    [Senate Hearing 117-602]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-602

                      RURAL QUALITY OF LIFE: OPPORTUNITIES
                             AND CHALLENGES FOR THE
                               RURAL CARE ECONOMY

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

                                    HEARING

                                   before the

                           COMMITTEE ON AGRICULTURE,
                            NUTRITION, AND FORESTRY

                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 March 22, 2022

                                   __________

                           Printed for the use of the
               Committee on Agriculture, Nutrition, and Forestry

                [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      Available on http://www.govinfo.gov/
               COMMITTEE ON AGRICULTURE, NUTRITION, AND FORESTRY

                                    ______

    	                U.S. GOVERNMENT PUBLISHING OFFICE
     50-070PDF                  WASHINGTON : 2023

                     DEBBIE STABENOW, Michigan, Chairwoman
    PATRICK J. LEAHY, Vermont            JOHN BOOZMAN, Arkansas
    SHERROD BROWN, Ohio                  MITCH McCONNELL, Kentucky
    AMY KLOBUCHAR, Minnesota             JOHN HOEVEN, North Dakota
    MICHAEL F. BENNET, Colorado          JONI ERNST, Iowa
    KIRSTEN E. GILLIBRAND, New York      CINDY HYDE-SMITH, Mississippi
    TINA SMITH, Minnesota                ROGER MARSHALL, Kansas
    RICHARD J. DURBIN, Illinois          TOMMY TUBERVILLE, Alabama
    CORY BOOKER, New Jersey              CHARLES GRASSLEY, Iowa
    BEN RAY LUJAN, New Mexico            JOHN THUNE, South Dakota
    RAPHAEL WARNOCK, Georgia             DEB FISCHER, Nebraska
                                         MIKE BRAUN, Indiana

                   Joseph A. Shultz, Majority Staff Director
                   Mary Beth Schultz, Majority Chief Counsel
                        Jessica L. Williams, Chief Clerk
                   Fitzhugh Elder IV, Minority Staff Director

                                C O N T E N T S

                                  ----------

                            Tuesday, March 22, 2022

                                                                       Page

    Hearing:

    Rural Quality of Life: Opportunities and Challenges for the Rural
      Care Economy...................................................     1

                                  ----------

                        STATEMENTS PRESENTED BY SENATORS

    Stabenow, Hon. Debbie, U.S. Senator from the State of Michigan...     1
    Boozman, Hon. John, U.S. Senator from the State of Arkansas......     3

                                   WITNESSES

    Torres Small, Hon. Xochitl, Under Secretary for Rural
      Development, U.S. Department of Agriculture, Washington, DC....     5
    Henning-Smith, Carrie, Ph.D., Deputy Director, Rural Health
      Research Center and Rural Health Program, University of
      Minnesota, Minneapolis, MN.....................................    21
    Inwood, Shoshanah, Ph.D., Associate Professor, School of
      Environment and Natural Resources, The Ohio State University,
      Wooster, OH....................................................    22
    Carrica, III, Joseph, Ed.D., Chief Executive Officer, Behavioral
      Health, Southeast Health Group, La Junta, CO...................    24
    Holtz-Eakin, Douglas, Ph.D., President, American Action Forum,
      Washington, DC.................................................    26
                                  ----------

                                    APPENDIX

    Prepared Statements:
        Torres Small, Hon. Xochitl...................................    44
        Henning-Smith, Carrie, Ph.D..................................    50
        Inwood, Shoshanah, Ph.D......................................    58
        Carrica, III, Joseph, Ed.D...................................    63
        Holtz-Eakin, Douglas, Ph.D...................................    67

    Document(s) Submitted for the Record:
    Stabenow, Hon. Debbie:
        American Farm Bureau Federation, prepared statement for the
          Record.....................................................    78
        Rural Policy Research Institute, prepared statement for the
          Record.....................................................    81
        Bipartisan Policy Center, prepared statement for the Record..    84
    Warnock, Hon. Raphael:
        The Counter, article for the Record..........................    87

    Question and Answer:
    Torres Small, Hon. Xochitl:
        Written response to questions from Hon. Sherrod Brown........   104
        Written response to questions from Hon. Amy Klobuchar........   104
        Written response to questions from Hon. Kirsten E. Gillibrand   105
        Written response to questions from Hon. Raphael Warnock......   107
        Written response to questions from Hon. John Hoeven..........   108
        Written response to questions from Hon. Cindy Hyde-Smith.....   109
        Written response to questions from Hon. Charles Grassley.....   110
        Written response to questions from Hon. John Thune...........   112
    Henning-Smith, Carrie, Ph.D.:
        Written response to questions from Hon. Amy Klobuchar........   114
        Written response to questions from Hon. Kirsten E. Gillibrand   114
        Written response to questions from Hon. Raphael Warnock......   117
    Inwood, Shoshanah, Ph.D.:
        Written response to questions from Hon. Sherrod Brown........   120
    Carrica, III, Joseph, Ed.D:
        Written response to questions from Hon. Kirsten E. Gillibrand   123
        Written response to questions from Hon. Raphael Warnock......   124
        Written response to questions from Hon. Charles Grassley.....   125
    Holtz-Eakin, Douglas, Ph.D.:
        Written response to questions from Hon. Charles Grassley.....   126

    RURAL QUALITY OF LIFE: OPPORTUNITIES AND CHALLENGES FOR THE RURAL CARE
                                    ECONOMY

                                  ----------

                            TUESDAY, MARCH 22, 2022

                                           U.S. Senate,
             Committee on Agriculture, Nutrition, and Forestry,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10:08 a.m., via
    Webex and in room 562, Dirksen Senate Office Building, Hon.
    Debbie Stabenow, Chairwoman of the Committee, presiding.
        Present: Senators Stabenow, Brown, Bennet, Gillibrand,
    Smith, Boozman, Ernst, Marshall, Tuberville, Grassley, Thune,
    Fischer, and Braun.

    STATEMENT OF HON. DEBBIE STABENOW, U.S. SENATOR FROM THE STATE
        OF MICHIGAN, CHAIRWOMAN, U.S. COMMITTEE ON AGRICULTURE,
                        NUTRITION, AND FORESTRY

        Chairwoman Stabenow. Good morning. I call this hearing of
    the U.S. Senate Committee on Agriculture, Nutrition, and
    Forestry to order.
        Let me just say in the beginning it was great to be with
    Senator Boozman yesterday on the Mall for National Ag Day on
    the Mall. We appreciate the Association of Equipment
    Manufacturers for putting that together.
        I was thinking about today and how we so focus on
    supporting our farmers, as we should, our farmers and ranchers,
    and another piece of this is supporting the quality of life for
    them and their families. This is not just on the farm. This is
    folks who want to live in the small towns around Michigan and
    around the country and certainly in a small town like where I
    grew up, in Clare, Michigan. To do that, we have to make sure
    that there is a wide variety of support and services available
    so that they can continue to enjoy what I think is just an
    incredibly important quality and rich quality of life, of
    being, of living, in rural America.
        We want to welcome our Under Secretary Torres Small, and we
    welcome our witnesses this morning. It is wonderful to have you
    here to discuss the opportunities and challenges of the rural
    care economy.
        Everyone deserves a great quality of life in America and
    quality care at every stage of life no matter where they live.
    One in five Americans live and work and raise their families in
    small towns, surrounded by mom and pop shops, family farms, and
    neighbors who double as the local doctor, the fire chief, the
    mayor, or the school teacher.
        The COVID-19 pandemic exposed vulnerabilities in our rural
    communities, as we know, putting a strain on families, our work
    force, and our health care system. The opioid epidemic
    continues to take the lives of our friends and neighbors. As a
    native of rural Clare, Michigan, I can tell you firsthand that
    rural American remains resilient and resourceful. Building a
    sustainable economy starts with reliable access to child care,
    elder care for our parents and grandparents, and health care,
    including mental health and substance abuse services.
        We all know a small business owner who sets store hours
    based on if, and when, they have someone available to take care
    of their young children or their aging parents. It is a godsend
    for their growing business when their local government and
    neighboring businesses team up to build a new child care center
    with the help of the USDA, and it is even better for the small
    business owner when her folks can stay in the very community
    where they grew up now that their local hospital has the
    modernized equipment and telehealth services to expand
    treatments or their local community center gets new digital
    tools to stay connected to friends and family.
        That is exactly what we have seen in Alcona County,
    Michigan, where USDA Rural Development and resources helped
    connect seniors with their families and friends through
    technology. Loneliness is tough on our seniors, but USDA is
    helping us beat it.
        We all know someone whose life has been changed as well by
    the opioid epidemic. As they work on their recovery, they may
    need to lean on new telemedicine services for addiction
    treatment because they cannot get to the clinic three towns
    over.
        We all have a friend who is spread thin driving all around
    the county to get critical community health services, taking up
    hours of their day and spending a lot of gas. It makes a big
    difference when they can get their health care needs met in one
    place.
        In Michigan, for example, Allegan County residents worked
    with USDA to purchase and renovate a building to consolidate
    the county's medical, dental, behavioral health, and other care
    management services, and they were able to become a certified
    community behavioral health clinic and provide more people with
    mental health services and addiction treatments.
        We all know a farmer who cannot take time to check in on
    their own health, physical or mental, when they are trying to
    keep the family farm afloat 24-7. The work the American Farm
    Bureau Federation does in its Farm State of Mind Program, in
    partnership with Michigan State University, for example, is
    taking the stigma out of mental health treatment so farmers
    know that they can, and should, seek the help they need.
        I ask unanimous consent that the statement from the
    American Farm Bureau Federation be entered into the record.
    Without objection.

        [The prepared statement can be found on page 78 in the
    appendix.]

        Chairwoman Stabenow. Our witnesses will attest, I am sure,
    that strengthening the care economy helps rural communities
    thrive, and I am sure Under Secretary Torres Small will share
    about how the USDA is a trusted partner with the local
    communities that you serve.
        I ask unanimous consent to enter into the record statements
    of support from the Rural Policy Research Institute and the
    Bipartisan Policy Center. Without objection, so ordered.

        [The prepared statements can be found on pages 81-86 in the
    appendix.]

        Chairwoman Stabenow. With that, I will turn to my friend,
    the Ranking Member from Arkansas, Senator Boozman.

