[Senate Hearing 117-389]
[From the U.S. Government Publishing Office]


                                                      S. Hrg. 117-389

                RECRUITING, REVITALIZING & DIVERSIFYING:
                  EXAMINING THE HEALTH CARE WORKFORCE
                                SHORTAGE

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

                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON EMPLOYMENT AND WORKPLACE 
                                  SAFETY

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                                   ON

 EXAMINING THE HEALTH CARE WORKFORCE SHORTAGE, FOCUSING ON RECRUITING, 
                     REVITALIZING AND DIVERSIFYING

                               __________

                           FEBRUARY 10, 2022

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
                               __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-900 PDF                 WASHINGTON : 2023 


         Available via the World Wide Web: http://www.govinfo.gov         
----------------------------------------------------------------------------------- 
      
          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 EMPLOYMENT AND WORKPLACE SAFETY

                 JOHN HICKENLOOPER, Colorado, Chairman
TAMMY BALDWIN, Wisconsin             MIKE BRAUN, Indiana
TINA SMITH, Minnesota                TOMMY TUBERVILLE, Alabama
JACKY ROSEN, Nevada                  RAND PAUL, M.D., Kentucky
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
PATTY MURRAY, Washington (ex         MITT ROMNEY, Utah
    officio)                         RICHARD BURR, North Carolina (ex 
                                         officio)
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                      THURSDAY, FEBRUARY 10, 2022

                                                                   Page

                           Committee Members

Hickenlooper, Hon. John, Chairman, Subcommittee on Employment and 
  Workplace Safety, Opening statement............................     1
Braun, Hon. Mike, Ranking Member, a U.S. Senator from the State 
  of Indiana, Opening statement..................................     2
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana, 
  Opening statement..............................................     4
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor, 
  and Pensions (ex officio)......................................    42

                               Witnesses

Flinter, Margaret, Ph.D., APRN, Senior Vice President and 
  Clinical Director, Community Health Center, Inc., and Chair, 
  Board of Directors, National Nurse Practitioner Residency and 
  Fellowship Training Consortium, Middletown, CT.................     6
    Prepared statement...........................................     8
Verret, Reynold, Ph.D., President, Xavier University of 
  Louisiana, New Orleans, LA.....................................    10
    Prepared statement...........................................    12
Quinones, Norma, LPN, Nursing Services Manager and National, 
  Institute for Medical Assistant Advancement (NIMAA) Site 
  Coordinator, Clinical Family Health, Lafayette, CO.............    18
    Prepared statement...........................................    19
Greszler, Rachel, Research Fellow in Economics, Budget and 
  Entitlements, Institute for Economic Freedom and Opportunity, 
  The Heritage Foundation, Washington, DC........................    27
    Prepared statement...........................................    28

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
Hickenlooper, Hon. John:
    13 letters from various organizations submitted for the 
      Record.....................................................    59
    ``Protecting Our Front Line" Ending the Shortage of Good 
      Nursing Jobs and the Industry-creating Unsafe Staffing 
      Crisis'', National Nurses United...........................    86
    ``Diversity, Equity, & Inclusion'', Advocate Aurora Health...   142

 
                RECRUITING, REVITALIZING & DIVERSIFYING:
                  EXAMINING THE HEALTH CARE WORKFORCE
                                SHORTAGE

                              ----------                              


                      Thursday, February 10, 2022

                                       U.S. Senate,
           Subcommittee on Employment and Workplace Safety,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:03 a.m., in 
room 430, Dirksen Senate Office Building, Hon. John 
Hickenlooper, Chairman of the Subcommittee, presiding.

    Present: Senators Hickenlooper [presiding], Murray, 
Baldwin, Rosen, Braun, Cassidy, Tuberville, and Romney.

               OPENING STATEMENT OF SENATOR HICKENLOOPER

    Senator Hickenlooper. The Subcommittee on Employment and 
Workplace Safety will come to order. Today we are discussing 
health care workforce, specifically how we can revitalize and 
reinvigorate the workforce we will need for the next several 
decades.

    Ranking Member Braun, who is even more of an expert than 
some of our panelists in his own way as an employer, Ranking 
Member Braun and I will each have an opening statement, then we 
will introduce the witnesses. After the witnesses have given 
their testimony, Senators will have 5 minutes each for a round 
of questions.

    While we were unable to have the hearing fully opened to 
the public or media for in-person attendance, live video is 
available on our Committee website, help.senate.gov. Senator 
Braun and I have invited Members outside the Subcommittee to 
participate in today's hearing, and we will look forward to 
them being a part of this conversation as well.

    There is no doubt that during the pandemic, health care 
workers have worked tirelessly on the front lines and faced, in 
many circumstances, unimaginative--unimaginable challenges. 
However, the critical needs of the health care workforce were 
here before, and we will extend well beyond COVID unless we 
act.

    The Association of American Medical Colleges estimates that 
we will face a shortage of up to 124,000 physicians by 2034. We 
will also need to hire at least 200,000 nurses per year to meet 
the increased need. Just in Colorado, we are facing an 
estimated shortage of 10,000 nurses over the next 5 years.

    We are also facing a critical shortage of medical support 
staff, like medical assistance and nursing assistants. If we 
are going to make a dent in these daunting estimates, we need 
to get started now. I am glad to welcome our excellent witness 
panel, who are themselves working tirelessly to make progress 
in creating a pipeline of talent to take us into the future. We 
need to improve the recruitment, retention, and upskilling 
opportunities of our health care workers.

    If they are--if we are serious about growing the field, we 
should make it easier for those without college degrees, for 
working parents, and for those without previous experience to 
break into early stage health care jobs. For those who are in 
mid-career or wanting a change, we should allow more 
opportunities to upskill and progress forward. And we need to 
recognize the importance of having a health care workforce that 
looks like America and brings diverse experiences to the 
medical field.

    We need to increase diversity of representation among 
health care workforce to reflect the communities that they 
serve. One way is to invest early in expanding STEM education 
and mentorship opportunities for students in the health 
professions, particularly students of color. Health care can be 
a vibrant, rewarding profession, but we have to give today is 
health care workers and future health care workers 
opportunities to learn and thrive and grow at every level.

    If we want to combat the current burnout and build a 
robust, diverse workforce in the future, this has to be a 
priority. I can't think of a topic more important, and I look 
forward to hearing our witnesses' testimony about how we can 
make progress in the weeks and years ahead.

    We have got so much outreach and interest in this hearing, 
which really does show what a pressing issue it is. I would 
like to ask unanimous consent at this point to enter 13 letters 
into the hearing record from various organizations, including 
letters from the American Academy of Family Physicians, 
National Nurses United, and the University of Colorado, among 
others. No objections. Good.

    [The following information can be found on pages 59 through 
85 in Additional Material:]

    Now, I will recognize Ranking Member Braun for his opening 
statement.

                   OPENING STATEMENT OF SENATOR BRAUN

    Senator Braun. Thank you, Chairman Hickenlooper. This is an 
interesting discussion for me because since I have come to the 
Senate, the high cost of health care, especially from the point 
of view of an employer.

    I had my own business for 37 years and it was so small for 
so long, shared it with some earlier, that it wasn't really a 
concern. It got to be as we grew from 15 employees into that 
next and most recent 20 years, 300, and now 1,250. Three of my 
four kids, along with a good young executive team run that 
business. I stay closely in touch with it.

    Health care has been navigating through a lot of 
challenges. When you look across the world, we spend about 18 
to 20 percent of our GDP on health care. The rest of the world 
has similar, if not better outcomes, in some cases for half 
that cost. We were in the throes of that challenge and then you 
get hit by the biggest pandemic health care challenge, it 
really shows a system where its weaknesses are.

    I can't talk about it today, but I think beyond what we are 
going to try to focus on today, health care has got to be a 
priority for the health care consumer. When I changed my plan 
15 years ago, most individuals weren't interested in prevention 
and wellness, they were interested in remediation at whatever 
the cost was. I flipped the paradigm upside down.

    I think the industry has catered to mostly remediation, and 
I think it needs to focus as we get through shortages in 
workforce in offering the health care consumer more information 
about how you avoid the system by staying healthy and 
prevention. It is the underpinning of what I did, in addition 
to making my employees health care consumers. Let us look at 
where we are now.

    In December 2021, 10.9 million job openings. About 15 
percent of these openings were in the health care industry. On 
the front line, had to put up with this formidable foe that we 
had no idea where it was going to take us. In October 2021, a 
report by Morning Consult found that 18 percent of health care 
workers, imagine that, quit their jobs. You can see why. They 
were there having to put up with the uncertainty of how this 
was going to work out, 31 percent thinking about leaving.

    I mean, most businesses can't take abruptly a 5 percent 
exit, let alone this. You know, when you look at shortages like 
this, it is always worse in some places. And I come from a 
State like Indiana, many of our States have a rural component. 
We found out we don't even have rural broadband in most places 
when you need to have it, when you are working away from home, 
or even in--as it relates to health care.

    It involves other issues as well. How do we get through it 
and how do we get workforce in the place that has been most 
ravaged by the events, the health care industry itself? I think 
it is going to take an interesting combination of the health 
care industry, hospitals, practitioners, insurance companies, 
even pharma to know that you are going to have to take some of 
the burden yourselves. That you can't rely on Government to do 
this.

    When it comes to how we educate our health care workforce, 
we have got to look at that in the same way as we are in many 
other areas. In my home State of Indiana, pre-COVID, we had 
probably 60,000 to 80,000 jobs that couldn't be filled because 
we weren't guiding our kids in middle school and high school to 
maybe look at the opportunities.

    We were stigmatizing many of these pathways that don't 
require a 4-year degree. In my experience in my own business is 
when we have a 4-year degree opening, we get flooded with 
applicants. We need better life skills, better guidance in 
those most formative years, and I think parents would buy into 
that. They have had enough issues of a kid gone after a 4-year 
degree, ending back in the basement, when maybe they would have 
needed just other common sense options put out there.

    I think that across the board we spent a lot of money, $178 
billion to the provider relief fund. It will take more than 
just spending money. And that is what we do best here. We 
borrow 23 now, up close to 30 percent of it. We have to have 
better ideas that are hard to arrive at a solution.

    Most of us in the real world don't have a printing press in 
the basement, and we have got to do it with limited resources 
in the rigor of competition. I think Government is got to take 
some of those cues in terms of what we need to do better. So I 
am glad we are having this hearing. Workforce is an issue 
across all States.

    It is now the biggest deal, the biggest issue in the 
biggest sector in our economy. And when you look at the 
percentages of how many have left, how many are considering 
leaving, we have got to make sure we are at least coming up 
with some good ideas and not necessarily just spending money on 
the problem.

    Senator Hickenlooper. Thank you, Ranking Member Braun. I 
appreciate that. I appreciate that perspective. Now what we 
will do is allow each of our witnesses to have 5 minutes, and 
at some point Chair Murray will be here and we will let her do 
her opening statement when she gets here as well.

    Senator Cassidy. Senator Hickenlooper, we will have the 
opportunity to introduce the witness?

    Senator Hickenlooper. You will certainly will. And you 
probably have a busy schedule, so I will even let you go first 
with Senator Cassidy. So why don't I turn it to you for that 
Member privilege.

                  OPENING STATEMENT OF SENATOR CASSIDY

    Senator Cassidy. I appreciate that consideration. Thank 
you, Chairman Hickenlooper and Ranking Member Braun. It is my 
honor to introduce Reynold Verret, the sixth President of 
Louisiana Xavier University, one of Louisiana is historically 
black colleges and universities.

    Dr. Verret is a proven leader in higher education, 
fostering an innovative university environment to address 
underrepresentation in medicine and other fields, and to 
respond to the workforce needs of today. Dr. Verret is also an 
accomplished biochemist and immunologist. And if you look at 
his tie, I think that is the periodic table, which I know that 
Senator Hickenlooper would recognize.

    He participated in the COVID-19 vaccine trials and has been 
a vocal advocate in my State for folks to take the vaccine. 
From the start of the pandemic, Dr. Verret and Xavier have 
worked with local health agencies and hospitals to host mobile 
testing centers and to set up a fully operational COVID-19 
testing lab to serve local communities and Xavier's campus.

    Before being President of Xavier, Dr. Verret was Provost at 
Savannah State and Wilkes University, a Dean at the University 
of the Sciences in Philadelphia, Faculty and Department Chair 
at the Chemistry Departments of Tulane University and Clark 
Atlanta University, and an Adjunct Professor of Immunology at 
the Tulane and Morehouse School of Medicine and has conducted 
cancer research at MIT.

    As a former academician, I am impressed with that resume. 
But I would say that Dr. Verret's leadership throughout the 
pandemic has been equally or more impressive. Dr. Verret 
clearly understands the challenges facing HBCUs in today is 
environment and the urgent need to address underrepresentation 
of racial minorities in the medical and health science fields.

    I am pleased to have worked with Dr. Verret on my bill with 
Senator Schatz, the John Lewis National Institute on Minority 
Health and Health Disparities Research Endowment Revitalization 
Act that would provide additional funding to HBCUs to research 
health disparities and to promote the diversity and strength of 
the science workforce.

    We need leaders like Dr. Verret that speak to the 
challenges to plot the way forward, and to help find solutions 
in recruiting a larger and more diverse health care workforce. 
With that, I yield.

    Senator Hickenlooper. Thank you. Appreciate that--that warm 
introduction. Now I will take over again for two introductions 
and then we will revert to Senator Braun for the last 
introduction. First, I would like to introduce Dr. Margaret 
Flinter from Middletown, Connecticut. She is the Senior Vice 
President and Clinical Director of the Community Health Center, 
Inc..

    She Chairs the Board of Directors, National Nurse 
Practitioner, Residency and Fellowship Training Consortium. I 
think it is fair to say that over these many decades, she has 
helped transform the Community Health Center, Inc. not only 
into one of the Nation is largest federally qualified health 
centers, but one of the most innovative health system networks 
of any category in the country.

    I know, I remember firsthand when they first began doing 
telemedicine back in the 1990's, before it was common, and 
certainly it was difficult to be able to do any billing for it 
at all. Anyway, thank you so much for being here, Dr. Flinter.

    Next, I am going to introduce Norman Quinones. She is a 
Nursing Services Manager for Clinica Family Health in 
Lafayette, not Lafayette, Louisiana, but Lafayette, Colorado. 
She is a Site Coordinator for the National Institute of Medical 
Assistant--Medical Assistant Advancement, NIMAA.

    Ms. Quinones started working at Clinica in 1992 as a 
Medical Assistant and has served in a variety of leadership 
roles, and I know for a fact that she is one of the people that 
holds Clinica together and helps them succeed in one of the 
most challenging and diverse, geographically diverse, as well 
as diverse among people, health care systems in the West and 
certainly in Colorado by a long measure.

    As I've said, she is from Lafayette, Colorado. I love the 
fact that she is next to Dr. Verret. We have the Lafayette kind 
of group together. We are delighted to have you here, Ms. 
Quinones. And now I am going to turn the last introduction over 
to my friend from Indiana, Senator Braun.

    Senator Braun. Thank you. You will also be hearing from 
Rachel Greszler, a Research Fellow in the Economics, Budget and 
Entitlement Center at the Heritage Foundation. Her area of 
focus is on labor and retirement policies. And previously 
served as a Senior Economist on the staff of the Joint Economic 
Committee of Congress for 7 years. Thanks for joining us today, 
Rachel. I look forward to hearing from you.

    Senator Hickenlooper. Perfect. Alright, so we will then 
start. Dr. Flinter, why don't you start and then we will go 
right down, right down along the table.

    STATEMENT OF MARGARET FLINTER, PH.D., APRN, SENIOR VICE 
PRESIDENT AND CLINICAL DIRECTOR, COMMUNITY HEALTH CENTER, INC., 
  AND CHAIR, BOARD OF DIRECTORS, NATIONAL NURSE PRACTITIONER 
  RESIDENCY AND FELLOWSHIP TRAINING CONSORTIUM, MIDDLETOWN, CT

    Ms. Flinter. Perfect. Can you hear me?

    Senator Hickenlooper. Yes.

    Ms. Flinter. Perfect. Well, good morning, Chairman 
Hickenlooper and Members of the Senate HELP Committee, and 
Members of the Employment and Workplace Safety Subcommittee. 
Thank you so much for having me here today. I hope to convey to 
you in my few minutes the urgency of the health care situation 
and to identify strategies that are working and that we can 
build upon.

    Primary care is in a crisis, as you have already alluded, 
between burnout, early retirement, an aging workforce, and 
competition with other medical specialties. As Senator 
Hickenlooper said, we are headed for a predicted shortage of 
almost 130,000 physicians by 2030.

    At the same time, the aging of the U.S. population, the 
impact of complex and multi chronic illness, and the persistent 
health disparities that we are also aware of all combined to 
make the need for every individual, every family, every 
community to have access to high quality primary care ever more 
important.

    The National Institute of Science, Engineering and 
Medicine's landmark 2021 report, issued just a few months ago, 
has laid out a blueprint of what needs to be done. Where is the 
next generation of primary care providers going to come from? I 
answered, it is already here.

    Nurse practitioners are here in number, and they are 
focused on primary care, but they want, need, and deserve the 
opportunity for post-graduate residency or fellowship training, 
similar to what their colleagues in medicine, dentistry, and 
other health professions have enjoyed in order to prepare for, 
practice, and settings in which the nurse practitioner is the 
bedrock, the core, and the foundation of primary care.

    Today I want to speak to what we are doing to address this 
and what remains to be done. I am going to focus on primary 
care providers today, but my comments are also relevant to 
psychiatric mental health nurse practitioners and to these 
specialty care and hospital outpatient setting and inpatient 
setting.

    15 years ago, based on both research and experience, I 
recognized it was a time for a major innovation and training 
for new nurse practitioners who are committed to being primary 
care providers and particularly in our safety net settings like 
community health centers, like rural health centers.

    We were asking them to embrace the full scope of primary 
care practice from the start. But we saw firsthand what one new 
nurse practitioner called the shock and awe of seeing just how 
sick people can be in primary care and how complex the care was 
in our settings like community health centers. And while all 
new nurse practitioners are prepared and competent for entry 
level practice, what we say is there are very few entry level 
patients in our settings and community health centers and in 
rural health.

    This gap between preparation and practice quickly gives 
rise to burnout, frustration, and too often we saw early 
departure by nurse practitioners from full scope primary care 
roles and the practices that so need them. And so, in 2007, the 
Community Health Center developed and piloted the country is 
first formal post-graduate residency training program for new 
nurse practitioners.

    We did it with four new nurse practitioner residents, but 
with a commitment to building a model that others could 
replicate across the country. This intensive yearlong training 
has given rise to a national movement. There are now 250 
postgraduate NP residency and fellowship training programs 
specializing just in primary care in the United States and many 
more in this specialty and acute care settings as well.

    Just in community health centers, there are now 75 
programs, some are joint nurse practitioner MPA programs. These 
programs are very carefully designed and structured to ensure 
intensive clinical training with expert preceptors, the 
development of mastery and caring for highly challenging 
conditions such as opioid use disorder, multi-chronic illness.

    But the training also includes the skills to improve 
practice as well as deliver care to provide the most effective 
prevention and health promotion care, and the resilience to 
thrive as primary care providers and members of a high 
performing team, which must of course, include our medical 
assistance, our nurses, our community health workers, and our 
behavioral health clinicians.

    What started as a model has grown into a movement and 
research indicates that nurse practitioner graduates of post-
graduate training programs remain in primary care and 
underserved practices at higher rates compared to national 
averages. They are also more likely to mirror their patient 
populations. They are more diverse, and they serve more 
underserved populations.

    An initial concern that creating such programs implied that 
nurse practitioners were somehow lacking has given way to a 
recognition that this is simply what new nurse practitioners 
want and deserve, and 77 percent of newly graduated NPs report 
that they would like to do a post-graduate residency program, 
if one were available. In 2019, HRSA's Bureau of Workforce 
funded 36 of these programs that is only 36 of the 250 in the 
country. They required that they be accredited in order to 
assure rigor in their program, rigor and quality.

    We are happy to say to a Consortium, of which I serve as 
chair, is recognized by the Department of Education as an 
accrediting organization. I want to say that in my work with 
the Consortium, I have had the pleasure of visiting NPR 
residency programs across the country, from the State of 
Washington to Maine, from Hawaii to Alabama, and many points in 
between, including Indiana.

    I am deeply impressed by the commitment of the boards, the 
executive and clinical leaders, and the frontline clinicians 
and staff to this model because it works. It works in 
attracting those for whom the desire to serve and care for 
people as a primary care provider is both a profession and a 
calling.

    It works in retaining them in our most challenging 
practices as primary care providers and as future leaders in 
health care. But these programs need Federal support to 
continue this work and for new programs to start. As I have 
said, HRSA has stepped up with a small program for 36, but we 
need more.

    Today, I focused on the nurse practitioner as a primary 
care provider, but I know firsthand we need to devote our 
attention to every member of the team. I am so glad that Norma 
Quinones is speaking to you today about medical assistance.

    Thank you for your concern, for your commitment to our 
health care workforce, and to our people and communities that 
rely on us for this primary care. Thank you so much.

    [The prepared statement of Ms. Flinter follows:]
                 prepared statement of margaret flinter
    Good Morning Chairman Hickenlooper, and Members of the Senate 
Health, Education, Labor and Pensions Employment Subcommittee. Thank 
you for the opportunity to speak to this Committee.

    We need to ensure that every person and every family in every 
community has the opportunity to get high quality primary care. Thus, 
we have a vital need to ensure that we are training the next generation 
of primary care providers to make that possible. Today, I will speak 
not just to the need, but to what is being done to meet that need. I am 
going to focus primarily today on primary care providers and the 
primary care setting but my comments are also relevant to psychiatric/
mental health care and specialty care.

    We know the United States has an urgent short and long term need 
for expert primary care providers. The National Academy of Sciences, 
Engineering and Medicine's landmark 2021 report, Achieving High Quality 
Primary Care, (Phillips et al., 2021) has laid out a blueprint of what 
must be done to achieve high quality primary care for all people but it 
does this against a backdrop of a projected shortage of 130,000 
physicians. (Zhang et al., 2020) This comes at a time when the 
healthcare needs of the population have never been more intense due to 
an aging population, the burden of chronic illnesses, and persistent 
health disparities by race, income and ethnicity. And of course, COVID 
has left its mark everywhere.

    Where will the next generation of primary care providers come from? 
I answer: they are already here. They are nurse practitioners. But we 
have to give them the opportunity to train and prepare for practice and 
settings in which they are the bedrock, core, and foundation of primary 
care in the U.S.

    Nothing is static in life or health care. Fifteen years ago, based 
on research and decades of experience, I recognized that it was time 
for a major innovation in training for NPs committed to being primary 
care providers, particularly in community health centers and rural and 
underserved areas. We needed them to be ready and able to embrace the 
full scope of primary care practice when they entered practice right 
from the start. We saw firsthand the ``shock and awe'', as one new NP 
described it, at just how sick the patients are, and how complex the 
care is. While all new NPs are prepared and competent for entry level 
practice, we recognized that there are few ``entry level'' patients in 
our very busy and stressed underserved communities and settings. This 
gap quickly gives rise to burnout and frustration. Too often we 
witnessed early departure of nurse practitioners from the very settings 
that needed them the most. The solution we proposed was formal 
postgraduate residency or fellowship training. This intensive yearlong 
training in the practice setting gives new NPs the opportunity to 
develop the confidence, competence, and mastery to undertake full scope 
practice in settings both rural and urban, and to embrace the full 
range of primary care services.

    In 2007, my colleagues and I designed and launched the first 
postgraduate residency program to support this level of intensive 
hands-on NP preparation at Community Health Center, Inc. (Flinter, 
2011) We did it with 4 NP residents and a commitment to designing a 
model that could be replicated nationally. Today, there are 250 
postgraduate NP residency and fellowship training programs specializing 
in primary care in the U.S. Seventy five are sponsored by FQHCs and an 
additional 20 six are sponsored by academic partners but carried out in 
an FQHC. The programs are carefully constructed to ensure progressive, 
intensive clinical training with expert preceptors, development of 
mastery in caring for highly challenging conditions such as substance 
use disorder, HIV, multiple chronic illnesses, and all intertwined with 
adverse social determinants of health and all while promoting wellness, 
prevention, and health promotion. The NP Residents are trained in the 
science of improving practice as well as delivering care. The programs 
provide the experience and skills for new NPs to practice as part of a 
high performing team, which leverages the contributions of medical 
assistants, RNs, behavioral health clinicians and, increasingly, 
community health workers.

    What started as a model has grown into a movement because it works. 
Research indicates that graduates of postgraduate training programs 
remain in primary care and underserved practices at high rates compared 
to national averages. In a nationally representative study conducted 
last year, primary care NPs with residency training were also more 
likely to mirror their patient populations (were more diverse) and also 
saw more underserved populations (minority populations with limited 
English proficiency. (Park et al., 2022)

    An initial concern of some that the creation of postgraduate 
training implied that NPs were somehow lacking has given way to 
recognition that this is what new NPs want and deserve. In a recent 
national survey, 77.5 percent of newly graduated NPs reported they were 
either ``willing'' or ``very willing'' to participate in a postgraduate 
training program. (Faraz, 2015) We are asking them to be the backbone 
of primary care, and they deserve the opportunity to choose intensive 
postgraduate primary care training, appropriate in length and content 
to today's primary care practice models.

    Pragmatically, the model addresses the most urgent need for primary 
care organizations: recruiting and retaining an expert primary care 
workforce. Today, we recognize that this must include training 
psychiatric/mental health NPs as a vital part of the primary care team 
to address behavioral health and substance use disorders. Many of the 
original NP Residency programs are expanding to include tracts for 
psychiatric/mental health NPs. And while today's testimony is focused 
on primary care, I want to stress that our colleagues in in-patient and 
specialty outpatient settings have identified the same needs, and 
concluded that postgraduate residency and fellowship training is 
essential for new NPs and PAs in their settings as well.

    In 2019, HRSA's Bureau of Health Workforce recognized the value and 
impact of postgraduate training for new NPs with a new program, ANE-
NPR, and funded a combination of 36 new and established programs. HRSA 
added requirements that programs seek and obtain accreditation, and 
also establish academic practice partnerships. It subsequently received 
modest appropriations in 2019 and 2020 to further support the program. 
In 2020-2021, 368 NP residents were supported by the program according 
to HRSA's data warehouse.

    The National Nurse Practitioner Residency and Fellowship Training 
Consortium (NNPRFTC or simply, ``the Consortium'') was created to 
ensure quality and rigor in postgraduate NP training through formal 
accreditation. It has earned recognition by the U.S. Department of 
Education as a federally recognized accrediting organization. The 
Consortium also works with new and existing programs to design their 
programs from the start using accreditation standards to provide a 
roadmap to a rigorous, successful program.

    How much impact can we have on the goal of ensuring that every 
person and every family have access to great primary care and a primary 
care provider? The Consortium's accredited programs plus a group of 
programs with whom CHC has formally collaborated can document 550 
alumni. With 250 programs nationally and a conservative estimate of 
four postgraduate trainees per program, we can assume up to 1,000 new 
NPs may now be able to choose a program--far more than just a few years 
ago, but far less than is needed. We are able to track where alumni of 
the Consortium's accredited programs practice upon completion of the 
program. The vast majority are practicing as primary care providers, 
mostly in community health centers and underserved areas. We need to 
continue to support the currently funded programs, expand access to new 
programs, and support those that have devoted scarce resources to 
standing up a program on their own.

    In my work with the Consortium, I have visited many programs: from 
the Yakima Valley Farmworkers Clinic and CHAS in the State of 
Washington, to Cahaba Medical Care in Alabama, from Waianae Coast 
Comprehensive Health Center in Hawaii to Thundermist Health Center in 
Rhode Island and many points in between. I am deeply impressed by the 
top to bottom commitment of boards, executive leadership, and front 
line clinicians and staff to this model because it addresses and 
resolves much of their highest priority: Recruiting and retaining 
expert primary care providers who are deeply committed to their 
practice and communities.

    Thank you.
                                 ______
                                 
    Senator Hickenlooper. Thank you.

    Dr. Verret.

     STATEMENT OF REYNOLD VERRET, PH.D., PRESIDENT, XAVIER 
            UNIVERSITY OF LOUISIANA, NEW ORLEANS, LA

    Mr. Verret. Chairman, thank you for having me today. 
Chairman Hickenlooper and Members of the Committee, thank you 
for the opportunity to address you today. My name--sorry. 
Chairman Hickenlooper and Members of the Committee thank you 
for the opportunity to testify today.

    My name is Reynolds Verret, C. Reynolds Verret. I serve as 
sixth President of Xavier University of Louisiana. My 
institution is historically a black university, an HBCU. It is 
also a Catholic institution. The ultimate purpose of Xavier is 
to contribute to the promotion of a just--a more just and 
humane society by preparing its students to assume roles of 
leadership and of service in a global society.

    I was asked testify before the Committee about how Xavier 
has employed innovative strategies to address in critical 
underrepresentation of blacks in health and other science--
health care and other sciences. I will speak for my 
institution, but you may extend many of my comments to the 
other 100 accredited HBCUs across the Nation.

    Xavier is renowned for its work as a leading institution in 
training African-American undergraduates to complete and go on 
to complete the MD across the Nation, and also PhDs in the 
physical and life sciences. Our considerations when developing 
new programs, especially the graduate and professional levels, 
includes special criteria. One, whether the programs reflect a 
growing demand.

    Two, will degrees lead to positions of--with possibilities 
for personal growth and flexibility, will degrees earn salaries 
that allow students to repay their loans, if the proposed 
degrees are of service to the larger society, and especially 
underrepresented communities, and most importantly, whether 
these degrees offered at Xavier help diversify professions and 
increase representation.

    Our new programs target professions in which only 1 to 3.5 
percent of practitioners identify as African-Americans. The 
diversity is critical to provide equitable health care 
outcomes. Xavier started this approach many years ago. However, 
the challenges of care, of health care equity was highlighted 
in the recent disparities demonstrated by the COVID pandemic.

    To provide an overall perspective of what we do in Xavier, 
since 2016, we have started 23 new programs. New undergraduate 
programs include from Bioinformatics, Data Science, Medical 
Laboratory Science, Neuroscience, Robotics, and Mechanical 
Engineering, and Statistics. At the graduate levels, programs 
include Masters of Health Science, Physician Assistant Studies, 
Masters of Public Health and Health Equity, Speech and Language 
Pathology, and Masters in Pharmaceutical Sciences.

    Three upcoming programs that are the MS in Health 
Informatics, and also MS in Genetic Counseling, and the 
Doctorate in Physical Therapy. While we are proud of the work 
we do at Xavier, we and the Nation are challenged to address 
the staggering numbers of black doctors and scientists 
nationally. Much more must be done to develop a representative 
community of health care providers and scientists, physicians 
to reduce and eliminate health disparities.

    To fully address this need, the pipeline of sending 
undergraduate students into schools such as Xavier must be 
vastly expanded. This will require providing pathways to all 
but most importantly to our first generation students, 
including information to families on pathways to college, the 
application financially processes, all to make the journey 
achievable without the burden of lifelong debt.

    America cannot afford to develop only a subset of its 
talent, forsaking many whose contributions are needed, losing 
them due to socioeconomic barriers. With this being said, I 
would like to firmly think Congress for most recent investments 
in funding to HBCUs, tribal colleges and universities, minority 
serving institutions.

    I am also grateful for funding which benefits our student 
population directly. Last, may I make a few suggestion 
recommendations? We need to double the Pell Grant. Embracing 
the only national program that helps low income students 
achieve higher education would serve the Nation and ease the 
path to needy professions. Revive subsidies for first 2 year 
education--for the first 2 years of education at HBCUs. Still 
more than 50 percent of all students at HBCUs are first 
generation learners. Removing financial impediments will expand 
the talent pool to the United States.

    Investing in an additional $5 billion to expand the Title 
III grant, institutional grant programs at HBCUs will go a long 
way to strengthen our institutions. A few historically black 
institutions produce a great percentage of the diversity in 
health and STEM. Acknowledge this work with more robust 
resources to expand their impact and capacity.

    Fully fund the HCOP, the Health Careers Opportunities 
Program and similar programs. Too few black institutions also 
have capacity--too few black institutions have capacity and 
resources to function as major research institutions. Why don't 
we speak of the R01 status, even though they are actively 
nearing that point? More Federal investment, developing and 
building capacity at a few HBCUs, Xavier included, will allow 
us to continue to expand our work in response to national need.

    In President Biden's Joint Families and Infrastructure 
plans, HBCUs, tribal colleges, and MSIs, will slate to receive 
$90 billion in investment in research related infrastructures. 
This is needed and essential. Another point I would say is to 
forgive the balance of the HBCU Capital Finance Program debt 
for the remaining HBCUs who were excluded from that 
forgiveness.

    We at Xavier understand that this really should not be 
routine. However, there are numerous opportunities in the 
Ignite HBCU Excellence Act. Unburden these institutions, 
including Xavier. Last but not least, we as a committee of 
institutions are still processing the cowardly acts of terror, 
which have disrupted so many HBCUs.

    I anticipate representations at UNCF and other 
representatives of our universities will put forward funding 
and policy recommendations for--to the appropriate committees 
in the coming weeks. I hope the members of this community will 
support these recommendations, mitigating threat and 
safeguarding our Nation is most precious assets, which are our 
students.

    Mr. Chairman, I thank you and I look forward to answer the 
questions of the Members of the Committee.

    [The prepared statement of Mr. Verret follows:]
                  prepared statement of reynold verret
    Subcommittee Chairman John Hickenlooper and Members of the 
Subcommittee, thank you for the opportunity to testify today.

    My name is C. Reynold Verret, and I serve as the 6 President of 
Xavier University of Louisiana (Xavier). Xavier was founded by Saint 
Katharine Drexel of the Sisters of the Blessed Sacrament. My 
institution is Catholic and considered a historically Black college and 
university (HBCU).

    The ultimate purpose of Xavier is to contribute to the promotion of 
a more just and humane society by preparing its students to assume 
roles of leadership and service in a global society. This preparation 
takes place in a diverse learning and teaching environment that 
incorporates all relevant educational means, including research and 
community service.

