recruit a psychiatrist even with a starting salary of $250,000 and loan 
repayment opportunities. The result is that there are no behavioral 
health programs at many institutions that need them, effectively 
restricting access to care for thousands upon thousands of high need 
individuals.

    This issue is one that is very real to Albany Area Primary Health 
Care. The conversation around Behavioral Health and the needs in our 
area and our country is continuous. Most federally Qualified Health 
Centers and Rural Health Centers are not financially sound enough to 
take on a salary for a Psychiatrist. This salary is very hard to offset 
when you are serving underserved, uninsured, and underinsured 
populations. These are the people who need it most and we struggle to 
meet the needs. I have had at least four Psychiatrists interview and 
ultimately decline an offer due to the salary. I can get them to 
interview because of their interest in the mission of our organization, 
but the salary is always insufficient to keep them. I and my colleagues 
across the country continue to try and be innovative and creative with 
trying to meet these needs through collaborations and partnerships 
because we believe persistence pays off. However, my goal is to hire a 
psychiatrist to be a part of our team and the challenges in doing so 
remain significant and unrelenting.

    Toward this same end, we need HRSA to change how it makes program 
awards. At present, awards are made on an annual basis. This is 
convenient for the government but does not address the real world of 
provider recruitment in the field. You see, when I try to hire new 
graduate doctors, perhaps I can offer $30,000 in loan repayment, IF 
they apply AFTER I hire them and IF that loan gets granted 6 months 
down the road. My competition for that newly minted doctor is the local 
hospital, which can guarantee prior to signing an extra $30,000 loan 
repayment, and a higher salary. This is all done in an age where 
twenty-somethings can get whatever they want delivered to their 
doorstep in a day. The competition has changed. We need systems to 
change to support this.

    Again, to give you a personal example of the reality of what this 
challenge looks like in practice, I have had a couple of physicians 
that declined our offer due to the competition offering a sign on bonus 
(which would equate to loan repayment), pay off their loans to relieve 
the interest, and commit to a 5-year contract. FQHC's just do not have 
that kind of money, so the idea of creating more than one application 
cycle would be a fabulous way to market our organization and clinicians 
wouldn't have to wait for the reward and can prevent the interest from 
accruing while awaiting the award.

    I'd like to leave you with some concrete suggestions of actions 
that Congress can take to make a noticeable, needed, and meaningful 
impact to address the Nation's workforce shortage and to support people 
in underserved areas:

        1. Increase funding for the national health service corps and 
        nurse service corps. We estimate total annual program cost for 
        the NHSC to be $1.5 billion. Taking into account funding 
        already in place for the NHSC, $310 million in mandatory 
        funding and $800 million via the American Recovery Act, a 
        minimum of $400 million in fiscal year 2022 annual 
        appropriations is needed in order to address existing need 
        within health profession shortage areas.

        2. Support the creation of state loan repayment programs in all 
        states and territories with dedicated funding to enhance 
        workforce recruitment and retention on a state-by-state basis.

        3. Increase funding, or reappropriate funding, for Teaching 
        Health Centers to at least double the size of the program and 
        corresponding funding in the coming year.

        4. Congress passed a historic increase to the Medicare graduate 
        medical education (GME) program at the close of last year--the 
        first increase to the program in nearly 25 years. The expansion 
        was part of the year-end Consolidated Appropriations Act, 2021. 
        The legislation includes 1,000 new Medicare-supported GME 
        positions. Congress should direct future expansions to 
        enhancing the primary care and behavioral health workforce.

        5. Allow providers working in an FQHC the ability to waive DEA 
        fees--this could be modeled from the present Veteran's 
        Administration (VA) system.

        6. Similarly, consider expanding the VA approach and policy to 
        redeploy workforce to areas of need via telemedicine, apply the 
        same concept to support areas of higher need for the 
        underserved. Unfortunately, cross-state licensure as well as 
        payer reimbursement prohibits this at present.

        7. Allow federally qualified health centers to participate in 
        government supported insurance programs. Many health centers 
        that serve the underserved are smaller organizations and are 
        forced to spend a significant amount of operational dollars on 
        health insurance. Allowing FQHCs the opportunity to participate 
        in government support insurance programs would enable these 
        health centers to invest a greater percentage of their 
        operating revenue in salaries for recruitment and retention.
                               Conclusion
    As a nation we are facing an urgent and critical issue with 
clinical workforce shortages, one that is predicted to worsen in the 
coming years. The Association of American Medical Colleges predicts 
that we will see a shortage of up to 55,000 primary care clinicians 
within the next 10 years--this is to say nothing of the damages and 
additional strain placed on primary care workforce as a result of the 
pandemic and chronic burnout faced by countless numbers of providers. 
Today, more than 16,000 NHSC clinicians serve 16 million people across 
the country. I stand before you as someone who has personally witnessed 
the incredible impact, value and effectiveness of this program. We are 
hopeful that we can strengthen and grow the National Health Service 
Corps and other key programs to help address the urgent need of 
millions of people who need access to primary health care services.

    Let us all take a moment to remember that these people have faces 
and names, they have families and children, and they have hopes and 
dreams. These are the people and patients we care for every day at 
Albany Area Primary Health Care. They are our neighbors. They are your 
constituents. They are the babies that our team welcomes to this world, 
they are the hands we hold as they manage their chronic illnesses and 
persevere, and they are the faces we hold in our hearts as they make 
their final transition from this life. The NHSC program has proven time 
and time again to be an effective program. I can assure you as someone 
working in an underserved community to care for those in need, in my 
opinion, the NHSC is one of the best programs this country has devised 
to incentivize primary care medical providers to be able to choose 
primary care and to serve in underserved communities. I appreciate the 
opportunity to testify before you today. We thank you for recognizing 
the urgent need to do more to address the Nation's clinical workforce 
shortages and making the National Health Service Corps a priority as we 
work collectively to solve this critical issue. I would be glad to 
answer any questions you may have.
                                 ______
                                 
    The Chairman. Well, thank you very much, Ms. Spires.
    Senator Collins will introduce the next panelist.
    Senator Collins. Thank you, Mr. Chairman.
    I am delighted to introduce Dr. James Herbert of the 
University of New England, who is here to testify. He is the 
sixth president of the University of New England. During his 
tenure, UNE has launched a Center for Excellence in Public 
Health, which has strengthened its partnership with external 
clinical partners and has built a health workforce pipeline to 
underserved areas in New England.
    He has a long and distinguished record. He is an 
internationally renowned psychologist who has done research 
into the treatment of mood and anxiety disorders and is a 
fellow of the Institute for Science and Medicine, the 
Association for Contextual Behavioral Science, and several 
other groups.
    I am going to stop so that he can get to his testimony. 
But, suffice it to say that we are delighted to have him 
leading UNE in the State of Maine and here with us today.

STATEMENT OF JAMES D. HERBERT, PH.D., PRESIDENT, UNIVERSITY OF 
            NEW ENGLAND, BIDDEFORD AND PORTLAND, ME

    Dr. Herbert. Thank you so much, Chairman Sanders and 
Ranking Member Collins. I appreciate the kind introduction.
    Just by way of context, the University of New England is 
Maine's largest private university. We have campuses in 
Biddeford and Portland, Maine, and in Tangier, Morocco, and we 
consider ourselves--although a private university, we very much 
have a public mission.
    As you probably know, Maine has the oldest population in 
the Nation, and we are tied with Vermont as being the most 
rural state. We also have one of the oldest healthcare forces 
in the Nation, and the challenges that we face in Maine are 
harbingers of what the rest of the Country is not only facing, 
but will increasingly face as our Nation ages and as 
urbanization creates pockets of need not only in urban areas, 
but especially in our remote, rural areas.
    I would like to address five specific strategies that I 
believe can go a long way to addressing the healthcare 
workforce crisis. At the University of New England, we are 
trying to act on each of these five strategies, and I would be 
happy to share any--answer any questions or share any ideas 
about what we are trying to do. But, let me hasten to add that 
I am not suggesting that we have all the answers that we 
figured it out. But, what we have found is that the key to 
moving the needle forward, regardless of strategy, are 
strategic partnerships between higher education, government, 
business, and the non-profit sector.
    The first thing we need to do--and Senator Sanders, you 
touched on this exactly--is we simply need to increase the 
number of healthcare professionals we train, including doctors. 
The single biggest challenge to doing that is the limited 
availability of clinical training opportunities, as you both 
have noted and as my fellow panelists have noted.
    As financial margins have tightened over the past three 
decades, practicing clinicians have less time to devote to 
clinical training. We must support partnerships between 
universities and healthcare systems to develop additional GME 
and other clinical training opportunities.
    Now, this is not the only infrastructure limitation. 
Standing up new educational facilities or expanding existing 
ones involves significant startup costs. This is true both in 
the case of GME, but also in the case of expanding the size of 
medical schools. For example, at UNE right now, we are looking 
to expand the size of our medical school significantly, but 
that involves building new facilities.
    The Chairman. How large is your medical school now?
    Dr. Herbert. One hundred and sixty-five, and we are looking 
to go to 200, and then a little beyond 200.
    Another barrier is the difficulty in hiring and retaining 
qualified faculty members who can typically earn more in direct 
care clinical services than they can as university professors. 
Support, such as that displayed by both of you, Senators 
Sanders and Collins, for strategic healthcare funding for 
faculty is vitally important to continuing those programs.
    The second thing we must do is we must train more 
healthcare students who look like the communities that they 
serve. It is well established that individuals from 
underrepresented groups are more likely to seek out 
practitioners who share their identities and backgrounds. 
Studies have found that minority patients who are treated by 
clinicians who look like them are more likely to use needed 
health services and less likely to delay care.
    Now, it is not enough if you both--as you have both noted, 
it is not enough to merely train more professionals. We must 
encourage them to practice in underserved areas following 
graduation, especially in rural and tribal communities. Like 
Maine, most states have vast rural areas with highly 
distributed populations, and these communities have far less 
access to healthcare.
    Programs that provide financial support in terms of loan 
repayment programs, there are Federal programs administered by 
HRSA. There are state programs, a new one in Maine. These kinds 
of programs are absolutely critical, and I thank you for your 
continued support of them.
    Fourth, we must leverage the power of technology to serve 
underserved communities. Digital health and emerging 
developments in telemedicine have enormous potential to 
transform healthcare delivery. Of course, these tools depend 
upon reliable and robust broadband systems, and I am delighted 
that the most recent COVID-19 stimulus legislation included 
funding for broadband infrastructure.
    Finally, we must fundamentally change the prevailing 
educational model. Anyone who has recently been a patient in a 
hospital or has cared for a hospitalized loved one understands 
how siloed the practice of healthcare tends to be.
    In response, a new educational model has emerged in which 
students from diverse disciplines are explicitly trained to 
work together, across traditional boundaries, in 
multidisciplinary teams. This is known as interprofessional 
education, or IPE for short, and this model has been shown to 
improve clinical outcomes, to reduce medical errors, to 
increase patient satisfaction, and to decrease provider 
burnout.
    One particular area that highlights the importance of this 
kind of collaborative, team-based approach is geriatrics. 
Diseases of aging often encompass a broad scope of conditions: 
heart disease and diabetes treated by primary care 
practitioners, isolation by social workers, oral health by 
dentists and hygienists, and so on.
    At UNE, we are weaving geriatric training throughout all of 
our healthcare professionals. So, rather than just merely 
training more geriatricians, we are weaving training in 
geriatrics and in behavioral health across all of our 
healthcare professionals in this team-based approach.
    I am pleased that working together with Maine's junior 
senator, Angus King, and the University of Maine and other 
statewide partners, we are one of 48 organizations to have 
received funding through HRSA's Geriatric Workforce Education 
program.
    In conclusion, successfully addressing America's healthcare 
workforce crisis will require not merely acting on each of 
these five strategies in isolation, but seamlessly integrating 
them. And strategic investment of resources will be required, 
but much of the work reflects cultural changes that will 
require strong leadership, a willingness to innovate, and 
coordinated partnership, again, between academia, government, 
industry, and the non-profit sector.
    I am grateful for your time and happy to address any 
questions.
    Thank you very much.
    [The prepared statement of Dr. Herbert follows:]
                  prepared statement of james herbert
    Thank you for the opportunity to speak with you today. It's a 
sincere honor to share some thoughts on strategies for addressing our 
Nation's healthcare workforce crisis.