     STATEMENT OF HON. SENATOR JOHN BOOZMAN, U.S. SENATOR FROM THE
                           STATE OF ARKANSAS

        Senator Boozman. Thank you very much and thank you for
    calling this hearing today, Chairwoman Stabenow. I look forward
    today, with my colleagues, as we examine the rural quality of
    life and care economy. I also look forward to hearing from
    Under Secretary Torres Small and our other witnesses.
        Thank you for being here, Under Secretary.
        There is no question that families in rural America need
    access to affordable, quality health care, child care, and
    elder care in their communities. USDA Rural Development has a
    number of programs to help purchase, construct, and improve
    rural health clinics, child care centers, nursing homes, and
    other facilities to meet the need and buildup the rural care
    economy. I strongly support the USDA Rural Development programs
    that make funding available to these vital services, and we
    appreciate the Under Secretary's hard work in providing
    leadership in this area.
        However, we should not approach this as a ``Field of
    Dreams'' scenario, where if we build it, they will come. Rural
    economic viability, a strong economic floor, is what is
    necessary to support a care economy. Federal policies and
    regulations can have an outsized impact on the economy of rural
    America. We have seen it time and time again, and we are seeing
    it right now. If we truly want rural America's families to have
    access to quality health care, child care, and elder care, then
    we must provide the stability and certainty necessary for our
    farmers and ranchers and the businesses they support to thrive.
        Unfortunately, the current economic and policy environment
    is far from stable for our rural communities. The economic
    headwinds facing Americans today are simply staggering, and
    rural America is taking a heavier hit. Inflation is at the
    highest it has been in more than four decades, at 7.9 percent.
    With half of the U.S. population under the age of 40, this is
    the highest inflation many have seen in their lifetime.
        Since President Biden has taken office, food prices have
    increased by more than eight percent, which is the fastest rate
    of food price inflation of any President since Jimmy Carter.
    Also, gasoline prices are up nearly 50 percent, electricity
    prices are up more than 30 percent, and piped gas utility
    prices are up 25 percent. The average price of unleaded
    gasoline is now at $4.25 a gallon.
        Last week, the Mayor of Monette, Arkansas, Bob Blankenship,
    spoke about how diesel prices are approaching $5 a gallon and
    his concerns about what fuel expenses may do to Monette's
    budget and, ultimately, operations of essential services if
    city officials are forced to make difficult budget choices.
        The numbers are equally dire for our Nation's farmers and
    producers. Farm production expenses will be a record high of
    $412 billion in 2022, an increase of $54 billion or 15 percent
    since the President entered office. Whether it is regulatory
    decisions like canceling the Keystone XL Pipeline, placing a
    moratorium on conventional energy development on Federal land,
    or failing to follow through on campaign promises to implement
    strong biofuels measures to reduce prices at the pump, and
    support our Nation's farmers, the actions of this
    Administration have certainly not been good for rural quality
    of life.
        The common theme I hear from farmers and other rural
    Arkansans when I am back home every weekend is frustration with
    misplaced priorities and misguided policies, proposals like
    doing away with the stepped-up basis or standing up programs to
    achieve the 30x30, without focusing on efforts to release
    disaster funding farmers have been waiting for. Agriculture is
    the economic driver for the vast majority of rural America, and
    the decisions that harm agriculture or place the needs of the
    industry in the background do nothing to foster rural
    communities.
        For example, as our Nation's ag stakeholders continue to
    face supply chain disruptions, high input costs, tariffs, and
    uncertainty surrounding global commodity prices, there is still
    no nominee for either USDA's Under Secretary of Trade or Chief
    Agriculture Negotiator at USTR. This means there is no trade
    agenda currently standing up for our Nation's farmers and
    producers in a time of hyper uncertainty surrounding global
    commodity markets.
        When we seek to work with the Administration on possible
    solutions to address some of the most pressing issues facing
    the world today, like extending the deadline for CRP signup, to
    help mitigate already high inflation and food security concerns
    made worse by Russia's ruthless invasion of Ukraine, USDA
    declines. Shouldn't we be doing everything in our power to
    address this and other issues that will very likely negatively
    impact global commodity markets for years to come? Again,
    misplaced priorities seem to be the common theme of the
    Administration.
        I would like to have Secretary Vilsack testify before our
    Committee, who, despite interest from myself and many of my
    colleagues, has not appeared before our Committee since his
    nomination hearing in February 2021. That is more than a year
    ago. That is simply unacceptable.
        Madam Chair, I appreciate you holding today's hearing. I
    did enjoy being with you yesterday at the Agri-Fair, seeing all
    the kids climbing on the tractors and this and that. I really
    look forward--I know everyone is interested as we go forward--
    beginning really addressing the problems that I talked about as
    we go forward with the Farm Bill. Like I said, I know you are
    excited about that; I am excited about it. Thank you very much.
        Chairwoman Stabenow. Thank you very much. I am excited. I
    am excited to go to Arkansas and have an opportunity with you
    to do a field hearing.
        I will say, to underscore, there were lots of things that
    you raise, all of which I am anxious to discuss. I will say,
    yesterday out on the Mall, we saw a biodiesel garbage truck,
    basically, that DC is using biodiesel. You know. Right now in
    the short run, if we want to help our farmers have cleaner
    fuels and be able to tackle the economic crisis, we need more
    biofuel; we need more biodiesel. This is something that I feel
    very strongly about.
        Eventually, I want to drive by the station and not even
    have to worry about the price, in my electric vehicle. There is
    a lot of good things, and the electric trucks that are coming
    online for our farmers is pretty exciting.
        A lot to talk about. We need to do that in a separate
    hearing, but certainly around gas prices and what I think is
    actually price gouging that is going on is not helping our
    farmers or anybody else. Today, a very important discussion.
        We want to welcome back our Under Secretary Torres Small.
    Congratulations again on your Senate confirmation. We are so
    pleased you are in this role.
        Before coming to Rural Development, Under Secretary Torres
    Small was a United States Congresswoman for the fifth largest
    district in the country. As a member of the House Agriculture
    Committee, Xochitl helped champion the needs of dairy farmers
    and sponsored legislation to help local produces in rural
    communities invest in infrastructure to navigate new markets.
        The granddaughter of farm workers, Xochitl Torres Small
    grew up in the borderlands of New Mexico. She continued serving
    rural New Mexico as a field representative for Senator Tom
    Udall. She has a law degree from the University of New Mexico
    School of Law and an undergraduate degree from Georgetown
    University School of Foreign Service.
        Thank you so much for being with us today, and I will turn
    it over to you for five minutes prepared response, comments.
    Whatever other comments or information you would like to have
    in the record, we would be happy to accept it. Under Secretary,
    welcome.

        STATEMENT OF THE HONORABLE XOCHITL TORRES SMALL, UNDER
          SECRETARY FOR RURAL DEVELOPMENT, U.S. DEPARTMENT OF
                     AGRICULTURE, WASHINGTON, D.C.

        Ms. Torres Small. Thank you, Chairwoman Stabenow; thank
    you, Ranking Member Boozman and members of the Committee, for
    this opportunity to discuss the rural care economy.
        This, as you know, is literally an issue of life and death.
    It is also an everyday issue of quality of life when it comes
    to rural Americans and an existential issue of the future of
    rural America. When it comes to health care, both physical and
    mental, elder care and child care in rural places, that enables
    families to enjoy every chapter of their lives in the places
    they want to call home.
        The phrase ``care economy'' may sound general, but it is
    deeply personal to each of us. It makes me think of a phrase--
    when I hear the phrase, I think about a woman in Arkansas who
    had complications during her pregnancy and she wanted the best
    start for her baby. Every day she left her house to go up to a
    hill where there was good enough service so she could upload
    her vitals and send them to the University of Arkansas High-
    Risk Pregnancy Program. That is the power of technology, that a
    dedicated mom and a network of care can make those first
    moments safer.
        We have work to do to make that care easier to access, and
    the numbers explain why. Since 2010, 135 rural hospitals have
    closed, and an additional 453 are vulnerable to closure. Rural
    care is, of course, more than hospitals, but the rest of the
    picture is similarly bleak. There are fewer nursing homes in
    rural America even though the average age in rural America is
    higher. More than 60 percent of rural residents live in a
    mental health desert, and more than 60 percent of rural
    families also live in a child care desert.
        As we all know, lack of good care has ripple effects.
    Addiction and substance misuse destroy lives and whole towns
    across rural America. When a sole community hospital closes,
    per capita income actually decreases by four percent and
    unemployment increases by 1.4 percent--1.6 percent. When
    parents cannot find care for their children, they have trouble
    keeping their jobs. When you do not have the care you need in
    the place you live, people start moving.
        That is why rural people are stepping up to the challenge.
    The Indian medical center in Gallup, New Mexico, recently
    worked with Rural Development to get better internet to their
    facility, which they then used to set up a Wi-Fi hotspot to
    serve that area. During COVID, a granddaughter who had not
    spoken to her grandfather for a long time was able to reach out
    to him during his final days. She was not able to be with him
    in his room because of the pandemic, but she connected to the
    medical center's Wi-Fi in the parking lot, and they were able
    to see each other and say their final goodbyes.
        As both of these stories show, the bipartisan
    infrastructure law's unprecedented investment in broadband can,
    when combined with rural determination and ingenuity, help
    bridge the divide in the rural care economy. It allows Rural
    Development to be there for rural workers, who know what they
    need to care for their community, to keep doors open and find
    other ways to reach rural residents.
        I also hope we talk about how creative flexible thinking
    can address core issues like staffing because human capital is
    the thread that holds the care economy together. Without it,
    everything else unravels. Lack of staff, both in terms of time
    and experience is also one of the greatest barriers to
    accessing Rural Development programs. Thankfully, in the
    American Rescue Plan, Congress helped Rural Development change
    that with a five percent set-aside for staffing, technology,
    and technical assistance for applicants to our Emergency Rural
    Health Care Grants. This allowed Rural Development to hire
    industry specific staff, to create a user-friendly application
    portal, and to provide technical assistance for customers to
    apply in record time.
        While some Federal programs of this scope can take years to
    stand up, Rural Development understood the urgency of the
    moment. We stood up this brand new approach in less than six
    months. It is a great example of the impact we can make when
    our programs are appropriately resourced and we have the
    capacity to administer them.
        I look forward to working with all of you to make sure we
    use Rural Development to its absolute fullest potential to
    support the rural care economy and the people who depend upon
    it. I look forward to your questions. Thank you.

        [The prepared statement of Ms. Torres Small can be found on
    page 44 in the appendix.]