    I was asked to testify before the Subcommittee today to share how 
our institution is addressing issues of underrepresentation of Blacks 
in medical and health sciences fields, how this nation can increase the 
numbers of Black students achieving advanced and terminal degrees, 
share information on the workforce development and new programs we are 
launching, and address shortages of practitioners of color in existing 
and emerging health science and medical fields.
                      HBCU History and Statistics
    Before I share how Xavier is impacting representation in Health and 
Science fields in the Nation with development of innovative academic 
programs at the undergraduate and graduate levels and preparing 
students to pursue and persist to graduate and terminal degrees, let me 
share some general statistics about. HBCUs and their performance.

    HBCUs were created as early as 1837 to provide African Americans 
access to higher education. Noted for their contributions in educating 
Black, low-income, and educationally disadvantaged Americans, the 101 
accredited HBCUs today constitute the class of institutions that 
satisfy the statutory definition of the term ``HBCU'' as defined in the 
Higher Education Act of 1965 (HEA). \1\
---------------------------------------------------------------------------
    \1\  The definition of an HBCU can be found in Section 322(2) of 
the HEA.

    HBCUs disproportionately enroll low-income, first-generation and 
academically underprepared college students--precisely the students 
---------------------------------------------------------------------------
that the country most needs to obtain college degrees. In 2018:

          Nearly 300,000 students attended HBCUs; \2\
---------------------------------------------------------------------------
    \2\  U.S. Department of Education, National Center for Education 
Statistics. (2020). Digest of education statistics 2019 [Table 313.20]. 
Retrieved from https://nces.ed.gov/programs/digest/d19/tables/dt19--
313.20.asp

          More than 75 percent of HBCU students were African 
---------------------------------------------------------------------------
        Americans; and

          Over 60 percent of undergraduate students at HBCUs 
        received Federal Pell Grants, and over 60 percent of these 
        students received Federal loans. \3\
---------------------------------------------------------------------------
    \3\  UNCF Public Policy and Government Affairs calculations using 
2018 data from the U.S. Department of Education, National Center for 
Education Statistics, Integrated Postsecondary Education Data System. 
Data shows that out of 257,451 total undergraduate students at HBCUs, 
159,101 students were receiving Pell Grants and 162,179 students were 
receiving Federal loans.

    HBCUs comprised 3 percent of all two-and 4-year non-profit colleges 
---------------------------------------------------------------------------
and universities, yet they:

          Enroll 10 percent of African American undergraduates;

          Produce 17 percent of all African American college 
        graduates with bachelor's degrees; and

          Graduate 24 percent of African Americans with 
        bachelor's degrees in STEM fields. \4\
---------------------------------------------------------------------------
    \4\  UNCF Patterson calculations using U.S. Department of 
Education, National Center for Education Statistics, Integrated 
Postsecondary Education Data System.

    A 2015 Gallup survey confirms that HBCUs are providing African 
American students with a better college experience than African 
---------------------------------------------------------------------------
American students at other colleges and universities.

          55 percent of African American HBCU graduates say 
        their college prepared them well for post-college life versus 
        29 percent for African American graduates of other 
        institutions. \5\
---------------------------------------------------------------------------
    \5\  Gallup, Inc. (2015). Gallup-USA funds minority college 
graduates report. Retrieved from UNCF Website: https://www.uncf.org/
wp--content/uploads/PDFs/USA--Funds--Minority--Report--GALLUP-2.pdf

    HBCUs attained these results at an affordable price for students--
that is, the cost of attendance at HBCUs is about 30 percent lower, on 
average, than other colleges--despite limited operating budgets and 
endowments that are roughly half the typical size of other 4-year 
---------------------------------------------------------------------------
public and private non-profit colleges and universities.

    Since our founding, HBCUs have been, and continue to be, under-
resourced institutions. An issue brief produced by ACE (American 
Council on Education) and UNCF (United Negro College Fund, Inc.) 
revealed the following:

          Public HBCUs rely more heavily on Federal, state, and 
        local funding in comparison with their non-HBCU counterparts 
        (54 percent of overall revenue vs 38 percent);

          Private HBCUs depend a little bit more on tuition 
        dollars than their non-HBCUs counterparts (45 percent compared 
        with 37 percent);

          Private gifts, grants, and contracts constitute a 
        smaller portion of overall revenue at private HBCUs compared to 
        their non-HBCU counterparts (17 percent vs 25 percent);

          Public and Private HBCUs experienced the largest 
        declines in Federal funding per full-time equivalent student 
        between 2003-2015; and

          In both the public and private sectors, HBCU 
        endowments lag behind those of non-HBCUs by at least 70 
        percent. \6\
---------------------------------------------------------------------------
    \6\  Williams, K.L. & Davis, B.L. (2019). Public and private 
investments and divestments in Historically Black Colleges and 
Universities. Retrieved from American Council on Education Website: 
https://www.acenet.edu/news-room/Pages/Public-and-Private-Investments-
and-Divestments-in-HBCUs.aspx

    Despite being under-resourced institutions, HBCUs have a large 
economic impact that often goes unnoticed by most. In 2017, UNCF 
released a report detailing the economic impact of HBCUs. The report 
revealed that in 2014, the impact of HBCUs on their regional economies 
---------------------------------------------------------------------------
included:

          $10.3 billion in initial spending, which includes 
        spending by the institution for personnel services, spending by 
        the institution for operating expenses, and spending by 
        students;

          An employment impact of 134,090 jobs, which 
        approximately 43 percent were on-campus jobs and 57 percent 
        were off-campus jobs;

          $10.1 billion in terms of gross regional product, 
        which is a measure of the value of production of all 
        industries;

          A work-life earnings of $130 billion for the Class of 
        2014, which is 56 percent more than they could expect to earn 
        without their 2014 certificates or degrees; and

          A total economic impact of $14.8 billion. \7\
---------------------------------------------------------------------------
    \7\  Humphreys, J.M. (2017). HBCUs make America strong: The 
positive economic impact of Historically Black Colleges and 
Universities. Retrieved from UNCF Website: https://www.uncf.org/
programs/hbcu-impact

    Regarding Xavier University of Louisiana specifically, my 
institution had the following economic impact on its regional economy 
---------------------------------------------------------------------------
according to the UNCF report:

          $200,000,000 in annual economic impact;

          1,715 jobs supported annually; and

          $1.7 billion in lifetime earnings for one graduating 
        class.

    In addition to the positive impact HBCUs make on the overall 
economy, HBCUs also have a strong impact academically when observed at 
the State and local level. An upcoming report to be released by UNCF 
shows that:

          HBCUs comprised 8.5 percent of the 4-year 
        institutions across the 21 states and territories in the 
        analysis;

          Across the 21 states and territories in the analysis, 
        HBCUs enrolled, on average, 24 percent of all Black 
        undergraduates pursuing a bachelor's degree in a college or 
        university in 2016;

          Across the 21 states and territories in the analysis, 
        on average, 26 percent of all Black bachelor's degree 
        recipients graduated from an HBCU in 2016; and

          In North Carolina, HBCUs are 16 percent of the 4-year 
        institutions, but enroll 45 percent of all Black undergraduates 
        and award 43 percent of all Black bachelor's degrees in the 
        state. \8\
---------------------------------------------------------------------------
    \8\  Saunders, K. & Nagle, B.T. (2018). HBCUs punching above their 
weight: A state-level analysis of historically Black college and 
university enrollment and graduation. Washington, DC: UNCF Frederick D. 
Patterson Research Institute

                           History of Xavier
    Xavier University of Louisiana is the only historically Black and 
Catholic institution in the Nation, and is nationally recognized for 
its science, technology, engineering, and mathematics (STEM) 
curriculum, while remaining close to its liberal arts roots. Xavier's 
mission is to create a more just and humane society by preparing its 
students to assume roles of leadership and service in a global society. 
This preparation takes place in a diverse learning and teaching 
environment that incorporates all relevant educational means, including 
research and community service.

    As of Fall 2021, the University has 245 full-time faculty members 
who offer courses in over 50 majors on the undergraduate, graduate, 
doctoral, and first-professional degree levels. Xavier's current 
enrollment is 3,604. Of these, 2,749 are undergraduates and 236 are 
graduate students enrolled in the College of Arts and Sciences. In 
addition, there are 613 students enrolled in the College of Pharmacy, 
which offers the Master of Health Science in Physician Assistant 
Studies, the Master of Science in Pharmaceutical Sciences, and the 
Doctor of Pharmacy, and 236 students are enrolled in Master's and 
Doctoral programs in the College of Arts and Sciences. Xavier's student 
body is 77 percent African American, with approximately 39 percent from 
Louisiana, primarily from the New Orleans area. The balance comes from 
41 other states, the District of Columbia, Puerto Rico, the Virgin 
Islands, and several countries. 50 percent of our students have an 
expected family contribution of below $2,500. 30 percent of our 
students are first generation students. (1st generation students have 
lower retention and graduation rates). Xavier welcomes students who are 
spread out across the academic profile spectrum and has a proven track 
record of meeting students where they are and filing educational gaps 
to assist in their perseverance to degree and beyond.
           How Xavier Overcomes Obstacles to Student Success
    Xavier achieves this student success despite the many obstacles 
posed through a strong support system for students through: Intensive 
advising by faculty and staff that includes Pre-Health advisors, career 
advisors, and graduate school advisors; Workshops and presentations to 
assist students on their pathway; Academic Resource Centers--provide 
tutoring and supplemental instruction; Early alert system that notifies 
key faculty and staff when students need intervention to put them back 
on track to success; Residential education program and co-curricular 
programs to develop the whole student and grapple with the socio-
economic challenges many of our students face.

    According to the U.S. Department of Education, during the past 
decade, Xavier has ranked first nationally in the number of African 
American students earning undergraduate degrees in Chemistry and the 
Physical Sciences overall, and in the top five in Biology. Many well-
prepared, highly motivated students are attracted by Xavier's 
reputation in this regard. Conversely, academically disadvantaged 
students also are drawn to Xavier because of its track record in 
``leveling the playing field,'' especially in the first year of 
college. The New York Times Selective Guide to Colleges observes, 
``Xavier is a school where achievement has been the rule and beating 
the odds against success a routine occurrence.''

    According to the Flexner report data for the 13 historically Black 
medical schools that were closed and 4 historically Black medical 
schools that remained open after the 1910 Flexner report, \9\ an 
extrapolation based on data from the medical schools that remained open 
indicated that 5 of the closed medical schools might have collectively 
provided training to more than 35, 000 graduates by 2019. If these 5 
closed schools had remained open, they could have produced a 29 percent 
increase in the number of graduating African American physicians in 
2019 alone. \10\ While this may seem to many a question purely of 
``what if,'' I posit it is an alarming look at how the U.S. could have 
had a more diverse mixture in the health professions, because the 
percentages of African-American U.S. doctors has remained unchanged 
largely throughout my adult life. According to the Association of 
American Medical Colleges (AAMC), only 5 percent of all U.S. doctors 
are Black or African American. A new UCLA study finds that the 
proportion of physicians who are Black in the U.S. has increased by 
only 4 percentage points over the past 120 years, and that Xavier has a 
long-standing national reputation in producing Black health 
professionals. The University has consistently been the No. 1 
undergraduate source of African Americans who persist to complete their 
MDs. Xavier is nationally ranked as one of the top institution's whose 
undergraduates achieve PhDs in the life and social sciences. The 
College of Pharmacy has also consistently been among the nation's 
leaders in awarding Doctor of Pharmacy degrees to African Americans.
---------------------------------------------------------------------------
    \9\  Abraham Flexner and Herman Gates Weiskotten. The Flexner 
Report on Medical Education in the United States and Canada (1910).
    \10\  Campbell KM, Corral I, Infante Linares JL, Tumin D. Projected 
Estimates of African American Medical Graduates of Closed Historically 
Black Medical Schools. Retrieved from https://jamanetwork.com/journals/
jamanetworkopen/fullarticle/2769573

    Since 2002, graduates have gone on to receive 2,755 master's 
degrees, 241 PhD degrees, and 1,529 First Professional degrees since 
---------------------------------------------------------------------------
matriculating at Xavier.

    Xavier is committed to ensuring that entering first year students 
persist and complete their educational goals and recognizes the value 
of reaching out to students well before their college years to enhance 
skills and habits that will lead to academic success. For over thirty 
years, Xavier has coordinated summer programs for high school students 
through its Summer Science Academy (SSA). Approximately 500 students 
participate each summer in an array of STEM programs including 
MathStar, BioStar, ChemStar and analytical reasoning programs.

    Xavier also has several programs that support minority student 
achievement for its undergraduates, including the LS-LAMP (Louis Stokes 
Louisiana Alliance for Minority Participation), BUILD (Building 
Infrastructure Leading to Diversity) Program, MICHESS (Materials and 
Interfaces Center for High Energy Storage and Sensing) Program, the 
Ronald E. McNair Program, HBCU-UP (Historically Black Colleges and 
Universities Undergraduate Programs) programs, Upward Bound Math and 
Sciences and McNair programs.

    Xavier's goal is to provide students the highest level of learning 
possible in all areas of the liberal arts and sciences, to help them 
develop their own commitment to life-long learning, and to prepare them 
for opportunities to enter and succeed in emerging as well as time-
honored careers that require a high level of talent, drive for 
excellence, and commitment to service.
 Developing Graduate Programs to increase Representation of Blacks in 
                     Careers of Today and Tomorrow
    At Xavier we continue to innovate in what programs we will invest 
in to better the success opportunities for our students. Our 
considerations when developing new programs, especially at the graduate 
and professional level include whether the program reflects a growing 
demand, if earning this degree will lead to positions that call upon 
personal judgment and to possibilities for continued personal growth 
and flexibility needed for rapidly changing markets, whether students 
who earn the degree will earn salaries that allow them to pay back 
their student loans and serve as economic generators for the 
communities in which they live, if the proposed degree make possible 
personal improvement while being of service to society and most 
especially to underserved communities of color.

    One of our biggest considerations in development of programs is 
whether the degrees offered at Xavier help diversify a profession and 
increase representation. Our recently launched programs and planned 
programs target professions in which only 1-3.5 percent of 
practitioners identify as African Americans. This is critical to 
providing equitable healthcare outcomes. While Xavier started this 
innovative method of considering programs for development many years 
ago, the challenge of health care equity was highlighted by the recent 
disparities demonstrated by COVID outcomes in Black communities.

    To provide an overall perspective, since 2016, we have started 23 
programs: 6 certificate programs, 9 bachelor's degree programs, 6 
minors, 4 master's programs, 1 dual degree program.

    New undergraduate programs include Bioinformatics, Data Science, 
Medical Laboratory Science, Neuroscience, Robotics and Mechatronic 
Engineering, Statistics.

    New graduate programs include Master of Health Sciences, Physician 
Assistant Studies; Master of Public Health, Health Equity; Master of 
Science, Speech-Language Pathology; Master of Science, Pharmaceutical 
Sciences. Three more in development include Master of Science, Health 
Informatics (start Fall 2022); Master of Science, Genetic Counseling 
(start Fall 2024); Doctor of Physical Therapy is in its early planning 
stages.
                         Challenges to Our Work
    Our greatest challenges to this work are the cost to develop the 
programs, space limitations that we and many HBCUs face as we deal with 
aging infrastructure and remain undersourced for capital improvement 
and expansion projects. The socioeconomic challenges that face our 
students and efforts that we must make for them to succeed despite 
these challenges. This includes lack of funding for entrance exams, 
travel for interviews, need to go directly into career field to 
alleviate the debt of achieving undergraduate degrees, and the cost of 
the graduate programs.

    Mr. Chairman, now that I have informed the Committee on what makes 
Xavier perform well at the production of health professionals, I want 
to leave you with some recommendations:

           1. Double the current Pell Grant. Embracing the only 
        national program that helps low-income students achieve higher 
        education would help ease the avenue to graduate and health 
        professions studies. One of the biggest impediments of Black 
        and low-income students is finances. Students with aptitude and 
        no resources all too often stop out of college, and that is a 
        national tragedy. Doubling Pell, immediately, can immediately 
        increase the odds of students to stay enrolled despite their 
        circumstances.

           2. To that end, every effort to provide subsidies to the 
        first 2 years of education at an HBCU should be revived. Still 
        in 2022, above 50 percent of HBCU students are first generation 
        learners. Allowing financial impediments to be diminished will 
        allow those learners to choose the institution which has a 
        proven track record of producing minority health professionals. 
        These financial impediments prevent much of our talent pool 
        from ever pursuing a graduate degree.

           3. HBCUs' institutional funding is so often in jeopardy. The 
        institutions are more reliant on tuition, room, and board. An 
        additional $5 billion to expand the Title III institutional aid 
        grants to HBCUs would go a long way to strengthen their 
        academic, administrative and fiscal capabilities, such as 
        creating or expanding educational programs in high-demand 
        fields like the health professions, STEM, computer sciences, 
        nursing and allied health. We are limited and delayed by 
        financial restrictions as we attempt to launch new and 
        innovative programs. Limited by space restrictions, 
        infrastructure restrictions, seed funding to hire talented 
        faculty and staff.

           4. There are only a few historically Black institutions 
        which produce a great percentage of the diversity in health and 
        research. Those institutions should receive more robust 
        resources for being excellent at what they do. I know there are 
        programs like the Department of Health and Human Services' 
        (HHS) ``Centers of Excellence'' and National Institutes of 
        Health's (NIH) ``Research Endowment'' programs, but if you look 
        at persistent health disparities and the national inability to 
        grow the number and percentage of African American health 
        professionals, more robust funding is needed. If you are 
        interested, we can share proposed funding numbers with you, 
        such as an additional $2 billion directed toward building a 
        pipeline of skilled health care workers with graduate degrees.

           5. I also mentioned that part of Xavier's success has been 
        various programs to prepare our students for the rigors of a 
        health professions education. Those programs have never been 
        fully funded, including the ``Health Careers Opportunities 
        Program'' (HCOP). HCOP and similar programs, and what Xavier 
        has learned from administering them, has allowed our 
        institution to excel and do as much as possible to increase 
        national diversity across the health sector.

           6. Too few Black institutions have capacity and resources to 
        function as major research institutions, often described as R01 
        status. We at Xavier and many other Black institutions are 
        creating huge results in the production of Black scientists and 
        contributing to research at the leading without the Federal 
        investments needed to attain this status that allows more 
        laboratory time for our faculty who are stressed with heavy 
        teaching loads and their institutions fiscal limitations to 
        release them for research. Investing in developing a few key 
        HBCUs, starting with Xavier, will allow us to continue and 
        expand our work and advance development of talent and ability 
        in response to national need. This investment will multiply the 
        number of Black students who go on to serve the physical and 
        life sciences (STEM), the health sciences, social sciences, and 
        research and innovation needs of the Nation. Xavier has been 
        historically proven by its success in this work. We urge you to 
        make investments in us and similar institutions now to build 
        capacity of our institutions to achieve R01 status.

           7. While historically Black colleges have always done ``more 
        with less,'' the year 2022 should be the year that changes. In 
        President Biden's joint families and infrastructure plans, 
        HBCUs, tribal colleges, and minority serving institutions 
        (MSIs) were slated to receive over $90 billion in investments 
        in research related infrastructure. This is essential. An 
        influx of funding is a recognition that HBCUs have 
        systematically been underfunded; and despite that, HBCUs have 
        excelled beyond the expectation. However, if the playing field 
        is leveled, with a backlog of deferred maintenance transformed 
        into the laboratories necessary to attract and educate the next 
        generation of health professionals, our production level can 
        increase.

           8. Forgive balance of HBCU Capital Finance Program debt for 
        remaining HBCUs: The long-term impact of the Federal Government 
        providing permanent relief the HBCU Capital Finance 
        institutions in December 2020 will be felt for generations. 
        Xavier knows this impact having survived the impact Hurricane 
        Katrina. We continue our recovery from the recent Hurricane Ida 
        However, the provisions of the Consolidated Appropriations Act 
        of 2020 State that only obligated funds borrowed from the 
        Department of Education's program were eligible for relief. 
        When Xavier, undertaking an opportunity to finally tackle a 
        backlog of deferred maintenance, borrowed $100,000,000 from the 
        HBCU Capital Finance Program, the subsequent permanent relief 
        proved to have little to no institutional impact. As an issue 
        of fairness for similarly situated institutions, the remaining 
        (and existing) HBCU Capital Finance Program loans should also 
        undergo permanent relief. We at Xavier understand that this 
        relief should not be routine; however, there are numerous 
        measures in the 117th Congress which include this permanent 
        relief, including the Institutional Grants for New 
        Infrastructure, Technology, and Education for (IGNITE) HBCU 
        Excellence Act.

           9. Last, but not least, we as a community of institutions 
        are still processing the cowardly acts of terror which have 
        disrupted so many HBCUs. I expect our representation at UNCF 
        will put forth funding and policy recommendations to the 
        appropriate appropriations subcommittees in the coming weeks. I 
        hope the Members of this Committee will support those 
        recommendations.

    Mr. Chairman, thank you. I look forward to answering the questions 
of the Members of the Committee.
                                 ______
                                 
    Senator Hickenlooper. Thank you.

    Ms. Quinones.

STATEMENT OF NORMA QUINONES, LPN, NURSING SERVICES MANAGER AND 
 NATIONAL, INSTITUTE FOR MEDICAL ASSISTANT ADVANCEMENT (NIMAA) 
    SITE COORDINATOR, CLINICAL FAMILY HEALTH, LAFAYETTE, CO

    Ms. Quinones. Good morning. What an honor for me to be 
here. My name is Norma Quinones, and I am the Nursing Services 
Manager at Clinica Family Health, a community health center in 
Lafayette, Colorado, that serves low income individuals.

    I applied to Clinica Family Health as a Medical Assistant 
in 1992, when our organization just had one clinic with six 
exam rooms and about 25 employees. I have been able to grow 
with Clinica over the past 30 years, and we will never forget 
being given the opportunity to start my career as an MA. Within 
Clinica's support, I became an LPN and worked as a nurse team 
manager for several years.

    I am now the Nursing Services Manager for Clinica. I love 
what I do. I get to dedicate my time to staff and students as 
they do deliver medical, dental, mental health care to 
thousands of patients. Part of my job is helping coordinate the 
NIMAA program at Clinica, which means I get to support future 
MAs on their own educational journey.

    The National Institute for Medical Assistance Advancement 
is unique, nationally accredited non for-profit post-secondary 
program formed in 2016 by two leading FQHCs, Salud Family 
Health Center in Fort Lupton, Colorado, and Community Health 
Center, Inc. in Middletown, Connecticut. NIMAA is a model for 
addressing primary care health workforce shortages, creating an 
accessible entry point for long term health care careers and 
diversifying the U.S. workforce.

    Before working with NIMAA, we had trouble finding qualified 
medical assistance prepared to work in our demanding 
environment. Some who graduated from expensive programs 
incurred a lot of debt, making it hard for them to resist 
higher paying jobs in the for-profit sector. It was hard to 
find good MAs and harder to keep them.

    NIMAA's program has helped us build a workforce pipeline 
within our community and reflective of our community. It 
provides an affordable option that allows students to work part 
time while they are completing the program. It prepares 
graduates well for demanding primary care settings that--where 
MAs are desperately needed.

    It is true--it is a true roll your own model that provides 
opportunity for nontraditional students, single parents, recent 
immigrants, first generation high school graduates, or those of 
us that enter the workforce at an older age.

    Nationally, 90 percent of medical assistance are female, 
and the majority are black, indigenous, or people of color. 
NIMAA's program allows us to help participants begin a health 
care career that would otherwise be out of reach for them and 
earn a livable wage. Over the past 3 years, Clinica has hosted 
18 NIMAA externs. We hired 15 of those 18 upon graduation.

    Most are still with our organization. This is a valuable 
workforce pipeline for Clinica, and it is extremely rewarding 
to watch the students grow in their careers as I did. MAs can 
enjoy a rewarding career, whether they stay in the MA role or 
move to management, nursing, administration, or other roles. 
For example, one of the early NIMAA graduates is applying to 
become a Nursing Team Manager--or, I am sorry, a Medical 
Assistant Team Manager.

    NIMAA is an excellent program with student retention of 89 
percent, a graduation rate at 84 percent, and national 
credential and exam pass rate of 89 percent, and a job--and a 
verified job placement at 81 percent. NIMAA's Program has 
already graduated more than 250 students, and it is growing 
rapidly.

    NIMAA has 48 active clinical partners across 14 States, 
including community health centers, hospital systems, and other 
safety net providers. This successful program could be scaled 
to reach thousands more students each year and to help address 
critical workforce shortages in diverse urban and rural 
communities across the country.

    Thank you for the opportunity to share Clinica and our 
students' perspective on NIMAA, what it has meant for Clinica, 
and how it can serve as a model for health care pipeline and 
pathway efforts.

    [The prepared statement of Ms. Quinones follows:]
                  prepared statement of norma quinones
    Good morning, what an honor for me to be here. My name is Norma 
Quinones and I am the nursing services manager at Clinica Family 
Health, a community health center in Lafayette, Colorado that serves 
low-income individuals.

    I applied to Clinica Family Health as a Medical Assistant in 1992, 
when our organization had just one clinic with six exam rooms and about 
25 employees. I have been able to grow with Clinica over the past 30 
years and will never forget being given the opportunity to start my 
career as an MA. With Clinica's support, I became an LPN and worked as 
a nurse manager for several years. I am now the Nursing Services 
Manager for Clinica. I love what I do. I get to dedicate my time to 
staff and students as they deliver medical, dental and mental health 
care to thousands of patients. Part of my job is helping coordinate the 
NIMAA program at Clinica, which means I get to support future MAs on 
their own educational journeys.

    The National Institute for Medical Assistant Advancement (NIMAA) is 
a unique, nationally accredited, nonprofit post-secondary program 
formed in 2016 by two leading FQHCs--Salud Family Health Center from 
Fort Lupton Colorado and Community Health Center, Inc. in Middletown 
Connecticut. NIMAA is a model for addressing primary care health 
workforce shortages, creating an accessible entry point for long-term 
health careers, and diversifying the U.S. workforce.

    Before working with NIMAA, we had trouble finding qualified medical 
assistants prepared to work in our demanding environment. Some who 
graduated from expensive programs incurred a lot of debt, making it 
hard for them to resist higher paying jobs in the for-profit sector. It 
was hard to find good MAs and also hard to keep them.

    NIMAA's program has helped us build a workforce pipeline within our 
own community, and reflective of our community. It provides an 
affordable option that allows students to work part-time while 
completing the program. It prepares graduates well for demanding 
primary care settings that desperately need MAs. It is a true ``grow 
your own'' model that provides opportunities for non-traditional 
students, single parents, recent immigrants, first generation high 
school graduates, or those re-entering the workforce at an older age. 
Nationally, ninety percent of medical assistants are female, and the 
majority are Black, Indigenous, or People of Color. NIMAA's program 
allows us to help participants begin a health career that would 
otherwise be out of reach for them, and earn a livable wage.

    Over the past 3 years, Clinica has hosted 18 NIMAA externs. We 
hired 15 of those 18 upon graduation, and most are still with our 
organization. This is a very valuable workforce pipeline for Clinica, 
and it is extremely rewarding to watch these students growing into 
their careers, as I did.

    MAs can enjoy a rewarding career, whether they stay in the MA role 
or move into management, nursing, administration or other roles. For 
example, one of our early NIMAA graduates at Clinica is applying to be 
a Medical Assistant Team Manager.

    NIMAA is an excellent program with a student retention rate of 89 
percent, a graduation rate of 84 percent, a national credentialing exam 
pass rate of 89 percent, and a verified job placement rate of 81 
percent. \1\
---------------------------------------------------------------------------
    \1\  2020-2021 Rates as reported to the Accrediting Bureau of 
Health Education Schools.

    NIMAA's program has already graduated more than 250 students and is 
growing rapidly. NIMAA has 48 active clinical partners across 14 
states, including community health centers, hospital systems and other 
---------------------------------------------------------------------------
safety net providers.

    This successful program could be scaled to reach thousands more 
students each year and help to address critical workforce shortages in 
diverse urban and rural communities across the country.

    Thank you for the opportunity to share Clinica's and our students' 
perspective on NIMAA, what it has meant for Clinica, and how it can 
serve as a model for health career pipeline and pathway efforts.
Further Description of NIMAA and Medical Assistant Workforce Needs and 
                             Opportunities
    Medical assisting provides an accessible entry-point to a health 
career and is a critical support role in advanced primary care 
practices.

    The National Institute for Medical Assistant Advancement (NIMAA) 
offers a unique workforce solution that leverages partnerships with 
local healthcare providers to provide both a high-quality educational 
program and extensive in-clinic experience. This approach results in a 
workforce pipeline from within and representative of the partner 
clinic's community.

    NIMAA and programs like it have the potential to increase rapidly 
the medical assistant (MA) workforce across the United States, and to 
create a pool of candidates for advancement to other high-demand health 
care jobs.

    This written statement provides further detail on the demand for 
and role of medical assistants, aspects of NIMAA's model that can 
inform workforce pipeline efforts, and opportunities and challenges for 
maximizing the reach of programs like NIMAA in the current workforce 
and educational environment.

    Federal support can serve to ensure the availability of effective 
programs in rural and medically underserved communities.
    The National Institute for Medical Assistant Advancement (NIMAA)
    NIMAA grew out of a need identified by Community Health Center, 
Inc., of Connecticut, one of the nation's largest federally Qualified 
Health Centers, which was spending months providing extensive 
retraining for newly hired medical assistants lacking competency in 
core skills and education in comprehensive, team-based care. In 
consultation with two noted leaders in the field, Thomas Bodenheimer, 
MD, MPH, and Edward Wagner, MD, MPH, CHC's President and CEO Mark 
Masselli formed a team and invested initial resources in developing a 
new way of providing MA training and education. After a period of 
incubation, NIMAA was formed in partnership with Salad Family Health 
Centers of Colorado. The Colorado Health Foundation recognized NIMAA's 
importance as a critical element in the redesign of primary health care 
and workforce development, and thanks to the Foundation's vision and 
support, NIMAA was established in Colorado. NIMAA remains an affiliate 
of Community Health Center, Inc., which provides operational support 
for this program and has facilitated its national growth.

    CHC was the first FQHC in the Nation to form its own research and 
education center, the Weitzman Institute. Founded in 2007, Weitzman is 
grounded in community health, and committed to improving healthcare for 
the vulnerable and underserved through research, education, and policy. 
The Institute is an incubator for programs such as NIMAA, and its 
experts and faculty conduct training and education through the on-line 
Project ECHO platform, hosting programs for thousands of providers in 
the U.S. and abroad annually.

    NIMAA enrolled its first class of 13 students in 2016, with its two 
founding partners as clinical externship sites. Since then NIMAA has 
grown substantially, and in the 2021-2022 calendar year will enroll 
over 135 students, with clinical externships offered in 40 
organizations across 14 states.

    NIMAA's growth to date, illustrated in the chart below, has been 
organic, as word of the program continues to spread and additional 
clinical practices learn about NIMAA and decide to participate.




    A focused investment in NIMAA and similar programs will greatly 
accelerate the rate at which the current health care workforce shortage 
is addressed while providing access to meaningful jobs and career 
advancement in communities economically impacted by the COVID 19-
pandemic in particular.
                         NIMAA Student Outcomes
    NIMAA collects and reports performance (outcome) data that meets 
the standards of its accrediting body, the Accrediting Bureau of Health 
Education Schools (ABHES). NIMAA's graduation, retention and placement 
rates all exceed ABHES standards and are considerably higher than those 
of many vocational education programs.

    For the 2020-21 school year, NIMAA reported an 89 percent 
retention, 84 percent graduation, 89 percent credentialing exam pass 
rate and 81 percent verified job-placement of graduates.

    Several unique characteristics of NIMAA's model contribute to these 
strong outcomes:

          NIMAA's extensive externship requirement (10 hours 
        per week, beginning in the first week of the program) is 
        consistent with the needs of adult learners, and ensures that 
        students are confident in their hands-on skills and have a full 
        understanding of the practice environment upon graduation.

          NIMAA's curriculum is tailored to the needs of 
        primary health care providers and is regularly updated to 
        reflect emerging needs and practices.

    As discussed above, NIMAA's program structure is accessible to and 
affordable for residents of medically underserved communities, 
resulting in strong retention and graduation rates.
                     Scalability of the NIMAA Model
    NIMAA's distance (on-line) education model allows NIMAA to grow 
rapidly. School operations are supported from NIMAA's Colorado-based 
office and do not require the establishment of a local physical campus 
to deliver the program. NIMAA instructors work from four US time zones, 
allowing them to be accessible to students when students need help.

    NIMAA is able to offer its program in any community where an 
appropriate primary care practice is interested in serving as an 
externship site, and where NIMAA has completed the required regulatory 
process to offer its educational program to State residents. \2\
---------------------------------------------------------------------------
    \2\  Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the Roles 
of Medical Assistants: Who Does What in Primary Care? JAMA Intern Med. 
2014;174(7):1025--1026. doi:10.1001/jamainternmed.2014.1319
---------------------------------------------------------------------------
                       Reach in Rural Communities
    Distance learning models, like NIMAA's, are available to rural and 
other underserved communities without the investment of capital 
infrastructure; they also eliminate the need for students to travel 
long distances to attend classes in person.

    Key resources need to be in place for models like NIMAA to be 
successful in rural communities:

          Broadband internet access is critical for students to 
        use advanced on-line learning tools, such assimulation software 
        and interactive learning modules.

          Rural clinical partners must have the human resources 
        to bring the program into their communities and to support the 
        extensive externship hours that are a key component of the 
        learner experience.

    Smaller practices, which includes many rural providers, are usually 
able to host only two or three student externs. However, the training 
provider expends the same resources on relationship management, program 
infrastructure, and support as it would for partners who host two or 
three times as many students. Thus, the per-student training cost is 
higher in rural areas.
                      UpSkilling the MA Workforce
    The critical role of Medical Assistants in the delivery of primary 
care is borne out by the projected growth of Medical Assistants over 
the next 10 years. The Bureau of Labor Statistics, Occupational 
Handbook projects a growth in MA jobs of 18 percent from 2020-2030, 
higher growth than for health care jobs overall. The BLS projects 
104,400 medical assisting openings annually, and a net growth of 
132,600 jobs over 10 years. \3\
---------------------------------------------------------------------------
    \3\  Bureau of Labor Statistics, U.S. Department of Labor, 
Occupational Outlook Handbook, Medical Assistants, at https://
www.bls.gov/ooh/healthcare/medical--assistants.htm (Visited February 3, 
2022).