    My name is James Herbert, and I am the president of the University 
of New England (UNE). UNE is Maine's largest private university, with 
campuses in Biddeford and Portland Maine and in Tangier Morocco. We are 
a comprehensive university that houses Maine's only medical school and 
only physician assistant program, and northern New England's only 
dental school. We're the largest provider of healthcare professionals 
to the state of Maine, \1\ and we take great pride in being a private 
university with a public mission.
---------------------------------------------------------------------------
    \1\  UNE offers programs in 14 health professions, including 
osteopathic medicine, dental medicine, pharmacy, physician assistant, 
nursing, nurse anesthesia, dental hygiene, occupational therapy, 
physical therapy, social work, nutrition, athletic training, applied 
exercise science, and public health.

    As you probably know, Maine is the oldest state in the Nation, \2\ 
and is tied with Vermont as being the most rural \3\ state. We also 
have one of the oldest healthcare workforces in the country. \4\ The 
challenges we face are in some sense harbingers of what the rest of the 
country will increasingly confront as our Nation ages and as 
urbanization creates pockets underserved populations in our cities as 
well as in our vast remote rural areas.
---------------------------------------------------------------------------
    \2\  Maine has the highest median age in the U.S.: 45.1 relative to 
the national average of 38.5 (US Census Bureau, 2019a). At 21.3 percent 
Maine also has the highest percentage of citizens over 65 in the U.S. 
(US Census Bureau, 2019b).
    \3\  US Census Bureau, 2019b
    \4\  At 36 percent, Maine ranks 5th in the Nation for the 
percentage of active physicians who are age 60 or older (AAMC, 2019). 
In 9 of 16 Maine counties, 50 percent or more of physicians are 55 or 
older (Skillman & Stover, 2018). Over 50 percent of Maine's registered 
nurses are 50 or older (Maine Nursing Action Coalition, Center for 
Health Affairs NEONI, 2017). Approximately 60 percent of Maine's 
dentists are older than 55 (State of Maine Board of Dental Practice, 
2019). Maine ranks in the top quartile of states with geriatrician 
shortages (Maine Senior Guide, 2019).

    I won't repeat the testimony of my colleagues about the growing 
shortage of healthcare professionals across our country, as I'm sure 
you already appreciate the scope of the problem. Rather, I will offer 
five specific strategies that I believe can go a long way to addressing 
the crisis. I will also offer some examples of how we at UNE are 
attempting to implement each of these strategies. This is not to imply 
that we've figured out all the best solutions, but rather to provide 
some specific examples of how higher education can partner productively 
with government, business, and nonprofit sectors to move the needle in 
---------------------------------------------------------------------------
important ways on this critical problem.

    First, we need to increase the number of doctors, nurses, and other 
healthcare professionals we educate. Although there are a number of 
challenges to doing so, by far the most important is the availability 
of clinical training experiences, which has been well documented by the 
Department of Health and Human Services Health Resources and Services 
Administration (HRSA). \5\ As financial margins have tightened and 
clinician workloads have increased over the past three decades, 
practicing clinicians in various healthcare settings have less time to 
devote to training students. \6\ The single most important thing we can 
do to increase the number of healthcare providers is to support 
partnerships between universities and healthcare systems to develop 
additional residencies, clerkships, practica, and other training 
opportunities.
---------------------------------------------------------------------------
    \5\  U.S. Congress: Advisory Committee on Interdisciplinary, 
Community-Based Linkages. (2018).
    \6\  Benbassat, 2020; Cox & Desai, 2019; Hanna, 2019; Graziano et 
al., 2018; Konrad et al., 2010; Krehnbrink et al, 2020; de Villiers et 
al., 2018; Rodriguez, 2013.

    At UNE, one way we have expanded clinical training opportunities is 
by working with partners in rural and underserved primary care sites 
and federally Qualified Health Centers. One advantage of such 
placements is that students learn how to deliver compassionate care to 
Maine's most vulnerable residents, many of whom are uninsured and also 
navigate chronic physical and mental health conditions. The precepting 
clinicians in these settings are dedicated to treating underserved 
patients, sometimes with limited access to specialized professional 
support. \7\ These settings afford students exposure to a broad range 
of conditions and allow them to perform a wider variety of procedures 
than they might in more specialized urban settings.
---------------------------------------------------------------------------
    \7\  Hempel et al., 2015; Lee et al., 2016.

    Clinical training opportunities are not the only infrastructure 
limitation to producing more healthcare professionals. Standing up new 
educational facilities, or expanding existing ones, involves 
considerable startup costs. Recognizing the region's significant unmet 
oral healthcare needs and the fact that there was no dental school in 
all of northern New England, in 2013 we partnered with both Federal and 
state governments, regional industry, non-profits, and philanthropists 
to establish a dental school. Senator Collins was critical in helping 
to secure Federal support for that project. And the people of Maine 
passed a $3.5 million bond to support not only creation of the school 
itself, but also community dental clinics around the state to help them 
increase their capacity to provide dental care and to take our students 
on rotation. The school was created with an explicit focus on 
addressing underserved populations, as reflected in its mission 
statement: `` . . . to improve the oral health of northern New England 
---------------------------------------------------------------------------
and rural and underserved populations.''

    Another barrier to training more healthcare professionals is the 
difficulty hiring and retaining qualified faculty members, who can 
typically earn more in direct care clinical settings and yet require a 
higher level of training and credentialing than those working 
clinically. \8\ At UNE, we are developing a specialized track within 
our dental program to educate students who are interested in pursuing 
an academic career. \9\ Support such as that displayed by Senators 
Collins, Sanders, and others for strategic loan repayment programs 
targeting those assuming faculty positions in dentistry, nursing, and 
other allied health professions is critical to ensuring the future of 
the healthcare workforce. Loan repayment programs improve access to 
graduate/doctoral education by encouraging qualified individuals to 
advance their education and subsequently become employed as faculty.
---------------------------------------------------------------------------
    \8\  Christmas et al., 2010; Feldman et al., 2015; Girod et al., 
2017; Nauseen et al., 2018.
    \9\  McAndrew et al., 2011.

    Second, we must intentionally recruit more students who look like 
the communities we need to serve. It is well established that 
individuals from underrepresented groups are more likely to seek out 
practitioners who share their identities and backgrounds. \10\ Studies 
have found that minority patients who are treated by race/ethnic-
concordant clinicians are more likely to use needed health services and 
are less likely to delay seeking care. \11\
---------------------------------------------------------------------------
    \10\  Shen et al., 2018; LaVeist et al., 2003.
    \11\  Saha et al., 2000; LaVeist & Nuru-Jeter, 2002.

    In Maine, we have a growing immigrant population, especially from 
Central and Eastern Africa, and not surprisingly, this community 
experiences significant healthcare discrepancies relative to the 
broader population. \12\ To address this issue, not only has UNE 
increased recruitment efforts targeting students of color across the 
entire university, we recently began ``Advanced Standing'' programs in 
dentistry and pharmacy, designed to accelerate the time it takes for 
foreign-trained immigrant professionals to achieve a U.S. degree and 
become eligible for licensure. We have also developed partnerships with 
local community colleges to matriculate students from our immigrant 
communities into certain healthcare programs (e.g., dental hygiene). 
\13\
---------------------------------------------------------------------------
    \12\  Drewniak et al., 2017.
    \13\  National Academies of Sciences, Engineering and Medicine, 
2021.

    Third, it's not enough merely to train more professionals, we must 
encourage them to practice in underserved areas following graduation, 
such as in rural, medically underserved, and tribal communities. Like 
Maine, most states have vast rural areas with highly distributed 
populations, and these communities have far less access to healthcare. 
\14\ The U.S. Government has invested in programs, administered through 
the Health Resources and Services Administration, that provide 
financial support in the form of loan repayment to graduates who serve 
in disadvantaged areas. These programs are absolutely critical, and we 
thank congressional leadership for their ongoing support.
---------------------------------------------------------------------------
    \14\  The US Department of Health and Human Services has designated 
nearly 200 geographic areas in Maine as health professional shortage 
areas for primary care, dental medicine, and mental health (US DHHS, 
2019). Maine also has 51 medically underserved areas/populations, 
defined as areas having too few primary care providers, high infant 
mortality, high poverty, and/or a high elderly population (US DHHS, 
2019). Nearly all of Maine's medically underserved areas are in Maine's 
congressional District Two, the second most rural congressional 
district in the country (US DHHS, 2019).