        Chairwoman Stabenow. Thank you so much. Six months is
    pretty fast, Under Secretary. Congratulations.
        Let me first start, and of course, members, we will each
    take five-minute rounds in questions.
        Nineteen rural hospitals closed in 2020. Nineteen. I
    remember I grew up with my mom being director of nursing at a
    small hospital in Clare, and the only reason they have now
    survived is that they are part of a bigger system that is
    Statewide. We have 19 rural hospitals in 2020, the largest
    number to close in a single year since 2005. By late 2021,
    twice as many rural residents were dying of COVID-19 as people
    who lived in urban communities. Why were rural communities hit
    so much harder?
        Ms. Torres Small. That is such a great question, and it
    does go back to the care economy, making sure that we have good
    places of care all across the country and access nearby. I have
    been inspired to see, as you said, the increased coordination
    and partnerships that happen within rural communities and the
    health care they provide.
        During COVID, what we saw for hospitals that were
    successful is that they were working together. I was in Alabama
    recently, and they talked about patients going to one place
    because there were not intensive care units in another
    hospital, but then that hospital taking on some of the load for
    non COVID 19 patients. That kind of collaboration is crucial so
    that we can survive the next challenge that we will face.
        Chairwoman Stabenow. As you mentioned, Congress has given
    USDA tools to support the health and quality of life in rural
    communities. You mentioned addressing hospital closures,
    emergency health care needs during the pandemic, opioid misuse,
    for example. Could you speak more about what these investments
    mean for a rural family and how do these USDA investments help
    keep rural people in the communities where they want to live?
        Ms. Torres Small. At every stage of life, there are
    challenges that if you do not have a rural care economy you
    might have to choose to leave. That is why it is so crucial
    when it comes to having child care so that parents can get to
    work and so that there is more employment in the area, or
    whether it is elder care so that people can age in the place
    that they love and finding ways to make that more accessible.
    Mental health care with telehealth is a crucial opportunity.
    The start of life. When you talk about rural hospitals, often
    when they are in financial stress, one of the first things that
    closes is the maternity ward, the OB ward, and so being able
    for people to start their lives in the place that they want to
    be.
        Chairwoman Stabenow. Well, thank you. Let us talk a little
    bit more about the alarming spikes in drug overdoses and a
    hidden epidemic really within the COVID pandemic. We know that
    roughly one out of five of those living in rural communities
    are struggling with mental illness.
        For the first time in the Farm Bill's history, the 2018
    Farm Bill included an entire section on rural health. How do
    rural hospitals and clinics use these funds to improve care for
    patients? Could you speak a little bit more about that? What is
    USDA doing to address the ongoing issue of substance use
    disorder?
        Ms. Torres Small. One of the ways rural hospitals are using
    the resources provided is to look at their financials. We have
    been able to set up a technical assistance program that works
    with rural hospitals to identify what their challenges are in
    covering their bills and to better make use so that they can
    have a more sustainable model. That has been incredibly
    successful. We really appreciate that investment.
        In addition, when it comes to taking on opioid abuse and
    the challenges that we have seen in the epidemic there, we have
    seen really exciting models. Winrock is doing--has a
    collaboration that has received a Delta Health Services Grant
    to make sure that they are reaching--training on NARCAN in
    places that people had not thought of. All of the volunteer EMT
    services, for example, reaching out to them when so often it is
    actually they are reaching out to the paid firefighters, for
    example. Having that rural expertise has really helped us find
    new ways to tackle the opioid epidemic.
        Chairwoman Stabenow. Thank you. Finally, let me just say we
    all know that families, individuals across the country, small
    businesses, large businesses are struggling with higher prices,
    and certainly families are struggling with the prices and what
    happens in terms of returning to work and so on. Unfortunately,
    with a global pandemic that shut the entire economy down, not
    just the United States but the globe, putting this back
    together and dealing with food supply chains and manufacturing
    supply chains and transportation supply chains and all of this
    is a huge task. We all know that. How can USDA investments in
    the rural care economy lower costs for families?
        Ms. Torres Small. You are absolutely right. When we look at
    the impact of the global supply chain right now and the
    challenges from the COVID-19 pandemic, the last thing that
    people, as they are struggling to get food on the table, can
    handle is if their child care provider gets COVID and they
    cannot bring them in to receive care or if they are worried
    about the mental health services that they need as they are
    trying to cope with this. Rural Development is crucial to be
    there for that care economy, to keep it open, as we all try to
    tackle these economic challenges together.
        Chairwoman Stabenow. Great. Well, thank you very much.
        Senator Boozman.
        Senator Boozman. Again, thank you so much for being here.
    One of the concerns I have, you mentioned the importance of
    community hospitals. Certainly, you lose your community
    hospital; you lose your doctors; you lose the best paying jobs
    in town. Very important.
        One of the things--it is not just this Administration, but
    it is administrations in general. It is just a regulatory
    burden that we are seeing that the hospitals face. You know,
    you go and visit with these folks, and it is difficult.
    Medicare cuts, you know. This last time, we were able to
    reverse like an 8 to 10 percent Medicare cut for some
    specialties. The list goes on and on.
        The ability to acquire grants, you know. The Federal
    Government has kind of moved to the grant program. They are
    telling me now that some of these things are getting such that
    it is so complicated to try and get your transportation grant
    or whatever grant. It might cost $150,000 to hire a consultant
    to get it done.
        I guess what I would like, you know, for you to kind of
    agree to, that we have got to reverse that. You know, that we
    cannot continue. You know, we say one thing, and yet--and
    again, you are the Federal Government. I am the Federal
    Government. We cannot continue to put additional burdens that
    actually go against what we are saying.
        The other thing--so I would like for you to talk about
    that.
        Then also, a commitment. As we talk about rural hospitals
    and stuff, USDA needs to be talking to CMS and vice versa. See
    what I am saying? It all goes together. I do not see that we
    are communicating very well in that regard at all because these
    policies really are having a very negative effect.
        The biggest problem I see with rural America is losing
    population. We have got 75 counties in Arkansas; 55 of them
    lost significant population. You lose your turn-back dollars.
    You dig yourself into a deeper hole. That is all about
    creating, I think, economic opportunity. We take that away to a
    certain extent by again just forcing all of these rules and
    regulations.
        Ms. Torres Small. Thank you so much for that question about
    the model for hospitals and how you can have a financially
    stable approach as well as coordination, the need for more
    coordination, and then opportunity when it comes to economic
    opportunity.
        The first part about financial models and adapting to that
    regulation, I am very grateful for the technical assistance
    program that you all supported because it has allowed us to
    look at, to support, rural hospitals in terms of their balance
    sheets. What are the changing challenges that they have, and
    how can they best shape their business model to address that so
    from a--we can get in there and help support to become more
    economically viable.
        As you mentioned, that also means making grants more
    accessible. I was looking recently at a--talking with a
    hospital that received a Community Facilities Grant. It can be
    life-changing. I mean, to have--to get to go from having to
    store all of your medical equipment in a Coke machine because
    that is the refrigerator that they could find, to then being
    able to shift and have one that, you know, beeps when the
    temperature changes or goes out of order. Makes a huge
    difference for their ability to function.
        Those grant dollars are hard to get, and the numbers show
    why. CF grants, last year's $24 million grants across the
    country, but when you look at guaranteed loans, it was 10 times
    as much, $242 million. Then CF direct loans was over a billion
    dollars. The competition for that grant money is high.
        Senator Boozman. Competition is high, but also in these
    rural communities they do not have the ability to get the grant
    writers. That is a big problem. That is a simple thing. That is
    a doable thing. A lot of these other problems are very, very
    difficult, but that is one we can fix.
        The other commitment that I would like to have is we have
    got to get the FSA and Rural Development people in place in the
    States. You know, we talk about these things. If your boots on
    the ground are not there, it is not happening. Okay? That is a
    big problem.
        The other thing I would like for you to comment on very
    quickly, USDA recently changed rules governing its ReConnect
    broadband program by increasing levels of speed to 100 over 20
    megabits per second when determining whether an area is
    eligible for funding. I think everyone on this Committee
    supports expanding broadband to rural areas. There are serious
    concerns about vastly increasing the standard from 10 over 1 to
    100 over 20. What we do not want to do is encourage
    overbuilding in areas that already have broadband at the
    expense of those lacking basic access. Will you commit to
    making sure that does not happen?
        Ms. Torres Small. We will commit to making sure that there
    we are taking all of the funding into consideration and doing
    everything we can to make sure they are complementary. It is
    crucial that we are using this money in a wise way, this
    funding in a wise way.
        Senator Boozman. Right. You talked about all these things
    we can do with broadband, you know, walking up to the top of
    the hill and things like that, which is so, so very important.
    All I am saying is let us get it to the areas that do not have
    it, as opposed to the areas that have pretty good that want
    better.
        Ms. Torres Small. One of the opportunities that Rural
    Development has is to create a backbone, that more can be--that
    can be used to expand service even further. In doing that,
    being able to have some of those upload speeds is crucial, like
    with those vitals. It was about the level of service, to upload
    as well as to download, in order to be able to communicate
    that.
        I do think there is a concern about not leaving rural
    communities in the slow lane but also making sure that we are
    reaching communities that do not have service at all, and that
    is why the priority there is crucial.
        Senator Boozman. Right. No, slow is better than none.
        Thank you, Madam Chair.
        Chairwoman Stabenow. Thank you very much.
        Senator Bennet.
        Senator Bennet. Thank you, Madam Chair, and thank you. I
    have got relatives in Lee County, Arkansas. I just have to say
    that to Senator Boozman. I completely agree on the broadband
    point. I think that----
        Senator Boozman. I am extra special nice to you because you
    have constituents.
        Senator Bennet. I know. That is right. I think they
    probably vote for you, too.
        Much more important than that, I think this
    infrastructure--you know, the broadband package in the
    infrastructure bill. You know, finally, this town is going to
    stop subsidizing the largest telecom companies in America and
    instead build broadband in rural parts of this country because
    of what we have done with Senator Portman and Senator King from
    Maine. It was a tripartisan bill, and I am very pleased. I hope
    it comes to everywhere in Arkansas that needs it because a lot
    of people need it, and in Michigan. Kids do not need to be
    doing their homework in grocery store parking lots.
        I want to thank you for holding this hearing. It is really,
    really important to my State. I want to start by thanking the
    extraordinary people in rural Colorado, the health care
    providers that have fought through and sustained our
    communities during this COVID challenge. Even before COVID,
    they did not have the--everybody here knows they did not have
    the resources they needed to do what we needed them to do.
        In the first year of COVID, from February to February, I
    actually traveled to all of Colorado's 64 counties, 47 of which
    are rural and frontier. Just last week, I had a conversation
    again with some rural providers, and they shared with me the
    challenges that they are facing to keep their doors open. I
    have heard a similar lament all over the State, which is we
    need to update health infrastructure and we have to address the
    mental and behavioral health crisis, especially facing our
    young people. The suicide rate in rural Colorado for young
    people is twice as high as it is in urban parts of my State.
        Secretary Torres Small, you mentioned in your testimony
    that hospitals are closing across rural America. Indeed, that
    is true. With other challenges, these closures contributed to
    COVID-19, listen to this, being twice as fatal for rural
    Americans than other Americans. That is one of the reasons why
    I wrote the Hospital Revitalization Act, which would invest $17
    billion in our rural hospitals and clinics that are physically
    deteriorating all at the same time, all across our country.
        Secretary Torres Small, could you tell us about the
    economic costs and other consequences of hospital and clinic
    closures in rural communities and why we should invest in our
    rural health infrastructure? I have one other additional quick
    question. Thank you.
        Ms. Torres Small. The economic costs are crucial when it
    comes to the impact in rural health care, whether it is the
    closure of an elder care facility, which I know in La Junta
    recently there was a closure and Rural Development helped build
    a new senior living facility to replace that. That is crucial.
        My parents actually--my grandparents ended up retiring in
    Colorado, and they chose the place specifically because there
    was a good living facility in a rural area where they could
    retire. That is the direct impact that it can have.
        When it comes to having those mental health care services
    that are crucial, you know, farmers' stress is an incredibly
    challenging issue. The American Farm Bureau, along with the
    National Farmers Union recently did a survey that showed that
    74 percent of farmers have been directly impacted by the opioid
    crisis. Being able to provide that mental health support is
    crucial for rural America.
        Senator Bennet. Thank you. Your parents, I am sure, came
    over Raton Pass to make it to La Junta. We are very happy to
    have them there.
        Madam Secretary, the COVID-19 pandemic has shed light on
    the mental and behavioral health crisis that has been under the
    surface for years and years. According to Mental Health
    America, Colorado ranks 47th in prevalence of mental health
    versus access to care. Screenings for depression in Colorado
    increased 600 percent over the past year.
        This is--again, everybody is being affected by this, but it
    is particularly our young people, as a former school
    superintendent, where I see the challenges of COVID. This is
    something I hear about from everyone in Colorado, but in rural
    Colorado barriers like work force shortage, low reimbursement,
    and stigma are only intensifying the problem.
        I have been working with a number of colleagues on
    proposals to address the crisis in the short term and the long
    term. For example, as the 988 Suicide Prevention Lifeline is
    fully implemented this summer, we were able to secure another
    $100 million to help with implementation in the latest
    Appropriations Bill.
        I know that you are largely focused on closing the digital
    divide to help improve and sustain telehealth and other remote
    services, which I am grateful. Secretary Torres Small, would
    you be able to identify any other USDA initiatives that would
    need more support from Congress to help address the mental and
    behavioral health crisis that we face?
        Ms. Torres Small. This is related to closing the digital
    divide, but it is not just about getting the fiber to the
    places that need it. It is about having the technology on the
    receiving ends.
        The distance learning and telemedicine grants are crucial.
    I have seen across the country places where they have been used
    to provide mental health services in rural schools, which
    limits the stigma because they can access it right in their
    school. That is, I think, a great opportunity to get that
    mental health service across the country in a way that makes it
    more accessible for rural communities.
        Senator Bennet. Thank you, Madam Chair. Thank you.
        Chairwoman Stabenow. Thank you very much. Important
    questions.
        Senator Ernst. Then I believe we have Senator Gillibrand
    virtually with us. Senator Ernst.
        Senator Ernst. Okay. Thank you, Madam Chair.
        Thank you, Under Secretary Torres Small, for being here and
    for your testimony today. I appreciate you sharing your ideas,
    your insight, and for representing the Biden administration for
    today's hearing on something that we can all get behind, which
    is supporting our rural communities and rural America.
        I will have to say I have been hoping, just as the Ranking
    Member has been hoping, to have Secretary Vilsack join us here
    in the Senate Agriculture Committee in person, and I continue
    to ask him to finally come before us to answer some of our
    questions. We do hope to have that very soon, but I do
    appreciate you being here today, Under Secretary. Thank you for
    your testimony.
        Today, on National Ag Day, we have heard a lot about the
    importance of our rural communities. It is something that
    absolutely is very near and dear to me. As some of you may
    know, I grew up on our family farm in southwest Iowa, not far
    from where I still live today, in Montgomery County. I know
    firsthand the hard work of our farmers and our farm families,
    what they put in day-in and day-out to make their living and to
    provide the food and critical goods for our State, our country,
    and the whole planet. There is no question that supporting our
    rural communities is a top priority for me.
        Today, we have heard a lot about how this Administration
    wants to work to support those communities. I want to believe
    that the Biden administration does want to support rural
    America, and I know that Iowa farmers want to believe that,
    too. The unfortunate reality is that after a year in office
    President Biden's track record, along with the agenda and the
    specific plans he is proposing, are telling a very different
    story.
        First, let us look at the President's track record after
    more than 14 months at the helm. Heading into the 2020
    election, the President talked a really big game in Iowa and
    throughout the Midwest when it comes to standing up for
    biofuels. While he was out in Iowa, talking to farmers on the
    campaign trail, he would say, for instance, ``A Biden-Harris
    administration will promote and advance renewable energy,
    ethanol, and other biofuels to help rural America and our
    Nation's farmers.'' Iowans believed him.
        Then this past December, after failing to meet the November
    30th deadline as required by law, President Biden took action
    to reopen the finalized 2020 RVO rule and propose 2021 and 2022
    volume obligations that strip out billions of gallons of
    biofuel demand. The decision was an about-face by a President
    who campaigned on his supposed support for renewable fuels.
        The reality is that these RVOs will slash demand for
    biofuel and will have devastating, long-lasting consequences
    for Iowa farmers and producers. In their rush to appease
    coastal elites and promote electric vehicles in the name of
    green energy, the Biden administration is snubbing biofuel, a
    readily available energy solution that deserves full
    consideration.
        Then there is the President's record on free trade and free
    trade deals, something that is critical for our farmers. At
    first, the Biden administration announced they would be putting
    domestic policy ahead of considering negotiations on new free
    trade agreements. We need action now, and unfortunately, the
    President has shown a reluctance to forcefully engage on free
    trade.
        In fact right now, a critical trade position is being left
    vacant by the President. After more than a year in office, the
    Administration has yet to fill the position for the USDA's
    Under Secretary for Trade and Foreign Agricultural Affairs, and
    this has been mentioned already this morning. It is a position
    that is critical for American farmers and producers so we can
    build and maintain strong relationships with our trading
    partners around the globe.
        Then just last week, the administration withdrew their
    nominee for the USTR's Chief Agriculture Negotiator, a position
    Iowa farmers and producers have been waiting over six months to
    get confirmed.
        At the same time, the President has been insistent on
    returning farmers to the harmful over-regulation of the Obama
    era, specifically with an over-regulation of the Obama era
    known as Waters of the U.S. or the WOTUS rule. They are working
    to renew that.
        As you can see, the Administration's record for rural
    America has been less than stellar to say the least.
        You know, I know my time is expiring. I could go--I have
    many, many more examples of where the President has taken a
    full-on assault of rural America. I am glad that we are