    While NIMAA's curriculum includes knowledge and skill-building 
specific to the medical assistant's role in a team-based primary care 
setting, the majority of Medical Assistants entering the workforce will 
be trained in traditional programs. These graduates will need 
upskilling in skills and competencies related to team-based care to be 
effective team members in the emerging primary care environment. 
Medical assistants already in the field will need continuing education 
to maintain their national credentials and ensure their skills are 
---------------------------------------------------------------------------
evolving along with the practice environment.

    NIMAA clinical partners requested that NIMAA develop UpSkilling 
courses in team-based care topics to support traditionally trained MAs 
to be successful in an advanced primary care setting where the medical 
assistant has an expanded role within the team.

    NIMAA has developed a set of UpSkill NIMAA courses, offered through 
the Weitzman Institute, and continues to add courses in response to 
industry demand. For example, the immunization course has been updated 
to include topics related to COVID19. UpSkill NIMAA courses have been 
used by both individual practices and accountable care organizations 
wishing to support implementation of an advanced primary care model in 
their practices.

    The UpSkill NIMAA courses are delivered on-line, and can count 
toward the continuing education hours needed to maintain a medical 
assisting certificate. UpSkill NIMAA courses can also support the 
advancement of medical assistants along an MA career ladder that meets 
the health care practice's needs. For example, an MA may be required to 
complete the Inter Professional Team-Based Care, Quality Improvement 
and Making the Data Count, and Professionalism and Communication 
courses, and demonstrate related competencies, to move from MA1 to MA2.
                         Funding Opportunities
    Authorization of national programmatic appropriations funding by 
the U.S. Congress in support of NIMAA would allow the nonprofit to 
scale its operations to meet primary care workforce needs nationwide, 
provide robust support to students, and reduce barriers to 
participation of small and rural primary care practices.
        About Medical Assistants and Medical Assistant Workforce
             The Role of Medical Assistants in Primary Care

    Well-trained medical assistants are essential to the delivery of 
effective and efficient care in advanced primary care settings, and to 
provider retention and satisfaction.

    Primary care practices are increasingly adopting a delivery model 
that requires integrated team-based care in which all members--
behavioral, oral and physical health providers; care coordinators; 
health educators; front office staff; and medical assistants--work 
together to meet individual patients' needs and manage population-based 
health prevention and screening efforts.

    Medical assistants serve as the ``choreographer'' in this model, 
ensuring that team members are prepared, facilitating the flow of the 
visit, coordinating follow-up care and ensuring screening, referral and 
other relevant data are documented and shared appropriately. The 
medical assistant's preparedness has a tremendous impact on the team's 
functioning and on the quality of care provided.

    The Center for Excellence in Primary Care at the University of 
California, San Francisco argues that medical assistants can be 
utilized in expanded roles such as health coaching, team documentation 
and panel management under the direction of a provider. This improves 
patient access while reducing the demands on primary care clinicians, 
positively affecting the work life of clinicians.

    Dr. Tillman Farley, Chief Medical Officer of Salud Family Health 
Center and member of NIMAA's Board of Directors says of Medical 
Assistants in his practice:

           ``I am in awe every day of the amazing individuals that do 
        our MA work. We put an incredible amount of work and 
        responsibility on them, and they carry that burden every day 
        with smiles on their faces . . . They are truly the lynchpins 
        of our organizations. We all need a superpower, and our 
        superpower is our MAs.''
            Medical Assistant Workforce Diversity and Equity
    The medical assistant workforce in the U.S. is diverse: 90 percent 
are women, 19 percent Latino and 42 percent Black. The median age of 
medical assistants is 37.

    NIMAA students are recruited from health center service areas, and 
they reflect the diversity of their communities in race and age. 
NIMAA's student body over the past 2 years was 64 percent Hispanic/
Latino (of any race); 7 percent American Indian/Native American; 9.6 
percent Asian; 6 percent Black or African American; and 4 percent 
Native Hawaiian/Pacific Islander. Fifty-four percent of NIMAA students 
were 25 years old or older, and approximately one third were single 
parents.

        Y  NIMAA's program is deliberately structured to be accessible 
        to low-income students and non-traditional learners.

        Y  NIMAA's tuition of $6,000 is much less expensive than the 
        $15,000 to $40,000 often charged by for-profit schools, making 
        it more accessible to low-income students.

        Y  NIMAA's 8-month program is shorter than most, which reduces 
        students' opportunity costs to participate, and permits the 
        program's graduates to move more quickly to paid employment.

        Y  The NIMAA distance-learning educational model allows 
        students to complete their coursework at times that are 
        convenient for them, and lets them balance their education with 
        their part-time employment and/or other responsibilities.

        Y  NIMAA's student services and instructional staff build one-
        on-one relationships with students and support them in 
        addressing personal and academic challenges.

        Y  NIMAA applicants are interested in advancing their health 
        careers over time, and NIMAA's training in team-based care 
        provides students with a strong foundation they can build upon 
        with addition education and training.
                 Career Pathways for Medical Assistants
    Medical assistant training is unique in that it encompasses a broad 
range of skills, including front-office administrative functions, 
billing and coding, patient communication, and medical (back office) 
skills. NIMAA's program includes curriculum and skills related to the 
team-based care model and empowers students to acquire knowledge and 
experience foundational to a number of career pathways.

    NIMAA's clinical partners report that staff who began their careers 
as medical assistants now work in many different roles, including as 
clinic managers, immunization program coordinators, care coordinators, 
operations managers and directors, billing managers, nurses, chief 
nursing officers and physician assistants, to name a few.

    Ms. Quinone's testimony delivered before the Senate HELP 
Subcommittee on February 10, 2022, illustrates this opportunity for 
advancement. A NIMAA graduate in the first group of students hosted by 
Clinica shared this with Ms. Quinones about her experience in NIMAA and 
as a medical assistant:

           ``I am writing to express my sincere gratitude to you for 
        making the NIMAA program here at Clinica possible. Three years 
        ago I was thrilled to learn I had been chosen as one of the 
        first candidates to participate in the NIMAA program. Clinica 
        and NIMAA gave me the opportunity to become a medical assistant 
        and I can honestly say I love what I do. My job gives me a 
        sense of accomplishment when I'm able to help patients and my 
        fellow co-workers. I've had the privilege of training two NIMAA 
        students by sharing my vision, experiences and also mistakes. 
        NIMAA has given me the knowledge, skills and courage to apply 
        for a leadership position. I will always be grateful for this 
        opportunity.''

    Medial assistant training and experience provide a foundation for 
many career pathways. However, those pathways and the related education 
needed to pursue them are not well documented. Thus, it is often up to 
the individual to identify and navigate these pathways, and for 
individual employers to provide the combination of experience and 
additional training or education that supports career advancement. 
Better documentation of ``organic'' career pathways that build upon 
medical assisting skills can create a pipeline for in-demand 
administrative, managerial and clinical roles in primary care settings. 
NIMAA is passionate about contributing to the delineation and further 
development of these pathways in collaboration with the health care 
industry and higher education partners.

    Most national health professions training initiatives, such as the 
National Health Service Corps, and the Teaching Health Center Graduate 
Medical Education (THCGME) Program, are focused on encouraging entry 
into health careers at the bachelor's or advanced degree levels, and 
bringing health professions into medically underserved areas. NIMAA, 
and other programs like it, create an additional workforce development 
strategy that facilitates entry into a health career for residents of 
medically underserved areas who need to maintain an income stream while 
starting a career, and for whom a 4-year course of study is not 
immediately feasible.
     Demand for Medical Assistants and other Allied Health Workers 
                       Nationally and in Colorado
    The Bureau of Labor Statistics Employment Projections Program 
estimates medical assistant job growth from 2020-2030 will be 18 
percent, much faster than the average for all occupations (8 percent) 
and, faster than other healthcare support occupations (16 percent).

    The Bureau of Labor Statistics Reports describes the demand for 
Medical Assistants as follows:

           About 104,400 openings for medical assistants are projected 
        each year, on average, over the decade. Many of those openings 
        are expected to result from the need to replace workers who 
        transfer to different occupations or exit the labor force, such 
        as to retire.

           The growth of the aging baby-boom population will continue 
        to increase demand for preventive medical services, which are 
        often provided by physicians. As a result, physicians will hire 
        more assistants to perform routine administrative and clinical 
        duties, allowing the physicians to see more patients.

           An increasing number of group practices, clinics, and other 
        healthcare facilities will also need support workers, 
        particularly medical assistants, to complete both 
        administrative and clinical duties. Medical assistants work 
        mostly in primary care, a steadily growing sector of the 
        healthcare industry.

    In Colorado there are an estimated 1,890 MA openings annually, with 
MA positions expected to grow by 36 percent with 4,110 jobs added by 
2028. \4\ The Colorado 2021 Talent Pipeline Report identifies medical 
assisting as one of Colorado's top jobs statewide, and in five of the 
state's eight regions, with 10-year growth rates in those regions of 
between 23 and 43 percent. \5\
---------------------------------------------------------------------------
    \4\  Projections Central https://www.projectionscentral.com/
Projections/LongTerm
    \5\  2021 Colorado Talent Pipeline Report. Colorado Workforce 
Development Council and Talent Found. Accessed at https://
cwdc.colorado.gov/blog--post/2020--talent--pipeline--report--released, 
2.3.2022.

    While medical assistant wages and cost of living vary regionally, 
medical assisting jobs in the US generally pay a livable wage. The 
living wage for a family of four in the US in 2019 was $16.54/hour, 
while the median wage for medical assistants in the US in 2020 was 
$17.23 per hour. Many health care providers require medical assistants 
be certified through one of the national credentialing bodies, and 
provide a higher wage to medical assistants who have passed a national 
certification exam.
          Reducing Barriers to Innovative Training Approaches
                       Regulatory Considerations
    The primary barrier that limits NIMAA's ability to expand 
nationwide is the lack of regulatory reciprocity across states for 
full-distance vocational programs, like that which exists among 4-year 
colleges with SARA (State Authority Reciprocity Agreements). NIMAA is 
regulated by the Colorado Department of Higher Education, Division of 
Private and Occupational Schools, and complies with all relevant 
Colorado regulations. However, some states still require that NIMAA go 
through the same application process as a school physically located in 
their State would, which can take months or even years. Other states do 
not regulate full-distance schools, or have a separate set of 
requirements for such schools. As a result, NIMAA must comply with 
multiple sets of regulations and requirements. The fees charged by 
State regulatory bodies (in addition to the fees NIMAA pays in 
Colorado, which cover all enrolled students regardless of residence), 
and the administrative burden of tracking and reporting on these 
regulations, is extremely costly. In several cases, it is not feasible 
for NIMAA to offer its program in a State even where it has willing 
clinical partners because the cost of the regulatory processes and 
barriers is too high.

    NIMAA fully understands and supports the importance of protecting 
students from predatory practices. However, many of the regulatory 
hurdles placed in front of NIMAA seem redundant for a non-profit school 
that has national accreditation and is in full regulatory compliance in 
its home state.
               Apprenticeship and Health Workforce Needs
    Apprenticeship, and other models that allow students to earn a 
salary while participating in training, can facilitate engagement of 
low-income and non-traditional students in training programs.

    Several of NIMAA's clinical partners have medical assistant 
apprenticeships in which NIMAA's on-line didactics fulfill the related 
instructional requirement, and where completion of the NIMAA program is 
one of the requirements of the apprenticeship, which then continues 
beyond graduation from NIMAA.

    NIMAA has encouraged its clinical partners to explore the 
apprenticeship model, and has facilitated conversations with local 
workforce offices to that end. Several aspects of apprenticeship limit 
participation by NIMAA partners, including:

          The 2,000-hour requirement of federally registered 
        apprenticeships is considerably longer than the 960 hours of 
        NIMAA's program.

          The industry-recognized credential for medical 
        assisting is a national credentialing exam, while an 
        apprenticeship completion certificate is not.

          The uncertainty regarding which or how many students 
        will qualify for apprenticeship support.

          The administrative tasks required to establish and 
        maintain registered apprenticeship programs.

          The lack of financial support for participation of 
        non-profit health care employers in apprenticeship.

    In addition, states sometimes limit the availability of 
apprenticeship programs or funds for training provided by specific 
types of training providers, such as Community Colleges. This restricts 
the participation of non-profit training providers like NIMAA.
             Workforce Resources and Health Workforce Needs
    Many workforce efforts are delivered through the workforce 
infrastructure, including local workforce boards. A strength of the 
workforce system is that local workforce boards prioritize programs 
according to local needs. Such a system, however, is challenging for a 
national distance-education solution like NIMAA, as it requires making 
connections and maintaining relationships with dozens of local 
workforce offices.

    NIMAA is very interested in engaging workforce program clients in 
its program, and has had success doing so. NIMAA has also facilitated 
introductions between its clinical partners and local workforce boards, 
as many are unaware of the role of workforce boards and are not 
familiar with the boards in their region.

    The Department of Labor in each State maintains lists of eligible 
training providers from which workforce participants may receive 
training and obtain support while doing so. NIMAA is on the Eligible 
Training Provider List (ETPL) in most states where it enrolls students.

    However, in some states there are challenges to ETPL participation. 
Some states require that a training provider be regulated by the State 
department of higher education to be on the ETPL, but does not regulate 
distance-only programs. Others require that a training participant 
themselves request that a school be added. Some local workforce boards 
will not support training by distance-education providers, regardless 
of whether that training entity is on the list.
Recommendations for Expanding Access to Health Careers through Medical 
                               Assisting
    Career pathways for medical assistants should be better documented 
within career pipeline and pathway efforts to:

          Identify paraprofessional or non-clinical roles (such 
        as certified nursing assistant, front desk staff, patient care 
        technician) for which medical assisting is a natural next step.

          Assist medical assistants with their long-term goal 
        of becoming a nurse or provider, and ensure they are aware of 
        the educational and career steps and that will allow them to do 
        so.

          Provide information to medical assistant students 
        regarding the many career pathways that stem from medical 
        assisting outside of provider roles.

          Assist health care employers in developing employee 
        retention and advancement initiatives and partnerships.

          Facilitate the development of stackable credentials 
        and articulation agreements in educational systems that reflect 
        and support the career pathways that exist organically in the 
        health care industry.

          Workforce funding should be available to facilitate 
        the participation of non-profit community-based health care 
        providers, including small and rural clinics as host sites for 
        students, and support pipeline development and internal career 
        advancement efforts.

          State and local efforts to expand healthcare 
        apprenticeships should include funding to support participation 
        by non-profit health care providers and should support training 
        provided by non-profit vocational schools in addition to 
        community college programs.

          Ensure that distance-education (on-line) training 
        providers are eligible to be included on Eligible Training 
        Provider Lists in all states, and streamline the process for 
        inclusion on State lists.
                                 ______
                                 
    Senator Hickenlooper. Thank you.

    Ms. Greszler.

  STATEMENT OF RACHEL GRESZLER, RESEARCH FELLOW IN ECONOMICS, 
  BUDGET AND ENTITLEMENTS, INSTITUTE FOR ECONOMIC FREEDOM AND 
      OPPORTUNITY, THE HERITAGE FOUNDATION, WASHINGTON, DC

    Ms. Greszler. Good morning and thank you for the 
opportunity to testify today. As an economist who focuses on 
labor policy, I would like to first discuss the current labor 
force shortage across the U.S. and then look specifically 
within the health care sector.

    The current labor shortage is unlike any before in U.S. 
history. We have an unemployment gap of at least 4 to 5 million 
workers. Job openings, which are currently at 10.9 million, are 
40 percent above their pre-pandemic record, and they are more 
than double the prior 10 year average. And employers are 
struggling, as 49 percent of businesses have positions that 
they are unable to fill.

    Nearly half of all businesses have increased compensation 
in December alone and 32 percent plan to increase over the next 
3 months. Those higher wages are a great thing when they come 
from workers becoming more productive, but when it is simply 
employers having to pay people more to do the exact same thing, 
that translates into higher prices.

    We have seen today with a 40-year record high inflation 
that those wage gains have been entirely erased and real wages 
are actually dipped down. Resignations are also at record 
highs, with nearly one in three workers quitting their jobs in 
2021. Replacing workers is extremely costly and this adds to 
burdens and creates higher costs. COVID-19 is not the main 
cause of the labor crisis, but rather bad policies that have 
restricted the labor supply and $6.6 trillion in deficit 
finance spending has artificially increased demand for goods 
and services.

    Instead of spending more Federal money and imposing more 
labor market distortions, policymakers should remove the 
employment barriers that they have created. That includes 
eliminating welfare without work policies, reducing tax burdens 
that are prohibiting higher wage and productivity gains, 
letting people pursue the work that they want, and expanding 
childcare options by allowing parents to use Federal head start 
funding dollars at a provider of their choice.

    The health care workforce shortage includes both long 
standing issues as well as pandemic related ones. So prior to 
the pandemic, health care employment had been growing faster 
than overall employment, but that has since reversed, and 
especially so since the implementation of COVID-19 vaccine 
mandates. If health care employment had grown at the same rate 
as total employment over just the past 3 months, we would have 
73,000 more health care workers today.

    It is one thing if we are frustrated by long waits at 
restaurants, it is certainly a major disruption to have 
canceled flights or school busses that don't show up. But when 
hospital units close or people have delays and surgeries and 
simply can't access health care that significantly impacts 
people's health and even their lives. The CMS vaccine mandate 
could remove 70,000 or more health care workers from their 
jobs.

    Congress should prevent this by protecting medical 
providers' right to set their own vaccine policies. The longer 
term health care workforce is primarily a State issue. State 
Governments need to eliminate unnecessary licensure, scope of 
practice, and certificate of need laws that limit the health 
care workforce. Doctors and nurses should be able to practice 
their professions where the need is greatest and not simply 
within the geographic confines of their license.

    It is particularly ludicrous when a provider can't have a 
telehealth visit with a regular patient simply because they are 
out of the State at that time. Also needlessly restricting 
nurse practitioners from performing services that they were 
trained to provide limits care and drives up costs, and 
certificate of need laws have consistently proven anti-
competitive and harmful.

    While States are the primary gatekeepers of the health care 
workforce, the Federal Government can renew unnecessary burdens 
and promote competition and flexibility to better meet 
America's health care needs.

    Some specific actions include adjusting Federal and State 
health care payments to shift the burden of bad policies like 
certificate of need laws onto the States that impose them. 
Expanding the use of telemedicine. Improving the graduate 
medical education system to meet more communities' needs. Not 
shortchanging home health care workers by sending part of their 
paychecks to unions without their consent. And reducing the 
regulatory burdens required by Federal health care programs.

    The time is spent on paperwork and regulatory compliance is 
time that is not spent treating patients. 58 percent of doctors 
list paperwork and regulatory burdens is their biggest 
complaints, and nearly half of all physicians say that they are 
considering retiring earlier than planned because of changes in 
the health care system.

    Lives are literally at stake because of the health care 
workforce shortage, and many regulations are needlessly making 
this worse. Congress should immediately stipulate the vaccine 
mandates are decisions for health care providers, and State and 
Federal policymakers should reduce barriers and burdens to 
better respond to Americans' increasing health care needs. 
Thank you.

    [The prepared statement of Ms. Greszler follows:]
                 prepared statement of rachel greszler
    My name is Rachel Greszler. I am a Research Fellow in Economics, 
Budgets, and Entitlements at The Heritage Foundation. The views I 
express in this testimony are my own and should not be construed as 
representing any official position of The Heritage Foundation.

    My area of expertise is in economics and labor policies, so I would 
like to focus first on the unprecedented labor shortage in the U.S. 
today, including why it exists and how policymakers can help alleviate 
it.

    I will then discuss recent trends in health care employment and 
provide recommendations for State and Federal policymakers to allow the 
health care workforce to more freely expand to meet growing health care 
demands.

    It is important to note that since State licensing laws serve as 
the gatekeepers to the health care workforce, the Federal Government 
has limited the ability to increase the supply of health care workers. 
Federal policymakers must take these limits into account to avoid 
wasting taxpayer dollars.
                           The Labor Shortage
    The U.S. is in the midst of a labor shortage unlike any other in 
U.S. history. This is affecting every sector of the economy and exists 
across all levels of jobs. Total employment today is between 4.1 
million \1\ and 5.3 million \2\ below where it might have been without 
the pandemic and absent other changes in economic conditions. \3\ This 
employment gap is entirely a labor-supply problem. Without the shortage 
of willing workers, employment would likely be above trend right now, 
with an employment surplus instead of a gap.
---------------------------------------------------------------------------
    \1\  The 4.1 million estimated gap relies on total employment 
figures from unpublished tabulations from the Current Population Survey 
(CPS) of the U.S. Bureau of Labor Statistics (BLS).
    \2\  The 5.3 million estimated gap relies on total payroll 
employment figures from the Current Employment Statistics of the BLS. 
Payroll employment figures are lower than total employment figures in 
the Current Population Survey because they do not include some workers 
such as the self-employed.
    \3\  For methodology of the employment gap, see Rachel Greszler, 
``What Is Happening in This Unprecedented U.S. Labor Market?, February 
2022 Update,'' Heritage Foundation Backgrounder No. 3684, forthcoming, 
http://report.heritage.org/bg3684

    This is the opposite of what was expected at the start of the 
pandemic, and in many ways is the result of bad policies that have 
restricted the supply of willing workers while simultaneously pumping 
large amounts of deficit-financed Federal spending into the economy 
---------------------------------------------------------------------------
with the effect of increasing the demand for workers.

    Labor Shortage Demographics. Throughout the pandemic, different 
groups of workers have been affected differently. For example, at the 
beginning of the pandemic, lower-wage workers and women who were 
caregivers were more likely to have lost or dropped out of employment, 
and older workers who were at greater risk from COVID-19 were more 
likely to stop working.

    Table 1 provides a breakdown of the employment gaps for various 
groups of workers, as measured by the percentage difference between 
current employment (December 2021) and where it would have been if, 
absent the pandemic, employment had followed steady-State employment 
growth. \4\ (All tables and charts are also provided in full-size 
graphics at the end of this testimony).
---------------------------------------------------------------------------
    \4\  All demographic employment data comes from unpublished 
tabulations from the Current Population Survey of the BLS. According to 
the BLS, these data are based on a very small number of observations 
and should be interpreted with extra caution. For further information 
on the CPS, see BLS, ``Labor Force Statistics from the Current 
Population Survey:

    Survey of the BLS. According to the BLS, these data are based on a 
very small number of observations and should be interpreted with extra 
caution. For further information on the CPS, see BLS, ``Labor Force 
Statistics from the Current Population Survey: Technical 
Documentation,'' http://www.bls.gov/cps/documentation.htm (accessed 
---------------------------------------------------------------------------
January 31, 2022).

    Employment gaps are widespread. Women's employment gap is slightly 
higher than men's, and parents' gap is significantly higher than non-
parents. Notable, however, is that the parental employment gap is 
entirely the result of lower employment among parents of school-aged 
children (ages 6--17) as opposed to younger children (under 6). In 
fact, the 1.9 percent employment gap of workers with young children is 
lower than the 2.1 percent employment gap of workers without children, 
and significantly lower than the overall 2.6 percent employment gap. 
This implies that while parents struggle with finding accessible and 
affordable childcare, this is not unique to the COVID-19 pandemic and 
is not a cause of the recent labor shortage.

    The rationale for large employment gaps of both men (5.1 percent) 
and women (5.2 percent) with school-aged children is unclear.

    Initially, parents consistently experienced lower employment gaps 
than non-parents. That changed in late spring 2021. One factor that 
could have been weighing on parents' employment in the latter half of 
2021 was Congress's passage of the American Rescue Plan including 
monthly child payments (beginning in July 2021) that were not 
conditioned on work.

    A study by researchers at the University of Chicago estimated that 
making the child payments permanent would reduce the labor-force 
participation and employment of parents by 2.6 percent, which is 1.5 
million workers. \5\ With these payments now expired, future economic 
studies may help reveal the impact of unconditional child payments on 
parents' work decisions.
---------------------------------------------------------------------------
    \5\  Kevin Corinth, Bruce D. Meyer, Matthew Stadnicki, and Derek 
Wu, ``The Anti-Poverty, Targeting, and Labor Supply Effects of the 
Proposed Child Tax Credit Expansion,'' Becker Friedman Institute for 
Economics at the University of Chicago, October, 2021, https://
bfi.uchicago.edu/wp--content/uploads/2021/10/BFI--WP--2021-115-1.pdf 
(accessed February 4, 2022).
---------------------------------------------------------------------------
 Labor Shortage Creating Tremendous Struggles for Employers, Consumers
    Businesses across nearly every industry in the United States are 
desperate for workers and have expanded their pay and benefit packages 
in response to the shortage of willing workers. Yet the number of job 
openings in the United States remains at record levels, with 10.9 
million job openings in December 2021--the equivalent of 1.7 jobs 
available for each of the 6.3 million unemployed workers.

    The current 10.9 million job openings are 3.4 million above the 
pre-pandemic high (November 2018) and reveal how difficult it is for 
employers to find the workers they need. \6\ Simultaneously, workers 
are quitting their jobs at record-high rates. In 2021, 47 million 
workers quit their jobs, requiring employers to replace 11 million more 
workers than they had to in 2020, and 14 million more than the average 
between 2011 and 2020. \7\
---------------------------------------------------------------------------
    \6\  BLS, ``Job Openings and Labor Turnover Survey,'' https://
www.bls.gov/jlt/ (accessed February 2, 2022).
    \7\  Ibid.

    With 4.3 million or 2.9 percent of workers quitting their jobs each 
month over the past 6 months, this pace translates into employers 
having to replace 35 percent of their workers (more than one of three) 
---------------------------------------------------------------------------
over the course of a year.

    According to the National Federation of Independent Businesses, 49 
percent of businesses had job openings that they were unable to fill in 
December 2021, with 95 percent of those businesses saying that they had 
no or few qualified applicants. \8\
---------------------------------------------------------------------------
    \8\  National Federation of Independent Businesses, ``Labor Market 
Challenges Breaks 48-Year Record as Biggest Issue Impacting Small 
Businesses,'' November 2021, https://assets.nfib.com/nfibcom/2021-Nov-
Jobs-Report-FINAL.pdf (accessed date January 12, 2022).

    Adding to Inflation. The labor shortage has caused employers to 
raise compensation, with a record-high 48 percent of businesses 
reporting that they increased compensation in December, and another 32 
percent saying that they plan to raise compensation over the next 3 
months. \9\ Although hourly pay increased by an above-average 4.7 
percent over the past year (December 2020 to December 2021), real 
average earnings (taking into account the effect of inflation) were 
down 2.4 percent. \10\ for all employees on private nonfarm payrolls, 
seasonally adjusted, December 10, 2021, https://www.bls.gov/
news.release/realer.htm (accessed January 13, 2022).
---------------------------------------------------------------------------
    \9\  Ibid.
    \10\  BLS, ``Real Earnings News Release,'' Table A-1: Current and 
real (constant 1982-1984 dollars) earnings for all employees on private 
nonfarm payrolls, seasonally adjusted, December 10, 2021, https://
www.bls.gov/news.release/realer.htm (accessed January 13, 2022).

    When employers have to pay workers more to perform the same jobs, 
they have to raise their prices, which has contributed to a four-decade 
high in annual inflation of 7.0 percent in December 2021. \11\
---------------------------------------------------------------------------
    \11\  BLS, U.S. Department of Labor, Consumer Price Index Summary, 
December 2021, https://www.bls.gov/news.release/cpi.nr0.htm (accessed 
January 12, 2022).
---------------------------------------------------------------------------
               Causes of the Current U.S. Labor Shortage
    While some factors related to COVID-19 may be affecting certain 
workers' employment, it does not appear that the pandemic itself is 
weighing significantly on employment. Rather, some of the policies 
enacted in response to the pandemic have reduced workers' willingness 
and capacity to work. Maximum employment requires not only that it pay 
to work, but also that it not pay to not work.

    Compensation Is Rising. Wages have been rising and workplace 
benefits have expanded (though high levels of inflation have reduced 
the value of wage gains). Over the past decade, average hourly earnings 
of all employees in the U.S. increased by 35.3 percent while average 
hourly earnings in health care increased 32.5 percent. Within the 
health care sector, average hourly earnings at hospitals rose 34.7 
percent and earnings at nursing care facilities increased 39.5 percent.

    Since the start of the pandemic, in February 2020, overall average 
earnings in the U.S. have increased 9.9 percent (through December 
2021), but health care has experienced significantly larger wage gains 
of 11.6 percent across all health care, 12.4 percent within hospitals, 
and 16.1 percent in nursing care facilities.

    Welfare-without-work Policies. Various government programs and 
policies enacted in the name of COVID-19 have made it easier for people 
to not work, and almost certainly continue to play a role in weak 
employment, particularly among lower-and middle-wage workers. Those 
include $600 weekly bonus unemployment insurance benefits, a 21 percent 
increase in food stamps, massive expansion in Obamacare subsidies, and 
an eviction moratorium and rental assistance.

    A measure called the reservation wage, which is the lowest wage at 
which individuals will accept a job, surged 26.4 percent between March 
2020 and March 2021 for workers making less than $60,000 (from $40,197 
to $50,825). It has since declined significantly as the bonus 
unemployment insurance benefits ended.

    Evidence from past studies of welfare--without-work benefits find 
that they tend to reduce the supply of work, and a recent National 
Bureau of Economic Research study on the effects of the pandemic 
unemployment insurance benefits found that they significantly 
restricted employment. \12\
---------------------------------------------------------------------------
    \12\  Harry J. Holzer, R. Glen Hubbard, and Michael R. Strain, 
``Did Pandemic Unemployment Benefits Reduce Employment? Evidence from 
Early State-Level Expirations in June 2021,'' National Bureau of 
Economic Research Working Paper No. 29575, December 2021, https://
www.nber.org/papers/w29575 (accessed February 5, 2022).

    Federal Spending Spree. The Federal Government has spent $6.6 
trillion on COVID-19 packages--the equivalent of $51,600 for every U.S. 
household. All this deficit-financed spending--over half of which has 
been purchased by the Federal Reserve--increases the demand for goods 
---------------------------------------------------------------------------
and services, which requires more workers to meet those demands.

    Vaccine Mandates. Various states, private businesses, and medical 
facilities began implementing COVID-19 vaccine, or vaccine-and-testing, 
mandates in the late summer and fall of 2021. The Federal Reserve's 
October 2021 Beige Book noted that vaccine mandates were contributing 
to high turnover and production slowdowns, and that impending ``Federal 
vaccine mandates were expected to exacerbate labor problems.'' \13\
---------------------------------------------------------------------------
    \13\  U.S. Federal Reserve, The Beige Book, October 20, 2021, 
https://www.Federalreserve.gov/monetarypolicy/files/BeigeBook--
20211020.pdf (accessed October 22, 2021).

    Comprehensive data does not exist on how many health care workers 
have lost their jobs because of the vaccine mandate, but employment 
growth in health care between September 2021 and December 2021 was more 
than 60 percent below total U.S. employment growth over the same 
period. Had the health care sector experienced the same growth rate as 
total employment over just those 3 months, there would be 72,900 more 
health care workers today. \14\
---------------------------------------------------------------------------
    \14\  BLS, ``Employment, Hours, and Earnings from the Current 
Employment Statistics Survey,'' available for download at https://
www.bls.gov/data/ (accessed February 2, 2022).

    This was during a time in which only some states had imposed 
vaccine mandates on the health care sector, and the legality of the 
Center for Medicaid and Medicare Services (CMS) vaccine mandate was 
still in question. With the CMS mandate going into effect across 25 
states and the District of Columbia between now and February 28th, the 
---------------------------------------------------------------------------
health care worker shortage will almost certainly increase.

    The experience thus far of health care providers subject to vaccine 
mandates shows that they have had a significant impact on employment 
and operations. While some providers have been able to keep 
terminations over vaccine requirements down to 0.5 percent or less of 
its workforce, some providers have had to terminate 2 percent or more 
of their employees. A sampling of news reports documenting significant 
effects include:

    New York State's largest health care provider, Northwell Health, 
had to lay off 1,400 workers--nearly 2 percent of its workforce. \15\
---------------------------------------------------------------------------
    \15\  Joseph Choi, ``Largest New York Health Care Provider Fires 
1,400 Employees over Vaccine Refusal,'' The Hill, October 4, 2021 
https://thehill.com/homenews/state--watch/575283-largest-new-york-
healthcare-provider-fires-1400-employee-over-vaccine (accessed February 
5, 2022).

    The Mayo Clinic fired roughly 700 workers--about 1 percent of its 
staff--due to the vaccine mandate. \16\
---------------------------------------------------------------------------
    \16\  Chantal Da Silva, ``Mayo Clinic Fires 700 Workers Who Failed 
to Comply with Covid Vaccine Mandate,''NBC News, January 5, 2022, 
https://www.nbcnews.com/news/us--news/mayo-clinicfires-700-workers-
failed-comply covid-vaccinemandate-rcna11004 (accessed February 7, 
2022).

    UVM Health Networks in New York reported that, ``vaccination 
mandate for healthcare workers has brought long-standing 
healthcarestaffing shortage into sharper focus.'' \17\ With 55 
employees voluntarily resigning for a variety of reasons since the 
mandate went into effect and another 30 leaving or being terminated as 
a result of the mandate, UVM has had to temporarily close units and 
delay inpatient surgeries by a week.
---------------------------------------------------------------------------
    \17\  The University of Vermont Health Network, ``UMV Health 
Network NNY Affiliates Continue to Provide Care Despite Mandate,'' 
Champlain Valley Physicians Hospital, September 28, 2021, https://
www.cvph.org/News/Detail/297 (accessed February 8, 2022).

    Mowhawk Valley Health System (MVHS) in New York State had to fire 
nearly 5 percent of its employees--180 in total--which increased the 
system's vacancy rate from 13.7 percent to 17.5 percent, meaning the 
hospital had only about four employees for every five positions. \18\
---------------------------------------------------------------------------
    \18\  ``MVHS Outlines COVID-19 Vaccine Mandate Impact on Health 
System,'' September 28, 2021,https://www.mvhealthsystem.org/news/2021-
09-28/mvhs--outlines--covid-19--vaccine-mandate-impacton-health-system 
(accessed February 5, 2022).

    When vaccine mandates leave hospitals and health care providers 
short-staffed, this reduces patients' access to care and can diminish 
the quality of care they receive. One of my own family members had to 
take her 4-year-old daughter to a hospital in another state, 160 miles 
away, for emergency diagnosis and surgery because the nearest 
Children's Hospital was experiencing significant staffing shortages due 
---------------------------------------------------------------------------
to the vaccine mandate.