    At UNE, we have successfully used various strategies to encourage 
our graduates to practice in rural areas. We intentionally recruit 
students from rural areas, both from Maine and around the country. 
Students from small towns and other nonurban areas are more likely to 
return to such communities after graduation. \15\ Regardless of where 
they come from, we place students in clinical training sites in 
underserved rural areas as part of their education to give them a taste 
of rural practice and lifestyle.
---------------------------------------------------------------------------
    \15\  American Academy of Family Physicians, 2016; Lee et al., 
2021; University of Wisconsin, 2020;
---------------------------------------------------------------------------
    Each year, many graduates exposed to these crucial settings during 
rotations return for employment, inspired by the commitment to quality 
patient care they witnessed, as well as their love of small-town life. 
\16\ Finally, in concert with state and philanthropic partners, we have 
developed loan repayment and scholarship programs to incentivize 
practice in rural settings. These efforts have paid off; over the past 
decade we have made dramatic inroads in addressing the needs of rural 
communities. For example, 40 percent of UNE medical school graduates 
who practice in Maine do so in health profession shortage areas (HPSAs) 
designated by the U.S. Government, positively impacting the HPSA 
designation of five counties. \17\ And in our dental school's first 
four graduating classes (2017-2020), we educated 250 dentists, 63 of 
whom are currently practicing in Maine. Nearly one in five is employed 
in a federally Qualified Health Center, a non-profit community clinic, 
or the Veteran's Administration, and four in ten are practicing in 
Maine's most disadvantaged areas. \18\
---------------------------------------------------------------------------
    \16\  UNE's dental school clinical model is an excellent example of 
success in this regard. UNE places students in up to two 12-week 
clinical rotations in settings throughout northern New England, working 
in collaboration with a network of FQHCs, community clinics, and even 
private dental offices. Students provide billable services while 
receiving supervision from the preceptor and most importantly, learning 
about the community they serve. We are grateful for the U.S. Department 
of Health and Human Services on-going funding to Maine's network of 
health centers providing access to many of our marginalized residents, 
while also offering much-needed clinical placements to students.
    \17\  NCAHD's Enhanced State Licensure Data, 2016; The Robert 
Graham Center, 2012.
    \18\  This is particularly noteworthy given that Maine has the 
fewest dental providers participating in Medicaid or CHIP in the entire 
country, according to research by the American Dental Association's 
Health Policy Institute.

    Fourth, we must leverage the power of technology to reach 
underserved communities. The COVID-19 pandemic has introduced many 
Americans for the first time to the value of telehealth, as we all 
learned to access healthcare providers via videoconferencing. \19\ 
Telehealth and digital medicine have enormous potential to transform 
healthcare delivery, particularly in underserved areas. \20\ In 
addition to patients accessing their providers through secure 
videoconferencing platforms, primary care providers in remote locations 
can themselves access specialist colleagues in urban tertiary care 
hospitals and university health centers for expert consultation. And 
emerging digital medicine and artificial intelligence technologies will 
increasingly allow clinicians to monitor patient symptoms and even 
deliver certain treatments remotely over the internet. These 
technologies can also enhance the reach and effectiveness of continuing 
medical education programs. At UNE, we are moving toward integrating 
robust telehealth training for all of our health profession students in 
close partnership with our various training sites. Of course, 
telehealth and digital medicine services are only as available as the 
broadband network that supports them, and like much of the country, 
many of Maine's most rural counties lack sufficient and reliable 
connectivity. I am delighted that the most recent COVID-19 stimulus 
legislation included funding for broadband infrastructure, a portion of 
which is headed to our rural state. This will make an enormous 
difference in narrowing Maine's digital divide, and will ensure rural 
Maine residents can benefit from UNE's clinical and educational 
expertise, regardless of where they live.
---------------------------------------------------------------------------
    \19\  Wosik et al., 2020.
    \20\  Kichloo et al., 2020.

    Finally, we must fundamentally change the prevailing educational 
model. Anyone who has recently been a patient in a hospital, or who has 
cared for a hospitalized loved one, understands how siloed the practice 
of healthcare tends to be. One often gets the sense that the various 
professionals are all practicing their respective crafts with little 
coordination or communication among themselves. This siloed practice is 
a result, at least in part, of the traditional discipline-centered 
model of educating healthcare professionals. In 2001, the Institute of 
Medicine issued a groundbreaking report, Crossing the Quality Chasm: A 
New Health System for the 21st Century, which laid out the case for 
dramatic, systemic changes to health care organization and delivery. In 
response, stakeholders from academia, health systems, and government 
convened to determine how best to address the Institute's 
recommendations. In 2012, these efforts led to the development of a new 
educational model in which students from diverse disciplines are 
explicitly trained to work together, across traditional boundaries, in 
multi-disciplinary teams. Known as ``interprofessional education'' \21\ 
or ``IPE'' for short, this training model prepares students with team-
based competencies, attitudes, and skills that complement distinctive 
disciplinary knowledge. Interprofessional health care teams offer more 
than any one discipline can achieve alone, and this is especially 
critical as patients' health conditions are becoming increasingly 
complex. \22\ Growing evidence suggests that interprofessional 
collaborative practice \23\ improves clinical outcomes, \24\ reduces 
medical errors, \25\ increases patient satisfaction, \26\ and decreases 
provider burnout. \27\
---------------------------------------------------------------------------
    \21\  Interprofessional Education occurs when two or more 
professions learn about, from, and with each other to improve 
collaboration and the quality of patient care.
    \22\  Mayo & Williams-Woolley, 2016.
    \23\  According to the World Health Organization, interprofessional 
collaborative practice happens when multiple health workers from 
different professional backgrounds work together with patients, 
families, care givers, and communities to deliver the highest quality 
of care (World Health Organization, 2010).
    \24\  Lutfiyya et al., 2019.
    \25\  Anderson & Lakhan, 2016; Hardisty et al., 2014; Irajpour et 
al, 2019; Lygre et al., 2017; Wilson et al., 2016.
    \26\  Will et al, 2019.
    \27\  Cain et al., 2017; Dow et al., 2019.

    The IPE training model, especially when paired with digital health 
technologies, can be instrumental in meeting the needs of underserved 
communities. The combination of IPE and telehealth allows doctors, mid-
level practitioners, and other primary care practitioners to 
effectively expand their scope of practice, while also extending 
---------------------------------------------------------------------------
specialist care to those for whom it is otherwise out of reach.

    One particular area of healthcare that exemplifies the value of 
this kind of collaborative approach is geriatrics. Diseases of aging 
often encompass a broad scope of conditions and disciplines: heart 
disease and diabetes treated by primary care practitioners; mobility 
issues by physical and occupational therapists; isolation by social 
workers; oral health by dentists and hygienists, and so on. At UNE, we 
weave training in geriatrics throughout all of our health profession 
programs. Thanks to legislation sponsored by Senator Collins and 
supported by Maine's Junior Senator Angus King, and working closely the 
University of Maine and multiple statewide partners, UNE is one of 48 
organizations nationally to have received funding through HRSA's 
Geriatrics Workforce Education Program, which aims to create a more 
age-friendly health system by transforming primary care practices and 
engaging and empowering older adults.

    At UNE, we have been pioneers in IPE over the past decade for all 
of our healthcare programs, and, once again in close coordination with 
our clinical partners, we are now standing up a university-wide 
Institute to deepen our commitment to this training model.

    In conclusion, successfully addressing America's healthcare 
workforce crisis will require not merely acting on each of these five 
strategies in isolation, but seamlessly integrating them. Although 
strategic investment of resources will be required, much of the work we 
confront reflects cultural changes that will require strong leadership, 
a willingness to innovate, and coordinated partnership between 
academia, government, industry, and the nonprofit sector.