    discussing how can we be supportive. There were a lot of
    promises made by this President; he has yet to live up to them.
        With that, Madam Chair, I yield back.
        Chairwoman Stabenow. Thank you very much.
        Senator Gillibrand, are you with us?
        Senator Gillibrand. Thank you, Chairwoman.
        Chairwoman Stabenow. Good morning.
        Senator Gillibrand. Under Secretary Torres Small, in your
    testimony, you articulated the many challenges that rural
    communities face, particularly when it comes to accessing
    comprehensive health care. Even before the COVID-19 pandemic,
    rural hospitals have been closing at an alarming rate in our
    State of New York.
        My Rebuild Rural America Act would create a Rural Future
    Partnership Fund that would provide multiyear, flexible block
    grants to support rural revitalization, with support for health
    care services as an eligible use of funds. Do you believe that
    the rural communities should have a dedicated Federal grant
    opportunity made available to them that allows for communities
    to make long-term investments?
        Ms. Torres Small. Senator Gillibrand, thank you for your
    vision for rural communities, and I think it reinforces some of
    the conversation we were having earlier today with Senator
    Boozman about how do we make funds more accessible to rural
    communities. I know I am in a rural community when I am in a
    room full of people who care deeply about their home but none
    of them are a grant writer. We have got to find ways to make
    sure that those communities can truly access our funds.
        I appreciate your work there and hope that that is an
    opportunity where we can work together and provide the
    technical assistance that you may have. It is certainly our job
    to follow Congress's lead on that work, but we are eager to
    find ways to support regional innovation and additional access
    to grants.
        Senator Gillibrand. Thank you. Our national investment in
    rural areas and small towns has not always matched their
    contribution. Instead of prioritizing the potential of rural
    communities invested in opportunities such as work force
    development training, many rural communities have been left on
    the sidelines. This is one of the reasons it is so important
    that we must increase our investment in rural communities to
    train the next generation of health care workers, child
    caretakers, and nursing home staff.
        Your testimony is focused on rural health care, and we know
    how important health care work force development is to
    achieving our shared rural health goals. What can we do to most
    effectively invest in our rural health care work force,
    particularly when it comes to addressing equitable health
    outcomes for communities of color?
        Ms. Torres Small. Thank you so much, Senator. I have seen a
    lot of exciting ideas from communities across rural America,
    and Rural Development is uniquely positioned to help support
    those exciting visions. Whether it is establishing a child care
    cooperative--we have seen the wages for cooperatives be higher,
    up to a dollar higher, than the industry standard. That is one
    idea that a rural community may have that we may be able to
    support.
        Whether it is doing more work force training through
    telecommunications through a distance learning and telemedicine
    grant is another opportunity that we have seen impact. I think
    actually in New York, in your own State, there was a recent DLT
    grant to train firefighters. That is another way, again, to
    support that work force.
        The real, I think, option is how do we link the resources
    across a rural area to best leverage and train the future work
    force in the rural care economy.
        Senator Gillibrand. Well, there is one idea. I secured $3
    billion in the American Rescue Plan to establish the Health
    Force. It is the first national community health worker grant
    program for the Centers for Disease Control and Prevention so
    that State and local health departments have resources to train
    and employ community health workers.
        How should we be incorporating community health workers
    into the rural health and social services framework? Are there
    any examples of community health worker models in rural America
    that you know about that we should learn from?
        Ms. Torres Small. That is such a great question, and it
    speaks to that need for coordination and interagency work. I am
    really pleased that this Committee invested in a rural health
    care liaison, and that is a great opportunity for us to be able
    to share the examples that we see on the ground and communicate
    with CDC, for example.
        I mentioned the worker co-ops. We have seen a lot of
    interest in that recently, and I think it could be an
    opportunity to share lessons learned. I have also seen
    economies of scale work really well. There was a Delta Health
    Partnership that was working to have shared training for work
    force by leveraging all of the different regional health care
    providers in a community. Working to collaborate regionally, I
    think, is a great opportunity to train rural care economy
    workers.
        Senator Gillibrand. Thank you. As we rapidly approach the
    2023 Farm Bill, we are at a unique opportunity to maximize our
    investments in our rural communities. Many of these communities
    are at a disadvantage when it comes to securing Federal funding
    as they could be competing against larger metropolitan areas
    with more resources and expertise in securing these funds. Do
    you think there should be a fund that is solely dedicated to
    the economic revitalization and work force development for
    rural America?
        Ms. Torres Small. Well, I certainly will follow what
    Congress does, but I have seen that Rural Development, with its
    being the sole agency with a mission for rural communities, has
    an impact in getting out funds to rural areas. I deeply
    appreciate the investments in that and am happy to provide any
    technical assistance as you pursue other options.
        Senator Gillibrand. Thank you.
        Thank you, Madam Chairwoman.
        Chairwoman Stabenow. Thank you so much.
        Senator Smith.
        Senator Smith. Thank you, Madam Chair and Ranking Member
    Boozman, and thank you for this Committee.
        Secretary Torres Small, it is wonderful to see you again.
    Welcome to the Committee. I really appreciate this conversation
    about health care and broadband, but I am going to pivot to
    talking about rural housing issues and the rural housing
    programs at USDA. I am the Chair of the Rural Development
    Subcommittee with the Ag Committee, with Senator Ernst, and so
    this is a matter of great interest to me.
        I know from so many conversations with Minnesotans that if
    you do not have a safe place to call home nothing else in your
    life works, not your education, your job, your health, none of
    the basis of life. Certainly before the pandemic, there was a
    shortage of affordable, livable housing, especially in rural
    communities. As we emerge from the pandemic, this is even a
    bigger issue. In fact, I would even go so far as to say that
    our housing market is broken. The supply of housing that people
    want, it does not exist at a price that people can afford.
        In Minnesota, nearly 10,000 families live in affordable,
    rental, rural housing that was originally financed with USDA
    loans, and the average income of these residents is about
    $17,000. They are much more likely to be people of color.
    Sixty-seven percent of these households are headed by women.
    These are the essential workers that work in low-wage jobs in
    agriculture, in food processing. They are the people that take
    care of our children and our elders. They make our communities
    work, and yet they are really struggling.
        Here is the problem. Once the mortgages on these affordable
    units financed by USDA loans mature or they are paid off, the
    property owners do not need to keep those units affordable any
    longer. They can change them to market rates, and then we lose
    that affordable housing that we need so much.
        Secretary Torres Small, could you talk about what we should
    do, what USDA should do, to preserve affordable housing in
    rural communities?
        Ms. Torres Small. It is such an important question. As you
    recognize, Rural Development has influenced or supported about
    400,000 units all across rural America, and it is some of the
    folks who need that housing the most. It is connected to the
    rural care economy and making sure that they have a safe place
    to live.
        We recognize that as those loans mature the ability to
    retain that rental housing is crucial, also to retain the
    rental assistance that comes with it. There is--the
    preservation funds are crucial to be able to not just retain
    that stock but make sure that stock is in good order. Right?
        Senator Smith. Exactly.
        Ms. Torres Small. That it is a safe place for people to be.
        Then in addition to that, you know, there are questions
    about how do we also invest in a housing stock in the future,
    what are the opportunities for new building in addition to
    those preservation funds, and certainly in another hearing I
    look forward to exploring that further with you.
        Senator Smith. Right. What do you think that we should be
    doing, that USDA should be doing, to make sure that native
    communities and communities of color in particular are not left
    out of USDA work around affordable housing in rural places?
        Ms. Torres Small. Certainly as we look at affordable
    housing, there are different models that are crucial. Having
    the trust in a community is vital to be able to support
    programs like single-family housing developments or
    developments in multifamily housing and being able to have
    those trust relationships. We have seen strong pilot programs
    where there is relending to rural housing nonprofits in Native
    American communities or tribal in Indian Country, and there has
    been enormous success with that relending with Native CDFIs to
    be able to then reach new people who could take advantage of
    single-family housing opportunities.
        Senator Smith. Thank you. I think that is a great point as
    well.
        We also know that elders living in rural places are really
    motivated to want to continue living at home as long as they
    can, to continue living in their community as long as they can.
    If this is going to happen, they have to stay connected to
    services and to friends and family and to their community. How
    can Rural Development work with other branches of the Federal
    Government to support elders in rural communities who want to
    stay living at home?
        Ms. Torres Small. This definitely seems to be one of the
    themes of the hearing is the need for coordination----
        Senator Smith. Yes.
        Ms. Torres Small--to be able to provide that. We certainly
    know that there is fewer Medicaid-supported services for home
    care in rural communities, which is where sometimes the
    transportation is needed most. Again, Rural Development can
    help by supporting new models for service, whether that is a
    cooperative, where there is lower turnover which also supports
    elder care, or whether it is a business that is looking for a
    B&I loan, guaranteed loan, to be able to provide some of that
    home care. Certainly coordination and making sure that there is
    a financial plan for sustainability for those efforts is
    crucial and coordinating with Federal agencies to ensure that
    everyone is on the same page there.
        Senator Smith. Thank you very much.
        Thank you, Madam Chair.
        Chairwoman Stabenow. Thank you very much.
        We will move to our second panel given that we have no
    further members here to ask questions on the first panel. We
    want to thank our Under Secretary very, very much for your
    leadership and hard work.
        As we transition, I do feel compelled to lift up a couple
    of positive things here that have been happening for rural
    America with the Administration. Certainly, the Infrastructure
    Bill, which gave us the opportunity for real investments in
    high-speed internet, and we want to make sure those things are
    happening in every corner of rural America and at the speeds
    that are needed to be able to do what we need to do. We are
    grateful for having done that and the strong support from rural
    groups like American Farm Bureau and so on to make sure we got
    for the first time--we have been talking about Infrastructure
    Week for I do not know how long. I have been here a long time.
    We have talked about Infrastructure Week. We finally got it
    done.
        Then I just want to give one other shout-out as folks are
    coming up and also reinforce what colleagues have said, that we
    need to get our trade positions filled, both this Committee and
    with my Finance Committee hat on. We need to get those trade
    positions filled. There is no question about that, and I am
    pushing to do that.
        Having said that, that is not all of the story. I have to
    say, in spite of that--and we have got to get those filled--
    2021 was a record year for exports despite all the challenges.
    We have got to make sure now with what is happening in Ukraine,
    all the dynamics there that complicate things. 2021 was a
    record year for exports.
        I do have to give a shout-out to the Administration. We
    have great news on cherries in India. We are opening up markets
    there. In Vietnam, we are opening up markets on corn and wheat
    and pork. We have a great victory for our dairy farmers through
    USMCA as well. There are positive things happening for farmers
    and rural America as we move forward, all the challenges that
    have occurred because of a worldwide pandemic and all the
    ramifications of that.
        All right. Thank you very much.
        Welcome to our second panel and so pleased to have all of
    you with us. Let me turn to colleagues that are going to be
    making introductions. I believe that Senator Smith has our
    first introduction today.
        Senator Smith. Thank you, Madam Chair. I want to welcome
    Dr. Henning-Smith to the Senate Ag Committee. Dr. Henning-Smith
    is an associate professor at the University of Minnesota School
    of Public Health, Deputy Director of the University of
    Minnesota Rural Health Research Center, and Deputy Director of
    the University of Minnesota Rural Health Program. In these
    important roles, Dr. Henning-Smith leads research to identify
    the barriers to health and wellbeing for rural people and
    communities and for older adults, and her work has helped us to
    see the diversity of rural communities and what we need to do
    to meet people's needs no matter who they are or where they
    live.
        Dr. Henning-Smith is known for identifying practical policy
    solutions to the big questions, like how do we improve access
    to health care, how do we advance health equity and get at the
    social determinants of health like food and safe housing and
    preventative care, especially for people who have historically
    faced barriers to opportunity.
        Dr. Henning-Smith holds a bachelor's in international
    relations, master's degrees in public health and health
    services research, and a doctorate in health services research
    policy and administration. She will speak today about the value
    of research and development to rural health.
        I thank you for being here today.
        Chairwoman Stabenow. Thank you very much. We have two of
    our members coming back to make other introductions. They are
    not quite here, so I am going to ask Senator Boozman to make an
    introduction at this point.
        Senator Boozman. Yes, I thank all of you for being here.
    You all are in the helping people business, which is so, so
    very important. We really do appreciate that.
        I want to introduce Dr. Douglas Holtz-Eakin. Dr. Holtz-
    Eakin has a distinguished record as an academic, policy
    advisor, and strategist. Currently, he is the President of the
    American Action Forum and most recently was a commissioner on
    the congressionally chartered Financial Crisis Inquiry
    Commission.
        He was the sixth Director of the nonpartisan Congressional
    Budget Office from 2003 to 2005. Following his tenure at CBO,
    Dr. Holtz-Eakin was the Director of the Maurice R. Greenberg
    Center for Geoeconomic Studies and the Paul A. Volcker Chair in
    International Economics at the Council on Foreign Relations.
        Dr. Holtz-Eakin serves on the boards of the Tax Foundation
    and National Academy of Social Insurance, and he is also a
    member of the Aspen Economic Strategy Group.
        Thank you again, Dr. Holtz-Eakin, for joining us today.
        Chairwoman Stabenow. Thank you so much. Well, I am going to
    introduce our next witness, Dr. Shoshanah Inwood. I know that
    Senator Brown is on his way and may interrupt me here in the
    middle of this, but I want to proceed at this point. I know he
    is so pleased that you are here.
        Dr. Inwood is an associate professor and rural sociologist
    in the School of Environmental and Natural Resources at Ohio
    State University. I have to say as a Michigan State grad twice,
    it takes a lot for me to make this introduction, naturally.
    Pleased to have you here.
        In recent years, her work has focused on the needs of farm
    families and the needs they have for accessing adequate health
    insurance and child care, addressing barriers to
    intergenerational farm succession, and exploring the
    contribution of local food systems to rural development. Dr.
    Inwood's integrated research and extension program explores the
    impact of national, State, and local efforts to create economic
    development through food and agriculture, and addresses the
    question of who will be the next generation of farmers in light
    of a shrinking and aging farm population.
        We are so pleased that you are with us.
        I am going to turn to Senator Bennet for our next
    introduction.
        Senator Bennet. Thank you. Thank you, Madam Chair. That is
    very kind of you.
        It is my honor to introduce to the Committee Dr. Joseph
    Carrica from La Junta, Colorado. Joseph Carrica, III, from La
    Junta, Colorado. Dr. Carrica is the CEO of Southeast Health
    Group, which provides critical services to six rural counties
    in southeast Colorado, including primary care, psychiatric
    care, physical therapy, mental health counseling, and treatment
    for substance abuse.
        Dr. Carrica currently serves as the past President of the
    Colorado Behavioral Health Care Council, our State's leading
    association of community behavioral health providers. He is
    also a certified addictions counseling with a doctorate in
    interdisciplinary leadership from Creighton University.
        I wanted the Committee to hear directly from Dr. Carrica
    because he is one of the top advocates in our State, I think
    probably in the country, for ensuring rural communities receive
    exceptional health care.
        He has also made it a priority to connect farmers and
    ranchers with mental health support. As this Committee
    appreciates, farmers and ranchers across the country have
    endured profound stress because of the uncertainty over
    everything from drought to trade to global commodity markets.
    It has been a very, very, very difficult time for America's
    farmers and ranchers, and that is why Dr. Carrica launched a
    grassroots initiative to promote suicide prevention and
    awareness about mental health among farmer and ranchers in
    southeast Colorado. The initiative was so effective that it has
    been extended across the entire State.
        Dr. Carrica, I am really grateful for your work in rural
    Colorado and for making the trip to Washington, DC. Welcome to
    the Committee and thanks for your testimony today.
        Thank you, Madam Chair.
        Chairwoman Stabenow. Thank you, Senator Bennet.
        As promised, Senator Sherrod Brown, who has been trying to
    be two places at once. Until we get ``beam me up, Scotty,'' we
    are going to be challenged I think, but, Senator Brown.
        Senator Brown. Thank you, Madam Chair and Ranking Member
    Boozman. Thank you. Senator Bennet, good to hear your comments.
        No disrespect to the Chair if I duplicate anything that she
    said, but it is my honor to introduce Professor Shoshanah
    Inwood from The Ohio State University. She is accompanied by
    her daughter, Ivah, who is also here. Dr. Inwood is a rural
    sociologist. She focuses her research in supporting the
    wellbeing of Americans in the food and agriculture sector to
    spur local economic development.
        Every member of this Committee recognizes that many of the
    farmers we meet are closer in age to us than they are to the
    staff sitting behind us in hearings like this. That is why we
    need to take concrete steps to support beginning farmers and
    beginning ranchers. Professor Inwood's research has highlighted
    the importance of supporting rural families to encourage
    entrepreneurship and to boost rural economies. In the last
    several Farm Bills that a group of us have worked together on,
    to support beginning farmers and ranchers, and I know the Chair
    and the Ranking Member have been integral in pursuing those
    efforts.
        As Dr. Inwood will discuss, when we support farm families
    and our rural communities, we get more young farmers; we spur
    innovation. It allows us to build the kind of dynamic food
    systems, to encourage entrepreneurship, and to promote
    resilient supply chains that help get food to stores and to our
    homes.
        Prior to joining Ohio State, Dr. Inwood was a graduate---
    she is pretty much an Ohioan now. She graduated from Oberlin
    College. She was a faculty member of the Department of
    Community Development and Applied Economics. She took a side
    trip to the University of Vermont.
        In addition to being recognized as an expert in her
    discipline, she also was a farmer about six miles from the farm
    I worked on, in Lucas, Ohio, in Richland County, for a period
    of several years.
        Madam Chair, thanks for giving me the chance to do this
    today. I have to return to the committee I am chairing, but
    thank you, Senator Stabenow.
        Chairwoman Stabenow. Thank you so much. Not everyone gets
    introduced twice before the Committee, but we appreciate all of
    you, frankly, all of you being here.
        We will turn first of all for five-minute opening comments
    and anything else you would like for the record. I believe that
    we have Dr. Carrie Henning-Smith, who is with us virtually as
    well.
        Dr. Henning-Smith. Yes, I am.
        Chairwoman Stabenow. Great. All right. Well, thank you. We
    will start with you. We appreciate the fact that you are with
    us virtually. Dr. Carrie Henning-Smith.