    As a labor policy economist, I have focused this Causes section on 
the current widespread labor shortage. I include some longer-term 
causes of health-care-specific labor shortages in the Solutions 
section.
                       Health Care Labor Shortage
    Shortages of health care workers--especially primary care doctors--
existed before the pandemic and are projected to grow drastically

    as the population of people ages 65 and older is expected in 
increase by 50 percent with the aging of the baby boomer population. 
Older people have more medical problems and more complex problems that 
result in higher medical utilization and costs.

    A 2018 analysis by the Association of American Medical Colleges 
predicted that the by 2030, there will be a shortage of between 42,600 
and 121,300 physicians in both primary and specialty care. \19\ There 
are also current and rising shortages in other health care positions 
such as nurses, home health care workers, and nursing home health 
aides. Too few health care providers translates into limited access to 
health care and worse health outcomes.
---------------------------------------------------------------------------
    \19\  Tim Dall et al., The Complexities of Physician Supply and 
Demand: Projections from 2016 to 2030 (2018 Update), IHS Markit Ltd., 
for the Association of American Medical Colleges, March 2018, https://
aamcblack.global.ssl.fastly.net/production/media/filer--public/85/d7/
85d7b689--f417-4ef0-97fbecc129836829/aamc--2018--workforce--
projections--update--april--11--2018.pdf (accessed August 24, 2018)

    Prior to the pandemic, health care employment had been growing 
faster than overall employment, but not fast enough to keep pace with 
growth in the aging population that consumes the most medical care. 
Between December 2011 and the start of the pandemic in February 2020, 
total employment grew by 14.8 percent while health care employment grew 
---------------------------------------------------------------------------
16.7 percent.

    Since the start of the pandemic (February 2020 through December 
2021), health care employment has been particularly hard-hit, 
experiencing a 2.7 percent employment decline compared to the overall 
2.3 percent workforce decline.

    Factoring in where employment would otherwise have been if the 
economy had experienced steady-State employment growthsince February 
2020, the overall employment gap is 3.5 percent \20\ and the health 
care employment gap is 3.9 percent, or 644,000 fewer health care 
workers than might otherwise have existed absent the employment changes 
that occurred since the pandemic.
---------------------------------------------------------------------------
    \20\  This employment gap is based on the BLS's Current Employment 
Statistics Survey. This is larger than the 2.6 percent gap reported in 
the demographic data because they include different populations and 
sample sizes. The demographic data is a survey of workers (not 
employers), and it has a smaller sample size and also a different 
method of measuring employment. (The demographic data can include self-
reported employment whereas the health care and total employment 
figures mentioned above are based on firms' payroll employment).
---------------------------------------------------------------------------
           Federal Government's Role in Health Care Workforce
    The Federal Government has a limited ability to affect the supply 
of health care workers because State licensing boards regulate who can 
obtain professional licenses and what medical services they can 
perform. Nonetheless, the Federal Government's role in health care 
through federally funded health care programs has created barriers to 
the health care workforce. Many of the rules and regulations of these 
Federal programs affect the supply of the health care workforce.

    Significant Control of the Graduate Medical Education (GME) System. 
The Federal Government currently spends billions of dollars each year 
on GME, or residency programs. Prior to the mid-20th century, hospitals 
usually absorbed the cost of GME without government subsidies, but in 
the 1960's, Federal funding for GME became part of Medicare spending. 
These Federal subsidies were supposed to be temporary, but have become 
the primary source of GME funding. By providing about $15 billion in 
funding per year, it is likely that the Federal Government has crowded 
out financing that might otherwise have come from various other 
stakeholders.

    The U.S. GME system fails to produce a sufficient number and 
adequate allocation of doctors to meet Americans' health care needs. 
Factors such as a 25-year-old cap on the number of Medicare-funded 
residency slots and the direct payment of GME funds to hospitals 
instead of being tied to students' results is a focus on teaching 
hospitals' needs instead of the health care needs of the American 
population as a whole.

    Recent Federal Investments in Health Care and the Health Care 
Workforce. Pandemic legislation, including the Coronavirus Aid, Relief, 
and Economic Security (CARES) Act of 2020 and the American Rescue Plan 
(ARP) of 2021 provided huge investments in the U.S. health care 
workforce. Some of those investments include $12.7 billion of increased 
Federal Medicaid matching funds to increase the workforce for home-and 
community-based services; $8.5 billion for rural health providers; $7.0 
billion to invest in the public health care workforce; $1.55 billion to 
address unmet health care needs and expand health care workforce 
programs in underserved communities; and about $250 million for 
behavioral health workforce expansions. \21\
---------------------------------------------------------------------------
    \21\  Angela J. Beck et al., ``Investing in a 21st Century Health 
Workforce: A Call for Accountability,'' Health Affairs, September 15, 
2021, https://www.healthaffairs.org/do/10.1377/
forefront.20210913.133585/full/ (accessed February 6, 2022).

    These recent funds are an enormous investment and will take 
significant time for their potential benefits to accrue. Congress 
should focus on ensuring the efficacy and accountability of these funds 
---------------------------------------------------------------------------
to meet their designated needs.

    Instead of jumping to spend more Federal money to increase the 
health care workforce, policymakers should allow time (with proper 
oversight) for the existing tens of billions of dollars in investments 
in the health care workforce to play out. Moreover, Federal lawmakers 
should not spend money in areas where existing state-imposed barriers 
to the expansion of the health care workforce and health care access 
will prevent those Federal dollars from achieving their full value.

    Veteran's Administration Not a Gold-Standard for Care. The Federal 
Government's direct provision of health care through the Veteran's 
Health Administration (VHA) and Veterans Affairs (VA) facilities falls 
short it its delivery of quality, timely, and affordable care.

    According to a 2016 report from The Heritage Foundation:

           Since 2014, investigations of the Veterans Health 
        Administration (VHA) have revealed glaring issues with the 
        Administration's policies and practices, including excessively 
        long wait times and secret waitlists for health care at 
        hundreds of Veterans Affairs (VA) facilities. A report from a 
        VA whistleblower \22\ shows that as many as 238,000 veterans 
        may have passed away before receiving care. \23\
---------------------------------------------------------------------------
    \22\  Ryan Grim, ``Leaked Document: Nearly One-Third of 847,000 
Vets with Pending Applications for VA Health Care Already Died,'' The 
Huffington Post, July 13, 2015, http://www.huffingtonpost.com/2015/07/
13/veterans-health-care-backlogdied--n--7785920.html (accessed June 14, 
2016).
    \23\  John O'Shea, ``Reforming Veterans Health Care: Now and for 
the Future,'' Heritage Foundation Issue Brief No. 4585, June 24, 2016, 
https://www.heritage.org/health--carereform/report/reforming-veterans-
health-care-now-andthe-future.

    The VA is uniquely structured to provide care for veterans and has 
plenty of need to improve on access, quality, and accountability. The 
VA should not become a means of expanding the government's role in 
---------------------------------------------------------------------------
health care beyond veterans.

    Federal Government's Failed Track Record in Job-Training Programs 
Evidence It Should Not Enact Health Care Workforce Training Programs. 
In light of the health care worker shortage, it may be suggested that 
the Federal Government embark in health workforce job-training 
programs. But the Federal Government has a terrible track record on 
job-training programs.

    A gold standard evaluation of the Workforce Investment Act found 
that despite the Department of Labor's directive to provide training 
for in-demand services, only 32 percent of participants found 
occupations in their area of training, and the majority of 
participants--57 percent--did not believe that their training helped 
them find employment. \24\ Moreover, individuals receiving the full 
workforce training were less likely to obtain health insurance or 
pension benefits, their households earned several thousand dollars 
less, and they were more likely to be on food stamps than participants 
who received minimal services.
---------------------------------------------------------------------------
    \24\  Sheena McConnell, Kenneth Fortson, Dana Rotz, Peter Schochet, 
Paul Burkander, Linda Rosenberg, Annalisa Mastri, and Ronald D'Amic, 
``Providing Public Workforce Services to Job Seekers: 15-Month Impact 
Findings on the WIA Adult and Dislocated Worker Programs,'' Mathematica 
Policy Research, May 30, 2016,https://www.mathematica.org/publications/
providingpublic-workforce-services-to-job-seekers-15-monthimpact-
findings-on-the-wia-adult (accessed February 4, 2022).

    Annalisa Mastri, and Ronadl D'Amic, ``Providing Public Workforce 
Services to Job Seekers: 15-Month Impact Findings on the WIA Adult and 
Dislocated Worker Programs,'' Mathematica Policy Research, May 30, 
2016, https://www.mathematica.org/publications/providing-public-
workforce-services-to-job-seekers-15-month-impact-findings-on-the-wia-
---------------------------------------------------------------------------
adult (accessed February 4, 2022).

    The National Job Corps Study (a youth job-training program), found 
that a Federal taxpayer investment of $25,000 per Job Corps participant 
resulted in participants being less likely to earn a high school 
diploma, no more likely to attend or complete college, and to earn only 
$22 more per week, on average. \25\
---------------------------------------------------------------------------
    \25\  David B. Muhlhausen, ``Job Corps: An Unfailing Record of 
Failure,'' Heritage Foundation WebMemo No. 2423, May 5, 2009, https://
www.heritage.org/jobsandlabor/report/jobcorps-unfailing-record-failure.

    It is not surprising that Federal job-training programs are out of 
touch with the needs of employers in high-demand occupations because 
politicians and bureaucrats will never know businesses' needs better 
than employers themselves. Politicians are particularly ill-equipped to 
understand and meet the needs of the health care industry. Any training 
efforts they may attempt to undertake would not only be thwarted by 
existing government regulations, but in the fast-paced and rapid-
response health care industry, Federal efforts would almost certainly 
come up a day late and a dollar short.
    Solutions to Increase Health Care Workforce, Health Care Access
    The severe labor shortage across the U.S. has had 
disproportionately large effects on the health care workforce, at the 
same time as the pandemic has increased the demand for health care and 
required new health care protocols that have made the provision of 
health care more costly and time-consuming.

    Even prior to the pandemic, however, the U.S. faced a shortage of 
health care professionals. According to the Health Resources and 
Service Administration, 88 million Americans live in areas designated 
to have shortages of primary care health professionals. \26\
---------------------------------------------------------------------------
    \26\  Health Resources and Services Administration, ``Shortage 
Areas,'' U.S. Department of Health and Human Services, https://
data.hrsa.gov/topics/healthworkforce/shortage-areas (accessed February 
7, 2022).

    Although there are some actions Federal policymakers can take to 
make it easier for international medical professionals to enter the 
U.S., most barriers to expanding the health care workforce and access 
to health care rely on removing state-level barriers. No matter how 
much money the Federal Government may spend attempting to increase 
employment in and access to health care, it will be of limited use so 
long as states continue to restrict entry into health care occupations 
and unnecessarily restrict the services health care workers can 
---------------------------------------------------------------------------
provide.

    There are steps, however, that Federal policymakers can take to 
enable greater flexibility for the health care industry to respond to 
Americans' health care needs, as well as to remove unnecessary burdens 
in Federal health care programs that limit health care access and 
prevent more innovative and cost-effective care.

    It is also important for the Federal Government to ensure proper 
accountability and effectiveness of the tens of billions of Federal 
dollars recently allocated to expanding the health care workforce. This 
may require the Federal Government working with states to encourage 
them to remove barriers to that funding to achieve its intended 
purposes.
           First, Ensure a Well-Functioning U.S. Labor Market
    Foundational to expanding the health care workforce--or any 
sector's workforce--is a well-functioning U.S. labor market with ample 
participants. For individuals, that requires that it pays to work and 
does not pay to not work. To help encourage more people to pursue their 
productive capabilities, policymakers should:

    Limit Taxes and Reduce Regulations so that individuals and 
employers can enjoy higher returns to work (such as greater pay, higher 
productivity, and increased opportunities). \27\
---------------------------------------------------------------------------
    \27\  Adam N. Michel, ``The Tax Cuts and Jobs Act: 12 Myths 
Debunked,'' Heritage Foundation Backgrounder No. 3600, March 23, 2021, 
https://www.heritage.org/taxes/report/the-tax-cuts-andjobs-act-12-
myths-debunked.

    Enable Greater Natural Wage Increases by making it easier and less 
expensive for people to obtain income-enhancing education and skills, 
and by eliminating the double tax in investments that boost 
productivity and wages. \28\
---------------------------------------------------------------------------
    \28\  Jamie Bryan Hall and Mary Clare Amselem, ``Time to Reform 
Higher Education Financing and Accreditation,'' Heritage Foundation 
Issue Brief No. 4668, March 28, 2017, https://www.heritage.org/
education/report/time-reformhigher-education-financing-and-
accreditation.

    Make Welfare Work Better Through Work-Oriented Programs that help 
---------------------------------------------------------------------------
people achieve independence (and also help break cycles of poverty).

    Let People Pursue the Work They Want by not forcing workers into 
unions, by not enacting laws that prohibit companies from doing 
business with independent workers, and by clarifying the definition of 
``employee'' across Federal laws based on the level of control the 
individual maintains over his work.

    Expand Accessible, Affordable Childcare by allowing parents to use 
Federal childcare subsidies and Head Start funds at a provider of their 
choice. \29\
---------------------------------------------------------------------------
    \29\  Rachel Greszler and Lindsey M. Burke, ``Rethinking Early 
Childhood Education and Childcare in the COVID-19 Era,'' Heritage 
Foundation Backgrounder No. 3533, September 30, 2020, https://
www.heritage.org/sites/default/files/2020-09/BG3533.pdf.

    Do Not Increase Government Spending. Passing big spending bills 
with new unfunded entitlement programs in addition to the recent $6.6 
trillion in COVID-19 spending and atop the $30 trillion U.S. Federal 
debt would be reckless and further interfere in the already troubled 
---------------------------------------------------------------------------
labor market.

    Second, Remove Barriers that Restrict the Healthcare Workforce

    Abandon Federal Vaccine Mandates. The Federal Government's vaccine 
mandate for Medicare and Medicaid providers extends to about 14 million 
workers. An October 2021 ``Vaccine Monitor'' survey from the Kaiser 
Family Foundation reported that 5 percent of adults say they would 
leave their job if their employer required them to get a vaccine or get 
tested weekly, and that figure jumped to 9 percent if weekly testing 
was not an option. \30\
---------------------------------------------------------------------------
    \30\  Liz Hamel et al., ``KFF COVID-19 Vaccine Monitor: October 
2021,'' Kaiser Family Foundation, October 28, 2021, https://
www.kff.org/coronavirus--covid--19/pollfinding/kff-vid-19-vaccine-
monitor-october-2021/ (accessed October 31, 2021).

    While health care workers may be less likely than the general 
population to quit their jobs over a vaccine mandate, if even 0.5 
percent of the 14 million workers subject to the CMS COVID-19 mandate 
---------------------------------------------------------------------------
quit, this would result in a loss of 70,000 health care workers.

    The Federal Government should abandon the CMS mandate and instead 
allow health care providers to set their own vaccination policies, 
based on their simultaneous goals of providing safe environments and 
ensuring access to quality care.

    Third, State and Federal Lawmakers Need to Remove Barriers to Entry 
and Eliminate Unnecessary Burdens in Health Care Delivery

    Reform the Graduate Medical Education System. Becoming a practicing 
physician in the U.S. requires between seven and 10 years of education 
that involves the certification of at least four different medical 
accreditation boards and councils. \31\ Dr. Kevin Pham explains that 
while these organizations originally arose ``to weed out sham schools 
and shoddy practitioners,'' their safeguards have become a bottleneck, 
and the ``organizations are becoming monopolistic.'' \32\
---------------------------------------------------------------------------
    \31\  Kevin Pham, MD, ``America's Looming Doctor Shortage: What 
Policymakers Should Do,'' Heritage Foundation Backgrounder No. 3343, 
September 5, 2018, https://www.heritage.org/sites/default/files/2018-
09/BG3343--1.pdf.
    \32\  Ibid.

    These barriers and the GME system's reliance on Federal funding 
makes it extremely difficult for smaller and rural community hospitals 
to sponsor residency programs, which results in a shortage of residency 
---------------------------------------------------------------------------
spaces and a misallocation of physicians across the U.S.

    Policymakers should improve the GME system by consolidating GME 
financing into a single funding stream based on the cost of training 
residents; allocating GME funding management to the states based on 
agreed-upon criteria; having funds follow the residents rather than the 
training programs; and by including all stakeholders--not just 
governments--in GME financing. \33\
---------------------------------------------------------------------------
    \33\  John O'Shea, MD, ``Reforming Graduate Medical Education in 
the U.S.,'' Heritage Foundation Backgrounder No. 2983, December 29, 
2014, http://thf--media.s3.amazonaws.com/2014/pdf/BG2983.pdf.

    Moreover, policymakers should break the accreditation monopoly to 
---------------------------------------------------------------------------
encourage the development of additional and innovative GME programs.

    Allow Provisional Licensing for Medical School Graduates Who Do Not 
Receive a Residency Position. Completing a residency program is 
generally necessary for medical school graduates to begin practicing 
medicine on their own. Yet, between 2014 and 2018, an average of 8,444 
medical school graduates per year did not find a position in a 
residency program (which operates through a monopoly matching system). 
\34\ States could potentially utilize the talent of these highly 
educated individuals by allowing for provisional licensing of medical 
graduates to work under the supervision of qualified physicians. A 
publication by Kevin Dayaratna, Paul Larkin and John O'Shea recommends 
that such provisional licenses, issued by state licensing boards, 
should include ``earning a medical degree from an accredited medical 
school, passing the USMLE, and collaborating with a supervising 
licensed physician.'' \35\
---------------------------------------------------------------------------
    \34\  Kevin Dayaratna, Paul J. Larkin, Jr., and John O'Shea, MD, 
``Reforming American Medical Licensure,'' Harvard Journal of Law and 
Public Policy, Vol. 42, No. 1, http://www.harvard-jlpp.com/
wplicensingcontent/uploads/sites/21/2019/02/Larkin-Final.pdf (accessed 
February 7, 2022).
    \35\  Ibid.

    Accelerate Visas for International Medical Graduates (IMGs). 
According to the Council on Graduate Medical Education, IMGs make up 
about 20--25 percent of the physician workforce, but visa restrictions 
and delays limit their ability to come to the U.S. and help fill unmet 
health care needs. According to the American Medical Association, ``The 
proportion of residency programs sponsoring H-1B visas for training has 
gradually decreased in the last few years as the immigration 
requirements are multistep, costly (for the employer), and often 
complicated with bureaucratic immigration nuances.'' \36\ U.S. 
immigration laws should make it easier for the U.S. to fill unmet 
physician needs through International Medical Graduates.
---------------------------------------------------------------------------
    \36\  American Medical Association, ``International Medical 
Graduates (IMG) Toolkit: Types of Visas and FAQs,'' International 
Medical Education, https://www.ama--assn.org/education/
internationalmedical-education/international-medical-graduatesimg-
toolkit-types-visas (accessed February 6, 2022).

    Streamline Entry for Experienced Medical Professionals from Abroad. 
To obtain a license to practice medicine in the U.S., many experienced 
doctors from foreign countries have to spend years completing the same 
type of internship and residency program as U.S. medical school 
graduates, even though many of those foreign doctors have already 
completed similar education and have years of practical experience. 
\37\ American medical licensing boards should streamline the process 
for experienced foreign doctors to practice in the U.S., potentially 
utilizing a provisional licensing system. \38\
---------------------------------------------------------------------------
    \37\  Dayaratna, Larkin, Jr., and O'Shea, ``Reforming American 
Medical Licensure.''
    \38\  Australia's Medical Board provides a promising example 
whereby foreign medical professionals that are licensed in their own 
country and have passed the Australian licensing exam or similar 
equivalent can obtain a provisional license. Provisionally licensed 
doctors are granted one of four different levels of practitioner 
supervision, based on their qualifications. After proving their 
competence, foreign practitioners are eligible to obtain a full medical 
license.

    American medical boards could also establish reciprocity agreements 
with other countries, so that the U.S. could accept certain levels of 
education and experience in other countries toward American licensure. 
Both of these policies would help reduce the shortage of spots in 
---------------------------------------------------------------------------
America's Graduate Medical Education system.

    Reduce Administrative and Regulatory Burdens. According to Dr. 
Kevin Pham, ``The essential health care interaction occurs between the 
physician and the patient, and anything that interferes with that 
relationship makes the best practice of medicine harder.'' \39\ The 
more time that doctors and medical professionals have to spend 
complying with administrative and regulatory burdens, the less time 
they can spend doing what they were trained and desire to do--treating 
patients.
---------------------------------------------------------------------------
    \39\  Pham, MD, ``America's Looming Doctor Shortage: What 
Policymakers Should Do.''

    Excessive regulatory burdens that make it less desirable to work in 
health care can cause workers to prematurely leave their professions. 
---------------------------------------------------------------------------
According to a Physicians Foundation survey,

    49 percent of doctors feel often or always burned out, and 58.3 
percent of doctors' primary complaints are the paperwork and regulatory 
burden. \40\ Moreover, almost half of physicians are considering 
retiring earlier than planned because of reasons related to changes in 
the health care system. This includes 41.2 percent of physicians 
younger than 45, and 50 percent of those 46 and older. \41\
---------------------------------------------------------------------------
    \40\  The Physicians Foundation, 2016 Survey of America's 
Physicians, Practice Patterns & Perspectives, 2016, pp. 7-17, https://
physiciansfoundation.org/wp--content/uploads/2018/01/Biennial--
Physician--Survey--2016.pdf (accessed February 8, 2022).
    \41\  The Physicians Foundation, 2016 Survey of America's 
Physicians, Practice Patterns & Perspectives, pp. 29-33.

    Some of the most significant administrative burdens include 
quality-reporting measures, prior authorization requirements, and 
excessive documentation of details in clinical encounters. For example, 
an American Medical Association study found that a small, three-
physician practice will complete an average of 100 prior authorizations 
per week. And Medicare requires doctors to recertify durable medical 
equipment every year for patients with chronic medical conditions, such 
as insulin pumps for individuals with type 1 diabetes. \42\ The Federal 
Government, through the CMS should reduce and eliminate unnecessary 
administrative burdens. \43\
---------------------------------------------------------------------------
    \42\  Pham, MD, ``America's Looming Doctor Shortage: What 
Policymakers Should Do.''
    \43\  Ibid. This report includes the following recommendations: 
``Ease policies driving administrative burdens in the form of paperwork 
requirements; ease documentation requirements for clinical visits; 
rescind the mandate to use EHRs in order to receive full compensation 
by Medicare; and respect and support the role the private sector has to 
play in developing products that meet doctors' needs.''

    Do Not Reduce Home Healthcare Workers Paychecks Through ``Dues 
Skimming.'' The Biden Administration seeks to force more workers into 
unions by extracting union dues from home healthcare workers' Medicare 
---------------------------------------------------------------------------
and Medicaid payments, without their consent.

    Docking the paychecks of home healthcare workers'--or any 
workers'--paychecks and requiring them to cede control over their work 
to union officials will make healthcare work less attractive. The fact 
that only 6.1 percent of private sector workers are union members \44\ 
shows that unions do not benefit all workers, and they would likely 
prevent some would-be healthcare workers from continuing in their jobs 
due to the higher costs and restricted autonomy that comes with union 
membership. No government--Federal nor state--should ever require 
workers to join a union as a condition of performing their desired 
jobs.
---------------------------------------------------------------------------
    \44\  BLS, ``Union Members-2021,'' News Release, January 20, 2022, 
https://www.bls.gov/news.release/pdf/union2.pdf (accessed February 8, 
2022).

    Reform State Licensure Laws and Accreditation Rules. State 
licensing laws determine who can perform various health care 
professions within a state. In many instances, State licensure boards 
function as political monopolies to prevent new entrants into the 
market, as opposed to public safety protectors. There are many ways 
states can and should prevent unnecessary licensure barriers, including 
by taking power away from monopolistic licensing boards, by reducing 
and eliminating unnecessary licensing requirements, by expanding 
options for individuals to obtain health care education, and by 
---------------------------------------------------------------------------
enacting reciprocity agreements with other states.

    Reform State Scope of Practice Laws. Scope of practice laws act as 
a second barrier to the delivery of health care by restricting the 
range of health care services and procedures that already licensed 
professionals can provide, and by requiring varying levels of 
supervision for these professionals to practice in their field.

    Most often, scope of practice laws apply to nonphysician providers 
such as nurse practitioners, or Advanced Practice Registered Nurses 
(APRNs). Currently, 25 states plus the District of Columbia provide 
Full Practice Authority (FPA) for nurse practitioners to perform all of 
the services and procedures they were trained to perform. \45\ The 
other 25 states reduce or restrict the ability of nurse practitioners 
to engage in one ore more element of their practice and require career-
long collaboration or supervision.
---------------------------------------------------------------------------
    \45\  American Association of Nurse Practitioners, ``State Practice 
Environment,'' https://www.aanp.org/advocacy/state/state-
practiceenvironment (accessed February 7, 2022).

    A Federal Trade Commission explains how scope of practice laws can 
limit the supply of primary health services and restrict competition 
---------------------------------------------------------------------------
between different types of practitioners:

           Physician supervision requirements may raise competition 
        concerns because they effectively give one group of health care 
        professionals the ability to restrict access to the market by 
        another, competing group of health care professionals, thereby 
        denying health care consumers the benefits of greater 
        competition. In addition, APRNs play a critical role in 
        alleviating provider shortages and expanding access to health 
        care services for medically underserved populations. For these 
        reasons, the FTC [Federal Trade Commission] staff has 
        consistently urged State legislators to avoid imposing 
        restrictions on APRN scope of practice unless those 
        restrictions are necessary to address well-founded patient 
        safety concerns. Based on substantial evidence and experience, 
        expert bodies have concluded that ARPNs are safe and effective 
        as independent providers of many health care services within 
        the scope of their training, licensure, certification, and 
        current practice. \46\
---------------------------------------------------------------------------
    \46\  Federal Trade Commission, ``Competition and the Regulation of 
Advanced Practice Nurses,'' Policy Perspectives, March 2014, https://
www.ftc.gov/system/files/documents/reports/policy-perspectives-
competition-regulation-advancedpractice-nurses/
140307aprnpolicypaper.pdf (accessed

    Eliminate State Certificate-of-Need (CON) Laws or Require States to 
Bear Financial Burden. Imagine if opening a business required procuring 
detailed analysis and projections, hiring lawyers, lobbyists, and 
consultants, and convincing existing competitors to not oppose your 
entry into the market. This is what hospital offices and medical 
providers must do to prove to a State agency that there is a ``need'' 
for the new or expanded facility they want to build. Academic studies 
show that Certificate-of-Need (CON) laws that exist in 35 states and 
the District of Columbia lead to lower quality, reduced access, and 
higher costs, including 30 percent fewer hospitals and 11 percent 
higher healthcare costs. \47\ The FTC and the Anti-Trust Division of 
the Department of Justice (DOJ) have consistently come to the same 
conclusion under both Democratic and Republican Administrations. \48\
---------------------------------------------------------------------------
    \47\  See State Policy Network, ``Certificate-Of-Need Laws: Why 
They Exist and Who They Hurt,'' SPN Blog, April 1, 2021, https://
spn.org/blog/certificate--ofneedlaws/text--The percent20Kaiser 
percent20Family percent20Foundation percent20found,residents 
percent20across percent20the percent20entire percent20'State (accessed 
February 8, 2022).
    \48\  Maureen K. Ohlhausen, ``Certificate of Need Laws: A 
Prescription for Higher Costs,'' Antitrust, Vol. 30, No. 1, Fall 2015, 
c 2015 by the American Bar Association, available at: https://
www.ftc.gov/system/files/documents/public--statements/896453/
1512fall15-ohlhausenc.pdf (accessed February 8, 2022).

    States should eliminate CON laws and Congress should consider 
evaluating the extent to which CON laws are driving up Federal 
healthcare costs and adjust payments to the states accordingly, to 
prevent Federal taxpayers from bearing the financial burden of states' 
bad policies. \49\
---------------------------------------------------------------------------
    \49\  Robert E. Moffit, ``State Certificate-of-Need Laws Deserve a 
Federal Response,'' Real Clear Health, January 10, 2022, https://
www.realclearhealth.com/articles/2022/01/10/state--certificate--o--
fneed--laws--deserve--a--Federal--response--111288.html (accessed 
February 8, 2022).

    Expand the Use of Telemedicine. Access to telemedicine can be 
extremely beneficial for all populations, and especially those in rural 
areas and older people or individuals with disabilities for whom it can 
be more difficult to travel to appointments. Ongoing private 
investments along with a recent $48 billion in Federal investments in 
broadband services will greatly expand broadband access. Federal 
lawmakers should provide parity of payments within Federal programs for 
telehealth and in-person visits. And State lawmakers should remove 
barriers that prevent healthcare practitioners in one State from 
providing telehealth services to patients in another state.
                                Summary
    The U.S. is experiencing a labor shortage unlike any before in U.S. 
history, and the health care sector has been particularly hard-hit.

    The Federal Government has limited availability to affect the 
supply of the health care workforce and it should not be in the 
business of directly training health care workers.

    Ultimately, states control the entry gates to the health care 
workforce. States need to eliminate unnecessary licensing and scope of 
practice restrictions. Unless or until they do so, any

    Federal funding aimed at expanding the health care workforce will 
be of limited value.

    Federal policymakers should immediately focus on removing barriers 
that are contributing to the nationwide labor shortage, such as vaccine 
mandates, welfare-without-work programs, and restrictions on 
individuals' ability to work in the ways that work best for them. 
Moreover, policymakers should refrain from enacting further massive 
Federal spending bills that would artificially and unsustainably pump 
up the demand for workers.

    Within existing Federal funding and health care programs, 
policymakers should enable greater flexibility to respond to America's 
health care needs, and remove unnecessary burdens in Federal health 
care programs that limit health care access and that prevent more 
innovative and cost-effective care.

    The Heritage Foundation is a public policy, research, and 
educational organization recognized as exempt under section 501(c)(3) 
of the Internal Revenue Code. It is privately supported and receives no 
funds from any government at any level, nor does it perform any 
government or other contract work.

    The Heritage Foundation is the most broadly supported think tank in 
the United States. During 2020, it had hundreds of thousands of 
individual, foundation, and corporate supporters representing every 
State in the U.S. Its 2020 operating income came from the following 
sources:

           Individuals--66 percent

           Foundations--18 percent

           Corporations--2 percent

           Program revenue and other income--14 percent

    The top five corporate givers provided The Heritage Foundation with 
1 percent of its 2020 income. The Heritage Foundation's books are 
audited annually by the national accounting firm of RSM US, LLP.

    Members of The Heritage Foundation staff testify as individuals 
discussing their own independent research. The views expressed are 
their own and do not reflect an institutional position of The Heritage 
Foundation or its board of trustees.

        Employment Gaps by Gender, Presence of Children, and Age
     Difference Between Actual Employment Levels and Counterfactual
          Employment Trend,\1\ February 2020 To October 2021\2\
------------------------------------------------------------------------
                       Employment Gap,  Employment Gap,   Share of Total
        Group            Individuals       Precentage     Employment Gap
------------------------------------------------------------------------
        All Workers       -4,137,893     -2.6 percent      100 percent
------------------------------------------------------------------------
                Men       -1,996,801     -2.4 percent     48.3 percent
------------------------------------------------------------------------
              Women       -2,141,091     -2.9 percent     51.7 percent
------------------------------------------------------------------------
Workers with children     -1,889,868     -3.8 percent     45.7 percent
------------------------------------------------------------------------
    Workers without       -2,248,024     -2.1 percent     54.3 percent
            children
------------------------------------------------------------------------
  Men with children         -823,138     -3.2 percent     19.9 percent
            under 18
------------------------------------------------------------------------
Women with children       -1,066,730     -4.3 percent     25.8 percent
            under 18
------------------------------------------------------------------------
Men without children      -1,173,663     -2.1 percent     28.4 percent
            under 18
------------------------------------------------------------------------
      Women without       -1,074,361     -2.1 percent     26.0 percent
   children under 18
------------------------------------------------------------------------
Workers with children     -1,490,634     -5.1 percent     36.0 percent
       6 to 17, none
             younger
------------------------------------------------------------------------
Workers with children       -399,234     -1.9 percent      9.6 percent
             under 6
------------------------------------------------------------------------
Men with children 6         -731,803     -5.1 percent     17.7 percent
 to 17, none younger
------------------------------------------------------------------------
Women with children 6       -758,831     -5.2 percent     18.3 percent
 to 17, none younger
------------------------------------------------------------------------
  Men with children          -91,335     -0.8 percent      2.2 percent
             under 6
------------------------------------------------------------------------
Women with children         -307,899     -3.1 percent      7.4 percent
             under 6
------------------------------------------------------------------------
\1\  Counterfactual trend is based on a definition of steady-state
  employment growth from the Federal Reserve, equal to monthly growth of
  about 84.000 (0.053 percent)
\2\  SOURCE: Unpublished tabulations from the U.S. Bureau of Labor
  Statistics' Current Population Survey. Data should be interpreted with
  caution as they are based on small sample sizes

  
  
                                 ______
                                 
    Senator Hickenlooper. Great. Thank you very much. Thank all 
of you. I look forward to beginning the question. And I before 
we get to that, I would like to turn the microphone over to the 
Chair of the overall HELP Committee. This is the Subcommittee 
on Employment and Workplace Safety. But Chair Murray is here, 
so I would like her opening statement.

                  OPENING STATEMENT OF SENATOR MURRAY

    The Chair. Thank you very much, Senator Hickenlooper, for 
organizing this hearing to talk about how we can support our 
health care workforce. And thank you to all of our witnesses 
for offering your insights on this really important topic. The 
discussion about how we can diversify our health care workforce 
is so important to improving health care for communities of 
color and increasing health equity.

    I am really glad to be able to join for a few minutes today 
and really highlight the challenges I have been hearing about 
from health care workers in particular, something I know is a 
big priority for all of us. I have heard from so many nurses 
and doctors and other health care workers back in Washington 
State about how hard this pandemic has been, and I know there 
are similar stories across the country.