    I am grateful for the committee's time and attention, and 
appreciate your efforts to address our Nation's healthcare workforce 
crisis. Thank you.
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    The Chairman. Thank you very much, Dr. Herbert.
    I have been impressed that, from the panelists and from the 
Members here, I think there is a general consensus about what 
the crisis is and probably the direction that we have to go 
forward.
    I have about 400 questions, but I have time for three or 
four. Let me start with--Dr. McDougle made an interesting 
point, which we do not talk about enough, and I would like each 
of you to tell me whether you think he is right.
    We are losing, as I understand it, 50, 60,000 people a year 
because they do not get to the doctor when they should. But, 
interestingly enough, when you have more primary care 
physicians, it not only saves lives, it saves money, as well. 
That is my impression. So, you get to a doctor when you are 
sick, you do not end up in the hospital or the emergency room.
    Is that a true assertion, that in the long run, having--
giving people more access to primary healthcare not only keeps 
them healthier, probably saves the system more money?
    Let's go to everybody. Dr. Skorton, you want to begin?
    Dr. Skorton. Thank you. Permit me 15 seconds to thank and 
congratulate the other panelists on their very important 
contributions, not only with the panel today, but in general.
    I agree with what you just said, Chairman, but I want to 
add one thing, and let me just give you my bona fides. I ran a 
general medical--general medicine division for 5 years at the 
University of Iowa in which we were a primary care provider, as 
well as rural health provider. And, so, I could not be more 
simpatico with the importance of rural health and rural 
healthcare and changing the calculus.
    However, we need clinicians in specialty areas, as well. 
And it is very, very important that we do not put those two 
things off sort of butting heads against each other. We need 
more of a variety of things. And, so, that is one thing that I 
would comment on.
    Then, second, I would say that there is no question that 
primary care and preventive care go together, just as Dr. 
McDougle stated. I will be very quick, Mr. Chairman. But, I do 
want to say that depending on the issue, the idea of 
interprofessional teams are very, very important. So, we have 
to think about things beyond the physician workforce.
    Overall, we continue to hope that you will help to do 
things like the Residency Act to have more GME slots in 
general; duty incentives to bring them to rural areas in 
primary care, but fill out all the areas that we need.
    The Chairman. Sorry to be rude, but there is not a lot of 
time and I wanted everybody to comment, and I have some other 
questions.
    Dr. McDougle, do you agree with yourself?
    Dr. McDougle. Yes, I do. And we spoke to geriatrics 
earlier. I am a geriatrics physician by trade. Most of the 
patients I see are older, so using the skills that I developed 
and learned in residency and so forth have allowed me to serve 
in that role.
    The Chairman. Okay. Ms. Spires.
    Ms. Spires. Yes, and thank you. I would certainly agree 
with that comment. I have seen it firsthand and with patients 
who, if it had not been for the primary care physician and in a 
setting such as a federally qualified health center, 
potentially would not have received the care they needed.
    The ongoing idea of the diagnosis would certainly lead to 
hospitalization. And, so, when you are looking at things such 
as chronic illnesses, which we face every day, which if it is 
managed, will decrease expenses as it relates to Medicare and 
Medicaid, putting people into the hospital.
    When you are looking at a primary care physician, who is 
the individual responsible for managing that chronic illness 
for that patient, it truly--if we do what we are supposed to do 
from our standpoint, it does truly decrease the cost from a 
bigger picture standpoint by being able to provide that care.
    The Chairman. Okay. Dr. Herbert.
    Dr. Herbert. The answer is absolutely yes. There is no 
question. It is not even up for debate. There is research 
showing very clearly that those investments in primary care 
pay.
    I would add two quick things. One is primary care involves 
more than just family practitioners, doctors. It also involves 
psychiatry, OBGYN, which are desperately needed.
    The second thing I would mention are mid-level 
practitioners, so-called physician extenders, PAs, nurse 
practitioners, those folks can be critical in meeting unmet 
needs in rural areas.
    The Chairman. I am running out of time, but one quick 
question here and I would like all four of you to comment on 
it.
    Explain to me why when primary care physicians often work 
so hard, crazy hours, why are they paid substantially less than 
other specialists? Does that make any sense at all?
    Dr. Skorton.
    Dr. Skorton. It is going to be hard to answer that question 
briefly.
    The Chairman. Well, you have to do it briefly. I have got 
16 seconds here. Very briefly.
    Dr. Skorton. Okay. It has to do with the way our payment 
systems are set up, and it is not directly linked to the 
quality or the importance of care.
    The Chairman. But it does say something about the system 
that primary care physicians receive substantially less than 
surgeons, for example?
    Dr. Skorton. That is right.
    The Chairman. Okay. Dr. McDougle.
    Dr. McDougle. We are not a procedure-based specialty. We 
are a person-focused specialty, and that does not necessarily 
lead to increased revenue, but an increased cost savings that 
does not necessarily reflect in pay.
    The Chairman. Ms. Spires.
    Ms. Spires. Absolutely. Yes, I think that they are 
certainly underpaid, not just from the standpoint of being a 
specialty service, but they actually take care of the entire 
person. I mean, we are looking at a holistic approach. And, so, 
they are managing multiple issues versus one dedicated issue.
    The Chairman. Dr. Herbert.
    Dr. Herbert. Our payment system is based on procedure and 
visit codes. That is what you get paid for. If a primary care 
physician spends 50 minutes counseling a patient on their diet, 
lifestyle, exercise, this sort of thing, a patient with chronic 
disease, they are going to get paid less than if they--they 
will get paid one-tenth to half what they would get paid if 
they did an EKG, maybe a catheterization, gave them some 
medications. It is--the payment system is flawed and it 
incentivizes the wrong things.
    The Chairman. Thanks very much.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    Dr. Herbert, U.S. nursing schools turned away more than 
80,000 qualified applicants from baccalaureate and graduate 
nursing programs in 2019, and faculty shortages were cited as 
the top reason. So, think about that. Eighty thousand qualified 
applicants who wanted to be either initial RNs or advanced 
practice nurses turned away because of a lack of faculty.
    How can Congress help with the faculty side of the equation 
that is creating this bottleneck and contributing to the 
shortages?
    Dr. Herbert. Thank you, Senator Collins, for the question. 
It is a challenge with nursing faculty in particular. I would 
say all of the faculty disciplines, it is a challenge, but 
nursing in particular. One of the things that many places, UNE 
being one that we are doing, is training our own now. So, we 
are standing up a program to train nurse educators who in turn 
will become our own faculty because there is not enough nurse 
educators out there.
    The second thing, the loan repayment programs are 
absolutely critical. There are a number of programs out there. 
I know you have sponsored many of these, and I am deeply 
grateful for that. I know right now that at least four of my 
nursing faculty are taking advantage of those programs, and 
these are individuals who would not have gone into nursing 
teaching were it not for those programs.
    Then, fundamentally, a big challenge is that nurses can 
simply make more out in practice than we can pay them at 
universities. And, of course, the easy answer would be, well, 
just pay them more, right? But, I have to balance my budget, 
and I have to live within a balanced budget, and if I--I do not 
want to charge my students higher tuition or to decrease their 
financial aid, the institutional aid, that we offer them in 
order to pay them more. So, therein lies the dilemma.
    Support on any one of those three initiatives would be 
phenomenal to help with this problem.
    Senator Collins. Thank you. I am very intrigued that you 
are training your own educators. I think that is a very 
innovative idea.
    Dr. McDougle, it is really distressing to hear from you 
that the number of Black physicians has remained flat for I 
think you said 80 years. I held what I believe to have been the 
first hearing in the Senate to look at the racial disparities 
in the COVID cases. And even as a state with a small Black 
population like Maine, we see that disparity. I get a report on 
it each and every day from the Maine CDC.
    I had at that hearing Morehouse University testify about 
what could be done, and they echoed what was said here, that we 
need to be training more people who look like the community 
that they are serving. That is clearly true, and it would help 
overcome the legacy of mistrust between the Black population 
and medical professionals that exists in some areas.
    But, how can we get more Black Americans, Hispanic 
Americans, Native Americans to apply to medical school and to 
see that as a career path?
    Dr. McDougle. Very good question. We need to go to our 
elementary schools, pre-K through 12th graders.
    We have a program at the Ohio State University called 
Health Sciences Academies where there is a cascading mentorship 
model involved with partnering with the teachers and parents of 
students who are in feeder schools into Columbus East High 
School, which is right across the street from Ohio State East 
Hospital.
    I think those types of initiatives where we have that 
expertise at the academic health center, at our seven health 
professions colleges, and we partner with the elementary, 
middle, and high schools to create that pathway of opportunity. 
And I think that is one example in addition to the existing 
HCOP programs and the other pathways funded through HRSA.
    Very good question. Thank you.
    Senator Collins. Thank you for an excellent answer.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Collins.
    I have on my list Senator Braun, Senator Kaine, Senator 
Hassan, Senator Baldwin. Senator Baldwin, are you there, Tammy?
    Senator Baldwin. I am.
    The Chairman. Where are you? I do not see you.
    Senator Baldwin. I am virtual.
    The Chairman. All right. There you are.
    Senator Baldwin. Hello, Mr. Chairman. Thank you for the 
recognition. And I want to thank our panelists. What an 
important hearing.
    I wanted to focus in on the importance of training in the 
area of palliative and Hospice care.
    Dr. McDougle, you just stated that you are not a procedure-
based specialty, your area of practice in geriatrics. You are a 
person-based specialty. And I would argue the same is true in 
palliative and Hospice care.
    One of the challenges in preparing health professionals for 
careers in palliative care is the lack of support for trained 
professionals to serve as faculty and dedicate time to the 
educational function. There is an urgent need to build our 
workforce, but we cannot do it without building the workforce 
training infrastructure.
    I have introduced bipartisan legislation with my colleague, 
Senator Shelley Moore Capito, called the Palliative Care and 
Hospice Education and Training Act, and we are working to re-
introduce it this year, shortly. It would grow and improve the 
palliative and Hospice care workforce by supporting the full 
pipeline of physician training in the subspecialty, including 
through academic career awards and fellowships for providers.
    I want to start with a question for Dr. Skorton. How can we 
better address the need for programs that train health 
professionals, and how does the idea of training the trainer 
support our healthcare workforce overall?
    Dr. Skorton. First of all, Senator, we want to thank you. I 
appreciate your leadership on working to authorize these new 
Title VII programs to train future physicians in palliative and 
Hospice care. It is incredibly important.
    In these Title VII type programs, including geriatric and 
mental and behavioral health, have a longstanding history in 
training health professionals to treat our most vulnerable 
Americans. So, I would take the--very, very quickly mention 
that we are supporting an investment of $1.5 billion in Title 
VII and Title VIII programs and hope that Congress will think 
carefully about that. Not only about this issue, but many of 
the things that we are talking about today would develop a 
great boost by more funding going into HRSA programs, Title VII 
and Title VIII, and I think that would speak directly to your 
question.
    Thank you for the question and for your creativity in this 
sphere.
    Senator Baldwin. Thank you.
    Dr. McDougle, this will go to you. As many of the witnesses 
have noted, the current healthcare workforce shortages that we 
face today are only going to continue to grow, and research 
projects an impending palliative care workforce crisis over the 
next 20 years. In the shorter time, by 2030, we could see a 
ratio of only one palliative care physician for every 26,000 
seriously ill patients. Part of why we urgently need to grow 
the palliative care workforce is to ensure that more Americans 
and their families have access to this type of care when they 
need it the most, and it is a matter of healthcare equity in my 
mind.
    Dr. McDougle, can you speak to how support for workforce 
development programs and provider training works to advance 
health equity and help us make sure that more Americans have 
access to the quality care and culturally competent care that 
meets their needs?
    Dr. McDougle. Another very good question. So, we know from 
research and data that physicians from underrepresented groups 
have a concordance with patients that they are caring for in 
the population, and we have seen where this has led to 
increased compliance with preventive care, even flu shots. And, 
so, that is important. And that visibility in the community, 
becoming a trusted messenger in the community, was also 
important and continues to be during this pandemic.
    In regards to palliative care, I think there is also a need 
for just broader public education, and I would recommend to the 
audience a book recently published by Dr. Dan Morhaim entitled 
Preparing for a Better End. He speaks to the importance of 
palliative care, and actually, I will read some of this.
    It means a practice where a patient suffering a serious 
illness will not--will have not only a medical team focusing on 
a cure, but also a team focusing on symptoms, pain, and quality 
of life.
    Many people do not know the difference between Hospice care 
and palliative care, so I thank you so much for lifting this 
important topic up because more discussion and education is 
needed, especially in the community.
    Senator Baldwin. Thank you. Mr. Chairman, I yield back.
    The Chairman. Thank you, Senator Baldwin.
    Senator Braun.
    Senator Braun. Thank you, Mr. Chairman.
    Healthcare has been the thing I have been most interested 
in since I have been here in the Senate and trying to reform it 
from the top down. I think it has evolved into a--I do not like 
to even call it free enterprise because there are so many 
things that bother me about it.
    It has gotten increasingly concentrated with large 
corporations. You have an urban, rural divide. I am from 
Indiana. A lot of our rural hospitals are in peril. Sometimes, 
they have to end up getting bought by an urban chain, and then 
it seems like it gets even worse.
    A lot of--and running a business for 37 years before I got 
here, you have to have transparency, competition. Things have 
got to work well. I harp on that all the time.
    Here, I would love to hear your comments, Dr. Herbert and 
Dr. Skorton, about on the workforce side of it. I have a 
healthcare advisory group that meets three times a year. 
Doctors and nurses are kind of tiring of the profession almost 
because it used to be they had a family practice or they had a 
viable rural hospital to work for. Now, it is working for a 
huge corporation that seems to have a disproportionate amount 
of wealth, will not accept transparency and competition. The 
insurance companies are along with them. They tell me that it 
has a lot to do with why we are having trouble getting nurses 
or even doctors. When they want to form their own hospital, 
cannot do it due to the big guys having regulations in place.
    How much of the nature of the industry evolving the way it 
has do you think has to play into the lack of people wanting to 
get into the profession when it is some of the highest paid 
jobs you could have out there?
    Dr. Skorton. Nobody wants to jump in first on this one, but 
it is a very, very important point that you make. And, I would 
say that right now is a great time to rethink all of these 
disincentives. We have an increasing interest in going to 
medical school across the Country. A lot more people want to go 
to medical school. Perhaps the work of those who were on the 
front lines in COVID had a little bit to do with that. Who 
knows?
    Whatever it is, it is a very positive trend. There is a lot 
of enthusiasm. Young people who want to go out there and do the 
right thing. Leaders like my fellow panelists today who are 
showing the right way to point to specific areas that need to 
be done. So, I think there is a great wave of optimism and 
desire to do things in the public interest.
    Through your wisdom, in consultation with us, we think, in 
the private sector, as well, as Dr. Herbert mentioned, we need 
to talk over these specific areas that are disincentives and 
see how we can focus on those specific areas. Throwing the 
whole system out, while it might be tempting in some ways, 
would be chaotic in a Country as large as ours.
    But, through your wisdom and our experience, I think we 
could work together to find those areas that cause 
disincentives for the profession in general. And we would be 
glad offline to talk with you and your staff about that if it 
would be of interest.
    Over to you, Dr. Herbert.
    Dr. Herbert. Thank you. This is a big problem and I do not 
pretend to have all the answers. I will mention a couple of 
things.
    The payment structure issue that we just mentioned creates 
incentives for doing certain kinds of procedures that is not as 
well aligned. I think that is part of the burnout issue. I 
mentioned before that there are actually compelling data that 
the interprofessional training model can actually reduce 
provider burnout.
    The other thing I would say is with some of these rural 
hospitals is that we need the--to help them develop GME so that 
they can become teaching hospitals. There are many rural 
hospitals out there that would like to do that. The problem is 
the investment, the upfront costs, to develop a GME program in 
a virgin, a so-called virgin hospital that has never had GME. 
The price tag just to begin the process, to get it through 
ACGME, the accreditation body, is between 1.5 and $3.5 million. 
And, that is not taking into account the first few years of 
having a residency program when the CMS payments are not going 
to be as high as they will be once it is at full steam.
    There is--and it may not sound like a lot of money in the 
grand scheme of things, but if you are a small, rural hospital, 