      STATEMENT OF CARRIE HENNING-SMITH, Ph.D., DEPUTY DIRECTOR,
        RURAL HEALTH RESEARCH CENTER AND RURAL HEALTH PROGRAM,
            UNIVERSITY OF MINNESOTA, MINNEAPOLIS, MINNESOTA

        Dr. Henning-Smith. Thank you, Chairwoman. Thank you,
    Ranking Member Boozman and distinguished members of the
    Committee. Thank you for the opportunity to provide testimony
    today and to do it virtually, with appreciation to good
    broadband, too.
        Everyone should have access to the opportunity for good
    health and good quality of life no matter where they live. Yet,
    on average, rural residents die sooner and have poorer health
    outcomes than urban residents. The COVID-19 pandemic has only
    made things worse, with higher COVID death rates in rural areas
    for most of the pandemic.
        It is important to note, however, that rural areas and
    rural residents are not monolithic. One in five rural residents
    today is Black, indigenous, or a person of color, and health
    outcomes for rural BIPOC residents are significantly worse than
    for rural White residents and for all urban residents. Rural
    counties with a majority of Black or indigenous residents have
    the highest premature death rates of any county in the country.
        Access to health care is one contributor to rural health
    disparities. Since 2010, 138 rural hospitals have closed their
    doors. Rural areas have also seen a decline in other health
    care services. These include nursing homes, pharmacies, and
    obstetric units. From birth to end of life, it is more
    difficult to access the care you need in rural areas.
        There are many causes for the decline in rural health care
    services. Reimbursement rates, uncompensated care, and access
    to health insurance are large contributors as are the general
    overhead costs in low-volume settings. Health care work force
    availability is another huge contributor and was made worse by
    the pandemic.
        Solutions for this may include training and pipeline
    programs as well as financial incentives for providers.
    However, solutions must also focus on the overall vitality and
    appeal of rural communities, including strong infrastructure,
    job opportunities, housing, child care, and education.
        The issue of rural health and quality of life is not
    limited to health care services. Infrastructure policy is also
    health policy. An urgent infrastructure challenge is access to
    reliable and affordable broadband internet. At the beginning of
    the pandemic, Congress and the executive branch acted quickly
    to ensure that health care was continued, resulting in a
    dramatic expansion of telehealth services, expanding options
    for rural health care delivery.
        Despite gains in telehealth, however, broadband
    connectivity remains an issue in many rural communities.
    Inclusion of $65 billion in funding for broadband connectivity
    buildout in the bipartisan infrastructure law was needed, but
    implementation will be critical. The USDA has a unique role to
    play in ensuring that broadband connectivity is built out
    equitably, particularly in rural communities.
        I have laid out several challenges in rural health and
    health care, but rural areas also have considerable strengths.
    Rural residents and organizations can be incredibly resourceful
    and innovative. Many rural areas also have particularly strong
    social capital. This social fabric provides a tapestry on which
    strong health and health care can be built given the right
    support through investment in infrastructure and resources.
        Moving forward, the USDA has a critical role to play in
    supporting rural health. I was honored to consult on the
    development of the Rural Health Liaison position in the 2018
    Farm Bill, and I thank members of this Committee for your
    leadership in that important work. The creation of that
    position symbolized and strengthened the importance of the USDA
    in rural health although the USDA has long been doing work that
    has improved rural health and quality of life.
        The USDA can play a significant role in ensuring that rural
    providers are equipped for the 21st century. Whether this is
    through ensuring adequate rural broadband access, data
    collection and research, or investment in capital
    infrastructure, the USDA is a needed partner for rural health.
        Thank you again for the opportunity to testify today, and I
    look forward to any questions you might have.