    Health care workers have handled long hours, overcrowded 
facilities, fighting a deadly new virus, often while receiving 
low pay. They have worried about whether they have the 
equipment they need, or whether they are safe at work, or would 
get sick, or bring a deadly virus home to their family, and 
whether they could make ends meet on the wages they were paid, 
let alone if they had to stay home to care for themselves or 
for a loved one.

    They have had to patiently deal, and compassionately deal 
with patients and family members who may have been afraid they 
may never see their loved ones again, frustrated by steps 
required to keep everyone safe, or even skeptical about the 
threat of this virus due to misinformation and angry with 
health care professionals who are just trying to help. They 
have seen the pain of this pandemic up close and personal, and 
it is taken a real toll.

    Far too many health care workers have been killed by this 
virus, and many more are dealing with the trauma, mental health 
challenges, and burnout in its wake. That is why I pushed for 
historic investments in the American Rescue Plan to further 
support our health care workforce, including robust funding for 
workplace safety and health protections from COVID-19, as well 
as address some of the personal challenges facing these 
workers.

    This pandemic has really made it clearer than ever how 
important it is that our health care workers are paid what they 
deserve, that they have a voice in the decisions about how we 
should recruit and train and retain health care workers, have 
safe workplaces which are adequately stocked and staffed, and 
are protected from infectious diseases and workplace violence.

    We also need to make sure that all workers have paid leave 
for when they need to care for themselves and their own 
families so they can get mental health care when they need it 
and can choose to join a union and collectively bargain for 
better wages and working conditions.

    After all they have done for our communities, we owe it to 
our health care workers and everyone on the front lines of this 
pandemic to listen to their experiences and respond to the 
challenges they are dealing with. As we work to improve 
recruiting, retaining, and training for health care workers, 
one critical aspect of this is ensuring we improve the working 
conditions.

    I am glad we are having this discussion today on ways we 
can support our health care workforce. And I am committed to 
making sure we include health care workers in this important 
conversation as it continues. And before I finish, I would just 
like to know we will have letters I plan to submit for the 
record and ask consent to do so.

    Senator Hickenlooper. Without objection.

    [The following information can be found on pages 59 through 
85 in Additional Material:]

    The Chair. Thank you, Mr. Chairman.

    Senator Hickenlooper. Terrific, thank you very much. I know 
we will start our questioning and I--my only guidance, I 
usually instruct witnesses to keep your answers concise because 
there is I think you will be amazed how many questions we have, 
and we will get two more questions if we can be concise.

    I realize I always hold that 45 seconds or 30 to 45 seconds 
is a goal. I realize that is usually not always possible. Let 
me start with Dr. Verret. Your university led the way in 
producing students and alumni who excel in various health 
professions. In particular, the Xavier is focused on intensive 
faculty advising, academic research centers, and co-curricular 
programs appears to have been critical to the success exhibited 
by your--achieved by your students.

    I mean, this is a clearly a successful model. Xavier has 
been consistently for a number of years the No. 1 university 
and as a source for African-American students who go on to 
become doctors. Now you described certain additional 
investments that the Federal Government could make.

    How else at the Federal level can we replicate, I mean, 
really tried to take the success that you have achieved with 
Xavier's programs and replicate it in schools across the 
country?

    Mr. Verret. Well, I would say that--to begin first is that 
clearly what we do in the pipelines before, in the pre-
collegiate experience is an important piece. I would add that. 
Because what are--in preparing students who may not be aware of 
the access, the opportunities themselves because in many cases 
they have not--they are only hearing of college toward the end 
of their high school years.

    It is a crucial piece in getting that type of pipeline. The 
other piece is that we also--it is important that we help 
students discover their weaknesses, because all students come 
with weaknesses, early in the education, so that what we do in 
providing academic support is first in the discovery process 
for students to discover what they know, where they are strong 
and where they are weak, and what support they would need.

    The other piece that is a difficult one to replicate easily 
is actually the intentionality of forming a faculty that is 
committed to that kind of work. And how the faculty reflect--is 
committed to actually recognizing that not all students come 
with the education that they fully deserve. Not--most children 
do not choose the schools that they attend, at least not yet, 
in this country.

    Students come with different--with different deficits. And 
the important thing is that deficit does not mean a lack of 
talent, ability. It is important that we remedy those deficits 
early in the experience, not later. It is important because 
what we discover in the first or second year, we can repair. In 
the third or fourth year is more difficult.

    It is important that we confront that, and I use the 
expression of one of our students in understanding that even 
though they may complain that the faculty--of the staff or 
other things at Xavier, they will say that the faculty has our 
back because they know that commitment and that, and faculty 
committed is an important element.

    Senator Hickenlooper. Excellent. And I just learned last 
week that the College Board, now known--is not just AP, 
advanced placement tests that they give, there are enough high 
schools all across the country recognizing the need for health 
care professionals that they are going to have an AC test so 
kids in high school will have it, it will be an advanced career 
opportunity and allow them to get some recognition and credit 
for taking these early, and during high school preparations for 
a health care career.

    Dr. Flinter, during the COVID-19 pandemic, obviously 
burnout reached an apex. Millions of workers are reevaluating 
what they value in their job or their career. I mean, even 
before the pandemic, burnout in the health care workers was a 
major challenge given the nature of the work, the intensity.

    Dr. Flinter, how can upskilling opportunities like nurse 
practitioner training programs help reduce burnout and address 
long term retention among the health care workers?

    Ms. Flinter. Well, thank you for the question. And let me 
say it was our honor to serve in the COVID pandemic.

    I think in my organization, we often felt like we were on 
the frontlines of a battle, unlike anything we had ever seen, 
and whether we were outside in the freezing cold or the burning 
heat of July, people were very grateful to serve and to make a 
contribution through first testing and then vaccine.

    But the work is very difficult, inherently. People sign up 
for the difficult work of health care, right to meet humanity 
sometimes at its most vulnerable moments, and to also work to 
keep them well. If in addition to that, you don't have the 
skills to provide the level of care that is needed by the 
population you care for, and again, I speak to our safety net 
settings in our rural areas where primary care is where 
everybody comes, they don't go off to a specialist on the first 
pass, you significantly increase the difficulty.

    If you don't have behavioral health clinicians as part of 
your primary care team, you significantly increase that 
difficulty. If you don't have the MAs who can help manage and 
make automatic, what should be automatic in prevention and 
screening, you increase the difficulties.

    Training is a big piece of it, making sure that we have the 
whole team and not just part of the team to have the most 
effective primary care, I think is another piece. And then the 
third, of course, is its every organization's responsibility to 
ensure that they are providing both the safe workforce, as 
Senator Murray alluded, but also providing the ongoing 
training.

    We participate in the NIMAA program. We welcome students, 
more than 200 a year, from all the disciplines and all the 
health care institutions in Connecticut to make sure that we 
are building that pipeline that can continue to increase that 
skill level.

    Senator Hickenlooper. Great. Thank you very much. I have 
more questions and hopefully we will have time for a second 
round. If not, I will make sure I submit them in writing. I now 
turn over to Senator Braun for his questions.

    Senator Braun. Thank you, Mr. Chairman. Touched on it 
earlier in my opening statement that I feel a lot of what we 
are navigating through currently addressing COVID, it was a 
feisty foe. None of us knew much about it. I know in my own 
company which in discussing what we were going to do when I 
touched base weekly, it was about treating it with respect.

    It was about doing those things that we all know now that 
the science is saying what did work and what didn't work. And 
so often you get the political science involved in the 
discussion and it keeps us off the mark. I was going to ask Ms. 
Greszler about vaccine mandates. I led the charge in the Senate 
with the Congressional Review Act about why that didn't make 
sense.

    Life is not fixed ever from the top down. It would be 
different if we were knocking it out of the park here at the 
Federal level. And in my 3 years, I have so many people come 
here wanting more of it, heard some from the panel that we need 
to spend more money.

    The reality check is we borrow almost 25 percent of 
everything that we spend here, and that is up close to 30 
percent. It is a bad business plan to probably look for more of 
that. I agree, on the other hand, that these are real issues. 
But do we keep shoveling more into a broken system or do we 
take a more entrepreneurial, a different approach?

    The results say do something different. It is 20 percent of 
our GDP. It is 10 percent elsewhere. Ms. , you, tell me what 
you think about vaccine mandates. That was going to be my first 
question. Being an economist--my degree was in economics after 
I thought I was going to be a biology major. And when I found 
out it took 9 years to become a surgeon, I didn't get into the 
field.

    That is part of the issue too, how long it takes, how 
costly it is for practitioners, for doctors on the firing line. 
How much of what we struggle with is due to the fact that I am 
a one of a lonely voice of Republicans that says the industry 
itself, no competition, no transparency, it is a business of 
remediation not prevention, increasingly dominated by large 
corporations that do not want to do the things that before you 
start throwing more Federal dollars at it, how do you fix the 
system itself?

    Is the health care industry broken in the fact that it 
doesn't embrace competition, transparency, all kinds of 
barriers to entry, not to mention that we have a health care 
consumer that really isn't interested in her or his own well-
being other than fix it when it is broke?

    Ms. Greszler. Yes, let me start there with the immediate--
and you mentioned the vaccine mandates, and that is where I 
think that you know what it is like as an employer. The medical 
facilities that are out there know the needs of their 
communities, they know the needs of their workers, and they are 
the ones that are better able to make the decision to balance 
the safety needs and the needs of actually having people there 
to treat their patients that come in.

    That is why the decisions need to be made there. And we 
have seen in places that have implemented these mandates, 
having to lay off up to 2 percent of their workforce. That is 
an enormous number if you multiply that across potentially 14 
million workers. And the particular problem is for more rural 
areas. I know a lot of you are from rural areas and those are 
smaller facilities.

    If they lose 2 percent of their workforce, that is really 
difficult for them. I know I had a family member myself that 
had a pediatric emergency and was told, you need to travel to 
another State 160 miles away to that hospital because the 
nearby Children is Hospital is having shortage because of the 
vaccine mandates.

    That is an immediate problem, but there are many long 
standing issues here. Ultimately, the States are the 
gatekeepers of who gets to practice medicine within their 
State. And so a lot of it comes down to that. And certainly, it 
doesn't make sense to be throwing Federal money at a gate that 
is not going to be opened up. We have seen more than $10 
billion invested recently.

    I think it will take time to--for that money to play out. 
You can't increase the workforce overnight. And so we need to 
wait and see what happens there. But there are also things 
immediately that don't even cost any money, just removing those 
regulatory burdens that are out there. Part of the burnout 
issue is you want to have more time----

    Senator Braun. Ms. Greszler, before we run out of time, and 
I will come back and ask it again, removing regulations, all of 
that. What about the industry itself? You are an economist. 
Does it embrace competition, transparency, and does it have 
barriers to entry? Give me your quick kind of pass on that, and 
if I need more, I will ask it on a second round.

    Ms. Greszler. Yes, there are absolutely barriers to entry 
out there, and there are interests that are fighting against 
the competition that could lower costs and that could improve 
the quality of care. And part of that has to do with, I would 
say, an excessive level of Federal money and Federal rules and 
regulations that kind of dictate the system.

    Senator Braun. Thank you.

    Senator Hickenlooper. Thank you.

    Alright, Senator Baldwin.

    Senator Baldwin. Thank you, Chair Hickenlooper. Thank you, 
panelists, for your testimony today. I really appreciate your 
focus on this critical issue. Certainly what you have been 
discussing as a parent in the State of Wisconsin, in my 
discussions with health care leaders and advocacy groups for 
the health professions.

    One thing I want to hear thoughts about is it in terms of 
preparation, especially in nursing. We have an urgent nursing 
shortage in the State of Wisconsin, in hospital settings, in 
clinical settings, in nursing home settings.

    Although at the same time, there are eligible students who 
are turned away from potential training because of the shortage 
of nursing faculty. And the aging of that workforce only 
suggests it is going to get worse rather than better. I wonder 
if Dr. Flinter and Dr. Verret, if you could both speak to those 
issues as you see them.

    Ms. Flinter. Excuse me. Thank you for the question. I think 
it is multi factorial, right, in terms of the issue. Certainly 
of the aging of the nursing workforce, including faculty, maybe 
one that is also a compression, often in clinical training 
sites.

    That is part of why I think nationally, community health 
centers have really tried to step forward and say, remember, 
training in primary care is very critical for our ends as well 
and really stepped forward to welcome more students, and that 
is one way we contribute in that setting to it.

    Beyond that, we need to recognize that nursing is a broad 
profession, and that people may find their place where they can 
make the greatest contribution as faculty people, they may find 
it in private settings, they may find it in our safety net 
settings and to support people and having opportunities for 
really good preparation for those roles at the graduate level, 
as well as at the entry practice level.

    We have just initiated a program with universities in 
Connecticut to make sure that their fourth year students 
actually have a capstone experience in a high-performing 
community health center to remind them that is an option as 
well. And we need to emphasize all of those pathways, research, 
practice, education.

    Mr. Verret. I would just want to add--I would just want to 
add that also we have, as Dr. Flinter mentioned, there are many 
factors, the shortage on the number of nursing programs, 
faculty and all that drives the issue. But also the other 
factor is the pipeline of students.

    That we have--the number of barriers to students, 
especially our students who are of modest means, who are making 
decisions based upon, can I afford it? Can my family afford it? 
What is the impact and how we actually create pathways where 
the barriers are not as high to access those fields because 
there is a lot of talent in our second, third, fourth and fifth 
grades? But I don't think we have also all the talent that we 
have on the table as a Nation.

    Senator Baldwin. We have been talking a lot about primary 
care, but the complexity, Dr. Flinter, of primary care, it 
doesn't suggest necessarily a healthy population, etcetera. I 
have been focusing in on some of the urgent shortage issues, 
whether it is the infectious disease area of practice or the 
palliative and hospice care workforce or the perinatal 
workforce.

    I wonder if you can talk about why it is important to fully 
build out the workforce and training pipeline when we think 
about shortages in these areas. And then Dr. Verret, if you can 
speak to particularly the necessity for a diverse workforce in 
all of these areas, but I think so strongly about the perinatal 
workforce.

    I am involved in the Perinatal Workforce Act because even 
before the pandemic, black women in Wisconsin faced 
significantly higher rates of maternal complications and deaths 
than white women.

    The Perinatal Workforce Act, which I sponsored with my 
colleague, Congresswoman Gwen Moore, to improve access to 
maternity care and grow diversity of the perinatal workforce, 
it is--this is critical to addressing some of the staggering 
maternal health inequities that we face as a country. So if you 
could start, Dr. Flinter.

    Ms. Flinter. I will, and I want to thank you for your 
comments about the critical issue of maternal infant morbidity 
and mortality. And I want to tell you that is front and center, 
I think, of all of our efforts wherever we are. You know, when 
it comes to the specialties and the pipeline, every specialty 
is critical.

    You speak to your passion of speaking to primary care 
today. But we could not do what we do without those specialties 
when the time comes. I think the most effective thing we can do 
in primary care is to make sure that we are practicing to the 
maximum competence that we can within primary care and then 
sending on the people that really need that specialist.

    If I may, one innovation that has been proven to reduce 
costs overall and to increase access and improve outcomes, is 
something called an e-consult. And we are used to in safety net 
settings in particular, you would wait months, months to get an 
appointment with an endocrinologist, with an allergist of just 
about any kind.

    We developed a model, we call it e-consults now through a 
group called ComfortMed, where we can get, a primary care 
provider can get an excellent, in-depth consultation within 2 
days and decide. And then it turns out about 75 percent of the 
time they don't need to follow-up in person. They can give 
guidance to the primary care provider.

    That means there is room in that specialist practice to see 
the people who really need to be seen, and I think that is 
absolutely critical. I know others that may decide what those 
numbers are, how many in each specialty. We need the right care 
from the right people at the right time.

    I think that is part of avoiding the kind of excess cost 
that people talk about. You need to see the right person at the 
right time. HIV used to be a disease of specialists. We trained 
all of our primary care providers to be HIV specialists, just 
as an example.

    Mr. Verret. What I would add to the diversity question, why 
diversity? I would first begin by that it does create an 
essential element of trust in the health care system, that is a 
barrier. It is not so much about having a physician--it is not 
so much about having your physician as the someone of the same 
sex, race, ethnicity as you are.

    But the presence within the health care system of people 
who resemble you creates trust in the system and that is one 
social factor. And as we mention in medicine often, the social 
factors are as important as the technical and clinical factors 
as well.

    The other piece that I would say is that we have to 
actually understand that our most precious resource as a 
Nation, as any nation, are our children and the brains that 
they have, and that we have in the last 100 years that we have 
dependent upon assuming that we could rely upon only a fraction 
of the resource of our population for talent.

    We do know that there is genius that is available to us, 
whether it is in architecture, construction, in medicine, or in 
science or wherever. That by not educating students who 
actually can become and aspire to join us in many of the 
professions we need, teaching, nursing, medicine wherever, we 
are driving this workforce shortage that we have--the talent 
need.

    I would even elevate the talk to talk to a high question 
that if the U.S., like any nation, aspires to lead 
internationally, globally on any dimensions as economically, 
from a geopolitical point of view, it needs to have the brains 
that--it needs to cultivate its own brains. And that begins in 
K-through-12.

    We have to funnel them to whatever level of education 
allows for them to refine those skills. And that is where we 
are seeing in health care that we need that presence, but we 
need those numbers. Those numbers are scary because as you and 
I are all getting old, we will need care, and that care may not 
be there.

    Senator Hickenlooper. Thank you.

    Now, I will turn it over to Senator Tuberville.

    Senator Tuberville. Thank you, Mr. Chair. Thank you very 
much. Thanks for being here. I continue to hear from hospitals 
in my home State of Alabama that our nursing shortage has 
reached a State of emergency. We have so few nurses to go 
around that hospitals have resorted to contracting with nurse 
staffing agencies to fill empty slots.

    These agencies pair nurses who are willing to travel with 
hospitals facing large vacancies, and in many cases, they fill 
a very important need. I am concerned, however, that these 
agencies might be taking advantage of a very dangerous 
situation. They are able to charge a high percentage cut for 
their services, and hospitals have no choice but to pay their 
prices. It is huge in our State of Alabama.

    I want to be clear, nurses with the backbone of our health 
care system and they have been on the front line heroes, our 
frontline heroes throughout COVID-19 pandemic. Every nurse 
should have the right to take the high salary available. I do 
not want my question to be interpreted as undervaluing nurses 
worth in our health care system, but I am concerned, however, 
that these staffing agencies might be exploiting are already 
overwhelmed health care system.

    I would like for all four of you to say something about 
this briefly. This question is for everybody. What do we 
currently know about these agencies, and the cut they get from 
our lucrative contracts with struggling hospitals, and what can 
be done to address this issue?

    Ms. Greszler. I will start. I don't know a lot about the 
agencies themselves, but the fact that so many are going to 
those agencies and needing that, and two things there is just 
the burdens that are placed on the nurses and those burdens 
were increased because of COVID-19, and some of them were 
necessary, some of them weren't and a lot of underlying things 
before them were, and so how can we reduce the amount of time 
that nurses and the doctors need to spend on needless paperwork 
and regulatory burdens so that they can have more time to be 
treating patients.

    That effectively gives you more workers because it is more 
worker time. And then also just addressing the State laws so 
that you can, the demand can go where it is needed most, and we 
don't have those barriers that are needlessly preventing people 
from practicing where they should be.

    Senator Tuberville. Thank you.

    Ms. Quinones. I am sorry, I don't know enough about 
nursing. That is out of my scope where I work, so I have no 
comment.

    Senator Tuberville. Thank you.

    Mr. Verret. I too don't know much about the agencies, but I 
am aware of--but there is, we have effectively a shortage of 
nurses. And so there is a supply issue, but also clearly it is 
becoming a compensation issue for many of our hospitals as 
well, how we compensate them will be an issue. But clearly that 
problem has to do with basically a shortage of nurses that 
hospitals are competing among themselves for nurses, even 
within the same city.

    Senator Tuberville. Thank you.

    Ms. Flinter. Thank you, Senator. May I say I just had a 
chance to visit Cahaba Medical Care in Alabama and a nurse 
practitioner residency program. There, you all are doing a 
great job down there and meeting the needs of your rural 
population. You know, the travel agencies have always been with 
us, I think, for decades so this is not new. I think they 
fulfill a certain role most of the time.

    There is a portion of people who like that lifestyle. 
Wouldn't work for me as a nurse, but they like the lifestyle of 
traveling to different organizations, and they play probably a 
vital role when, not in COVID times in the same way, when there 
is a shortage of people in one area or another of a hospital. 
Where we have an issue, where I have an issue is when we are 
losing valuable experienced nurses from positions because that 
position is no longer attenable. And often that position is no 
longer attenable because it is been understaffed for a long 
time or under-resourced and people are just frustrated.

    I think the issue is to support our host organizations and 
making the environment for nursing practice, whether that is 
thinking about the patient workload so you can give safe care, 
the other people on team to make that organization a place that 
nurses want to commit to and stay. I don't think people lightly 
give up a satisfying practice as a nurse to do travel nursing. 
But I think the travel agencies also play some role on an 
ongoing basis. Again, COVID threw everything to the wind. State 
policy, I think, can sometimes aggravate or help this.

    I will say my State of Connecticut took broad action to 
credential a whole group of people is what they called Tier 2 
vaccinators during the COVID pandemic in order to not have to 
rely only on nurses or physicians, PAs to give vaccines.

    Our dentists, our dental hygienist, podiatrists were able 
to come and get trained and get an additional certification. So 
we need to, I think, always look at these things from a variety 
of perspectives. But the core is to make practice satisfying 
where nurses are in their communities, I think.

    Senator Tuberville. Thank you very much. Thank you.

    Senator Hickenlooper. That was an instructive row of 
answers to a good question. Now, and I am sure you are aware--I 
should have said this earlier. We do have this virtual hearing, 
it is a bilateral hearing, so we have now Senator Rosen from 
Nevada on virtual. So, she is next.

    Senator Rosen. Well, thank you, Chair Hickenlooper, and of 
course, Ranking Member Braun for holding this really important 
to me hearing today. And of course, the witnesses, for 
everything you do and for being here with us. And of course, it 
is so important that we lower those barriers for providers.

    We all know that because health care providers with 
advanced training, such as physicians or some of you just 
mentioned dentists, they have to complete residency trainings 
in order to care for patients. They often exit the training 
with significant student loan debt. The debt is made far worse 
by the fact that interest accrues while they are still in 
residency training. They are not actually in practice.

    That creates additional financial barriers for providers 
otherwise interested in serving patients in rural areas or 
underserved areas, of course, all across this country. All 17 
counties in Nevada, unfortunately, are designated as health 
professional shortage areas, and our health outcomes are 
especially likely to be worse among rural and minority 
residents than those in more urban centers.

    In order to improve health outcomes, to address our 
Nation's doctor shortage, we have to do more not only to 
encourage providers to serve in rural and underserved 
communities, but also to reduce those existing barriers. And 
that is why I am working on bipartisan legislation with Senator 
Boozman that would allow medical and dental residents interest 
free deferment on their student loans while serving medical, 
dental, internship or residency programs Dr. Flinter, someone 
who found America's first nurse practitioner residency program, 
how could pausing student loan interest accruing during 
residency help provide flexibility for providers who opt to 
serve patients in rural and underserved areas?

    What other incentives do you think the Federal Government 
should be looking at to make it easier for us to get the really 
good quality health care we need all across this Nation?

    Ms. Flinter. Well, thank you for that question. I will tell 
you that facing that mountain of debt, as you are coming into 
your residency program, those mandatory payments, is a daunting 
challenge for providers who are still in their training phase.

    I think that what you have proposed, Senator Rosen, pausing 
student loan interest accrual during residency is what I would 
call a very pragmatic, reasonable thing that probably makes a 
big difference for people. I think the issue is that debt 
influences people is choice of where they are going to 
practice, as you have used the example of the State of Nevada, 
so I think that is a very pragmatic and useful idea.

    I want to point out that is part of a constellation of 
strategies that we have here in the United States that all 
could be expanded to make it easier for people to tackle the 
training and then to choose the practice setting based on where 
they want to serve and where their passion is.

    I will tell you that when I was an undergraduate student 
earning my Bachelor's degree in nursing long time ago, I worked 
off my student loans through a Federal loan repayment program 
as a rural public health nurse.

    When I chose to go back to the school, to the Yale School 
of Nursing and become a nurse practitioner, I was fortunate 
enough to be taken into the National Health Service Corps, 
which had an obligated period of service afterwards. They sent 
me to what was then a small community health center that 
Senator Hickenlooper knows on Main Street in Middletown.

    I think 47 years of practice is a pretty good return on the 
Federal Government's investment in those loans. This is what we 
see in my own organization. There are many people with decades 
of experience who started in community health service in 
underserved areas because they had help from something like 
Federal loan repayment or the National Health Service Corps. So 
this would be one more tool, I think, in the toolkit to help 
people.

    Senator Rosen. Well, that is great, because I want to build 
on exactly this because we not only have this area of just in 
overall physicians and dentists, nurse practitioners, and the 
like.

    We have, especially in my State, shortage of certain 
medical specialties. And so we have our urban, our underserved 
communities, and particularly our rural, our far frontier 
communities, they have to go with that specialty care at all. 
And so I am currently working on some legislation to create a 
loan forgiveness program for specialists who care for patients 
in rural areas.

    Can you speak about maybe the challenges that primary care 
providers have in trying to bring specialists either in-person, 
maybe even virtually through telehealth? We have to ask people 
to refer them to. And what do you think we can do to help with 
that and just building on what you said before.

    Ms. Flinter. Great. Well, thank you. I think a few months 
ago, I addressed the issue of what we can do with e-consult 
access from primary care to specialists so that which can be 
done by primary care, often in consultation with the 
specialist, so not the specialists necessarily directly seeing 
the patient, is a very important piece of that.

    We have done the research on that. It is clear that is now 
becoming a national best practice. And the people seeing the 
specialist are the people who really need to see the 
specialists and others can be done in management between 
specialists and primary care providers. Telehealth has 
certainly been a huge benefit to us, I think we would say.

    It certainly is true of rural areas, but even in urban 
areas, I think we have all seen how difficult it can be to 
connect primary care providers and specialists. And how much 
additional double work you can eliminate if you can connect 
with people virtually as opposed to in-person. But beyond that, 
we need the training programs. We need the training programs 
for our specialists.

    They should have experience in caring for people in rural 
and underserved communities and for care and for all 
populations. One of the things that we know about training, and 
I think Dr. Verret would agree with me, that where you train 
has an awful lot to do with where you practice. If you can even 
have a part of your training experience in a rural area, in 
underserved communities with underserved populations, there is 
a much greater chance, I think we call it imprinting, and you 
are continuing to care for that population and remaining in 
that area.

    Like everything we are talking about today, there is not 
one strategy that is an answer. There are multiple strategies, 
and we need to embrace all of them. Technically, in terms of 
training, in terms of financial support for trainees, and in 
making sure that we get the right people to the right kind of 
provider at the right time.

    Senator Rosen. Well, I couldn't agree more. Addressing the 
medical workforce shortage across the spectrum, having a broad, 
good strong broadband base to potentiate care through 
telehealth and qualified professionals all along the way, all 
of it makes a difference.

    All of that matters, and I am trying to work on and getting 
us all there. So appreciate you all for being here today. Thank 
you, Mr. Chair. I see my time is up.

    Ms. Flinter. Thank you.

    Senator Hickenlooper. Thank you, Senator Rosen.

    Senator Cassidy.

    Senator Cassidy. Yes. Dr. Flinter, you call it imprinting, 
I call it marrying a local.

    [Laughter.]

    Ms. Flinter. That works, too, I guess.

    Senator Cassidy. As a man, it is my observation that men 
live where either Uncle Sam or the wife tells them to, and so 
that is mine. I rarely start off with a personal anecdote, but 
I am today because it is something that is so powerful in my 
experience, in my professional life. As many of you may know, I 
am a physician who works in a public hospital for the uninsured 
for over 25 years or about 25 years.

    There is a woman who happened to be African-American. Her 
nickname was Olive. She started off as an LPN, or maybe even a 
medical assistant, went back to school, single mom, went back 
to school part time, became, say the LPN. Went back to school 
and continued to education and became an RN. Kept going back to 
school and then got her master is in nursing. And when the 
nurse supervisor of the clinic retired Olive took her place.

    Now one, it is a great success story for her personally, 
but it demonstrates to her children and a community the power 
of education, aside from giving us a crackerjack nursing 
supervisor. And so although I have not seen Olive since her 
hospital was literally blown up, that is the kind of facility 
it was, you just discarded it, she did an incredible job taking 
care of patients who otherwise would not have received such 
good care.

    That said, I am heartily in favor of creating this 
opportunity for folks who perhaps would be the first in their 
family, first generation in their family to go to school. But 
there is other issues that separate. Dr. Verret, I am the 
author of the John Lewis National Institute for Minority 
Health, Research and Endowment Revitalization Act that would 
revitalize the Research and Endowment Program or the REP at the 
National Institute on Minority Health and Health Disparities.

    The REP was established to assist minority serving 
institutions with low endowments to develop institutional 
capacity to successfully compete for NIH funding with their 
well-endowed, non-minority school counterparts. Now, Xavier 
College of Pharmacy has been a beneficiary of this program.

    Can you talk about the challenges that universities like 
Xavier face in trying to be more competitive for Federal 
research dollars, and why revitalizing this program would be 
important to Xavier, to others, and to our nation?

    Mr. Verret. Well, that endowment program, I think which was 
paused some years ago, as for schools like Xavier, is the 
resource by which we build out the quality--bring the quality 
of faculty that our students need to encounter, but also 
facilities and in order to be competitive as research----

    Senator Cassidy. So the facilities are as important as the 
faculty?

    Mr. Verret. As important as the faculty. Because one needs 
laboratories. One needs the equipment. For example, as was 
mentioned of putting a testing facility for HIV means that you 
have to have the thermal cyclers. But that the equipment and 
also--and the faculty.

    That is faculty, for example, who are researchers in a 
variety of areas, have to be able to set up laboratories or 
their computer systems for the work they do. So that one needs 
to be able to compete and place those faculty with those 
students. And also understanding that the research that we do 
at schools like Xavier is not separate from the instructional 
program.

    Our students enter as researchers with faculty in their 
research programs early as undergraduates in their second year. 
Likewise, it is about doing the practicing on the discipline. 
Our students do not only learn as biologists or learn as 
chemists, they become--they do chemistry the same way they do 
history, the way our musicians do music as well.

    That research--because that is different between the 
higher-ed and what we call secondary school.

    Senator Cassidy. I think it is safe to say the role model 
of somebody who is successfully doing research can inspire. I 
have a professor that inspired me to become a hepatology, just 
a liver specialist, because of a couple of them. Between the 
two of them, they were so remarkable, I wanted to be like them.

    Mr. Verret. One becomes a junior colleague, as a 
researcher. And so that experience, and also it readies them 
for whether they go into professional school or whether they go 
into a PhD program. It is amazing that some of these students 
were actually following into the MDP speed track also.

    Our pharmacy students also who are pharmacists who are not 
only going into the retail sector as was traditional for many 
pharmacists, who are taking the higher status of the pharm D 
and becoming part of the clinical sector or managing the 
therapeutics or the chemotherapy programs in some hospitals.

    They are being taught to practice at the highest level of 
their license.

    Senator Cassidy. Yes. And of course, been a springboard. I 
mentioned to you earlier, a family friend, Dr. Holden, 
originally went to Xavier Pharmacy School from Missouri, but 
that was when educational opportunity was not available for 
African-Americans. And after going to Xavier Pharmacy School, I 
went to DO school in California and practiced in California, a 
large pediatric practice in South Central, L.A., and changed a 
lot of lives that way. Thank you for your mission. I yield.

    Senator Hickenlooper. Thank you, Senator Cassidy. I think 
we have time to--we are going to, Senator Braun is going to be 
back in the second to do a, let's call it a lightning round. 
No, I guess that is inappropriate. But I do, I think we do have 
a few more questions. Ms. Quinones, I was going to ask the 
projections we have been hearing from everybody about the 
critical need to start growing our health care workforce, 
yesterday.

    Obviously, the key there is to do it now, and we need to 
make it easier for those who don't have any experience to break 
into the field instead of creating barriers and making it 
possible to expand the workforce. We have heard a variety of 
people mention that over this last hour and a half. So you have 
unique experience because you came in as an entry level 
assistant in Clinica, to kind of begin your career in nursing.

    What were some of your experiences and what are some things 
you think might be applicable, could be useful to other 
institutions, other health care providers that are looking to 
expand their workforce and provide, become a conduit for people 
coming into the profession?

    Ms. Quinones. Yes, thank you for the question. So one of 
the unique situations at Clinica is that I recruit within our 
organization, because No. 1, somebody already has made the 
decision that this employee is a fit for Clinica. And the other 
thing that we focus on is development and growth within our 
system. And so we recruit within Clinica, go through the 
process of the NIMAA program, and I facilitate and coach them 
and be a--how do I want to say, a connection between Clinica 
and NIMAA.

    This is the way that we really grow our own. They are 
already--they are already in the system, they know our culture, 
they know our mission. And so we have found out through other 
conversation is that this model really works for us because the 
commitment is already there from our staff.

    They go through their training and upon graduation--they 
are already trained, I would say greater than 85 percent. So as 
soon as they graduate, they pass their MA exam, they are ready 
to start working as soon as they complete the 8 month program 
through NIMAA. And so that is a huge benefit for our MA staff 
and nursing staff as well, because one thing that we encourage 
at Clinica is to work at the top of your license.

    This is a way that the medical assistants that have been 
working with Clinica for a while can support providers, nurses, 
and continue on.

    Senator Hickenlooper. Interesting. Interesting. Dr. Verret, 
you mentioned a little bit about the reaching out to high 
school students in the summer--was it Summer Science Academy, 
the Xavier Summer Science Academy, it is five 500 kids, to 
participate in, it sounds like a cross-section of sciences, 
biology, and math, yes let's call it STEM. How do you get, how 
do you reach out to find those students in the high school 
network? Are they from--all from within Louisiana or are they 
from around the country?

    Mr. Verret. The majority are from within Louisiana, but 
some come from around the country, a significant number, 
because we have a long history. The graduates of the program to 
a high number of go on to college. Many of them do not go to 
Xavier, but they go to other colleges, to us a success. It is 
what I call our external mission.

    Funding that has been a challenge because we fund that on 
dollars that we have all from foundation dollars when we can. 
But because those are not accessible through any funding 
program that we normally have. That is one pipeline of getting 
students early in their education to consider the science and 
to be exposed to that.