three million bucks is a lot of money. But, that small 
investment could be just enough to develop a GME program, to 
develop a new residency program. Suddenly, now there is new 
energy. It brings a cultural change in many positive ways to 
these hospitals.
    There is a way that I think the Federal Government could 
help substantially, just getting us over that hump. We are 
partnering right now with a hospital in Maine trying to do 
exactly this. But, three million bucks is a lot of money, so--
--
    Senator Braun. Thank you for that. And I think for this to 
really be solved holistically before we get more government 
involved with it, the industry has obviously in itself evolved 
in a way that I do not think is good.
    Transparency, transparency, transparency. Let the consumer 
see things. Get the hidden veil that insurance companies, and 
especially hospitals have out there that frustrate nurses, 
doctors, and especially stakeholders like myself where I have 
wrestled with it in my own business prior to coming here. It 
does work. When you do those things, engage your healthcare 
employee, make them into a consumer, a lot of these other 
things start to fall in place.
    Thank you.
    The Chairman. Senator Kaine.
    Senator Kaine. Thank you, Mr. Chairman and Senator Collins. 
What a wonderful hearing.
    Dr. Skorton, the AAMC did a report that came out last June, 
I believe, that predicted a shortage of 139,000 physicians by 
2033. A report dated June 2020 was probably done a few months 
before and probably did not even take into account the pandemic 
effect. I understand that you are looking at an update of that 
report.
    My prediction, before I read the update, is that number 
will not have decreased because a pandemic that has now 
infected more than 30 million Americans with COVID, and 10 to 
20 percent are claiming to have long-term effects after COVID. 
I am one of those 10 to 20 percent. And, then, there has been a 
mental health impact of COVID, which has also been significant, 
very significant. I doubt that the number of the shortage is 
going to go down.
    Recruiting people in is important. You have addressed 
strategies on that. I really want to focus on keeping people in 
the profession once they are in.
    Dr. Skorton, I appreciate your testimony today focusing on 
the Lorna Breen Act that I have introduced with Dr. Cassidy and 
other colleagues. The problem of keeping our healers healthy, 
the mental health, the frontline health providers is so 
important.
    Lorna Breen was a New York emergency room physician with 
family in Virginia, who died by suicide in April, in the early 
days of the pandemic, as she was, just facing an onslaught of 
sickness and death. And, then, she got COVID herself, and, 
then, tried to get back to work but was worried about seeking 
mental health counseling because she felt like there would be a 
stigma, she might lose her license, she might lose her 
practice, ability to practice.
    We have to do things to break down any stigma about seeking 
mental health training among our professionals, and we have to 
come up with novel strategies so that we can keep our healers 
healthy.
    I have even, Mr. Chairman, started a rankle when I hear 
people talking about our healthcare workers as heroes because 
sometimes heroes are people we put up on a pedestal, and that 
might make it even harder for somebody to seek help. They are 
healers. That is a good enough word, and we have got to keep 
our healers healthy.
    Chairman Murray has noted the Lorna Breen Act for action in 
our next Committee markup. It is very widely supported on both 
sides of the aisle. And I hope my colleagues will join me in 
doing something really important for the healthcare of our 
healers.
    A mental health issue I want to ask each of you about is 
this. As we are talking about shortage of healthcare workers, 
let's talk about mental health workers. The National Council 
for Behavioral Health reported, also in a 2020 report that was 
done before COVID, that 77 percent of the counties in the 
United States are experiencing a severe shortage of mental 
health providers. The Virginia Healthcare Foundation indicates 
that much of Virginia is essentially a mental health 
professional desert, a shortage area. And these were before 
COVID.
    The after effects of COVID, people having lost loved ones, 
people having lost income, lost their jobs, seen so much 
suffering, these mental health needs are not going down.
    Many in Virginia who were participating in substance use 
group therapy sessions or other modes of treatment to try to 
deal with substance use issues saw those treatments become more 
difficult. Zoom sessions are not as good as in-person sessions, 
et cetera.
    If we had a 77 percent shortage of mental health providers 
pre-COVID, or 77 percent of counties were sort of short of 
mental health providers pre-COVID, it is going to be more after 
COVID. What can we do to make sure that the Nation has the 
mental health workforce that we need? And I would offer that to 
any of the witnesses.
    Dr. Skorton. First of all, let me thank you for the Lorna 
Breen Act. It is very important. She was at Allen Hospital--
rest in peace--which is part of the New York Presbyterian world 
where I practiced, saw patients, and taught up to about 2 years 
ago. So, I very much appreciate what you have done.
    In terms of long COVID, we are working on research to 
understand what is going on. Please stay tuned and stay of good 
cheer because we are going to figure this out like we have 
figured everything else about COVID.
    This mental health issue is dramatic and getting worse. 
There is no question about it. I think two Members of the 
Subcommittee who have developed the Opioid Workforce Act, which 
is incredibly, incredibly important because, as the Ranking 
Member mentioned--and thank you, Senator Hassan, for that, as 
well--we are really suffering with all of those things related 
to substance abuse throughout America, urban, rural areas, you 
name it.
    But, to focus specifically on stigma, which is probably the 
biggest single issue, I am afraid to say that healthcare 
workers, like many other people, are afraid to come forward and 
say, I need help. Very afraid to do that. Afraid for the 
stigma, afraid perhaps even to be limited in their practice 
prerogatives.
    This is something the profession itself really has to work 
on. This is not something we can unload on Congress. We have to 
develop ways to reduce that stigma and to make sure that coming 
forward does not result in something that will limit someone's 
professional choices. And I have had some experience with that, 
friends and personally, and would be glad to talk to you 
offline.
    But, we thank you or the Lorna Breen Act. I hope that comes 
to completion and that we can do all of these things together, 
and the Opioid Workforce Act. Those things, I believe, would 
come together, both the providers and to reduce stigma.
    Thank you for all you are doing.
    Senator Kaine. I yield back, Mr. Chairman. Thank you.
    The Chairman. Thank you.
    Senator Hassan.
    Senator Hassan. I want to thank the Chairman and Ranking 
Member for holding this hearing. And to all of the panelists, 
thank you for being here. Thank you for your work.
    I want to start with a question to Dr. McDougle. I have 
heard heartbreaking firsthand accounts from K through 12 
students in New Hampshire about their own struggles with mental 
health during the pandemic or their worries about their 
friends.
    Maybe the silver lining here, to follow-up on what Dr. 
Skorton was just saying, is that last week in a meeting with 
them in person, I was tiptoeing around the issue. I was not 
sure fifth graders and high school students would want to talk 
to me about mental health. They had no inhibitions about 
talking to me about mental health. They are worried about it 
for themselves, for their friends, and the pandemic has really 
obviously exacerbated it.
    In 2020, mental health related emergency department visits 
for children increased dramatically. And we know because of the 
pandemic, it has been harder for them to get in to see their 
primary care docs or to get to school in person to have the 
kind of mental health supports that school might provide. So, 
we have to do better for our kids.
    Dr. McDougle, what steps can Congress take to ensure that 
pediatricians and primary care providers are prepared to 
respond to the pediatric mental health crisis we are 
experiencing as a result of the pandemic? And what can we do in 
Congress to improve access to mental health services for kids 
through their communities, including their schools?
    Dr. McDougle. Very good question. As primary care 
physicians, we many times are the first persons who are talked 
to about the mental health concerns. In some cases, we are able 
to manage the mental health concerns. That being said, 
typically it may involve referral to a psychologist or a 
licensed social worker to work in concert with us.
    Someone mentioned earlier about the importance of 
telehealth. Congress has to continue funding of telehealth. 
That has to continue. And we need to also prioritize training 
of licensed social workers, psychologists, and psychiatrists.
    A strong message needs to be sent to our medical schools, 
our health professions schools, that this is a national crisis 
that we all need to step up to.
    Those are my initial thoughts.
    Senator Hassan. Thank you very much for those initial 
thoughts. They are great ones.
    I want to--I am just going to comment quickly that I thank 
all of the panelists for the support that you have all 
expressed for boosting the behavioral workforce and the 
workforce to treat substance use disorder. And I am pleased and 
honored to work with Senator Collins on the Opioid Workforce 
Act and we will continue to push that through.
    Dr. Herbert, under the American Rescue Plan, Congress 
increased Federal funding for home-and community-based services 
to help more people access the care they need in the setting 
that best suits their needs.
    But, this funding increase is temporary. Congress needs to 
make long-term, sustainable investments in the home health and 
community-based workforce that is going to ensure access to 
quality, comprehensive health services for older adults and 
individuals with disabilities who choose to remain in their 
homes.
    Doctor, can you speak to the role that home health workers 
play in improving care for older adults and individuals with 
disabilities? And how will additional sustained investments in 
home-and community-based health workers strengthen our 
healthcare system?
    Dr. Herbert. I think you nailed it. We need additional 
funding to support--it is absolutely critical, the home 
healthcare workforce, in terms of maintaining the health, 
especially of our older populations.
    If I--so, I would simply support your assertion that 
funding needs to continue post-COVID.
    Could I add something about----
    Senator Hassan. Sure.
    Dr. Herbert [continuing]. Behavioral health----
    Senator Hassan. Yes.
    Dr. Herbert [continuing]. Since you brought that up?
    As a clinical psychologist by training, I could go on for 
hours on this topic, but I will try to just keep it very brief.
    It is absolutely critical that we train more behavioral 
health professionals, there is no question, at all levels; not 
just doctoral level trained people, but masters level 
counselors, social workers.
    At the same time, what we also need to do is--and this gets 
back to that interprofessional model I was talking about. We 
need to train all healthcare professionals----
    Senator Hassan. Right.
    Dr. Herbert [continuing]. Including dentists, to 
recognize--and OBGYNs, for example----
    Senator Hassan. Yes.
    Dr. Herbert [continuing]. To recognize and diagnose 
behavioral health problems. And there are behavioral health 
interventions that those non-expert providers can also learn to 
provide.
    Also, I would add that we have made tremendous progress 
over the past 30 years in non-pharmacological treatments that 
in many cases have longer lasting effects, but they are still 
not widely practiced.
    Senator Hassan. Right.
    Dr. Herbert. Because it is much easier to just give 
somebody a pill.
    Senator Hassan. Okay.
    Dr. Herbert. I am not suggesting there are not appropriate 
places for pharmacological intervention.
    Senator Hassan. Sure. No, I understand that. I appreciate 
that.
    I realize I am out of time. I am just going to say I am 
going to submit a question for the record to the panel because, 
Mr. Chairman, one of the things I think we really also need to 
focus on is a partnership between our primary care docs and 
community health workers to help address the social 
determinants of health. Because it is so critical if people--
docs who are treating, can actually get the nutrition 
assistance or housing that they need. That can be a big step 
forward, too.
    Thank you.
    The Chairman. Thank you.
    Senator Rosen.
    Senator Rosen. Well, thank you, Chairman Sanders, Ranking 
Member Collins. I really appreciate this hearing. It is just so 
important. And the witnesses for your work, your compassion, 
and caring. I really appreciate that.
    The entire State of Nevada has shortages of healthcare 
providers. It is especially true for our rural areas; of 
course, of rural areas probably across this Country. We 
desperately need more doctors and nurses. We have to support 
our existing medical providers who choose to care for those 
patients in rural and underserved areas so that they stay in 
those communities.
    One of the things my office has heard from Nevada primary 
care physicians, that they could use more support from 
specialists to meet the needs of their patients. That is why I 
introduced the bipartisan Improving Access to Healthcare in 
Rural and Underserved Areas with Senator Murkowski. It is going 
to provide additional support for primary care providers in 
community health centers or rural health clinics through 
specialist support and accredited continuing medical education.
    Ms. Spires, as the leader of a large community health 
center, could you please speak a little bit about the 
challenges patients have accessing the center, specialty care, 
and how having the option for concurrent visits with both their 
primary care and a specialist might really improve those 
patient outcomes that of course we all want? And what kind of 
Federal support would you like to see going forward to 
potentiate positive outcomes for patients? That is what we all 
want; right?
    Ms. Spires. Absolutely. I would certainly be glad to 
address that.
    As far as being in a community health center and access 
available to our patients, we do have the barrier of resources, 
special--subspecialties, if you will.
    One of the things that we try to do is integrate 
interdisciplinary teams into our organization as much as 
possible. So, we have included in that podiatry, optometry, and 
some of those things that--thinking particularly about a 
diabetic population, when you look at them and you start 
looking at foot exams and retinal exams and things like that, 
indicative of the holistic care of that diabetic patient.
    One of the things we also started was when we were looking 
at endocrinology, which is kind of connected with that, as 
well, and having limited resources. And, so, we continue to 
face that challenge.
    Transportation is an issue as we, all know, as well. So, 
when I have remote areas, such as 40 miles away, it is how do 
we get those patients in to be seen?
    I think funding that would support some opportunity for 
collaboration and partnerships with some of the subspecialties, 
if you will. One of the things we have done is actually we have 
corroborated with our local hospital to see what some of those 
specialties that they have hired, how do we take our mobile 
units on the road and go to some of these rural areas. And I do 
primary care and then they handle specialty care, just so that 
we can continue to control cost. Because if we can get out 
there and see them, when you are looking at the issue of 
finances available, then that is going to ultimately save the 
tax dollars money, as well.
    We are continuing to work on that. But, I think one 
suggestion would be is to continue to have inside conversations 
with those individuals and organizations that do have good 
partnerships and relationships and decide how can we address 
this issue. But, I would love to see that happen. That would be 
great for our patients.
    Senator Rosen. Thank you. I appreciate what you are doing.
    I will tell you, I am also so proud that, of course, Dr. 
Skorton, UNLV graduated its very first medical school class. 
Ninety-five percent of the graduates were from Nevada; twenty-
six percent first generation college students.
    We passed bipartisan legislation to support 1,000 new 
Medicare-funded Graduate Medical Education residency positions. 
Of course, really important because we have got to address the 
workforce shortage so we can use things like mobile units, 
collaborative care, comprehensive care. And, so, we have to 
work on these GME slots, especially maybe redistributing some 
of those unused slots.
    Dr. Skorton, in this short time I have left, even though we 
did increase the GME slots by 1,000, some of them are not 
always a match. And, so, there soon will be qualified medical 
school graduates. How can we utilize these while they may be 
perhaps on a gap year waiting for a residency, to potentiate 
some of our rural and underserved areas? What options do you 
think we might use?
    Dr. Skorton. Well, first I want to tell you that I had the 
honor of giving the commencement speech at UNLV--it was 
recorded about 2 weeks ago--to congratulate them on their first 
class, as well as UNR. And they are doing a lot of very 
interesting, important things.
    The idea of volunteerism and other things that people can 
do while they are awaiting the next step in their careers is 
one that our medical schools themselves are working on.
    By the way, in the State of Nevada, both in Reno and in Las 
Vegas, there is a lot of very innovative things happening to 
connect the medical school itself with the community.
    I would like to get back with you offline, Senator, with 
some ideas about that business of the gap year. There are some 
of our schools in other states that are also thinking about 
that. And if it is acceptable, I would like to get back to you 
on that.
    Senator Rosen. I would love to have that conversation 
because I--we have such a shortage of medical resources across 
the spectrum and across the Country. We have to do everything 
we can to promote, protect, and enhance our collaborative 
models for patient care. So, I look forward to that.
    My time is expired. Thank you.
    The Chairman. Thank you, Senator Rosen.
    Let me conclude by thanking all of the Senators for their 
questioning. I perceive that there really is a general 
consensus. We may not agree on every detail, but I think there 
is a general understanding that we have a crisis. I think we 
have a pretty good understanding of where we want to go and 
have to go.
    This is a solvable problem. I mean, this is the wealthiest 
country. Yes, we can have enough doctors, and we can have 
doctors and nurses in the places that we need them. I think we 
can do this. And I think the Congress and the medical 
profession have got to be working together on this. So, I just 
look forward to working with my colleagues here.
    I want to thank the panelists for their great testimony, 
Senator Collins for her help on this.
    I would ask unanimous consent to put into the record 
letters from nine different healthcare organizations who are 
interested in this issue.