        [The prepared statement of Dr. Henning-Smith can be found
    on page 50 in the appendix.]

        Chairwoman Stabenow. Thank you so much. We will next hear
    from Dr. Shoshanah Inwood.

      STATEMENT OF SHOSHANAH INWOOD, Ph.D., ASSOCIATE PROFESSOR,
      SCHOOL OF ENVIRONMENT AND NATURAL RESOURCES, THE OHIO STATE
                       UNIVERSITY, WOOSTER, OHIO

        Dr. Inwood. Thank you, Chairwoman Stabenow and Ranking
    Member Boozman, for the opportunity to testify. My comments
    today are based on over a decade of USDA and more recent CDC-
    funded research examining how the availability, affordability,
    and quality of child care affects the economic development and
    quality of life of America's farmers and ranchers and their
    rural communities.
        As a land-grant university scientist, I have had the
    privilege of traveling across the country, interviewing and
    surveying thousands of farmers and ranchers across our great
    nation. My testimony today reflects their lived realities.
        Our national research indicates child care is a critical,
    yet undervalued, work force attraction and retention issue in
    the farm sector that has the potential to undercut Congress's
    investments in growing the next generation of farmers. Many
    Federal programs, such as BFRDP, tend to focus on access to
    land, capital, production skills, and market development, all
    of which are critical. However, farmers are also family based
    businesses. Successfully recruiting and retaining farmers
    requires recognizing the fact that many young people are in
    their prime childbearing years and have children.
        Our pre-pandemic national survey found almost two-thirds of
    all farm families with children under 18 report child care
    difficulties due to affordability, availability, and quality.
    We found child care has direct economic impacts by affecting
    the farm's production and marketing systems, which, in turn,
    affects farm viability, risk management, farm safety, farmer
    mental health, and quality of life. Our research has
    consistently found child care is an issue that affects all of
    agriculture regardless of farm size, production system, or
    geographic location.
        There are many benefits to growing up on a farm, and
    farmers shared with us how much they love to live and work on
    the farm with their kids. However, farm parents are working
    parents, and child care accommodations of some kind are
    necessary to ensure farm work can get done in addition to
    ensuring farm safety.
        Family care is a highly desired care arrangement and works
    well for farmers with able family nearby. However, a
    significant number of farmers shared how their parents' age and
    declining health limited their capacity to care for the kids.
    One farmer who relied on her mother for child care described
    how upon returning home from the fields she found her
    daughter's diaper had not been changed for 6 hours. She
    realized her mother suffered from dementia, yet she still
    needed her mother to watch her daughter and found herself in
    the sandwich generation, caught between taking care of her
    children, aging parents, and the farm operation.
        Farmers also reported finding child care for children with
    special needs to be especially challenging.
        These issues are particularly significant for beginning,
    first-generation, and women farmers. Over 67 percent of first
    generation farmers experience child care problems. A farm
    father said he hoped his young son would be his little
    sidekick, but he admitted he had not thought about a baby not
    being able to be out in the sun all day or the dangers of large
    livestock and machinery and was now struggling to balance care
    and farm work. Women are one of the fastest growing groups of
    farmers. They are twice as likely as men to report that child
    care is an important factor in farm decisions.
        Child care is expensive, and farm families are struggling
    to find affordable, high-quality care. In Ohio, it costs
    $10,000 a year for infant care. Rural areas suffer from
    scarcity of essential services. Before COVID decimated the
    child care sector, a 2018 study found that three in five rural
    communities lacked adequate child care supply. In other cases,
    farmers shared that child care and schooling options were so
    low quality they would not send their children. Formal daycare
    providers are typically open from 7:30 a.m. to 5:30 p.m. and
    closed on weekends. Yet, the rhythms of farming rarely
    correlate to this rigid schedule.
        Our research indicates that child care can shape business
    decisions and limit economic growth. Initiatives to create
    direct marketing opportunities for farmers rarely consider how
    the availability of child care correlates with market
    schedules, which can result in lost sales and income. Farmers
    are making difficult labor cost calculations. On one hand,
    hiring employees will let farmers spend more time with their
    children, but child care would let them do the field work
    themselves more efficiently than an employee.
        The impacts of COVID have exacerbated these issues. The
    National Farm Medicine Center found in the early months of
    COVID, as daycare and school shut down, 58 percent of farmers
    reported that taking care of kids became harder and 57 percent
    reported that changes in child care and schooling negatively
    their ability to get farm work done.
        What is to be done? The USDA-HHS Guide to Strengthen and
    Expand Child Care Facilities in Rural Communities does an
    excellent job of identifying opportunities for building the
    physical infrastructure needed for rural child care. Yet, we
    hear from farm parents that the issues of availability,
    quality, and cost also need to be tackled.
        To increase the availability of child care as a broader
    economic development strategy, we must increase the pay for
    providers while lowering the cost to families. As we address
    rural broadband connectivity, we can leverage our cooperative
    extension system to develop and deliver in-person and online
    provider professional development. These investments can create
    good-quality jobs, improve child development, and mobilize the
    parental work force while building more prosperous and robust
    rural communities.
        The consequences of not making these investments is a
    threat to America's food, fiber, and fuel supply. In some
    cases, the pressure to juggle kids and farms is too much,
    leading some farmers to divorce and others to exit from
    agriculture. Other farmers shared they purposely decided not to
    have children for fear they cannot raise both a child and a
    farm. Even for farmers deeply committed to raising their
    children on farms, accessing, arranging and negotiating child
    care introduces new stresses. Child care is an ordinary
    stressor with the power to amplify extraordinary stressors,
    such as extreme weather, commodity market volatility, or public
    health issues.
        In response to the question, what do you want
    decisionmakers to know, farm parents have consistently replied,
    if America wants farms and farm families, we need help and
    support with child care.
        Thank you.

        [The prepared statement of Dr. Inwood can be found on page
    58 in the appendix.]

        Chairwoman Stabenow. Thank you very, very much for those
    comments. Now we will hear from Dr. Joseph Carrica.

       STATEMENT OF JOSEPH CARRICA, III, Ed.D., CHIEF EXECUTIVE
     OFFICER, BEHAVIORAL HEALTH, SOUTHEAST HEALTH GROUP, LA JUNTA,
                                COLORADO

        Dr. Carrica. Good morning, Chair Stabenow, Senator Boozman,
    and members of the Senate Agriculture Committee. Thank you to
    Senator Bennet for the kind introduction, and thank you all for
    the opportunity to testify today.
        I am Dr. Joseph Carrica, III, but I simply go by J.C. I am
    the CEO of Southeast Health Group in southeast Colorado, where
    the cattle outnumber the people seven to one. I am also a
    fourth-generation Otero County resident as my Basque
    sheepherder family homesteaded in Colorado in 1909.
        Southeast Health Group is located in the historic
    agricultural plains of southeast Colorado, nowhere near
    mountains or skiing, and we are largely represented by farmers,
    ranchers, ag workers, and their families.
        I would like to briefly touch on several of the important
    mental health and substance use issues we are seeing in rural
    Colorado, but before I do, I would like to acknowledge the
    great partnership we have with Colorado State University
    Extension Office, the Colorado Department of Agriculture,
    AgrAbility, Farm Bureau, Rocky Mountain Farmers Union, Mountain
    Plains Mental Health Technology Transfer Center, the National
    Council on Mental Health Wellbeing, the United States
    Department of Ag, and the Farm and Ranch Stress Assessment
    Network. These organizations have done a tremendous job in
    Colorado bringing rural stress to the forefront of mental
    health and substance use discussions. We share products,
    promote each other's programs, and cross-train on what we find
    to be effective interventions for our agricultural community
    that I still call home.
        I would also like to thank Senators Jon Tester and Chuck
    Grassley for the Seeding Rural Resilience Act, which recognized
    that farmers, ranchers, and other rural Americans are at a
    particular risk of suicide given a variety of stress inducing
    factors, including social isolation, economic challenges, and
    poor access to mental health resources and support services.
        In the spring of 2021, we were notified that we were
    awarded a CCBHC Readiness Grant. While we began to develop our
    competencies as an organization regarding services to veterans
    and Native American, indigenous peoples as a requirement of
    CCBHC, we found an opportunity to begin mimicking special
    population work for rural stress and embedded our ag advisory
    board into our CCBHC transformation. This advisory board
    develops culturally competent marketing material while
    providing training and education on behavioral health
    interventions.
        Most recently, members of this advisory group developed a
    Soil Health and Mental Health: Growing Together support group.
    It has volunteer representation from the seed industry, the
    water conservation district, crop protection, behavioral
    health, ag research, and of course, our farmers and ranchers.
    During conversations on weather, commodities, the increased
    price of fertilizer and diesel, bank loan payments coming due,
    and how to deal with the end of legacy ranches and farms as
    children are not returning to take over operations, mental
    health check-ins covertly happen in those discussions.
        As a result, this summer we created a safe space in Rocky
    Ford, Colorado, melon capital of the world, where we offer free
    coffee, donuts, and conversation two days a week. All of our ag
    advisory committee's efforts now are coined the Coffee Break
    project.
        CCBHC funding allowed Southeast Health Group to purchase
    and deploy nearly 100 iPads, with data packages included, into
    the region to accommodate those that have access to care
    issues, whether that is transportation, profound remoteness, or
    simply the fear of having your car or flatbed pickup seen in
    our parking lot. This teleservice now keeps five therapists
    very busy.
        It is also clear that COVID has worsened the opioid
    epidemic across the U.S. Rural communities have especially been
    hit hard with heroin overdoses, the resurfacing of
    methamphetamine, and now the acceleration of fentanyl
    distribution and deaths. I was granted the privilege of being
    appointed to the Colorado's Opioid Crisis Recovery Funds
    Advisory Committee, and while I believe the settlement funds
    across the State will undoubtedly help us build infrastructure
    to address this opioid addiction problem, it is going to take
    cross-system, across-aisle collaboration to develop a well
    coordinated effort over a couple of decades to have measurable
    impacts. We are seeing early wins in our region by introducing
    opioid-addicted patients to alternative health care options
    through our pain management program that is coordinated by our
    physical therapy and physical health departments.
        As I come to the end of my presentation, I would be amiss
    to not mention the concern I have for my athletes. I have
    coached girls fast-pitch softball for over 20 years at the
    collegiate, high school, and club levels and am gravely
    concerned about the COVID-19 pandemic effects on my kids. It is
    extremely important that our rural schools have the ability to
    provide consistent mental wellbeing supports and provide our
    educators and administrators training on useful and effective
    interventions.
        Thank you again for your invitation and allowing me to
    share just a glimpse of the great collaborative efforts
    currently happening in Colorado to address rural stress
    supported by our CCBHC award and the Farm and Ranch Stress
    Assistance Network program. Thank you for your time.