    We also--what we also do is even weekend academies. For 
example, the robotics academy that is done, a work that is done 
on weekends, is one way of capturing the imagination of young 
people. I like to make the point that, if we remember that for 
science and health, it is not like music that students develop, 
discover their passions very early in life before high school, 
or they are not musicians or decided great musicians at the age 
of 18 or 19.

    I say the same for sciences and also clinicians as well. So 
catching them even before high school is fundamental so that it 
is about getting that imagination and seeing that I can be, and 
this is a possible pathway. Role models are important. Seeing 
older students who are not only maybe three or 4 years older or 
and at it is important.

    That is--especially given if you are coming from families 
when college is a new thing, that no one in this family has 
ever attended college, which is a large--we are, in our 
campuses, it is in the high 30, 40, 50 percent of students.

    Senator Hickenlooper. Wow, that is amazing. Alright. So 
thank you.

    With that, I will turn it over to Senator Braun.

    Senator Braun. Thank you, Mr. Chairman. I am going to 
circle back to the structure of the industry again, and my 
question is going to be for Dr. Flinter. Years ago, we had a 
lot more hospitals, especially in rural areas. Currently, when 
you look at the health care dollar, 30 percent give or take 
hospitals, 30 percent give or take practitioners, 15 to 20 
percent pharma and then insurance.

    As these stakeholder that pays all the bills in the 
country, meaning any company that does not, is other than a 
health care company, it would be the rest of us employers. And 
in the transparency issue, even when you can self-insure, has 
been challenging.

    The other thing is you have fewer options. You get fewer 
and fewer hospitals that control a lot of these markets and 
even fewer insurance companies. Getting workforce into the 
nursing side of it, how difficult is it now when it comes to 
the fact that you end up, unless you have a clinic or you are 
doing your own thing, which oftentimes are rules and 
regulations don't make that as easy it should be, how difficult 
is it to be a nurse practitioner, not only with the training 
and the cost of that you are talking about, but in terms of the 
new structure with the fact that you are working for a 
hospital.

    Doctors complain about that often. They used to have their 
own businesses. Would you want to comment on that a little bit?

    Ms. Flinter. Sure. Well, thanks for the opportunity. And it 
is actually something I have been thinking about quite a bit 
recently, in part because there is a whole area within nurse 
practitioner practice of nurse practitioners who are going into 
entrepreneurial practice on their own, and there is a network 
set up to support them.

    What it reminded me is, and there probably is a right place 
for everybody, right. For me, the right place is a structure 
like a community health center. Takes all comers regardless of 
insurance, comprehensive care. There is a tradeoff around how 
much you do individually and how much is organizational policy, 
but if the organizational policies line up in the direction of 
the values that it should, that is a plus, not a minus for me.

    For other people, being an independent entrepreneur or a 
group nurse practitioner practice, for instance, is the right 
structure for them. I think people really have to think very 
critically about their employer, and the right employer is an 
employer who lines up with your mission, vision, and values for 
your own career.

    I think people are becoming much more savvy about the kind 
of people, the kind of organization, the kind of structure that 
they want to practice in, and employers beware. No matter how 
big your health system is, you cannot run it without expert 
people to care for the patients in it. The emerging legislation 
around transparency and billing, about no surprise billing--we 
are in community health centers, our patients are the most 
savvy consumers of all because they are often paying out of 
pocket as people who are fully uninsured.

    This is just a part of a fairer economy in which we make it 
clear what those prices are. We make sure that people 
understand what the deal is, and I think that is true for the 
people who work in them, as well as the people who receive 
care.

    Senator Braun. Thank you. Next question for Ms. Greszler. 
Indiana visited last week, and I was shocked that it was only 
the second one in the U.S., the other one is in Oklahoma City, 
and this is a group of surgeons that didn't like the idea that 
their only employment opportunity is now for a huge 
corporation. They had a vision of having their own shingle hung 
out there and increasingly difficult to do. Here is what caught 
me.

    They are going to be a cash only surgical outpatient 
center. I said, what about inpatient? Oh, there are so many 
regulations. If doctors wanting to do that, you couldn't even 
get the first base. Listen to this on a gallbladder operation, 
in Indiana, to negotiated rate between insurance companies and 
hospitals, $22,000.

    If you come into the system and you just need it, you have 
no insurance, $32,000. They will do it for $8,000. And that is 
going to be the same proportionality on a lot of other surgical 
procedures. That is entrepreneurism. That is what we have got 
to do before we start spending more Federal dollars in terms of 
fixing the system.

    What do you think when it comes to that kind of breaking 
the system apart, how important is that to fix health care in 
general?

    Ms. Greszler. I think that is extremely important because 
as far as I know, the studies have shown that those smaller 
practices actually have better outcomes. And there is a lot of 
broken parts of the health care market, but this is one of them 
where the prices that are charged don't necessarily reflect the 
services that were provided, the outcome of those services, the 
amount of time, but they instead reflect insurance codes that 
they are allowed to bill.

    It is in many ways broken. One thing that could be done is 
the Federal Government has a lot of programs, they are in 
charge of payment rates there, to allow for some innovation and 
flexibility in those ones. We have seen that doctors and other 
practitioners, they want to move toward having more autonomy 
and not just having to go by the books of what they are told 
they can charge and what services they can and can't provide.

    But just being free to practice is, others are in the 
private sector not encumbered by all these burdens that are 
imposed on the health care sector.

    Senator Braun. I think it is a good point. Yours as well. I 
view practitioners and doctors about the same way as farmers in 
big Ag. It is so much different from what it used to be. And 
whenever we get industries that get too concentrated, the 
consumer never ends up being in the best place.

    Senator Hickenlooper. On that note, although I think 
Senator Braun and I could probably spend the next couple of 
hours asking you questions, but I suspect you have other 
schedules, other things in your schedule. So I guess I will end 
our hearing for today. Let me just thank you all, Dr. Flitter, 
Ms. Quinones, Dr. Verret, Ms. Greszler.

    I can't remember a more interesting panel and with such 
clear translation of your experiences in your lives into, I 
think, really valuable testimony that we will take going 
forward.

    If there are other Senators who are watching at home and 
have questions or watching from their office, I shouldn't make 
jokes about virtual hearings, questions for the record will be 
due in 10 business days, so that is on February 24th at 5 p.m.

    The hearing record will also remain open until then for 
Members who wish to submit additional materials for the record. 
The HELP Committee will next meet, well actually shortly, in 
room S-127 at noon to mark up several pending nominations, and 
then again on Tuesday, February 15th at 10 a.m. for a hearing 
on supporting quality workforce development opportunities and 
innovation to address barriers to employment.

    Thank you again for all your excellent work today. We stand 
adjourned.

                          ADDITIONAL MATERIAL

                     american ambulance association
    Chairman Hickenlooper, Ranking Member Braun, and Members of the 
Subcommittee on Employment and Workplace Safety, the American Ambulance 
Association (AAA) commends the Subcommittee for holding this critical 
hearing on healthcare workforce shortage issues. Our country's 
emergency medical services (EMS) system is facing crippling staffing 
challenges that threaten the provision of crucial emergency healthcare 
services at a time of maximum need. As we face a pandemic that waxes 
and wanes but does not end, our 9-1-1 infrastructure is at risk due to 
these severe workforce shortages. The Congress must act if we are to 
prevent vital ground ambulance services from disappearing in rural and 
underserved urban areas and from the country as a whole, which is 
experiencing longer and longer wait times for 9-1-1 services. We 
outline some potential congressional actions to address this crisis 
below.

    The AAA is the primary association for ground ambulance service 
suppliers/providers, including private for-profit, private not-for-
profit, governmental entities, volunteer services, and hospital-based 
ambulance services. Our members provide emergency and non-emergency 
medical transportation services to more than 75 percent of the U.S. 
population. AAA members serve patients in all 50 states and provide 
services in urban, rural, and super-rural areas.

    Our paramedics and emergency medical technicians (EMTs), as well as 
the organizations they serve, take on substantial risk every day to 
treat and transport patients who call 9-1-1. Our industry's crippling 
workforce shortage is a long-term problem that has been building for 
over a decade. It threatens to undermine our emergency 9-1-1 
infrastructure and deserves urgent attention by the Congress.

    The most sweeping survey of its kind--involving nearly 20,000 
employees working at 258 EMS organizations--found that overall turnover 
among paramedics and EMTs ranges from 20 to 30 percent annually. With 
percentages that high, ambulance services face 100 percent turnover 
within a 4-year period. Staffing shortages compromise our ability to 
respond to healthcare emergencies, especially in rural and underserved 
parts of the country.

    The pandemic exacerbated this shortage and highlighted our need to 
better understand the drivers of workforce turnover. There are many 
factors. Chief among them is inadequate reimbursement by governmental 
payers. We must have a reimbursement system that matches payments with 
the costs of providing services and allows us to increase wages as 
competition for personnel intensifies.

    Our ambulance crews are suffering under the grind of surging demand 
and burnout. In addition, with COVID-19 interrupting clinical and in-
person training for long periods of time, our training pipeline has 
been stretched even thinner. The challenge is to make sure that the 
paramedics and EMTs of the future know that EMS is a rewarding 
destination. Many other healthcare providers have extensive 
governmental professional development resources, but that simply often 
does not exist for EMS.

    One of the most critical gaps in an adequate pipeline of trained 
EMS personnel results from the fact that many existing Federal training 
programs and other forms of assistance are not eligible for 
nongovernmental or for-profit ambulance service providers. We believe 
that all providers, regardless of organizational form, should have 
access to the full range of Federal and state training and retention 
resources that are available.

    The following potential congressional actions would help mitigate 
the current workforce shortage by expanding and strengthening the EMS 
workforce:

          Provide eligibility during the current public health 
        emergency and for at least 2 years thereafter for first 
        responder training and staffing grant programs administered by 
        the U.S. Department of Health and Human Services (HHS) such as 
        SAMHSA Rural EMS Training Grants and HHS Occupational Safety 
        and Health Training Project Grants to for-profit entities.

          Authorize the establishment of a new HHS grant 
        program open to public and private nonprofit and for-profit 
        ambulance service providers to fund paramedic and EMT 
        recruitment and training, including employee education and 
        peer-support programming to reduce and prevent suicide, 
        burnout, mental health conditions and substance use disorders.

          Provide tax credits to companies for employee 
        education loan repayment assistance, provisions which would 
        encourage training and retention of personnel who are often 
        recruited by other healthcare providers.

          Implement minority and low-income recruitment 
        programs. The AAA is committed to increasing diversity in the 
        ground ambulance service workforce. We are the healthcare 
        sector with the lowest barrier to entry, given our shorter 
        training periods. We are supportive of provisions currently 
        pending in this Congress, such as the Health Professions 
        Opportunity Grants, which would provide increased access to 
        training opportunities.

          Reduce barriers that prevent veterans from becoming 
        certified as paramedics/EMTs. The military has a highly trained 
        EMS workforce, but bureaucratic red tape, particularly in the 
        state certification process, can make the transition cumbersome 
        and time-consuming.

          Access unused visas for EMS-trained individuals.

                               Conclusion
    The AAA thanks you for your time and attention to the critical 
healthcare workforce shortages facing our Nation today. We stand ready 
to work with Subcommittee Members and staff to develop workable 
solutions to strengthen the vital ground ambulance service workforce. 
The crisis is real. Desperately needed rural and urban services are 
closing weekly and many more are at risk in areas of the country where 
EMS is often the sole provider of after-hours healthcare services.
                                 ______
                                 
                     American Ambulance Association
                                       Washington, DC 20090
                                                  February 10, 2022
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Dear Chairman Hickenlooper and Ranking Member Braun:

    On behalf of the American College of Emergency Physicians (ACEP) 
and our 40,000 emergency physicians, and the Emergency Medicine 
Residents' Association (EMRA) and our 17,000 members, thank you for 
your attention to the issue of health care workforce shortages and 
efforts to improve recruitment and to revitalize and diversify the 
health care workforce. The health professions, especially those on the 
front lines of the pandemic response, have been strained like never 
before, and the underlying workforce challenges that existed even 
before the COVID-19 pandemic have been exacerbated by the overwhelming 
and prolonged effects of and response to this disease. Physicians, 
nurses, and other essential health care workers have tirelessly given 
their all--often at great personal cost--to provide high-quality care 
during this unprecedented public health crisis, and dedicated efforts 
are needed to rebuild and maintain the health and well-being of the 
individuals who provide our health care safety net.

    Workforce shortages are especially pronounced in rural and 
underserved areas throughout the country, and numerous barriers to 
providing equitable care in these communities persist. Among these are 
the inability to recruit qualified and sufficiently experienced, 
educated, and trained physicians, nurses, ancillary support staff, and 
other health care providers. Despite a 28 percent increase in emergency 
medicine residency positions over the past 10 years, there has been no 
corresponding increase in emergency medicine residency trained or 
emergency medicine board certified physicians working in rural EDs. 
This is a complex problem due to a variety of factors, including 
limited opportunities for exposure to these communities during 
residency training, fewer full time employment opportunities overall 
due to ED staffing requirements and continued rural facility closures, 
a lack of recruitment tools and incentives such as those provided for 
primary care professions, among many others. Additionally, rural EDs, 
compared to their urban counterparts, are resource limited, financially 
stressed, and experience higher interfacility transfer rates. And while 
the COVID-19 pandemic has increased the use of telehealth, rural areas 
still suffer from inconsistent availability of telehealth access and 
structural challenges like limited/nonexistent broadband access. 
Transportation issues also limit many individuals' ability to reach 
hospitals, and emergency medical services (EMS) in rural areas also 
experience significant transportation delays due to issues with crew 
availability.

    We hope the Committee's examination of current health care 
workforce shortages will include a focus on the ongoing nursing 
shortages and the recent practices of nurse staffing agencies that have 
resulted in exorbitant increases in costs to already-strained health 
care systems. The extreme physical and mental toll of the COVID-19 
pandemic response has inflicted enormous trauma and stress on 
physicians and nurses, resulting in increased burnout and 
dissatisfaction for those on the front lines and greater attrition in 
the health care workforce. This has left many health systems desperate 
to fill workforce gaps by relying on nurse staffing agencies, some of 
whom have imposed extreme rate hikes to supply travel nurses to 
hospitals.

    Especially during the Omicron wave when hospitals have tried to 
continue providing care for COVID-19 patients and other conditions 
requiring hospitalization, facilities have been left with no other 
choice than to pay substantially inflated rates in their attempts to 
maintain staffing levels capable of meeting their community's needs. We 
appreciate the recent attention to this issue raised by some in 
Congress and other health care stakeholders and encourage continued 
investigation and oversight of potentially anticompetitive practices 
occurring in the health care workplace.

    Such shortages also greatly exacerbate the issue of crowding and ED 
``boarding,'' a scenario where patients are 1kept in the ED for 
extended periods of time due to a lack of available inpatient beds or 
space in other facilities where the patient can be transferred. 
Empirical studies have shown boarding contributes to worse patient 
outcomes and increased mortality related to downstream delays of 
treatment for both high-and low-acuity patients. In addition to 
disrupting the ED workflow and creating operational inefficiencies, it 
often also creates additional dangers, such as ambulance diversion, 
increased adverse events, preventable medical errors, more walkouts by 
patients, lower patient satisfaction, violent episodes in the ED, and 
higher overall health costs. Solving ED boarding is not an isolated 
emergency department issue but rather a hospital-wide imperative.

    Reducing boarding and mitigating its effects on all patients is 
critical in improving patient outcomes and their overall health, 
especially for those with mental or behavioral health needs. ED 
boarding challenges disproportionately affect patients with behavioral 
health needs who wait on average three times longer than medical 
patients because of these significant gaps in our health care system. 
Some research has shown that 75 percent of psychiatric emergency 
patients, if promptly evaluated and treated in an appropriate 
location--away from the active and disruptive ED setting--have their 
symptoms resolve to the point they can be discharged in less than 24 
hours, further highlighting the need to provide timely, efficient, and 
appropriate mental healthcare.

    Many emergency physicians report that given ongoing shortages and 
the influx of patients (both COVID-and non-COVID-related) that ED 
boarding is at an all-time high. Adding to this challenge is the fact 
that EDs are also not subject to the same staffing ratio requirements 
as other parts of the hospital often are, and as a result, the ED too 
often becomes the only place in which to keep many patients. While we 
have shared ideas and suggestions with legislators and regulators to 
provide both short-and long-term solutions to reduce ED boarding (such 
as regulatory waivers and flexibility around documentation requirements 
that contribute to burnout among nurses), more fundamental efforts to 
address the root causes of nursing and physician shortages are needed 
to ensure patients have timely access to care.

    Finally, as you work to address these challenges, ACEP and EMRA 
urge Congress to ensure that American patients have access to high-
quality lifesaving emergency care. We believe the gold standard for 
care in an emergency department (ED) is via a physician-led emergency 
care team, with that care performed or supervised by a board-certified/
board-eligible emergency physician. Physician Assistants (PAs) and 
nurse practitioners (NPs) can and do serve integral roles as members of 
the emergency care team, but do not replace the medical expertise 
provided by emergency physicians. The physician-led emergency care team 
is the safest care model for our patients and particularly important 
for Medicare beneficiaries, who are some of the most medically 
vulnerable patients in our population, often suffering from multiple 
chronic conditions or other complex medical needs and account for 
nearly 20 percent of ED encounters each year.

    Supporting physician-led health care teams is also aligned with 
most state scope of practice laws. For example, over 40 states require 
physician supervision of or collaboration with PAs. Most states require 
physician supervision of or collaboration with nurse anesthetists, and 
35 states require some physician supervision of or collaboration with 
nurse practitioners, including populous states like California, 
Florida, New York and Texas. These states represent more than 85 
percent of the U.S. population. Moreover, despite multiple attempts, in 
the last 5 years no state has enacted legislation to allow nurse 
practitioners full-immediate independent practice.

    Some have proposed expanding the scope of practice of nonphysician 
professionals in order to increase access to care, especially in rural 
and underserved communities. However, in reviewing the actual practice 
locations of nurse practitioners and primary care physicians, it is 
clear nurse practitioners and primary care physicians tend to work in 
the same large urban areas. There remain significant shortages of nurse 
practitioners in rural areas--the very problem with physician access 
that scope expansion has sought to address. This occurs regardless of 
the level of autonomy granted to nurse practitioners at the state 
level. We believe that the ongoing challenges in recruiting and 
retaining all levels of health care professionals in rural and 
underserved areas are more complex, and that this persistent issue 
requires more innovative solutions to incentivize physicians and other 
health care professionals to work in these communities. We would 
welcome the opportunity to work with you and your colleagues to find 
more effective and durable solutions to these longstanding workforce 
challenges to ensure that Americans in rural and underserved areas have 
access to high-quality emergency care, recognizing the level of 
expertise and training required for independent practice of emergency 
medicine and supporting the provision of physician-led team-based care.

    Once again, we are grateful for the opportunity to share these 
comments with you and appreciate your attention to the ongoing 
workforce challenges facing health care professionals, especially in 
light of the continued response to the COVID-19 pandemic. ACEP and EMRA 
stand ready to work with you and your colleagues to respond to these 
challenges and ensure that all Americans have access to the high-
quality health care they need and deserve.
            Sincerely,
                                           Gillian Schmitz,
                                                    ACEP President.
                                             Angela G. Cai,
                                                    EMRA President.
                                 ______
                                 
                     american hospital association
    On behalf of our nearly 5,000 member hospitals, health systems and 
other health care organizations, our clinician partners--including more 
than 270,000 affiliated physicians, 2 million nurses and other 
caregivers--and the 43,000 health care leaders who belong to our 
professional membership groups, the American Hospital Association (AHA) 
appreciates the opportunity to submit this statement for the record as 
the Subcommittee on Employment and Workplace Safety of the Committee on 
Health, Education, Labor and Pensions examines America's health care 
workforce shortage.

    As America enters the third year of the COVID-19 pandemic, health 
care providers are confronting a landscape deeply altered by its 
effects. As of Feb. 10, 2022, there have been approximately 80 million 
COVID-19 cases and over 900,000 deaths in the U.S., with nearly 30 
million cases and approximately 110,000 deaths in just the last 2 
months.

    Our nation's hospital and health system workers have been on the 
front lines of this crisis since the outset, caring for millions of 
patients, including nearly 4.4 million patients hospitalized with 
COVID-19. During this time, hospitals have continued to face a range of 
pressures, with workforce-related challenges among those most critical.

    Though managing workforce pressures were a challenge for hospitals 
even before the pandemic, these challenges have only grown more acute. 
The incredible physical and emotional toll that hospital workers have 
endured in caring for patients during the pandemic has, among other 
issues, exacerbated the shortage of hospital workers. This shortage has 
become so critical that some states and the Federal Government have 
deployed military and National Guard resources to help mitigate 
staffing challenges at some hospitals. As this shortage has worsened 
and COVID-19 hospitalizations have reached record levels, labor costs 
for hospitals have increased dramatically. This combination of factors 
has been exploited by travel staffing companies and other firms that 
provide contract labor resources, driving up workforce costs even more 
for hospitals. Hospitals also have incurred significant costs in 
recruiting and retaining staff, which have included overtime pay, bonus 
pay and other incentives. This is occurring at a time when many 
hospitals and health systems are still facing other immense financial 
constraints. For many hospitals around the country this has led to an 
unsustainable situation that threatens their ability to care for the 
patients and communities they serve.
                    Health Care Workforce Shortages
    Hospitals are facing a critical shortage of workers. Approximately, 
1,130 hospitals or 27 percent of hospitals that reported data on 
staffing to the Federal Government indicated that they were 
anticipating a critical staffing shortage within the week of Feb. 8. 
Further, 15 states had 33 percent or more of their hospitals reporting 
a critical staffing shortage.

    Nurses, who are critical members of the patient care team, are one 
of the many health care professions that are currently in shortage. In 
fact, a study found that the nurse turnover rate was 18.7 percent in 
2020, illustrating the magnitude of the issue facing hospitals and 
their ability to maintain nursing staff. The same study also found that 
35.8 percent of hospitals reported a nurse vacancy rate of greater than 
10 percent, which is up from 23.7 percent of hospitals prior to the 
pandemic. In fact, two-thirds of hospitals currently have a nurse 
vacancy rate of 7.5 percent or more.

    Almost every hospital in the country has been forced to hire 
temporary contract staff to maintain operations at some point during 
the pandemic. According to a survey by AMN Healthcare, 95 percent of 
health care facilities reported hiring staff from contract labor firms, 
with respiratory therapists being the primary need for many hospitals 
and a critical team member necessary for COVID-19 patient care.

    As hospitals have looked to bring in more staff, job postings for 
both clinical and non-clinical staff have increased from pre-pandemic 
levels. Based on data from Liquid Compass analyzed by Prolucent Health, 
job postings for clinical staff have increased by 45 percent for nurses 
and 41 percent for other allied clinical staff between January 2020 and 
January 2022. At the same time, non-clinical staff such as 
environmental service and facilities workers, who play in important 
role in maintaining hospital operations, have seen job postings 
increase nearly 40 percent.

    Hospitals were already spending more money on contract labor even 
before the latest COVID-19 surge. According to a Definitive Healthcare 
study, contract labor expenses for hospitals have more than doubled 
over the last decade. However, the prices charged by contract labor 
firms during the pandemic have become exorbitant as supply is scarce 
and demand is at an all-time high. For example, average pay for 
hospital contract nurses has more than doubled compared to pre-pandemic 
levels. According to Prolucent Health, there has been a 67 percent 
increase in the advertised pay rate for travel nurses from January 2020 
to January 2022, and hospitals are billed an additional 28 percent-32 
percent over those pay rates by staffing firms. In fact, in some areas 
pay rates for travel nurses have been as high as $240/hour or more, 
which have contributed to the dramatic increase in hospitals' labor 
costs. Labor expenses are up 12.6 percent on an absolute basis, and 
19.1 percent on a per patient basis compared to levels in 2019.

    With COVID-19 hospitalizations reaching record highs, the staffing 
crisis currently plaguing our Nation's hospitals is only expected to 
worsen. In 2017, more than half of nurses were age 50 and older, and 
almost 30 percent were age 60 and older. According to Bureau of Labor 
Statistics data, it is anticipated that 500,000 nurses will leave the 
workforce in 2022, bringing the overall shortage to 1.1 million nurses. 
And due to significant shortages of faculty, classroom space and 
clinical training sites, nursing schools actually had to turn away more 
than 80,000 qualified applicants in 2019. These data highlight the need 
to develop and implement longer-term solutions to avoid the further 
deepening of this crisis, which includes investing in more 
opportunities and slots for health care workers in the pipeline.
                        Supporting the Workforce
    Because our workforce is our most precious resource, hospitals and 
health systems are committed to supporting them. That's why we've 
created programs and developed resources to promote caregiver well-
being and resiliency. Examples include helping to pay back student 
loans, providing child care and transportation, offering tuition 
reimbursement and training benefits, providing referral and retention 
bonuses, and supporting programs that address mental and physical 
health.

    Hospitals also are developing new team-based care models that allow 
health care workers from various disciplines and specialties to provide 
customized, patient-centered care. This allows them to manage medical 
and social needs across all settings to improve care and enhance 
professional satisfaction.

    For example, in Virginia, Mary Washington Healthcare collaborated 
with a local community college on a clinical education model allowing 
student nurses to support the current nurse workforce before they had 
graduated, addressing the critical demand for more nurses. In 
Pennsylvania, Geisinger provides $40,000 in financial support each year 
for up to 175 employees who want to pursue a nursing career and make a 
5-year work commitment as an inpatient nurse. And in Maine, Northern 
Light Maine Coast Hospital invites financial support from the local 
community to help underwrite the cost of programs to train future 
nurses and medical assistants and alleviate a crucial shortage of these 
professionals.
                            Policy Solutions
    Our workforce challenges are a national emergency that demand 
immediate attention from all levels of government and workable 
solutions. These include recruiting, revitalizing and diversifying the 
health care workforce by:

          Lifting the cap on Medicare-funded physician 
        residencies;

          Boosting support for nursing schools and faculty;

          Providing scholarships and loan forgiveness;

          Expediting visas for all highly trained foreign 
        health care workers;

          Disbursing any remaining funds in the Provider Relief 
        Fund, as well as replenishing the fund to help providers cope 
        with increased staffing costs;

          Investigating reports of anticompetitive behavior 
        from nurse-staffing agencies during the pandemic that is 
        further exacerbating critical workforce shortages;

          Pursuing visa relief for foreign-trained nurses; and

          Supporting the health of physicians, nurses and 
        others so they can deliver safe and high-quality care by 
        providing additional funding and flexibility to address 
        behavioral health needs and funding for best practices to 
        prevent burnout.

    We urge Congress to enact the Lorna Breen Health Care Provider 
Protection Act, which would direct resources to reduce and prevent 
health care professionals' suicides, burnout and behavioral health 
disorders. This bipartisan, bicameral legislation would authorize 
grants to health care providers to establish programs that offer 
behavioral health services for front-line workers, and require the 
Department of Health and Human Services (HHS) to study and develop 
recommendations on strategies to address provider burnout and 
facilitate resiliency. The bill also would direct the Centers for 
Disease Control and Prevention to launch a campaign encouraging health 
care workers to seek assistance when needed.

    In addition, we must support state efforts to expand scope of 
practice laws to allow health care professionals to practice at the top 
of their license. Congress also should increase funding for the Health 
Resources and Services Administration's Title VII and VIII programs, 
including the health professions program, the National Health Service 
Corps, and the nursing workforce development program, which includes 
loan programs for nursing faculty. Congress also should consider 
expanding the loan program for allied professionals and direct support 
for community college education to high priority shortage areas in the 
health care workforce.

    Finally, Congress should expand and increase funding for Centers of 
Excellence and the Health Careers Opportunity Programs, which focus on 
recruiting and retaining minorities into the health professions to 
build a more diverse health care workforce.
                               Conclusion
    The AHA appreciates your recognition of the challenges ahead and 
the need to examine America's health care workforce shortage. We must 
work together to solve these issues so that our Nation's hospitals and 
health systems can continue to care for the patients and communities 
they serve.
                                 ______
                                 
               american association for respiratory care
    The American Association for Respiratory Care thanks Chairwoman 
Patty Murray, Ranking Member Richard Burr, and Members of the Health, 
Education, Labor and Pensions (HELP) Committee for holding this 
important hearing on Recruiting, Revitalizing & Diversifying: Examining 
the Health Care Workforce Shortage. In particular, we urge the 
Committee to consider the Allied Health Workforce Diversity Act as part 
of its work on this important topic.

    The ongoing public health crisis due to COVID-19 has resulted in 
unexpected challenges involving the delivery of healthcare and the need 
for long-term recovery. We urge Congress to focus its efforts on 
ensuring our Nation can meet these challenges in part by working to 
promote a workforce adequate to meet the needs of the country, and one 
that reflects the diverse communities it serves. The allied health 
professions that include respiratory therapy, physical therapy, 
occupational therapy, speech-language pathology, and audiology are well 
positioned to assist with both the immediate care and long-term 
recovery and rehabilitation of those affected by COVID-19. Diversifying 
this workforce will help better enable these health care professionals 
to meet the current and future needs of this population.

    As the Committee undertakes an evaluation of health workforce 
shortages, it is important to point out that the pandemic has resulted 
in regional and nationwide shortages of respiratory therapists. Given 
the unknown long-term respiratory needs of those individuals who were 
diagnosed with COVID-19 and discharged from an inpatient hospital stay, 
it is important now more than ever that the Committee address the 
market forces that can lead to decreasing enrollment in respiratory 
care education programs, escalating burnout in the healthcare 
profession, and steadily growing retirement among the baby boomer 
generation. According to a recent health resources survey by the 
American Association for Respiratory Care, \1\ by 2030, approximately 
92,000 respiratory therapists are projected to have left the 
profession.
---------------------------------------------------------------------------
    \1\  2020 AARC Human Resource Study. Table 47, page 123. aarc-hr-
study-rt.pdf

    As the Committee seeks to address issues around recruiting and 
diversifying the healthcare workforce, we strongly believe increasing 
diversity will lead to improved access to care, greater patient choice 
and satisfaction, and better education experience for health 
professions students, among many other benefits. In particular, a 
diverse health care workforce can help to both address preexisting 
health disparities among the population, as well as those disparities 
exacerbated by the COVID-19 pandemic. This is supported by the Centers 
for Disease Control and Prevention assessment that there is an 
increased ``risk for severe COVID-19 illnesses and death for many 
people in racial and ethnic minority groups.'' \2\
---------------------------------------------------------------------------
    \2\  Centers for Disease Control and Prevention. COVID Data Tracker 
Weekly Review, Interpretive Summary for April 2, 2021. Accessed April 
4, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/
covidview/index.html

    We appreciate the support of HELP Committee Members Senators Casey 
and Murkowski, who have been strong champions for diversifying the 
allied health professions by introducing the Allied Health Workforce 
Diversity Act (S. 1679), which would create a workforce development 
program for rehabilitation therapy providers and audiologists to 
increase the percentage of individuals from underrepresented 
communities in these professions. We urge you to build on their efforts 
to create this new program to support better representation in the 
professions of audiology, physical therapy, occupational therapy, 
respiratory therapy, and speech-language pathology as the Committee 
tackles a wide range of health care workforce issues. We appreciate the 
opportunity to provide our comments and look forward to working with 
you to improve the diversity of the respiratory care workforce.
                                 ______
                                 
                         Workforce Issue Brief
    Advocate Aurora Health (Advocate Aurora) has developed a diverse 
and inclusive workforce to support the delivery of quality, integrated 
inpatient, outpatient, and home-based health services. Our workforce is 
comprised of more than 75,000 employees, including more than 10,000 
physicians and 22,000 nurses. With 27 acute care hospitals, an 
integrated children's hospital and a psychiatric hospital, primary and 
specialty physician services, outpatient centers, physician office 
buildings, pharmacies, rehabilitation, home health, and hospice care, 
Advocate Aurora provides a continuum of service at more than 500 sites 
of care in northern Illinois and eastern Wisconsin.

    Currently, staffing shortages are the most urgent challenge facing 
our hospitals and other sites of care; accompanying these shortages are 
higher costs to recruit and retain health care workers and paying the 
exorbitant rates some staffing agencies are charging. According to an 
AHA report, current labor expenses per adjusted discharge for hospitals 
have increased 12.5 percent compared to 2019. \1\ Moreover, in late 
January 2022, the Bureau of Labor Statistics reported that compensation 
for hospital workers was 4.5 percent higher in December 2021 compared 
to the year prior. \2\
---------------------------------------------------------------------------
    \1\  https://www.aha.org/fact--sheets/2021--11--data--brief--
health--care--workforce--challenges--threaten--hospitals--ability--care
    \2\  https://www.bls.gov/news.release/eci.t05.htm
---------------------------------------------------------------------------
                     Supporting Federal Initiatives
    COVID-19 has taken a heavy toll on our employees who have been on 
the front lines of the pandemic for 2 years, and Advocate Aurora is 
grappling with health care worker shortages as hospitalizations 
increase and ICU capacity decreases across Illinois and Wisconsin with 
each wave of COVID variants. Physicians, nurses, and other clinical and 
non-clinical health care professionals are critically needed, but 
ongoing COVID-19 hospitalizations have created unprecedented levels of 
demand that are exceeding supply. Advocate Aurora supports the efforts 
of Congress and the Biden-Harris Administration to address the issue of 
workforce shortages among health care workers, as well as the following 
initiatives:

          Make permanent the telehealth flexibilities permitted 
        during the pandemic, including removing geographic restrictions 
        on the location of the patient, allowing rural health clinics 
        and federally qualified health centers to serve as the distant 
        site, and allowing critical access hospitals the same ability 
        to offer and bill for telehealth services as other providers.

          Provide resources to assist hospitals with 
        unprecedented staffing and COVID response costs by 
        appropriating additional dollars through the Provider Relief 
        Fund (PRF).

          Ensure the public health emergency (PHE) period does 
        not expire until ICU capacity has returned to pre-pandemic 
        levels.

          Extend J1 visas for international health care workers 
        and ensure a timely process for review, streamlining entry into 
        the U.S. for clinical staff with approved immigrant visas.

          Plan for future workforce shortages by increasing 
        Graduate Medical Education (GME) residency slots under Medicare 
        and increasing funding for the Children's Hospital Graduate 
        Medical Education program to support Federal investment in 
        pediatric physician training.