    [The following information can be found on page 48 in 
Additional Material]

    Okay. Well, thank you all very much. This was, I think, a 
great hearing, and let's go forward together on this.
    Thank you all.

                          ADDITIONAL MATERIAL

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                         QUESTIONS AND ANSWERS

      Response by Dr. James Herbert to questions of Senator Casey

                             senator casey
    Question 1. The primary care physician shortage is particularly 
acute in rural areas such as the one you serve. Access to mental health 
care is also severely challenged and has been called a crisis, 
particularly for the underserved. Increasingly, primary care providers, 
if properly trained, have been seen as part of the remedy to help 
address mental health needs. You spoke to the importance of considering 
not only physicians as part of our primary care workforce, but the 
necessity and benefits of an interprofessional approach. Please 
elaborate on the roles of nurses and other providers to extend primary 
and mental health care. How might we best increase the capacity of 
rural providers, including physicians, nurses and others to meet our 
Nation's mental health and social care needs?

    Answer 1. I completely concur regarding the problem of access to 
behavioral healthcare. As with the healthcare workforce more broadly, 
this is reflected by an undersupply of mental health professionals and 
maldistribution of the workforce. The National Center for Health 
Workforce Analysis projected that by 2025 there will be a nationwide 
shortage of at least 10,000 FTEs in each of six categories of 
behavioral health practitioners (e.g., psychiatrists, psychologists, 
social workers, counselors, etc.). In addition, most practitioners are 
concentrated in urban areas, leaving large rural areas without access. 
According to a 2020 report by the Health Resources and Services 
Administration, 119 million Americans currently live in behavioral 
health care professional shortage areas. The problem of access to 
behavioral healthcare in rural areas is compounded by higher rates of 
uninsured or underinsured populations in these areas. And experts 
predict that the behavioral health care workforce shortage will be 
exacerbated in the aftermath of the COVID-19 pandemic (Bryant, 2020).