        [The prepared statement of Dr. Carrica can be found on page
    63 in the appendix.]

        Chairwoman Stabenow. Thank you very much.
        Now we have Dr. Douglas Holtz-Eakin, no stranger to
    testifying before committees, and we welcome you.

     STATEMENT OF DOUGLAS HOLTZ-EAKIN, Ph.D., PRESIDENT, AMERICAN
                      ACTION FORUM, WASHINGTON, DC

        Dr. Holtz-Eakin. Well, thank you, Chairwoman Stabenow,
    Ranking Member Boozman, and members of the Committee. It is a
    privilege to be here today. I have submitted a written
    statement for the record. Let me make a few points, and then I
    look forward to answering your questions.
        The first point is that as important as these Federal
    programs are, neither they nor the rural economy in general can
    withstand poor overall macroeconomic performance. Now at the
    moment, there are many good things about the U.S. economy.
    Gross domestic product, a measure of income, grew at an
    annualized rate of seven percent in the fourth quarter of last
    year; that is very fast. We have an unemployment rate of 3.8
    percent, not historically low but outstanding. We have seen
    wages rise year over year by about 5.1 percent, and for
    nonsupervisory production workers, the lower end of the income
    distribution, even faster, 6.7 percent. At the moment, there
    are 1.7 job openings for every person looking for a job in
    America. There is a lot of good news out there.
        The Achilles heel of the U.S. economy is the inflation that
    has emerged over the past year, year over year, at 7.9 percent,
    which has outstripped all of those wage gains. Some of the
    numbers are even more daunting. If you look at the bundle of
    food, energy, and shelter that is over 50 percent of the
    typical American's budget, inflation is at an 8.4 percent
    annual rate. That is the real pain that people are feeling on
    the ground. Individual prices are rising faster. Energy overall
    is up 25.6 percent. Gasoline is up 38 percent in the past year.
    The overall environment is not a particularly hospitable one
    for Americans right now.
        My second point is this inflation did not just happen. It
    is the result of policy decisions that were made. There are
    really two components, as I laid out in my written testimony.
    In part, it is reminiscent of the 1970's, where COVID has
    produced supply shocks much like the oil price shocks of that
    era, and those costs have to get passed on to consumers. We
    have seen supply chain difficulties all across the globe, in
    especially the United States. Labor market policies had a big
    impact on that.
        The second part is simply excessive demand stimulus in the
    United States, which is really personified by the American
    Rescue Plan. The ARP passed last March was passed at a time
    when the U.S. economy was growing at 6.5 percent and it was a
    well-known fact that we were expanding at an extremely rapid
    rate. In terms of sort of macroeconomic stimulus, it is exactly
    the wrong time. In contrast to the CARES Act, which intervened
    when we really needed help in the second quarter of 2020, the
    ARP came at a time when the U.S. economy was expanding at a
    very rapid rate.
        It was also inappropriately large. My old shop, the
    Congressional Budget Office, does a calculation of the gap
    between actual activity in the U.S. economy, GDP, and the
    potential activity in the U.S. economy, potential GDP. In fact,
    that was a third of the American Rescue Plan. There is no
    reason to solve a $600 billion problem with a $2 trillion
    stimulus.
        It was too big, it was at the wrong time, and it has
    generated substantial inflation which persists to this day and
    which will take a long time to wring out of the economy. I
    listened to Chair Powell talk yesterday, and he expects that it
    will take three years for the Federal Reserve to return to the
    two percent target that it has had.
        The third point is that these are not the only policies
    that have contributed to the problems. There are energy
    specific policies where the Administration has not been
    particularly supportive of domestic production and where its
    response to global oil price rises, both before and after the
    Russian invasion of Ukraine, are really quite small and
    ineffective. Dropping the moratorium on leases will do little.
    Tapping the SPR is more symbolic than real.
        On the trade front, it has really hurt the rural economy.
    There have been some direct actions it has taken to put tariffs
    on fertilizers, for example, which have raised costs for
    America's farmers. There has been its conclusion that the phase
    one agreement with China is not working, but in response to
    making that conclusion, it did not drop the tariffs imposed on
    China. As a result, U.S. farmers continue to face the
    retaliation that came from the imposition of those tariffs.
    There is an opportunity, which the Administration has not
    taken, to improve the trade policies and help the rural economy
    in the United States.
        As I elaborated in my written testimony, some of the
    specifics that are under consideration in the Build Back Better
    Act and other variations on those policies are either a
    macroeconomic danger of the type in the American Rescue Plan or
    poorly designed in their attempt to reach their target
    audiences. I would be happy to elaborate on those during the
    questions.
        Thank you for the chance to be here, and I look forward to
    the discussion.

        [The prepared statement of Dr. Holtz-Eakin can be found on
    page 67 in the appendix.]