          Invest additional resources in nursing education 
        programs and other initiatives to support nursing school 
        enrollment, faculty positions, educational programming, and 
        educational and technological infrastructure.

          Consider increased and expanded tax incentives to 
        encourage health care workers to increase their tenure at their 
        current positions and reduce turnover rates, which can threaten 
        patient safety and continuity of care.

          Expand and increase funding for mental health 
        services and other programs to support current health care 
        professionals to reduce burnout.

          Implement student loan forgiveness or assistance, and 
        provide increased incentives and programs to create a health 
        care workforce pipeline with features like scholarships, 
        training, and financial incentives.

          Address price gouging by certain nursing staffing 
        agencies, which have been charging nearly three times the 
        amount for nurses compared to pre-pandemic rates.

          Increase funding for nursing and allied health 
        programs and the National Health Service Corps program, 
        directing higher numbers of participants to serve in hospital 
        settings.

          Advance efforts to diversify the health workforce, 
        including grants to education programs to increase workforce 
        diversity in the allied health professions.

                Advocate Aurora's Workforce Development
    While we are calling on Congress and the Administration to enact 
policies and programs and provide increased resources to strengthen, 
expand, and diversify the Nation's health care workforce, we at 
Advocate Aurora are doing our part. Advocate Aurora is focused on 
recruiting and retaining a diverse array of team members to inspire 
creativity and innovation. We aim to cultivate an atmosphere of 
inclusion and compassion to create a welcoming and safe space for all 
team members. Specifically, we have sponsored the following initiatives 
to achieve positive workforce development:

          In 2021, we increased our minimum wage to $18 an 
        hour. The wage increase, intended to recognize Advocate Aurora 
        team members' critical work, also reflects another major effort 
        to create social impact that dramatically improves individuals' 
        health and well-being. The 10,800 team members directly 
        impacted by Advocate Aurora's new minimum wage include those in 
        food service and environmental services positions. An 
        additional 20,000 team members who already made more than $18 
        an hour, including pharmacy technicians and licensed practical 
        nurses (LPNs), also received raises. This $93 million 
        investment, which included compression adjustments, benefited 
        more than 30,000 team members and in turn, strengthened our 
        marketplace and most importantly, enhanced the quality of life 
        across our communities.

          Advocate Workforce Initiative (AWI): With funding 
        from JP Morgan Chase, Advocate Aurora developed a pipeline of 
        diverse talent from the greater Chicagoland area by seeking out 
        individuals who are interested in entry-to mid-skill level 
        health care careers. Since 2015, our partnership with JPMorgan 
        Chase has allowed us to bring together stakeholders--health 
        care systems, education providers, and community-based 
        organizations--to connect diverse job seekers with health care 
        career training, support services and employment opportunities. 
        Advocate Aurora co-led the Chicagoland Healthcare Collaborative 
        and implemented the AWI. To date, these partnerships have 
        resulted in training more than 900 community residents. More 
        than half of the program participants secured employment in 
        health care, and 84 percent were persons of color. While the 
        AWI funding sunset in 2020, it will be relaunched in mid-2022.

          Advocate Aurora Corporate Internship Program: For the 
        last 7 years, we have awarded competitive summer internships to 
        a small group of college students to support hard-to-fill 
        corporate positions in our organization. To date we have hired 
        interns from more than 40 colleges across the Nation, 
        partnering with local organizations that support up to 20 
        underrepresented students each year. These are paid internships 
        that focus on corporate careers, such as: Human Resources; 
        Finance; Accounting; Diversity, Equity, and Inclusion (DE&I); 
        and Information Technology. The apprenticeship program focuses 
        on recruiting diverse and underrepresented talent, including 
        people with disabilities, into these roles. Advocate Aurora had 
        15 virtual corporate interns in 2021 and will have 23 in 2022.

          Earn-While-You-Learn Corporate Apprenticeship 
        Program: We have partnered with the Wisconsin Department of 
        Workforce Development and the Wisconsin Technical College 
        System to offer job seekers the opportunity to earn while they 
        learn and expand their skills for middle-skill positions. In 
        2022, Advocate Aurora will be expanding the Culinary 
        Apprenticeship program to Illinois. In partnership with the 
        Illinois Department of Labor and the City Colleges of Chicago's 
        Washburn Hospitality and Culinary Institute, the Culinary 
        Apprenticeship program will place seven new apprentices to five 
        of our medical centers--Christ, Lutheran General, Illinois 
        Masonic, South Suburban, and Trinity hospitals. In total, there 
        will be 11 full-time Culinary Apprenticeships in Illinois and 
        four in Wisconsin.

          Community Scholarships and Education Reimbursement: 
        Annually, we partner with both Milwaukee and Chicago businesses 
        to distribute scholarships--Phase 1 awards 10 community 
        scholarships up to $5,000 each; Phase 2 awards 20 scholarships 
        Up to $5,000 Each (10 to Community Members, 10 to Dependents of 
        Team Members). Priority is given to students in STEM/health-
        related or corporate fields of study. Also, Advocate Aurora 
        operates an Education Assistance Partnership with Bright 
        Horizons for current employees to receive tuition benefits up 
        to $5,250 per year for non-nursing programs and up to $7,200 
        per year for nursing programs.

          The Milwaukee Healthcare Workforce Initiative 
        operates in close partnership with Employ Milwaukee (workforce 
        investment board), bringing together five community-based 
        organizations, including the Milwaukee Urban League, and 
        providing them leveraged funds to help recruit and train 
        participants for in-demand careers in health care. Advocate 
        Aurora obtained a $500,000 grant through the Medical College of 
        Wisconsin's Advancing a Healthier Wisconsin (MCAHW) endowment 
        to support this important effort. This program is similar to 
        the AWI program described above.

          The Medical Assistant Accelerated Pathway to 
        Employment Training Project (MAAPET) meets a crucial workforce 
        need by increasing a diverse talent pool of Medical Assistants 
        (MAs) working in ambulatory clinics across Southeast Wisconsin. 
        Advocate Aurora Health is collaborating with our partners in 
        the Center for Healthcare Careers of Southeast Wisconsin to 
        launch an accelerated Medical Assistant Training Program with 
        assistance from a generous grant provided by the Medical 
        College of Wisconsin Advancing a Healthier Wisconsin Endowment. 
        This grant-funded program will train 100 new Medical 
        Assistants. In this pathway program, trainees will be paid to 
        go through a 14-week training program. The first 10 weeks (400-
        hours) will be dedicated to in-class learning and laboratory 
        demonstrations. Students will then transition into a 4-week 
        (160-hours) clinical placement. Upon the completion of the 14-
        week training program (560-hours), students will sit for the 
        CCMA (Certified Clinical Medical Assistant) exam through the 
        National Healthcareer Association.

    A key aim of the MAAPET project is to develop an MA workforce that 
is reflective of the community that it serves. Key to this is 
recruitment of participants from the community who wish to gain a 
career in health care. By providing an accelerated, financially 
supported training, low income/underrepresented individuals will be 
given priority opportunities to enroll. The training team will monitor 
overall recruitment achievements and monitor the goal of having at 
least 70 percent of each cohort class meet target demographic goals. To 
date, 23 AAH team members have enrolled in the program.

          The Bridge Initiative Chicago was made possible by a 
        $1 million dollar grant awarded by JPMorgan Chase to support 
        workforce development efforts in the Chicagoland area through a 
        partnership with AAH, Sinai Health and University of Chicago 
        Medicine (UCM). It has three tracks to encourage and support 
        individuals in pursuing a career in health care:

           COMMUNITY TRACK (``HEALTHCARE FORWARD'') led by Sinai 
        Chicago incorporates community-facing strategies to increase 
        engagement in the health care workforce at the entry-level, 
        including fortified recruitment protocols and industry-focused 
        training offered at accessible community venues. This track 
        invites disenfranchised community members, particularly persons 
        of color (POC), to seek jobs and realize a living wage.

           INCUMBENT ADVANCEMENT (``EVOLVE'') track led by AAH 
        addresses disparity of opportunities for POC within health care 
        by introducing self-directed digital skills training, cohort-
        based training, and career coaching. This track aims to develop 
        new technical, discipline-specific skills (entry-level to 
        middle skills).

           EMERGING LEADERSHIP (``RISE HIGHER') track led by UChicago 
        Medicine incorporates a new leadership curriculum and 
        certificate program to promote career advancement and 
        leadership skills among incumbents. This track seeks to promote 
        racial equity and leadership success from middle skill to 
        management level.

          Workplace Transition Policy and Practice: In the fall 
        of 2020, Advocate Aurora created guidelines to support our 
        transgender, non-binary, and gender diverse team members who 
        may be socially, legally, or medically transitioning during 
        their employment with Advocate Aurora.

          LGBTQ Cultural Awareness: Based on feedback we 
        received from team members participating in the Healthcare 
        Equality Index (HEI) accreditation process, we are expanding 
        our LGBTQ cultural awareness initiative and exploring easily 
        accessible and trackable LGBTQ learning opportunities for our 
        team members.

          Inclusion Council and Core Teams: The Advocate Aurora 
        Inclusion Council is a newly launched, differentiated model for 
        integrating DE&I into our health system. This model addresses 
        the challenge of locally executing our system DE&I strategy by 
        deploying 11 inclusion council core teams dedicated to leading 
        DE&I action plans for our patient service areas, corporate 
        functions, and select ancillary services.

          Advocate Aurora Employee Wellness Support: Advocate 
        Aurora is committed to creating and maintaining diverse, 
        inclusive, and engaged working environments where team members 
        can pursue their passion and feel supported, valued, and 
        recognized. Further, the team member well-being program at 
        Advocate Aurora is designed to educate team members and 
        encourage them to manage and improve their health, including 
        offering incentives, such as discounts at its fitness centers, 
        indoor and outdoor guided walking paths at each hospital 
        location and a variety of physical, mental, and social 
        programs, resources, and interventions to support team members 
        in their well-being journey.

                      About Advocate Aurora Health
    Advocate Aurora Health is one of the 12 largest not-for-profit, 
integrated health systems in the United States and a leading employer 
in the Midwest with 75,000 employees, including more than 22,000 nurses 
and the region's largest employed medical staff and home health 
organization. A national leader in clinical innovation, health 
outcomes, consumer experience and value-based care, the system serves 
nearly 3 million patients annually in Illinois and Wisconsin across 
more than 500 sites of care. Advocate Aurora is engaged in hundreds of 
clinical trials and research studies and is nationally recognized for 
its expertise in cardiology, neurosciences, oncology and pediatrics. 
The organization contributed $2.5 billion in charitable care and 
services to its communities in 2020. The Centers for Medicare & 
Medicaid Services in 2020 announced that Advocate Aurora Health's three 
affiliated Accountable Care Organizations (ACOs) combined saved 
taxpayers $87.5 million through the Medicare Shared Saving Program, the 
most of any integrated system in the country.
                                 ______
                                 
               american occupational therapy association
    Dear Chair Hickenlooper, Ranking Member Braun, and Members of the 
Subcommittee:

    The American Occupational Therapy Association (AOTA) is pleased to 
submit the following comments for the Senate Health, Education, Labor 
and Pensions (HELP) Subcommittee on Employment and Workplace Safety 
hearing on the growing shortages in the health care workforce.

    The American Occupational Therapy Association (AOTA) is the 
national professional association representing the interests of more 
than 213,000 occupational therapists, occupational therapy assistants, 
and students of occupational therapy. The practice of occupational 
therapy is science-driven, evidence-based, and enables people of all 
ages to live life to its fullest by promoting health and minimizing the 
functional effects of illness, injury, and disability.

    The ongoing public health crisis due to COVID-19 is a challenge in 
two parts and therefore recovery must continue two-fold. First: 
treatment and immediate care. Second: recovery in the long term. We 
urge Congress to focus its efforts on ensuring our Nation can meet both 
aspects of this crisis in part by working to promote a workforce 
adequate to meet the needs of the country, and one that reflects the 
diverse communities it serves. The Allied Health professions are well 
positioned to assist with both the immediate care and long-term 
recovery and rehabilitation of those affected by COVID-19 and 
diversifying this workforce will help better enable these health care 
professionals to meet the current and future needs of this population.

    The Allied Health professions play a crucial role in recovery from 
COVID-19 infections, as well as treatment of the effects of ``Post-
Acute Sequelae of SARS-CoV-2 infection,'' (PASC), \1\ often self-
described as ``long-haulers'' or ``long-COVID''. Issue 13 of The 
Exchange, an information sharing publication produced by the Office of 
the Assistant Secretary for Preparedness and Response (ASPR) in the 
Department of Health and Human Services, entitled The Work of Hospital 
Allied and Supportive Care Providers During COVID-19 states, ``The 
articles in this section illustrate the work performed by physical, 
respiratory, and occupational therapists to ensure patient comfort and 
assist COVID-19 patients through the recovery process.'' \2\
---------------------------------------------------------------------------
    \1\  https://www.usatoday.com/story/news/health/2021/02/24/covid-
19-long-haulers-fauci-announces-launchnationwide-initiative/4572768001/ 
viewed March 4, 2021
    \2\  U.S. Department of Health & Human Services. (2021). The work 
of hospital allied and supportive care providers during COVID-19. The 
Exchange, 13. https://files.asprtracie.hhs.gov/documents/aspr--tracie--
the--exchange--issue--13.pdf

    It is vital to anticipate what is required to promote a thriving, 
diverse health workforce. Health workforce diversity was important 
prior to the pandemic, as the Institute of Medicine raised concerns 
about the diversity of the health care workforce in its 2004 study: In 
the Nation's Compelling Interest: Ensuring Diversity in the Health Care 
Workforce. \3\ The report found that racial and ethnic minorities 
receive a lower quality of healthcare than non-minorities. \4\
---------------------------------------------------------------------------
    \3\  Institute of Medicine. (2004). In the Nation's compelling 
interest: Ensuring diversity in the health care workforce. Washington, 
DC: National Academy Press
    \4\  Institute of Medicine. (2003). Unequal treatment: Confronting 
racial and ethnic disparities in health care. Washington, DC: National 
Academy Press.

    Overall, increasing diversity will lead to improved access to care, 
greater patient choice and satisfaction, and better education 
experience for health professions students, among many other benefits. 
\5\ In particular, a diverse health care workforce can help to both 
address preexisting health disparities among the population, as well as 
those disparities exacerbated by the COVID-19 pandemic.
---------------------------------------------------------------------------
    \5\  Institute of Medicine. (2004). In the Nation's compelling 
interest: Ensuring diversity in the health care workforce. Washington, 
DC: National Academy Press.

    In addition to these reasons, a more diverse healthcare workforce 
---------------------------------------------------------------------------
is important because:

          Patients who receive care from members of their own 
        racial and ethnic background tend to have better outcomes; \6\
---------------------------------------------------------------------------
    \6\  Institute of Medicine. (2004). In the Nation's compelling 
interest: Ensuring diversity in the health care workforce. Washington, 
DC: National Academy Press.

          Health professionals from underrepresented and 
        minority backgrounds are more likely to practice in medically 
        underserved areas; \7\
---------------------------------------------------------------------------
    \7\  Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., Vu, H. T., 
Powe, N. R., Nelson, C., & Ford, D. E. (1999). Race, gender, and 
partnership in the patient-physician relationship. JAMA, 282, 583--589.

          Minority groups disproportionately live in areas with 
        provider shortages. \8\
---------------------------------------------------------------------------
    \8\  Reyes-Akinbileje, B. (2008, February 7). Title VII health 
professions education and training: Issues in reauthorization. 
Washington, DC: U.S. Congressional Research Service.

    We appreciate the support of Senators Casey and Murkowski, Members 
of the full HELP Committee, who have been strong champions for 
diversifying the allied health professions by introducing the Allied 
Health Workforce Diversity Act (S. 1679), which would create a 
workforce development program for rehabilitation therapy providers and 
audiologists to increase the percentage of individuals from 
underrepresented communities in these professions. We urge you to build 
on their efforts to create this new program to support better 
representation in the professions of audiology, physical therapy, 
occupational therapy, respiratory therapy, and speech-language 
---------------------------------------------------------------------------
pathology.

    Solving the diversity gap in our Nation's health systems will need 
a multistep approach. The step presented in this letter includes the 
creation of a workforce development program for rehabilitation therapy 
providers. The potential program under the Health Resources and 
Services Administration (HRSA) would be the modeled after the Title 
VIII Nursing Workforce Diversity program that has successfully 
increased the percentage of racial and ethnic minorities pursuing 
careers in nursing. This new program would help strengthen and expand 
the comprehensive use of evidence-based strategies shown to increase 
the recruitment, enrollment, retention, and graduation of students from 
underrepresented and disadvantaged backgrounds for the professions of 
audiology, physical therapy, occupational therapy, respiratory therapy, 
and speech-language pathology. The result would be better care for 
individuals who live in areas with provider shortages.

    Thank you for the opportunity to provide input on solving the 
Nation's health care workforce challenges. We stand ready to provide 
any additional information you need, as well as collaborate on any 
efforts in this area.
                                 ______
                                 
               physician assistant education association
    The Physician Assistant Education Association (PAEA), representing 
the 282 accredited physician assistant (PA) programs in the United 
States, welcomes the opportunity to submit a statement for the record 
regarding health care provider shortages and health workforce 
diversity.

    Throughout the course of the COVID-19 pandemic, the implications of 
chronic underinvestment in the development of our Nation's health 
workforce have been starkly illustrated. As hospital systems have been 
overwhelmed by COVID-19 patients, an already insufficient supply of 
frontline providers has faced unprecedented demands, leading to 
significant burnout among clinicians and reduced access to needed care 
for patients. As Congress seeks to develop policy to improve 
preparedness for future public health threats, ensuring the 
availability of a sufficient supply of well-trained, diverse providers 
must be a top priority.

    To effectively respond to the issue of workforce shortages, 
Congress must take immediate action to address the most urgent 
challenges limiting both the overall number of graduates being produced 
by health professions programs and the diversity of matriculants. As PA 
programs have sought to expand, the most challenging barrier that they 
have consistently encountered is the availability of clinical training 
sites necessary for students to complete their required rotations. As a 
condition of graduation, every PA student is required to complete a 
series of clinical training experiences in family medicine, emergency 
medicine, internal medicine, surgery, pediatrics, women's health, and 
behavioral/mental health. According to a recent survey of PA programs, 
however, more than 85 percent of respondents indicated that their 
clinical training sites are now taking fewer students than prior to the 
pandemic. \1\ This dramatic reduction in clinical education capacity 
threatens the ability of PA programs to meet the demand of health 
systems for graduates and must be addressed to reduce projected 
shortages.
---------------------------------------------------------------------------
    \1\  Physician Assistant Education Association. (2021). COVID-19 
Rapid Response Report 3. https://paea.edcast.com/insights/ECL--
c621408d--c82a-43f5--a067-75a03494d8be

    Beyond addressing clinical education limitations, PAEA strongly 
supports congressional action to help develop pathways to PA education 
for underrepresented minority (URM) students. According to PAEA's most 
recent Student Report, only 3.9 percent of first-year PA students 
identified as Black or African American while 9.1 percent identified as 
Hispanic or Latino as of 2019. \2\ Federal policy can play a critical 
role in addressing the barriers that have long prevented URM students 
from matriculating into PA programs, successfully graduating, and 
providing care to the communities most in need.
---------------------------------------------------------------------------
    \2\  Physician Assistant Education Association. (2020). By the 
Numbers: Student Report 4: Data from the 2019 Matriculating Student and 
End of Program Surveys. https://paeaonline.org/wpcontent/uploads/
imported-files/student--report--4--updated--20201201.pdf.

    To address these challenges, PAEA has endorsed legislation in both 
the House and Senate. PAEA would encourage the Subcommittee to advance 
the following legislation that has been introduced in the Senate and 
integrate that which has been introduced in the House into broader 
legislative proposals.
                  The Perinatal Workforce Act (S. 287)
    To combat significant rates of maternal morbidity and mortality 
among Black women, Senators Tammy Baldwin and Jeff Merkley introduced 
the Perinatal Workforce Act in 2021. This bill is intended to ensure 
the provision of culturally competent care by facilitating the 
recruitment and retention of maternal care providers that are 
reflective of the communities that they serve. To break down barriers 
facing URM students seeking to become health care providers, the bill 
would authorize $15 million annually over 5 years to support PA and 
other programs training students intending to specialize in obstetrics/
gynecology/women's health. This bill would support training 
experiences, scholarship aid, and other interventions proven to 
significantly contribute to the success of URM students.
 The Physician Assistant Education Public Health Initiatives Act (H.R. 
                                 3890)
    In response to the growing issue of clinical site shortages, Rep. 
Karen Bass introduced the Physician Assistant Education Public Health 
Initiatives Act in mid-2021. Based upon the success of the Teaching 
Health Center Graduate Medical Education program in retaining 
physicians in underserved communities after the completion of their 
residency training, this bill would authorize a Rural and Underserved 
Clinical Training Demonstration at $5 million annually over 5 years. 
This funding would allow PA programs to facilitate partnerships with 
federally qualified health centers, critical access hospitals, and 
rural health clinics to both immediately expand clinical site access 
and build a sustained pipeline of graduates to these underserved 
settings following the completion of their training.
 The Physician Assistant Higher Education Modernization Act (H.R. 2274)
    Under the Higher Education Act, existing sources of aid intended to 
support minority-serving institutions explicitly prioritize the 
development of programs for certain named high-demand professions, not 
including the PA profession. In early 2021, Rep. Karen Bass and Rep. 
David Trone the Physician Assistant Higher Education Modernization Act, 
which would explicitly prioritize PA program development at minority-
serving institutions, such as Historically Black Colleges and 
Universities (HBCUs) and Hispanic-serving institutions, to create a 
sustainable pipeline of diverse PA graduates to the health workforce.

    PAEA appreciates the opportunity to share the Association's 
perspective on effective policy solutions to promote the development of 
a sufficient supply of diverse health care providers and looks forward 
to the opportunity to serve as a resource to the Subcommittee. Should 
you require additional information or have questions, please contact 
Tyler Smith, Senior Director of Government Relations, at 
[email protected].
                                 ______
                                 
                    children's hospital association
    On behalf of the Nation's more than 220 children's hospitals and 
the children and families we serve, thank you for holding this hearing 
on ways to address the health care workforce shortage. We appreciate 
your leadership on this issue and look forward to working together to 
improve this imminent need. As you consider program improvements and 
other policy options, we urge you to recognize the unique staffing 
challenges that our Nation's children's hospitals face and the tailored 
support and care children, adolescents and young people we serve need.
                   Children's Hospital Staffing Needs
    Children's hospitals' frontline health care workers are facing 
extraordinary burdens as a result of the COVID-19 pandemic. We have 
unparalleled numbers of children in need of inpatient pediatric care at 
the same time that our frontline providers are themselves coming down 
with COVID-19, exacerbating persistent pediatric workforce shortages 
that have existed for years. Staff retention is a critical issue for 
children's hospitals and is reducing the amount of care they can 
provide. We are seeing nurses and other bedside staff reducing their 
work hours, with many others leaving health care completely. Some 
children's hospitals have been forced to resort to temporary staffing 
agencies to fill their workforce gaps, further straining financial 
resources. At the same time, many children's hospitals have reduced 
their care capacity, with some forced to temporarily close entire 
pediatric intensive care units and other critical services.

    We urge you to give special consideration to ways to immediately 
help the pediatric physical and mental health care workforce so 
children can get the care they need when they need it. Solutions must 
be pediatric-specific and not based on Medicare metrics as self-
governing children's hospitals operate outside of the Medicare program 
and care for very large numbers of pediatric Medicaid beneficiaries. An 
immediate targeted investment is needed, as our continued time in this 
pandemic is steadily weakening the health care system for our Nation's 
children. Several key opportunities for committee action to address our 
pediatric workforce challenges are highlighted below.

    Immediately address the current pediatric workforce crisis. 
Existing loan forgiveness programs can sometimes be difficult for 
pediatric specialty providers to access. We therefore support robust 
funding for the pediatric subspecialty loan repayment program, which 
would provide loan forgiveness for pediatric subspecialists, including 
mental health providers, practicing in underserved areas. We strongly 
support the $30 million for fiscal year 2022 proposed by Senate 
appropriators, but additional funding would expand the reach of this 
program to better meet the crisis moment we face. We look forward to 
working with you to identify realistic and effective immediate 
solutions.

    Increase funding for the Children's Hospitals Graduate Medical 
Education (CHGME) program. The CHGME program supports the training of 
more than half of the Nation's pediatric physician workforce and is 
essential to the continued access of children to needed pediatric 
specialists. However, CHGME represents only 2 percent of the total 
Federal spending on GME. These funding shortfalls must be financed by 
children's hospitals' child-patient care operations and are a key 
contributor to the overall pediatric workforce shortage. We appreciate 
the funding levels included in the House and Senate appropriations 
bills, but we would encourage Congress to consider a higher overall 
appropriations level to reduce the growing and unsustainable gap 
between GME and CHGME funding. Additionally, we believe a future 
reconciliation package would be an appropriate vehicle to increase 
CHGME funds. CHGME is vital to those self-governing children's 
hospitals that cannot receive Medicare GME funding, and other sources 
of financial support for training, such as Medicaid GME, are not 
available to many children's hospitals.
                        Children's Mental Health
    Congress must address the urgent need to relieve pressure on the 
existing pediatric mental health workforce, as well as invest in its 
long-term expansion across disciplines to meet the ongoing and growing 
mental health needs of our children. Pediatric mental health workforce 
shortages are persistent and projected to increase over time. 
Nationally, there are approximately 8,300 practicing child and 
adolescent psychiatrists and only 5.4 clinical child and adolescent 
psychologists per 100,000 children 18 years of age and younger, \1\ far 
fewer than needed to meet the existing and increasing demand. Shortages 
also exist for other vital pediatric mental health specialties critical 
to improving early identification and intervention for children with 
mental health needs. Additionally, there is a dire shortage of minority 
mental health providers, which represents an added burden on racial and 
ethnic minority communities who already face inequitable access to 
care. More dedicated support for a larger and more diverse pediatric 
workforce is critical to addressing children's mental health needs now 
and into the future. Congress can take several immediate steps to 
address the current and ongoing mental health workforce shortage.
---------------------------------------------------------------------------
    \1\  American Psychological Association. The Child and Adolescent 
Behavioral Health Workforce. Accessed Oct. 22, 2021.

    Mental and Behavioral Health Education and Training grants. The 
Mental and Behavioral Health Education and Training (BHWET) grants 
program was introduced as part of the Now is the Time initiative to 
increase the mental and behavioral health workforce serving children, 
adolescents and young adults. The program supports pre-degree clinical 
internships and field placements for doctoral-level psychology 
students, master's level social workers, school social workers, 
behavioral pediatricians and psychiatric mental health nurse 
practitioners, among others. Over the years, the program has expanded 
to include programs to train mental health providers and provide 
services for individuals across their lifespan. Several children's 
hospitals have received funding through this program, and we support 
further targeting existing funding toward pediatric providers. We also 
support an additional designated pool of funding under the oversight of 
the Health Resources and Services Agency (HRSA) to support training and 
development in children's hospitals, pediatric practice and clinical 
settings and related mental health disciplines providing pediatric 
---------------------------------------------------------------------------
behavioral health.

    Minority Fellowship Program. The value of a diverse pediatric 
mental health workforce prepared to deliver culturally and 
developmentally appropriate care cannot be overstated. While all mental 
health professionals receive training that prepares them to provide 
care with cultural sensitivity and awareness, the ability of a child, 
adolescent and their family to connect and identify with a mental 
health professional can be critical. Shared cultural beliefs and 
experiences can further strengthen therapeutic relationships and lead 
to better outcomes for kids and families. The Minority Fellowship 
Program provides training, career development opportunities and 
mentorship to racial and ethnic minority mental health professionals 
and researchers with the goal of reducing health disparities within 
minority communities. We support the essential aims of this program and 
encourage the Committee to explore how to sustainability expand its 
reach, including enhanced support for the participation of fellows who 
plan to serve pediatric populations.

    Enact H.R. 4944, the Helping Kids Cope Act. At the core of a strong 
pediatric mental health care delivery system is a strong, 
interconnected network of pediatric mental health providers and 
supportive services that are available to deliver high-quality, 
developmentally appropriate care. To expand and strengthen these 
networks at the community level, the Senate should consider H.R. 4944, 
the Helping Kids Cope Act of 2021, bipartisan legislation that supports 
flexible funding for communities to support a range of child and 
adolescent-centered, community-based services, as well as to support 
efforts to better integrate and coordinate across the continuum of 
care. It also supports pediatric mental health workforce development 
for a wide array of physician and non-physician mental health 
professions to expand children's long-term access to providers and 
services across the continuum of care.

    Pediatric Mental Health Care Access (PMHCA) program. While 
workforce shortages persist, innovative solutions like the Pediatric 
Mental Health Care Access (PMHCA) program, which this Committee has 
championed, help children's hospitals expand the reach of their 
workforce and ultimately ensure that more children receive the 
behavioral health screenings, assessments and referrals they need. As 
of today, 45 states, Washington, DC, tribal organizations and 
territories have received a grant from HRSA to create or expand their 
programs. Integrating mental health with primary care has been shown to 
substantially expand access to subspecialist physicians, such as child 
and adolescent psychiatrists, while boosting a pediatric provider's 
knowledge of mental health care, improving health and functional 
outcomes, increasing satisfaction with care and achieving cost savings. 
Expanding the capacity of pediatric primary care providers to deliver 
behavioral health through mental and behavioral health consultation 
programs is one way to maximize a limited subspecialty workforce and to 
help ensure more children with emerging or diagnosed mental health 
disorders receive early interventions and continuous treatment.

    Thank you again for your commitment to improving the current health 
care workforce shortage. Children's hospitals and their affiliated 
providers stand ready to partner with you to advance workforce policies 
that will make measurable improvements in the lives of our Nation's 
children.

    Children need your help now.
                                 ______
                                 
Hon. John Hickenlooper, Chairman,
Hon. Mike Braun, Ranking Member,
U.S. Senate Committee Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety,
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Dear Chairman Hickenlooper and Ranking Member Braun:

    On behalf of the 75,000 employees, including more than 10,000 
physicians and 22,000 nurses of Advocate Aurora Health (Advocate 
Aurora), I am writing to thank you for this opportunity to submit 
written testimony for the record of the Thursday, February 10, 2022 
hearing titled, ``Recruiting, Revitalizing & Diversifying: Examining 
the Health Care Workforce Shortage.'' We very much appreciate your 
attention to the current health care workforce shortage and, in 
particular, highlighting the need to strengthen and diversify the 
Nation's health care workforce. We stand ready to work with you and 
your colleagues to ensure that the patients, families, and communities 
we serve across Illinois and Wisconsin can continue to receive the 
emergency, urgent, primary, specialty, post-acute, and home care they 
need and deserve in the setting most appropriate for their particular 
condition.

    As you may know, Advocate Aurora is comprised of 27 acute care 
hospitals, an integrated children's hospital and a psychiatric 
hospital, and we offer inpatient, outpatient and physician-office based 
primary and specialty physician services, pharmacy, rehabilitation, 
home health, and hospice care. We provide a continuum of service at 
more than 500 sites of care in northern Illinois and eastern Wisconsin. 
We maintain a strong commitment to recruiting and retaining a diverse 
workforce and creating and maintaining an inclusive, engaged working 
environment across all our sites of care, where team members can pursue 
their passion and feel supported, valued, and recognized.

    Since the COVID-19 public health emergency (PHE) began, our team 
members have experienced significant strain and stress due to the heavy 
burdens associated with providing care to people infected with COVID-
19. Moreover, many of our team members themselves have been exposed, 
requiring quarantine, and/or infected with COVID-19, turning our 
caregivers into patients. The negative physical and mental health 
impact of the PHE on our team member--and health care employees across 
the country--has been sustained and must be recognized and addressed.

    We are working hard to ensure our team members have the support 
they need, as you will read in the attached Advocate Aurora Health 
Workforce Issue Brief, which we submit as our written testimony. 
Nonetheless, there remain myriad challenges facing front-line health 
care workers as we enter the third year of the PHE and, we--like our 
colleagues--continue to experience staff departures, turnover, and 
other recruitment and retention challenges. Our normal vacancy rate 
across our whole system typically--at any given time is 3,000 open 
positions; currently, we have more than 6,000 unfilled positions.

    Again, we thank you for holding this important hearing and draw 
your attention to the attached Advocate Aurora Health Workforce Issue 
Brief, which outlines what we are doing within Advocate Aurora to 
diversify, strengthen, and retain our workforce as well as enumerates 
the Federal policies and programs we need you and your colleagues to 
support so that the Nation can bolster our health care workforce. We 
thank you for your attention to our recommendations.

    Please do not hesitate to contact me (Meghan.Woltman--aah.org, 312/
933-0455) or Tom McDaniels, Advocate Aurora Director Federal Government 
Relations ([email protected], 202/409-0865) if we can answer any 
questions or be of any assistance to you or your staff as you consider 
next steps following the hearing.

            Sincerely,
                                      Meghan Woltman Chief,
                                         Government Affairs Officer
                                 ______
                                 
                    american federation of teachers
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Chairman Hickenlooper:

    On behalf of the 1.7 million members of the American Federation of 
Teachers, including 230,000 healthcare professionals, I write to offer 
our views on the workforce shortage in our Nation's health care system 
in advance of your February 10, 2002, hearing (Recruiting, Revitalizing 
& Diversifying: Examining the Health Care Workforce Shortage).

    Simply put, there is a staffing crisis in our Nation's hospitals. 
As Lucy King and Jonah Kessel powerfully laid out in their Jan. 19 New 
York Times video editorial titled ``We Know the Real Cause of the 
Crisis in Our Hospitals. It's Greed,'' our Nation's hospitals are 
responsible for this crisis, which undermines the access to care and 
the quality of care we all depend on, especially during a pandemic. 
While the pandemic has strained our Nation's healthcare system and its 
frontline healthcare workers to the breaking point and beyond, this is 
a crisis that started well before the COVID-19 pandemic. Hospitals were 
understaffed, in many cases dangerously so, long before the current 
public health emergency. And now, frontline care givers are burned out, 
exhausted from the moral injury of being forced to provide inadequate 
care, and leaving hospital employment in record numbers.