    Early identification, assessment, and treatment of mental health 
problems is critical to reducing morbidity. Most mental health problems 
do not remit without treatment and many progress with respect to 
morbidity and functional impairments. Efforts are needed to train more 
behavioral health practitioners and to incentivize clinicians to 
practice in underserved areas, for example through loan repayment 
programs. But it is unlikely that these efforts alone will solve the 
problem. An alternative model of health care education that stresses 
collaborative, cross-disciplinary training and practice has the 
potential to help address our country's unmet behavioral health needs.

    The collaborative, team-based approach to healthcare education 
known as Interprofessional education (IPE) can help address the 
behavioral health workforce crisis. At its core, IPE is an education 
model designed to bring students from various health care disciplines 
together to learn with, from, and about each other with the goal of 
improving patient care (Rubin, Cohen Konrad, Nimmagadda, Scheyett, & 
Dunn, 2017). Collaborative training includes reviewing roles and 
responsibilities of various disciplines, shared didactics, shadowing 
professionals from diverse disciplines, participating in cross-
disciplinary clinical simulations and other experiential learning 
activities with peers and professionals. In addition to classroom and 
simulation experiences, students participate in collaborative 
experiences in actual healthcare settings.

    Especially when paired with telehealth, interprofessional training 
has the potential to positively impact gaps in behavioral health 
workforce. One model is behavioral health integration, in which a 
mental health professional is embedded within a primary care practice, 
allowing for early assessment and intervention and referral to more 
specialized or long-term care as needed (Talley et al., 2021). Whereas 
this model can work well, it is not always possible to place a 
behavioral health specialist in all settings, especially in the most 
remote, rural areas. Another model is to train primary care 
practitioners themselves, including family practice physicians and mid-
level practitioners (physician assistants, nurse practitioners), to 
screen for and mental disorders and even offer basic interventions in 
partnership with specialist clinicians located remotely from the 
primary care provider.

    This expanded scope of practice is made possible by telehealth and 
related digital tools. Primary care clinicians can use 
videoconferencing tools to consult with psychiatrists, psychologists, 
and other behavioral health experts located in distant universities and 
medical centers. Using secure videoconferencing tools, these 
practitioners can introduce patients to distant therapists, help 
socialize them to telehealth interventions, and then the therapist can 
provide expert care remotely. The local clinician and remote therapists 
can then coordinate ongoing care with the former periodically seeing 
the patient in person to encourage ongoing engagement with treatment 
and to provide in-person assessments.

    Finally, primary care practitioners can themselves learn not only 
to screen and assess for psychological problems, but also to provide 
certain interventions themselves. In addition to psychotropic 
medications, certain forms of brief, semi-structured cognitive 
behavioral psychotherapy lend themselves to provision by non-
specialists (Weisberg & Magidson, 2014). For example, a treatment known 
as behavioral activation can be highly effective in treating mild to 
moderate depression, which is one of the most common conditions seen in 
primary care. Another example is "SBIRT" (Screening, Brief 
Intervention, and Referral for Treatment), an evidence-based program 
targeting substance abuse. These interventions, and many others like 
them, can be successfully provided by physicians, nurses, and other 
primary care practitioners who are appropriately trained and who 
practice in an interprofessional model, thereby greatly extending the 
reach of behavioral health services.

    The University of New England (UNE) is Maine's largest private 
university and home to Maine's only medical school, only physician 
assistant program, Northern New England's only dental school, Maine's 
largest nursing program, and many other health care programs. The 
University is Maine's largest provider of health care professionals. 
UNE is known nationally for its innovations in interprofessional 
education, and is currently expanding programming to further integrate 
telehealth into our interprofessional training to address behavioral 
health programs.
                               References
    Bryant, B. (2020). COVID-19 likely to worsen behavioral health 
workforce shortage. Behavioral Health Business, March 13, 2020.

    Bureau of Health Workforce, Health Resources and Services 
Administration (HRSA), U.S. Department of Health & Human Services. 
Designated Health Professional Shortage Areas Statistics: Designated 
HPSA Quarterly Summary, September 30, 2020.

    Health Resources and Services Administration/National Center for 
Health Workforce Analysis (2015). Substance Abuse and Mental Health 
Services Administration/Office of Policy, Planning, and Innovation. 
National Projections of Supply and Demand for Behavioral Health 
Practitioners: 2013-2025. Rockville, Maryland.

    Rubin, M., Cohen Konrad, S., Nimmagadda, J., Scheyet, A., & Dunn, 
K. (2017). Social work and Interprofessional Education: Integration, 
intersectionality, and institutional leadership. Social Work Education, 
1-17.

    Talley, M., Williams, Srivatsan, Y., Li, P., Frank, J. S., Selleck, 
C. (2021). Integrating behavioral health into two primary care clinics 
serving vulnerable populations. Journal of Interprofessional Education 
& Practice, 24.

    Weisberg, R. B., & Magidson, J. F. (2014). Integrating cognitive 
behavioral therapy into primary care settings. Cognitive and Behavior 
Practice, 21(3), 247-251
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      Response by Dr. David Skorton to questions of Senator Casey

                             senator casey
    Question 1. Dr. Skorton, you shared data predicting a substantial 
10 to 12 year physician shortage, ranging from over 50,000 to nearly 
140,000. Even today there is a shortage in rural and other underserved 
areas. The AAMC report accounts for the 45 percent growth of our U.S. 
population over age 65 years, in the face of an also aging physician 
workforce. However, it does not fully account for equal health care 
access and utilization by underserved populations, highlighting that 
removal of barriers for these populations would mean nearly a doubling 
of the predicted shortage. As health care access improves health 
outcomes, we will want to remove barriers for the underserved. The 
report suggests several steps to mitigate the predicted shortage. 
Focusing on disparity reduction for the underserved, what additional 
steps are necessary to reduce health inequity, to increase not just the 
number of physicians, but the number of physicians who will serve the 
underserved?

    Answer 1. The 2021 version of the AAMC report includes estimates 
that if marginalized minority populations, people living in rural 
communities, and people without health insurance had the same health 
care use patterns as populations with fewer barriers to access, an 
additional 102,400 to 180,400 physicians would be needed now. \1\ 
COVID-19 has put a spotlight on disparities in health and access to 
care among underserved populations, and this analysis underscores the 
systematic differences in health care services by insured and uninsured 
individuals, individuals in urban and rural locations, and individuals 
of differing races and ethnicities. These estimates, which are separate 
from the shortage projection ranges, help illuminate the magnitude of 
current barriers to care and provide an additional reference point when 
gauging the adequacy of physician workforce supply.
---------------------------------------------------------------------------
    \1\  The 2020 version of the AAMC report estimated 74,100 to 
145,500 physicians would be need now to address health care utilization 
equity scenario.

    Even before the COVID-19 pandemic, physician shortages were being 
felt by patients across the country. In 2019, the U.S. Health Resources 
& Services Administration estimated that an additional 13,758 primary 
care physicians and 6,100 psychiatrists would have been needed to 
remove Health Professional Shortage Area designations for areas with 
primary care and mental health shortages. According to public opinion 
research conducted by the AAMC in 2019, 35% of survey respondents said 
they or someone they knew had trouble finding a doctor in the past year 
or two. This is a 10-point increase from when the question was asked in 
---------------------------------------------------------------------------
2015.

    At the end of 2020, Congress took an important step to address the 
physician shortage by adding 1,000 new Medicare-supported graduate 
medical education (GME) positions--200 per year for five years--
targeted at underserved rural and urban communities and other teaching 
hospitals nationwide, ending a nearly 25-year freeze on Medicare 
support for GME. Bipartisan legislation recently introduced in both the 
U.S. House of Representatives and the Senate, the Resident Physician 
Shortage Reduction Act of 2021, would build upon this historic 
investment and help expand the physician workforce by adding 2,000 
federally supported medical residency positions annually for seven 
years.

    In addition to increasing the number of physicians to reduce 
workforce shortages and access barriers, AAMC supports several federal 
programs to help shape the physician workforce and target underserved 
communities. In particular, the Health Resources and Service 
Administration (HRSA) Title VII pipeline programs (discussed in greater 
detail in response to question (2) play an important role in improving 
the diversity of the health workforce. Studies show that students from 
underserved communities are more likely to serve patients from similar 
communities in practice. \2\
---------------------------------------------------------------------------
    \2\  Stewart, K., Brown, S. L., Wrensford, G., & Hurley, M. M. 
(2020). Creating a Comprehensive Approach to Exposing Underrepresented 
Pre-health Professions Students to Clinical Medicine and Health 
Research. Journal of the National Medical Association, 112(1), 36-43. 
doi:10.1016/j.jnma.2019.12.003.

    Additionally, students and physicians who train in underserved 
areas are more likely to practice in those communities. Regional 
medical campuses, teaching health center graduate medical education 
(THCGME), and rural training tracks help expose students and residents 
to underserved communities. AAMC supports investing in these training 
opportunities as part of a multi-pronged approach to addressing 
physician workforce shortages. As Congress considers improving the 
Nation's health infrastructure, AAMC supports the Expanding Medical 
Education Act (H.R. 801), which would authorize grants to enhance 
---------------------------------------------------------------------------
current and establish new regional medical campuses (RMCs).

    Finally, public service loan repayment programs offered by HRSA, 
the Department of Education, the Department of Veterans Affairs, the 
Department of Defense, and the Indian Health Service are effective, 
targeted incentives for recruiting physicians and other health 
professionals to serve specific vulnerable populations. Increasing 
federal investment in these programs is a proven way to increase the 
supply of health professionals serving HPSAs, nonprofit facilities, and 
other underserved communities.

    For example, the Public Service Loan Forgiveness (PSLF) program 
administered by the Department of Education encourages physicians to 
pursue careers that benefit communities in need. In an annual AAMC 
survey of graduating medical students, over one-third of 2020 medical 
school graduates indicate an interest in pursuing PSLF. \3\ The AAMC 
supports preserving physician eligibility for PSLF to help vulnerable 
patients and nonprofit medical facilities that use the program as a 
provider recruitment incentive.
---------------------------------------------------------------------------
    \3\  Medical School Graduation Questionnaire: 2020 All Schools 
Summary Report (Rep.). (2020). https://www.aamc.org/media/46851/
download.

    The NHSC in particular has played a significant role in recruiting 
primary care physicians to federally designated HPSAs through 
scholarship and loan repayment options. With a field strength of 13,053 
in 2019, including 2,418 physicians, more than 13 million patients 
relied on NHSC providers for health care. \4\ Despite the NHSC's 
success, it still falls far short of fulfilling the health care needs 
of all HPSAs due to growing demand for health professionals across the 
country. We are pleased Congress recognized the vital role the NHSC has 
in caring for our nation's most vulnerable patients by providing the 
program with $800 million in supplemental funding in the American 
Rescue Plan. The AAMC supports continued growth for the NHSC in FY 2022 
appropriations, and we urge Congress to provide a level of funding for 
the NHSC that would fulfill the needs of all current HPSAs.
---------------------------------------------------------------------------
    \4\  Health Resources and Services Administration. Department of 
Health and Human Services Fiscal Year 2021 Justification of Estimates 
for Appropriations Committees. hrsa.gov/sites/default/files/hrsa/about/
budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.