    As one of the Nation's largest unions of healthcare workers, a week 
does not go by when we don't hear from frontline workers about 
dangerously high patient loads; dangerous working conditions; and the 
mental, physical and emotional toll this crisis has taken on them and 
their families. The data paints an alarming picture. Since the 
beginning of the COVID-19 pandemic, 18 percent of healthcare workers 
(nearly 1 in 5) have quit their jobs. And for healthcare workers who 
have stayed in their jobs, nearly 1 in 3 (31 percent) has considered 
leaving. \1\ In a survey conducted by Mental Health America in summer 
2020, 76 percent of healthcare workers reported exhaustion and burnout. 
\2\ According to a Kaiser Family Foundation/Washington Post survey, a 
majority of frontline healthcare workers (62
---------------------------------------------------------------------------
    \1\  Morning Consult: https://morningconsult.com/2021/10/04/health-
care-workers-series-part-2-workforce/
    \2\  Mental Health America: https://mhanational.org/mental-health-
healthcare-workers-covid-19
---------------------------------------------------------------------------
    percent) say worry or stress related to COVID-19 has had a negative 
impact on their mental health; and 13 percent of healthcare workers say 
they have received mental health services or medication specifically 
due to worry or stress related to COVID-19, with an additional 1 in 5 
(18 percent) saying they thought they might need such services, but did 
not get them. \3\ So it should come as no surprise that healthcare 
workers are quitting; they are not just retiring early. Rather, we are 
hearing increasing reports of mid-and early career health 
professionals, some still paying off their student loans, quitting 
their jobs because they simply cannot take it any longer. They are not 
necessarily leaving the healthcare field, but they are definitely 
leaving their hospital jobs.
---------------------------------------------------------------------------
    \3\  Kaiser Family Foundation: https://www.kff.org/report-section/
kff-the-washington-post-frontline-health-care-workers-surveytoll-of-
the-pandemic/

    While the American Hospital Association tries to dance around the 
cause of this crisis, there is no denying its culpability in creating 
it. The revenue-and profit-driven, often callous, decisionmaking of 
hospitals put their economic bottom line ahead of patient care and the 
safety of their frontline healthcare workers long before the current 
pandemic. Quite simply, too many members of the AHA have failed their 
most basic responsibility: providing a safe place for patients to 
---------------------------------------------------------------------------
receive care from healthcare professionals.

    Early in the pandemic, hospitals' decisions to save money by not 
keeping sufficient stockpiles of personal protective equipment 
needlessly exposed frontline care givers to infections. As a result, 34 
percent of healthcare workers employed in either hospitals or nursing 
homes said in the spring that at some point during the pandemic, their 
workplace ran out of PPE for its employees. \4\ Sadly, 3,600 healthcare 
workers paid the ultimate price, tragically dying during this pandemic. 
\5\ Yet hospitals opposed the Occupational Safety and Health 
Administration (OSHA) Healthcare Emergency Temporary Standard, which 
was enacted far too late, and then following its withdrawal, too many 
removed the limited protections that were put in place. And now an 
increasing number of hospitals are considering requiring their COVID-
19-positive care givers to return to work before they are COVID-19-
free, denying them the time to get healthy themselves before they care 
for others.
---------------------------------------------------------------------------
    \4\  Kaiser Family Foundation: https://www.kff.org/report-section/
kff-the-washington-post-frontline-health-care-workers-surveytoll-of-
the-pandemic/
    \5\  Kaiser Health News: https://khn.org/news/as-coronavirus-
spreads-widely--millions-of-older-americans-live-in-counties-withno-
icu-beds/

    But the indifference of our Nation's hospitals to the safety of 
their workforce started long before COVID-19. Hospitals have been one 
of most dangerous places to work in America. Healthcare workers are 
five times more likely to experience workplace violence than other 
workers. In fact, in 2018, long before the COVID-19 pandemic, assaults 
on healthcare workers accounted for 73 percent of all nonfatal 
workplace violence. \6\ And there is every reason to believe that these 
rates have only gotten worse during the pandemic. There is a desperate 
need to pass legislation like the Workplace Violence Prevention for 
Health Care and Social Service Workers Act.
---------------------------------------------------------------------------
    \6\  U.S. Bureau of Labor Statistics: https://www.bls.gov/iif/
oshwc/cfoi/workplace-violence-healthcare-2018.htm

    Patient loads before the pandemic undermined the quality of care. 
Oppressive patient loads during the pandemic have broken the Nation's 
healthcare workforce. Data tells us that adding just one additional 
patient to a nurse's workload results in an increased risk of urinary 
tract infections and surgical site infections, \7\ a 48 percent 
increased risk of a child being readmitted to the hospital within 30 
days, \8\ and a 7 percent increased risk of 30-day in hospital 
mortality. \9\ This was true before the pandemic and will be true after 
the pandemic. To address this issue, the Senate should move reasonable 
legislation to require minimum staffing levels such as Sen. Sherrod 
Brown's Nurse Staffing Standards for Hospital Patient Safety and 
Quality Care Act.
---------------------------------------------------------------------------
    \7\  Cimiotti et al., 2012: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3509207/pdf/nihms387953.pdf
    \8\  Tubbs-Cooley et al., 2013: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3756461/pdf/bmjqs-2012-001610.pdf
    \9\  Aiken et al., 2014: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4035380/pdf/nihms571000.pdf

    There are additional strategies to address this crisis, such as 
improving the pipeline for healthcare workers through expanded funding 
for training programs as well as student financial aid, and making the 
compensation more competitive with that provided by staffing agencies. 
However, hospitals will continue to lose care givers more quickly than 
they can be trained until hospitals stop treating healthcare workers 
like disposable parts, and instead treat them like highly trained 
professionals and provide them an appropriately staffed, safe place to 
---------------------------------------------------------------------------
work that puts the quality of care above hospital profits.

    Thank you for considering our views on this crucial topic. The AFT 
looks forward to working with you on solutions to address the current 
workforce shortages in our health care system.
            Sincerely,
                                          Randi Weingarten,
                        President, American Federation of Teachers.
                                 ______
                                 
                             National Nurses United
                                    Silver Spring, MD 20910
                                                   February 8, 2022
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety,
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Dear Chairman Hickenlooper and Ranking Member Braun:

    National Nurses United is the largest union and professional 
association of registered nurses (RNs) in the United States, 
representing more than 175,000 nurses across the country. Our members 
have been on the frontlines of the Covid-19 response for 2 years and 
are dealing first-hand with the repercussions of the nurse staffing 
crisis that the health care industry is facing today. I write to you 
today in advance of your hearing on ``Recruiting, Revitalizing & 
Diversifying: Examining the Health Care Workforce Shortage,'' to 
provide you with frontline insights into the working conditions that 
have created this staffing crisis, and to discuss the important 
solutions needed to address this crisis and ensure a robust health care 
workforce in the future.

    Throughout the Covid-19 pandemic, nurses have been dealing with 
dangerous working conditions, including low RN staffing levels, 
inadequate health and safety protections, insufficient stock of 
critical medical supplies and PPE, and increasing levels of violence in 
the workplace. While the Covid crisis has exacerbated these challenges, 
nurses have been facing these issues in their hospital workplaces for 
decades. The staffing crisis we are experiencing now is the result of 
years of industry neglect and intentional policies of short-staffing 
and cost-cutting measures enacted by hospital employers.

    According to statistics from the National Council of State Boards 
of Nursing and the U.S. Bureau of Labor Statistics, there are at least 
1.2 million actively licenses registered nurses who are not employed as 
RNs. There is no shortage of trained and licensed RNs, but there is a 
shortage of good nursing jobs where RNs are valued for their work, have 
strong health and safety protections, and are not required to care for 
more patients at any given time than is safe for optimal, therapeutic 
care. We don't have a shortage of nurses, but we do have a staffing 
crisis.

    The first step to addressing this staffing crisis is to revitalize 
the workforce by increasing nurse retention and bringing licensed 
nurses back to work. To do this, it is critical that the Federal 
Government implement policies that will require the hospital industry 
to provide safe and healthy workplaces.

    Nurses are leaving the bedside because their employers refuse to 
staff their units appropriately and fail to supply the resources 
necessary to provide safe, therapeutic patient care. Many hospitals 
have chosen to adopt policies that result in high patient caseloads 
that compromise the health and safety of both nurses and patients. 
Moreover, hospital employers have failed to implement programs to 
protect nurses from infectious diseases, prevent violence, and enable 
safe patient handling.

    Although working conditions have been deteriorating for decades, 
the problems intensified during the pandemic. Hospital employers showed 
their disregard for nurses' health and safety by failing to implement 
infection control practices and failing to provide appropriate PPE. 
Nurses working on the pandemic's front lines are experiencing severe 
moral distress and injury (often incorrectly labeled ``burnout''); 
mental health issues such as stress, anxiety, depression, and post-
traumatic stress disorder; and physical exhaustion.

    To bring nurses back to the bedside and increase nurse retention, 
NNU recommends the following solutions:

          Congress must mandate minimum nurse-to-patient 
        staffing ratios, through passage of the Nurse Staffing 
        Standards for Hospital Patient Safety and Quality Care Act, 
        sponsored by Senator Sherrod Brown and Congresswoman Jan 
        Schakowsky.

          The Occupational Safety and Health Administration 
        (OSHA) must issue a final permanent Covid-19 Health Care 
        Standard to enforce Covid protections for health care workers 
        and retain its Emergency Temporary Standard until the permanent 
        standard takes effect. Further, OSHA should issue an Infectious 
        Diseases standard, so that workplace protections will be 
        enforced during future infectious disease outbreaks.

          Congress must pass the Workplace Violence Prevention 
        for Health Care and Social Service Workers Act, sponsored by 
        Congressman Joe Courtney and passed in the House of 
        Representatives, and introduced by Senator Tammy Baldwin in the 
        116th Congress. The bill would mandate that OSHA issue a 
        Workplace Violence Prevention Standard for health care and 
        social service workplaces.

          The Federal Government must do everything in its 
        power to restore and protect the right of nurses and other 
        health care workers to organize and bargain collectively.

    While there is no general nursing shortage in the United States, 
there is a lack of racial, ethnic, cultural, linguistic, and 
socioeconomic diversity within the current nursing workforce. This 
challenge has resulted from a lack of investment in nursing education, 
job placement, and hospital industry practices that have restricted the 
pipeline of nurses from socioeconomically diverse and underserved 
communities. The Federal Government should take measures to recruit 
nurses from underserved communities, and to ensure that hospital 
industry practices support a diverse nursing pipeline.

    Diversity in the health care workforce facilitates health care 
access and health care quality, necessary elements of health equity. 
Patient-provider racial, ethnic, and linguistic concordance improves 
communication, trust, and health care quality. Black, Indigenous, and 
People of Color (BIPOC) communities, along with rural communities, 
often have fewer health care professionals practicing locally and even 
fewer who are culturally and linguistically competent. Studies show 
that Black, Hispanic/Latinx, and Native American health care providers 
are more likely to practice in underserved communities. \1\ Similarly, 
students from rural areas are more likely to practice in rural 
communities. \2\
---------------------------------------------------------------------------
    \1\  Pittman P et al. 2021. Health Workforce for Health Equity. 
Medical care, 59(Suppl 5), S405--S408. https://doi.org/10.1097/
MLR.0000000000001609. Citing Goodfellow A et al. Predictors of primary 
care physician practice location in underserved urban or rural areas in 
the United States: a systematic literature review. Acad Med. 
2016;91:1313--1321 and Mertz E et al. Underrepresented minority 
dentists: quantifying their numbers and characterizing the communities 
they serve. Health Aff. 2016;35:2190--2199
    \2\  Ibid.. Citing Rabinowitz H et al. The relationship between 
entering medical students' backgrounds and career plans and their rural 
practice outcomes three decades later. Acad Med. 2012;87:493--497. 
MacQueen I et al. Recruiting rural healthcare providers today: a 
systematic review of training program success and determinants of 
geographic choices. J Gen Intern Med. 2018;33:191--199

    To increase diversity within the nursing workforce, investments 
must be made to support education and job placement for nurses from 
underrepresented communities. This should include the following 
---------------------------------------------------------------------------
investments:

          Long-term funding for tuition free nursing programs 
        at community colleges

          Increased funding for the Nursing Workforce Diversity 
        Program

          Increased funding for Nurse Corps scholarship and 
        loan repayment programs

    At the hospital level, the industry needs to adjust practices that 
have limited the ability for nurses from underrepresented communities 
to find work. Most notably, some hospitals refuse to hire nurses with 
an associate degree in nursing (ADN), choosing to prioritize hiring of 
nurses with 4-year bachelor's degrees of nursing (BSNs). Nurses with 
ADN and BSN degrees must fulfill the same education and clinical 
experience requirements, and they must pass the same licensing 
examination. By choosing to prioritize BSN nurses, hospitals are 
restricting diversity in the workforce. A BSN requires a larger time 
and financial commitment, and statistics on RN graduates show that 
nurses from underrepresented communities, and specifically communities 
of color, are more likely to graduate with an ADN. It is important to 
note that hospitals refusing to hire nurses with ADNs is happening 
while the hospital industry is lobbying to delegate nursing work to 
lesser licensed and unlicensed personnel and family members.

    As the Committee explores approaches to addressing the current 
health care staffing crisis, it is crucial to protect RNs' scope of 
practice. We urge you to focus on providing the resources needed to 
educate more RNs in 2-year nursing programs rather than on 
``upskilling'' other workers. Nursing practice is fundamentally 
holistic in nature. Registered nurses have extensive education and 
clinical experience that enables them to provide safe, therapeutic 
patient care. Attempts to break down registered nursing practice into 
tasks, and shifting the tasks to unlicensed workers, undermines patient 
care. Even the simplest RN-patient interactions involve skilled 
assessment and evaluation of the patient's overall condition. Subtle 
changes in a patient's skin tone, respiratory rate, demeanor, and 
affect provide critical information to their health and well-being that 
can be easily overlooked or misinterpreted by those without an RN's 
education and clinical experience.

    Attached to this letter is NNU's report, ``Protecting Our Front 
Line: Ending the Shortage of Good Nursing Jobs and the Industry-Created 
Unsafe Staffing Crisis,'' which contains more detailed information on 
the hospital industry practices that have created the nurse staffing 
crisis we are experiencing right now, and NNU's proposed solutions to 
increase nurse retention and diversity.

    We look forward to working with your Committee to protect the 
workplace health and safety of nurses, improve staffing levels and 
nurse retention, and build a sustainable nursing workforce well into 
the future.
            Sincerely,
                                 Zenei Triunfo-Cortez (RN),
                                                         President,
                                             National Nurses United
                                 ______
                                 
                  National Healthcareer Association
                                          Leawood, KS 66211
                                                  February 10, 2022
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Dear Chairman Hickenlooper and Ranking Member Braun:

    On behalf of the more than 380,000 nationally certified allied 
health professionals that the National Healthcareer Association (NHA) 
represents, thank you for holding the important hearing on Recruiting, 
Revitalizing & Diversifying: Examining the Health Care Shortage. This 
is an extremely important and timely topic.

    Since 1989, NHA has prepared and awarded more than one million 
certifications to healthcare students and professionals, providing them 
with nationally recognized measurements of competency and easy-to-use 
training and study resources paired with high quality, personalized 
customer care. NHA is passionately committed to develop, advance, and 
advocate for the frontline healthcare worker, resulting in improved 
patient care. It does this by working with thousands of secondary, 
post-secondary schools, and health care employers across the country to 
assist with the training and certification of professionals in the 
following areas:

          Medical Assisting (Clinical and Administrative)

          Pharmacy Technician

          Phlebotomy

          EKG Technician

          Patient Care Technician

          Billing and Coding Specialist

          Electronic Health Records Specialist

    In 2022, more than ever, the healthcare industry is at the core of 
our Nation's success. The pipeline to healthcare careers has been 
greatly impacted by Covid-19 challenges and shutdowns. Based on 
research we conducted in 2021, enrollments of first-year students at 2-
year institutions is down 21 percent compared to pre-pandemic numbers. 
For example, in 2019 schools were producing around 60,000 medical 
assistants (MA). In March 2021, ZipRecruiter.com had nearly 700,000 
open MA positions. We also have data showing that 88 percent of 
healthcare leaders report having difficulty recruiting medical 
assistants. In addition, female workers represent nearly 70 percent of 
the global healthcare workforce and according to the National Women's 
Law Center Analysis, four times as many women as men dropped out of the 
labor force in September 2020. Please use this link to access these 
statics and more compelling articles as a part of NHA's annual allied 
health industry journal Access.

    As the Committee on Health, Education, Labor & Pensions considers 
this important topic, we urge your support for the following principles 
and urge the Committee to consider and pass these principles into 
legislation as swiftly as possible:

          Reauthorization of the Health Profession Opportunity 
        Grant (HPOG) Program, which provides grants for the purpose of 
        preparing certain low-income individuals to enter into the 
        health care profession;

          Inclusion of authorization for increased home care 
        funding to recruit and retain direct care workers and improve 
        care wages through training, registered apprenticeships, the 
        creation of career pathways, and mentoring;

          Authorization for funding for higher education and 
        workforce development, including:

                Y   Adult and Dislocated Worker Employment and Training 
                Activities and for Youth Workforce Investments under 
                the Workforce Innovation and Opportunity Act

                Y  Expanded registered apprenticeships, pre-
                apprenticeships, and youth apprenticeships. We urge the 
                Committee to ensure these opportunities include people 
                with barriers to employment, people with disabilities, 
                and populations underrepresented in apprenticeships;

                Y  Industry or private sector partnerships that would 
                bring together state and local workforce boards, 
                employers, labor organizations, and education and 
                training providers to expand training for high-skill, 
                high-wage, or in-demand industries such as health care;

                Y  Authorization and funds for core Title I WIOA 
                program activities;

                Y  Dedicated funding for state and local workforce 
                development boards to implement industry and sector 
                partnership grants;

                Y  Inclusion of an increase in the maximum Pell Grant 
                award;

                Y  Retention and Completion Grants to eligible states 
                and state systems to support the development of 
                practices that have been shown to improve student 
                outcomes, such as providing comprehensive academic, 
                career, and student support services; assistance in 
                applying for financial aid or mean-tested benefits; 
                accelerated learning opportunities; an improved 
                developmental education and transfer pathways; and

                Y  Career and technical education grants for CTE 
                programs and to carry out an innovation and 
                modernization programs.

    As NHA continues to advance and advocate for frontline healthcare 
workers, we strive to create a ripple effect on the healthcare 
industry. By working to certify professionals who meet a national 
recognized measure of competency, we help improve patient care and make 
for a better, more thoughtful patient experience. As the current COVID 
pandemic continues to demonstrate, the need for high quality healthcare 
workers is more important than ever. Continued support of the above 
principles is essential to meet the need for qualified healthcare 
workers now and in the future.
            Sincerely,
                                           Jessica Langley,
                      Executive Director of Education and Advocacy,
                                  National Healthcareer Association
                                 ______
                                 
                  Federation of American Hospitals,
                                      Washington, DC 20001,
                                                 February 10, 2022.
Senator John Hickenlooper, Chairman,
Senator Mike Braun, Ranking Member,
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety,
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Dear Chairman Hickenlooper and Ranking Member Braun:

    On behalf of the Federation of American Hospitals (FAH), thank you 
for the opportunity to comment in advance of the Senate Health, 
Education, Labor, and Pensions (HELP) Subcommittee on Employment and 
Workplace Safety hearing, Recruiting, Revitalizing & Diversifying: 
Examining the Health Care Workforce Shortage.

    The FAH is the national representative of more than 1,000 leading 
tax-paying hospitals and health systems throughout the United States. 
FAH members provide patients and communities with access to high-
quality, affordable care in both urban and rural areas across 46 
states, plus Washington, DC and Puerto Rico. Our members include 
teaching, acute, inpatient rehabilitation, behavioral health, and long-
term care hospitals and provide a wide range of inpatient, ambulatory, 
post-acute, emergency, children's, and cancer services.
            Health Care Workforce: Challenges and Solutions

    As the third year of the pandemic begins, the mental and physical 
toll of the COVID-19 public health emergency (PHE or pandemic) has put 
an unprecedented strain on our frontline caregivers and hospital 
support staff. The struggle to maintain a robust workforce has been 
exacerbated in recent months as Omicron has rapidly spread, while 
potential future variants also threaten to sideline critically needed 
health care providers. At the same time, caregivers are still bearing 
the emotional burden of treating patients throughout multiple COVID-19 
waves.

    The pandemic continues to have lingering effects on health care 
providers, as we are seeing rising instances of burnout and 
resignation. According to the American College of Healthcare 
Executives' annual survey, hospital CEOs reported `personnel shortages' 
as their top organizational concern. \1\ FAH members are experiencing 
staffing shortages that existed prior to COVID-19 and have become 
significantly more pronounced and problematic due to the strain and 
ongoing nature of the PHE. We therefore must implement policy solutions 
that will yield short and long-term stability in the recruitment, 
retention, and diversification of our health care workforce.
---------------------------------------------------------------------------
    \1\  https://www.ache.org/learning--center/research/about--the---
field/top--issues--confronting--hospitals

    FAH members are experiencing shortages of medical technicians, 
laboratory assistants, and nurses, as well as food service, 
housekeeping, and sanitation staff, and in some instances, hospitals do 
not have enough staff to operate at full capacity. To ensure that 
patient care and general operations are not compromised, hospitals have 
been forced to significantly increase their reliance on contract labor 
---------------------------------------------------------------------------
and staffing companies.

    It has been widely reported that nurse-staffing agencies are 
exploiting the COVID-19 crisis with predatory price increases that can 
be disconnected from the wages paid to these contract nurses who are 
providing needed clinical care to hospitals. Bipartisan Members of the 
House and Senate have expressed concerns over these practices and, in 
particular, worry that hospitals will be unable to sustain these 
exorbitant staffing costs. We join those in Congress to urge the 
Administration to investigate nurse-staffing agencies' conduct during 
the pandemic through Federal agencies with jurisdiction.

          We further urge Congress to prioritize certain 
        measures to support frontline health care providers and 
        maintain a strong workforce, including:

          Extending the Medicare-funded residency training 
        slots cap building period to 10 years, as opposed to the 
        current 5 years, for new teaching hospitals

          Enacting the Healthcare Workforce Resilience Act to 
        recapture 25,000 unused immigrant visas for nurses and 15,000 
        unused immigrant visas for doctors that Congress has previously 
        authorized and allocate those visas to international doctors 
        and nurses

          Enhancing investment in provider loan repayment 
        programs, including the Nurse Corps, to incentivize providing 
        care in rural and underserved communities

          Enacting the Technical Reset to Advance the 
        Instruction of Nurses (TRAIN) Act, which would prohibit the 
        Centers for Medicare and Medicaid Services (CMS) from recouping 
        overpayments made in past years to hospital-based nursing and 
        allied health education programs when CMS failed to make 
        technical annual updates to the program, and instead invest 
        those resources in training the next generation of caregivers

          Ensuring any policy that increases Pell Grant funding 
        makes certain that nursing students are eligible to receive 
        such benefits to attend high-quality nursing schools, 
        regardless of the educational institution's tax status

          Enacting the Conrad State 30 and Physician Access 
        Reauthorization Act to extend and expand the Conrad 30 program.

Parity for Tax-Paying Hospitals--and Our Workforce--is Needed Regarding 
            Eligibility for Federal Health-Related Programs
    We strongly urge Congress to expand the eligibility of Federal 
health-related programs that currently and unjustly exclude tax-paying 
hospitals--and thereby our workforce--to the detriment of our patients 
and communities. Tax-paying hospitals are not eligible to apply for 
many Federal programs, including some within the Public Health Service 
Act, based solely on their tax-filing status. This lack of program 
access among tax-paying hospitals, especially in rural communities, 
unjustly ignores a significant component of the health care safety net 
serving impoverished and uninsured patients.

    For example, for years, nurses practicing at tax-paying hospitals 
located in a critical shortage area were ineligible to benefit from the 
Nurse Corps Loan Repayment program--a key recruitment tactic that 
incentivizes patient care in rural and underserved communities. With 
the leadership of the Senate HELP Committee and other bipartisan 
Members of the House and Senate, this eligibility restriction was 
finally struck in The Coronavirus Aid, Relief, and Economic Security 
(CARES) Act in the 116th Congress. But we now need an across-the-board 
solution that can play a pivotal role in addressing the health care 
workforce crisis.

    As a first step toward rectifying this matter, we urge the Senate 
HELP Committee to direct the Government Accountability Office (GAO) to 
prepare a comprehensive analysis of all Federal health care programs 
that exclude tax-paying hospitals (and/or providers serving in such 
facilities) from eligibility. Such an analysis will shed light on how 
this lack of parity is a disservice to the health care workforce and 
our patients, and further demonstrate the dire need for Congress to 
take corrective action.

    We appreciate the opportunity to comment and look forward to 
working with you in 2022 to meet the significant challenges that 
hospitals face in treating patients during these unprecedented times. 
If you have any questions or wish to discuss these issues further, 
please do not hesitate to reach out to me or a member of my staff at 
202-624-1534.
            Sincerely,
                                      Charles N. Kahn, III,
                                                 President and CEO.
                                 ______
                                 
                           Global Medical Response,
                               Greenwood Village, CO 80111,
                                                 February 10, 2022.
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.

    Dear Chairman Hickenlooper and Ranking Member Braun:

    We appreciate the opportunity to submit written testimony for the 
Senate Health, Education, Labor, and Pensions Committee's Subcommittee 
on Employment and Workplace Safety hearing: Recruiting, Revitalizing & 
Diversifying: Examining the Health Care Workforce Shortage. While 
workforce shortages are impacting every aspect of the health care 
industry, the multiple headwinds facing the private ambulance industry 
in particular have resulted in a staffing crisis at a time when our EMS 
professionals have been challenged with unprecedented numbers of 
acutely ill and injured patients during the COVID-19 pandemic, natural 
disasters and other emergencies. We appreciate the attention this 
Committee is providing to resolving this crisis and we urge you to 
address and incorporate EMS professionals in any of your policy 
solutions to help recruitment and efforts to diversify the health care 
workforce.

    Global Medical Response (GMR) is the largest air and ground medical 
transportation company in the United States with more than 36,000 
employees, including 25,000 clinicians and 11,000 support staff across 
most of the lower 48 states, Alaska and Hawaii. GMR team members 
perform a critical intervention every 9 minutes and completed more than 
five million patient transports last year, utilizing 8,700 ground 
vehicles, 158 fire vehicles, 344 helicopters and 111 airplanes. As the 
Nation's largest provider of emergency medical services and medical 
transportation, we are on the frontlines both in the communities we 
serve, as well as in the areas that needed additional aid to supplement 
fellow emergency service providers. We are especially proud to service 
rural and underserved areas, where so many Americans rely on our 
services to navigate long distances to reach facilities that can 
provide the appropriate level of care. GMR provides the ``last mile'' 
infrastructure that helps secure critical care for over 43 percent of 
the rural counties in the United States.

    Our mission is to provide care at a moment's notice, and this 
guides our emphasis on patient-driven care that can respond to any 
health issue in any emergency scenario with the utmost quality. Due to 
our emphasis on giving the patient the highest quality care, we provide 
extensive training to our paramedics, emergency medical technicians 
(EMTs), and registered nurses (RNs). We value the skill set of these 
EMS professionals--who are called on to provide care on wheels or in 
the sky in high-stress situations--and we work with states and 
municipalities around the country to meet their unique requirements and 
needs. Many of our workforce moves around the health care field to 
serve in other capacities, and we take pride in ensuring that they can 
transfer the skills they learn with GMR into other segments of the 
industry.

    Since the start of the pandemic, GMR's EMTs, paramedics, nurses, 
physicians, and other caregivers have led the country's COVID-19 
response, risking their personal safety to administer life-saving care. 
We have made more than 350,000 COVID-19 patient transports and made 
emergency FEMA deployments to 31states including six states represented 
on this Subcommittee during coronavirus surges. GMR employees also 
screened more than 500,000 passengers for COVID-19 at airports and 
other ports of entry.

    Proud of our partnership with the Federal Emergency Management 
Agency (FEMA), GMR continued to respond to natural disasters, whose 
impact have been exacerbated by the pandemic. Since the virus first 
appeared in the United States, we participated in 7,874 patient 
missions in response to devastating wildfires and led operations 
deploying more than 600 ambulances and 25 airplanes in response to 
Hurricane Laura, Hurricane Delta, and Hurricane Zeta. To support these 
operations, we procured more than 25 million medical and K-95 masks, as 
well as 55 million gloves and gowns.

    In addition to the substantial time and effort GMR's first 
responders have devoted to confronting COVID-19, the company has made 
significant economic investments to protect its employees during the 
pandemic. Since March 2020, GMR has incurred $230 million in 
incremental expenses related to COVID. This includes $70 million in 
employee assistance like payments to staffers under quarantine, 
childcare stipends, workers compensation and health insurance, and one-
time bonuses. It also included $40 million for personal protective 
equipment (PPE) and cleaning costs. Additionally, GMR delivered 
approximately $30 million in one-time retention payments, made $90 
million in annualized wage adjustments, and approved nearly 93 percent 
of its 632 childcare stipend application requests. This has come at 
significant financial cost to the company, but we have done it because 
without our first responders, we would be unable to service vulnerable 
populations under our care.

    As a company, GMR has also been proactive in recruiting talent and 
training the next generation of EMS providers. Our driving force for 
retention and recruitment is the ability to save lives and impact 
patient care and outcomes. In 2018, we launched the Earn While You 
Learn program, a GMR academy that pays prospective EMTs during their 
training and certification process. Since 2018, more than 800 students 
have graduated from Earn While You Learn programs at 59 locations 
nationwide, over 35 percent of whom were minorities. In addition to our 
Earn While You Learn program, 593 students graduated from paramedic and 
EMT training programs from GMR's National Training Center in 2021 
joining 523 graduates in 2020.

    We have put into place a variety of other recruitment and incentive 
programs to attract and retain staff. These include reducing hours on 
call, providing bonuses and increased wages, providing wellness and 
stress management resources. And 10 years ago, the company established 
a GMR employee foundation to provide paid time off (PTO) and financial 
assistance in times of need to other GMR employees. In the last 2 years 
the company has provided over $1 million to employees to cover emergent 
personal needs.

    Despite our best efforts, this has not been enough. Even before the 
pandemic, the EMS workforce was hobbled by a lack of a pipeline to 
train professionals, significant burnout and stress, a competitive 
market, and unpredictable needs for ground ambulance protocols. 
According to a 2021 survey by the American Ambulance Association 
involving nearly 20,000 employees and 258 EMS organizations, overall 
turnover among paramedics and EMTs ranges from 20 to 30 percent 
annually, meaning that ambulance services could face a 100 percent 
turnover in a 4-year period. This has only been exacerbated by the 
coronavirus pandemic when in-person training was halted for a period of 
time further straining an already deteriorating pipeline and the 
industry began to face increased competition from others in the 
healthcare industry who were able to hire away EMS professionals to 
work in other settings for higher pay. These staffing shortages are 
problematic, and compromise GMR's ability to respond to healthcare 
emergencies.

    Despite the essential work our EMS professionals perform, economic 
headwinds facing the industry continue to contribute to a staffing 
crisis for private ambulance companies. These systemic headwinds have 
been left unaddressed for years and we hope to work with this Committee 
to enact policy changes that result in a viable, sustainable workforce. 
This crisis is driven largely by the low reimbursement rates these 
companies receive from Medicare and Medicaid. While Medicare and 
Medicaid rates for ground and air transports are well below cost and 
comprise close to 70 percent of GMR's total transports along with 
uninsured patients, our crews are required to respond to patient 
emergency requests regardless of the patient's ability to pay; medical 
crews respond to these requests within minutes--day or night, operating 
24 hours per day 7 days per week.

    GMR strongly believes the best way to alleviate the issue is to 
permanently update the Medicare and Medicaid reimbursement rates to 
reflect the standard of care. In the meantime, a temporary Medicare 
payment increase that reflects costs to increase wages and competes 
with the rest of the health care could also infuse additional funds 
into the workforce and spur innovative responses to workforce 
shortages. Appropriate reimbursement by government payors will allow 
private companies to increase wages for EMTs and alleviate the staffing 
crisis.

    In addition, we support additional steps Congress can take to 
alleviate the impact of the workforce shortage. Congress can provide 
specific direction and funds to the Health Resources and Services 
Administration (HRSA), which can be used to pay for training and 
professional development programs. HRSA can also disburse funds through 
grant programs to be paid directly to paramedics and EMTs for training 
initiatives In addition, Congress should strongly consider expanding 
HRSA loan repayment programs to include EMS professionals and establish 
a grant program providing funding to payors, public and private 
universities, and local governments to reimburse costs associated with 
education, loan forgiveness, and relocation for individuals who are 
pursuing careers in emergency transportation services.

    While a temporary solution, we support a Medicaid Federal Medical 
Assistance Percentage (FMAP) increase of 10 percent for emergency 
transportation services, identical to what was provided to home and 
community-based services during the pandemic.

    Finally, we support tax incentives for organizations who absorb 
significant costs due to uncompensated care and allocate significant 
resources to paying prospective EMS professionals while they get 
certified so they may serve their local community.

    It is important to note that many of our clinicians further their 
medical training to become nurses and even doctors. EMS is a pathway 
for recruitment and advancement of medical professionals across the 
health care system. We work with our team members to advance their 
learning and graduate from medical technician status to paramedic and 
to even become flight nurses and partner with hospitals on their 
staffing needs. We also invest in recruitment efforts to have our teams 
reflect the communities they serve.

    The more we can professionalize the emergency response industry and 
recognize the essential contributions EMS make to keeping our country 
healthy, the better it will be to retain and recruit people at this 
critical time while establishing a long-term sustainable workforce. 
Unfortunately, in the meantime, healthcare workforce shortages continue 
to meaningfully compromise our ability to respond to medical 
emergencies. Our workforce delivers services that are integral to the 
health care ecosystem. When frontline EMS is not available or delayed 
in responding due to staffing issues, the end result can be devastating 
to patients in need of critical care within minutes to prevent 
irreversible harm or even death. We thank you for your attention to 
this essential matter. We stand prepared to assist in ensuring the 
continuity of emergency medical care and are eager to work with you on 
how revitalize and diversify the heath care workforce.
                                ------                                

[[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    [Whereupon, at 11:39 a.m., the hearing was adjourned.]

                                  [all]