    Similar to the NHSC, the State Conrad 30 J-1 visa waiver program 
has been a highly successful program for underserved communities to 
recruit both primary care and specialty physicians. Conrad 30 allows 
physicians to remain in the U.S. in an underserved community after 
completing medical residency on a J-1 ``exchange visitor'' visa (the 
most common nonimmigrant visa for GME), which otherwise requires 
physicians to return to their home country for at least 2 years. Over 
the last 15 years, the Conrad 30 program has brought more than 15,000 
physicians to underserved areas--comparable to (if not more than) the 
---------------------------------------------------------------------------
NHSC, at no cost to the federal government.

    As the 117th Congress considers immigration reform, the AAMC 
endorses the bipartisan Conrad State 30 and Physician Access 
Reauthorization Act (S.1810, H.R. 3541), which among other improvements 
would allow Conrad 30 to expand beyond 30 slots per state if certain 
nationwide thresholds are met. We applaud this bipartisan 
reauthorization proposal for recognizing immigrating physicians as a 
critical element of our Nation's health care infrastructure, and we 
support the expansion of Conrad 30 to help overcome hurdles that have 
stymied growth of the physician workforce.

    Question 2. Continuing to focus on the goal of improving care 
through equitable health care, increased diversity of the physician 
workforce has been strongly recommended, not only as an end in and of 
itself, but because minority physicians are more likely to choose 
primary care and to serve the underserved. African Americans are not 
proportionally represented among the profession nor its training 
programs. Rectifying that will likely require complementary solutions. 
Would you please speak to how we can increase the pipeline to assure 
that more minority students apply to medical school? What steps are 
needed? Who is responsible to make the change? What role do American 
medical schools play now and how will they expand that role?

    Answer 2. Over the past year, the COVID-19 pandemic has laid bare 
the existing health inequities harming our Nation's racial and ethnic 
minority communities, exposing the structures, systems, and policies 
that create social and economic conditions that lead to health 
disparities, poor health outcomes, and lower life expectancy. Your 
questions importantly highlight these persistent challenges and the 
need for academic medicine's ongoing work with communities to eliminate 
health disparities. A diverse and inclusive health workforce 
contributes to culturally responsive care, helps to mitigate bias, and 
improves access and quality of care to reduce health disparities, such 
as those seen during COVID-19. Improving diversity of our workforce 
requires both private and public ownership of the problems and 
contributions to the solutions.

    The AAMC is committed to increasing significantly the number of 
diverse medical school applicants and matriculants, and last year 
launched a new strategic plan that will take a multitiered approach 
with sustained investment, collaboration, and attention over time to 
significantly increase the diversity of medical students. Our goal is 
to keep increasing the number of students from underrepresented groups 
until they are no longer underrepresented in medicine.

    According to the AAMC Medical School Enrollment Survey, \5\ 
virtually all medical schools have specific programs or policies 
designed to recruit a more diverse student body. The majority of 
respondents to that survey had established or expected to establish 
programs/policies geared toward minorities underrepresented in 
medicine, students from disadvantaged backgrounds, and students from 
underserved communities. Schools also reported a variety of approaches, 
with a focus on outreach at high schools and local four-year colleges 
and admission strategies such as holistic review. Holistic Review 
refers to mission-aligned admissions or selection processes that take 
into consideration applicants' experiences, attributes, and academic 
metrics as well as the value an applicant would contribute to learning, 
practice, and teaching. In addition to these efforts, AAMC believes 
earlier and greater intervention prior to the medical school admissions 
process is necessary to diversify the physician workforce.
---------------------------------------------------------------------------
    \5\  Results of the AAMC Medical School Enrollment Survey: 2017, 
May 2018. https://www.aamc.org/media/8276/download.

    In particular, pipeline programs play an important role in 
improving the diversity of the health workforce and connecting 
unrepresented students to health careers by enhancing recruitment, 
education, training, and mentorship opportunities. Inclusive and 
diverse education and training experiences also expose students and 
providers to backgrounds and perspectives other than their own and 
heighten cultural awareness in health care, resulting in benefits for 
all patients and providers. One example is the Summer Health 
Professions Education Program (SHPEP), a free summer enrichment program 
focused on improving access to information and resources for college 
students interested in the health professions. SHPEP is a national 
program funded by the Robert Wood Johnson Foundation with direction and 
technical assistance provided by the Association of American Medical 
Colleges (AAMC) and the American Dental Education Association (ADEA). 
SHPEP's goal is to strengthen the academic proficiency and career 
development of students underrepresented in the health professions and 
prepare them for a successful application and matriculation to health 
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professions schools.

    Likewise, the federal HRSA Title VII health professions diversity 
programs help support medical schools and students:

          Health Careers Opportunity Program (HCOP), which 
        invests in K-16 health outreach and education programs through 
        partnerships between health professions schools and local 
        community-based organizations;

          Centers of Excellence (COE) program, which provides 
        grants for higher education mentorship and training programs 
        for underrepresented health professions students and faculty;

          Faculty Loan Repayment, which provides loan repayment 
        awards to retain minority health professions faculty in 
        academic settings to serve as mentors to the next generation of 
        providers; and

          Scholarships for Disadvantaged Students (SDS), which 
        grants scholarships for health professions students from 
        minority and/or socioeconomically disadvantaged backgrounds.

    Studies have demonstrated the effectiveness of such pipeline 
programs in strengthening students' academic records, improving test 
scores, and helping racial and ethnic minority and students who are 
economically disadvantaged pursue careers in the health professions. 
\6\ Title VII diversity pipeline programs reached over 10,000 students 
in the 2018-2019 academic year (AY), with HCOP reaching more than 4,000 
disadvantaged trainees, SDS graduating nearly 1,400 students and COE 
reaching more than 5,600 health professionals; 56% of whom were located 
in medically underserved communities. \7\ This success is even more 
impressive considering that only 20 schools have HCOP grants and only 
17 have COE grants--down from 80 HCOP programs and 34 COE programs in 
2005 before the programs' funding was cut substantially.
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    \6\  Ojo, K. (2020). Preparing Minority Students For Careers in 
Health: A Case Study Investigation of a Health Careers Opportunity 
Program (HCOP) (Temple University Press). Temple University. 
doi:https://scholarshare.temple.edu/handle/20.500.12613/287.
    \7\  Health Resources and Services Administration. Department of 
Health and Human Services Fiscal Year 2021 Justification of Estimates 
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.

    The AAMC appreciates that Congress reauthorized the HRSA Title VII 
and Title VIII programs in the Coronavirus Aid, Relief, and Economic 
Security (CARES) Act (P.L. 116-136). However, increased funding is 
necessary for these programs to reach their full potential. For FY 
2022, AAMC joined an alliance of over 90 national organizations, the 
Health Professions and Nursing Education Coalition (HPNEC), in 
recommending $1.51 billion for Title VII and Title VIII, which includes 
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doubling funding for the HRSA diversity pipeline programs.

    In addition to pipeline programs, the AAMC works continuously with 
the academic medicine community to advance equity, diversity, and 
inclusion. We would be happy to discuss any of the following AAMC led 
or supported initiatives in greater detail:

          Action Collaborative for Black Men in Medicine - The 
        Action Collaborative will be a network community that will 
        focus on systemic solutions to increase the representation and 
        success of Black men interested in medicine sponsored by the 
        AAMC and the National Medical Association (NMA).

          CDC Cooperative Agreement - The Centers for Disease 
        Control and Prevention's Academic Partnerships to Improve 
        Health focuses on improving the health of individuals and 
        communities through alliances among academic associations, 
        universities, and CDC.

          Health Equity Research and Policy - Funding and 
        training opportunities, case studies and best practices, and 
        solutions-focused research initiatives for AAMC member 
        institutions to move their communities--and the Nation--toward 
        health equity.

          Improving Sexual and Gender Minority Health - These 
        resources help promote the health of people who are lesbian, 
        gay, bisexual, transgender (LGBT), gender nonconforming (GNC), 
        and/or born with differences of sex development (DSD).

          Medical Career Fairs - Medical career fairs offer 
        workshops on medical school admissions, opportunities to meet 
        admissions officers and current medical students, as well as 
        hands-on activities.

          Population Health Education -The AAMC seeks to 
        improve the integration of public health concepts into medical 
        education and enhance and expand a diverse and culturally 
        prepared health workforce.

          Promising Practices to Improve Hispanic Health - This 
        webinar series is designed to increase awareness, foster 
        discussion, and catalyze further research among health 
        professions faculty on how to best advance Hispanic health.

          Sexual and Gender Harassment - These AAMC resources 
        contain key terms, findings, recommendations, and general 
        information from the National Academies of Science, 
        Engineering, and Medicine (NASEM) report Sexual Harassment of 
        Women: Climate, Culture, and Consequences in Academic Sciences, 
        Engineering, and Medicine.

          Unconscious Bias - At medical schools and teaching 
        hospitals, unconscious biases can compromise diversity and 
        inclusion efforts across the board. The AAMC provides resources 
        and trainings to help members address unconscious biases.

          Urban Universities for HEALTH - Urban Universities 
        for HEALTH (Health Equity through Alignment, Leadership, and 
        Transformation of the Health Workforce) aims to enhance and 
        expand a culturally sensitive, diverse, and prepared health 
        workforce that improves health in urban communities.

    Thank you again for your questions and leadership on the important 
topic of physician workforce shortages and the challenges the country 
faces. We believe there must be a private-public, multipronged approach 
to bolstering the physician workforce and the diversity of the 
physician workforce. Academic medicine is committed to working to 
address the challenges and has made significant investment in both 
these areas. At the same time, we believe there must be a corresponding 
increase in the federal government's investments for a variety of 
federal programs that are already working. The cost of inaction today 
will result in higher costs and a less healthy population tomorrow. We 
look forward to continuing to work with you and the Senate HELP 
Committee to achieve this goal. If you have any further questions 
please contact Matthew Shick, Senior Director, AAMC Government 
Relations.
                                 ______
                                 
    [Whereupon, the hearing was concluded at 11:58 a.m.]

                                 [all]