        Chairwoman Stabenow. Well, thank you very much and look
    forward to the many opportunities to debate you about all the
    small businesses and restaurants and families and hospitals and
    local communities who have survived the pandemic because of the
    American Rescue Plan.
        Let me first start and ask J.C.--we will call you J.C. That
    would be easier if that is what you would like to do.
        Let me just start out by saying, as the author, with my
    good friend, Senator Roy Blunt, of the Certified Community
    Behavioral Health Center model, I am so pleased to hear you
    speak about that today. I am very impressed by the way you have
    used CCBHC's startup funding and USDA funding to both expand
    telehealth services and to reach out to folks in the community
    who need it. I wonder if you might talk a little bit more about
    how this model, community model for high standards and
    community behavioral health services, gives rural clinics like
    yours the flexibility to really meet local needs.
        Dr. Carrica. Thank you for the question, and again, thank
    you for the opportunity to be a CCBHC. One of the things that
    is intriguing about the CCBHC is the prospective payment system
    that is allowable, and that is transformational for especially
    small clinics like ours. We are now funded through what we call
    an encounter-based system. You provide a service; you get a
    payment. While we are able to provide what I think to be
    adequate and, at most times, high-quality services, it does not
    allow us to think upstream and really look at what communities
    need, what small counties need, what regions need.
        A PPS system would allow us to build and plan
    infrastructure into the future. Rather than counting widgets of
    care, we would be measuring outcomes and the work that we have
    done, and we should be able to see those outcomes in three to
    five years. Right now, when you are paid on an encounter-based
    system, a fee-for-service system, it is very hard to build a
    strategic plan that is more than one year long. It seems to be
    just budget modification after budget modification. PPS systems
    allow you to build for the future and develop strategy, which I
    think can achieve desirable outcomes specific to the regions
    and community members you serve.
        Thank you.
        Chairwoman Stabenow. Thank you very much. This is really
    the community health model. When we have what we call FQHC,
    that is broadly supported on a bipartisan basis, they are using
    that model that you are talking about. The whole point on
    behavioral health, mental health, and substance abuse services
    is to say, health care above the neck should have the same kind
    of funding and structure as health care below the neck.
        I would just have to add a good news point as you are
    talking about three to five years for outcomes. We were
    absolutely thrilled that after only two years on the original
    demonstration project that Health and Human Services indicated
    that there was a 63 percent reduction in folks sitting in the
    emergency room because there was no place else to go, 60
    percent less time in jails, which is why law enforcement is so
    hugely supportive of moving forward, and 41 percent decrease in
    homelessness.
        I am hoping that if we can get the bill passed that we have
    done, that some many of our colleagues here on the Committee
    are co-sponsoring--and we would love to have everyone on the
    bill. To take this model nationwide and give you the full
    funding, permanent funding you are talking about, I am hopeful
    you can get results in less than three to five years because I
    really think that we have seen that and it is very, very
    positive.
        Dr. Inwood, let me say this Committee has a long bipartisan
    track record of supporting the next generation of farmers,
    including getting more women and young families involved in
    agriculture. We know that women are often tasked with not only,
    as you said, being the principal farm operator but also the
    principal family caregiver, which is the challenge that you
    spoke about with child care. What improvements should USDA make
    to the beginning and young farmers program as we look at the
    next Farm Bill to address these challenges?
        Dr. Inwood. Thank you for the question, Senator Stabenow. I
    think one of the things that is so important to realize in the
    difference between beginning and first-generation farmers
    versus multi-generation farmers is that we know that multi
    generation farmers are coming with extra access to land and
    knowledge and skills. What we are seeing is that they also come
    with additional community resources, particularly through
    family and community networks. Young and first generation
    farmers are moving to communities because of good soil and
    access to markets but not necessarily to the community
    connections which are so critical for child care.
        I think starting to include these people-centered policies
    around child care, putting the availability of how do we
    include curriculums and modules around how does child care fit
    into your whole farm plan, would be an excellent opportunity to
    start making that realistic vision and building a more
    prosperous farm business.
        Chairwoman Stabenow. Great. Well, thank you very much.
        I will turn now to Senator Boozman.
        Senator Boozman. Thank you, Madam Chair. Senator Fischer is
    very busy today, and so what I would like to do is give her my
    time now and then get back in the queue.
        Chairwoman Stabenow. All right. Senator Fischer.
        Senator Fischer. Thank you. Thank you, Senator Boozman, for
    your kindness. Thank you, Madam Chair, for holding this hearing
    today. Thank you to our panel members.
        J.C., you mentioned the number of cattle to people in your
    area. I would just say, in Nebraska we have four cattle for
    every person in the State, and I happen to come from a family
    ranch where we have in my county 30 cattle for every person.
        You mentioned mental health. You mentioned behavioral
    health. I fully understand that we are fortunate to even have
    our family doctors, our general practice doctors in rural
    areas. Specialists are few and far between, very, very
    difficult to come by.
        Dr. Inwood, when you mentioned child care, that is
    difficult at best for anybody in a rural area, especially those
    who live on their land, and it is impossible when you live 30,
    40, 70 miles to your nearest community. In my case, that would
    be a community of 3,000 people. I would say I am the member of
    this Committee, if not in the U.S. Senate, with the greatest
    understanding of what being rural truly means in the United
    States of America and especially what being rural means in very
    sparsely populated areas.
        I have a question for Dr. Henning-Smith. Great Plains
    Health in North Platte, Nebraska, began expanding its use of
    telehealth to remote clinic sites before COVID-19 hit us. While
    this allowed Great Plains to be ahead of the curve when dealing
    with the pandemic, the true value of telehealth in Nebraska is
    the ability to provide quality health care to rural
    communities. It allows doctors to provide services to rural
    Americans who otherwise may have to drive over an hour in order
    to visit a doctor.
        Dr. Henning-Smith, can you tell us about some of the
    barriers that telehealth still faces and the value that it has
    for rural communities, particularly in filling gaps in that
    specialty and primary care, and how we can leverage technology
    better to address these needs?
        Dr. Henning-Smith. Yes. Thank you for the question. I have
    to say my grandmother was from rural Nebraska. It is near and
    dear to my heart, and I appreciate----
        Senator Fischer. Oh, what area of rural Nebraska?
        Dr. Henning-Smith. She was from outside of Blair, Nebraska.
        Senator Fischer. Ah, okay.
        Dr. Henning-Smith. I really appreciate the question on
    telehealth. It has the potential and already is filling a lot
    of the gaps in access to care, particularly access to specialty
    care. As you say, that is a particularly important and urgent
    need in rural places. We just do not have enough people to fund
    a specialist for each rural area, and so we need to find ways
    to connect patients with the care that they need.
        Yet, there are gaps that remain, and those gaps are largely
    about infrastructure. The availability of broadband and a
    reliable connection is essential to be able to use telehealth,
    either as a provider or a patient. Also, we need the right
    equipment. People need to have devices in their hand. Whether
    they are accessing telehealth with a smartphone or an iPad or a
    tablet or whatever else they are using to connect, they need to
    have access to that. In both cases, the broadband
    infrastructure and the access to devices----
        Senator Fischer. Right.
        Dr. Henning-Smith [continuing]--is more rare in rural
    communities.
        Senator Fischer. Right. I totally agree with you on that.
    We have to get broadband deployed all across this country.
        For all of you, I have a question. When I am back in the
    State, which just is about every weekend, what I am hearing
    from Nebraskans is their concern about inflation and the prices
    of food and the prices of gas. That is the No. 1 concern. It
    has been for many, many months, long before the Ukraine
    situation that we are facing. It is a deep concern for families
    across the State.
        Do you have concerns that inflationary pressure on
    essential products, like food, could have impacts on the health
    of rural families as their incomes are continually squeezed by
    these higher prices?
        Also, how has the high cost of gas impacted people living
    in rural communities? Do you have concerns that that is going
    to affect their decisions on if they can even afford to drive
    many miles to access that health care?
        We have family practice physicians in the community closest
    in my county, but for any kind of specialty it is about 130
    miles or more, or more, to be able to reach a specialist. With
    food, gas--I am asking the indulgence of the Committee
    Chairwoman if we can quickly, you know, kind of hit on the
    stresses that families face.
        Chairwoman Stabenow. All right, if we can do this quickly.
    An important question, but we will do this quickly. Thank you.
        Senator Fischer. Thank you very much.
        Dr. Inwood. Okay. Well, first of all, thank you so much for
    the question. We have a lot of families from Nebraska and
    farmers from Michigan who have also been very helpful in us
    understanding what these issues are.
        The issue of being able to get to work in order to have
    enough money to pay for all those essential services, like food
    and rent, which you alluded to, is critical. Child care is what
    enables families to get to work. When we hear about the
    distance, of farmers driving up to 30 minutes for child care
    providers, that exactly is a stress. We need to think about how
    can we do more child care provider training within communities,
    whether it is home-based care or more localized cooperatives,
    that can alleviate some of those additional stressors of
    driving.
        Dr. Carrica. Thank you for the question. As a community and
    mental health center, it is our expectation to get the service
    to the person in need. We are actually taking the iPads to
    people's residence so that they can access care from home.
        We are also experimenting with trying to get providers into
    more communities. We have purchased three tiny homes in the
    last three years, and what we do is we deploy those tiny homes
    into those communities to try to get access to care closer to
    those people and where they live. The abilities of those tiny
    homes allow us the mobility to move those from community to
    community and try to embed those services closer to people that
    may not have the means to come to a city for care.
        Dr. Holtz-Eakin. Well, I sort of do not think you should
    ask the economist about people's mental health, but we do know
    from lots of survey data that this is the No. 1 issue across
    America. There is no question about that.
        We also know that people are not optimistic about dealing
    with it quickly. One of the striking things in the data has
    been the rapid rise in inflation expectations from under three
    percent in January 2021 to over six percent now. It is not that
    they feel stressed at the moment; it is they feel stressed for
    the foreseeable future.
        Senator Fischer. That is across the board.
        Dr. Holtz-Eakin. That is the concern.
        Senator Fischer. Okay. Thank you.
        Chairwoman Stabenow. I am going to turn Senator Bennet.
        Senator Bennet. Thank you. Thank you, Madam Chair. I
    appreciate it.
        Dr. Carrica, it is great to see you. Thank you for being
    here. I have seen, obviously, what you are doing in person, and
    I really am grateful that you are here to share it with the
    panel. I would like to just start with you and Dr. Henning
    Smith.
        We have all been hearing about the lack of parity and the
    need to better integrate mental and behavioral health with
    primary care. I have been learning that there are things we can
    do to try to do that, like increasing reimbursement for mental
    health providers, encouraging integration and support for
    primary care practices, bringing care to communities like
    schools, as you mentioned. I have been working closely with
    Senators Burr and Cornyn to try to develop some of these
    issues.
        I wonder whether you would be able to highlight why
    improved reimbursement and integration models are important for
    long-term improvements in the mental and behavioral health
    system. If you could wave some magic wands about how those
    reimbursements work and to be able to create more integrated
    care, what would they look like? What else can we focus on in
    the long term to be able to create more integrated care, and is
    it important, to begin with?
        Dr. Carrica. Thank you for the question. Certainly, it is
    important. Anytime we can integrate care, it is care that is
    more efficiently delivered, more appropriately delivered, more
    timely. You also have the ability in an integrated setting to
    work as a health team, a team of health care professionals that
    can bring their level of expertise to the table to better
    diagnose and treat that particular person's need.
        The importance of working across systems is something we
    also need to keep in mind. We are still facing a work force
    shortage, and trying to find enough people to provide the level
    of care necessary to all the people in need is a barrier and
    one that is going to be around a long time.
        One of the things we are working with our FQHC on in our
    region is how to unite our systems closer together from a care
    delivery process, one of which they will do the screenings in
    the FQHC and start the initial behavioral health support. In
    the event the person has complex needs and needs more
    additional support, they would deploy basically the mental
    health center to help step in and provide adjunct services or
    whatever additional services the FQHC may not be able to do.
        I believe that reimbursement rate is a factor. It is
    getting more and more difficult to recruit therapists into the
    profession. Part of that is burnout, or ``burnt out,'' as we
    are calling it now. I think we need to be able to take the
    behavioral health profession and make it one that is
    compensated at a level that is more enticing to help with our
    work force shortage.
        Senator Bennet.
        [Inaudible--off microphone.]
        Chairwoman Stabenow. Yes.
        Senator Bennet. Dr. Carrica, just while you are here, I
    wonder whether, from southeast Colorado, you could give America
    a perspective on the fentanyl and methamphetamine crisis that
    we are seeing in this country. What kind of effect is it having
    on your community, on our community? If there are any rays of
    hope you can give us, what do those look like, and how can we
    help?
        Dr. Carrica. Absolutely. Thank you. I can tell you about
    six months ago I was walking out of softball practice. We were
    actually in downtown Rocky Ford, Colorado.
        Senator Bennet. The melon capital of the world.
        Dr. Carrica. Melon capital of the world. As I was crossing
    the street, there was an overdose happening right in front of
    the public safety building. What was encouraging to me was a
    19-year-old gentleman gets out of his car--pulls over, gets out
    of his car, and goes over to help that person in distress. We
    were able to get EMS involved, and EMS was able to revive that
    person, bring them to life with the assistance of NARCAN.
        That same fire chief is on my Rocky Ford advisory council,
    and now he has 75 cases of NARCAN that he is distributing to
    the community. I am encouraging all my behavioral health
    providers to keep it in their glove compartment box. The
    pharmacy in Rocky Ford now is prescribing or handing out NARCAN
    as well.
        I think the first start is to get people to identify and
    accept that there is a problem and not look the other way.
    Unfortunately, it takes situations like that one, where it
    happens right in front of you, to make you understand that it
    is there and that is all of our issue to try to solve.
        We are working closer with EMS. We are working closer with
    law enforcement. We also work very close with our ERs to do a
    continuity of care plan from the emergency room to our
    outpatient, as well as our transitional residential treatment
    programs, to better address the downhill effects.
        What we need to do a better job with, Senator Bennet, is
    getting education into the schools and get it in there early
    and explain to kids, explain to educators these effects that we
    are currently facing. We need to focus a lot more upstream, I
    believe, as well.
        Senator Bennet. Thank you, Madam Chair.
        Chairwoman Stabenow. Thank you very much.
        Senator Boozman.
        Senator Boozman. Thank you very much, Madam Chair.
        Dr. Holtz-Eakin, you mentioned that Chairman Powell said
    that it would take three years to get down to two percent, and
    again, that is with raising interest rates, affecting the
    economy, and things like that. If we did do Build Back Better,
    in light that it would result in hundreds of billions of
    dollars, perhaps a trillion dollars', worth of deficit
    spending, what would that do to that timeframe? It certainly
    would be longer than three years, I would assume, or the
    economic--or the stress on the economy would have to be much
    greater to get us back in line, into a favorable line.
        Dr. Holtz-Eakin. Yes, I think you framed it up correctly. I
    mean, you could still attempt to hit a 3-year trajectory, but
    you would have to raise rates more sharply and rapidly up
    front. That enhances the risk that you actually make the
    mistake of tipping the economy into a recession. That is a risk
    the Federal Reserve faces already. That would make it even
    larger.
        Senator Boozman. Right. Very good.
        Dr. Carrica? Did I get it right? Close?
        Dr. Carrica. Yes, sir.
        Senator Boozman. I am Boo-zman
        [phonetic], Bo-zman
        [phonetic], whatever.
        Dr. Carrica. I understand.
        Senator Boozman. Tell me--I am interested. Tell me, when
    you have your coffee sessions--I have done a lot of work. I am
    on the veterans committee and this and that, but we have done a
    lot of work with veterans to this side. As you have the
    individuals sitting around and they are talking, what are they
    talking about?
        You mentioned legacy. You mentioned high input costs, not
    getting labor. You know, all of those kinds of things. Worrying
    perhaps that they are the ones that are going to lose the
    family farm, you know, that has been in generations. Can you
    talk a little bit about that?
        Then the other thing is I would like for you to talk about
    how inflation is playing a factor in your survival as community
    health care. I know your nurse cost, your--and yet, you know,
    we are decreasing Medicare and, you know, all of these things
    where Medicare is flat, which is actually a tremendous decrease
    now with the inflationary spiral. If you could do that quickly
    for us, we would really appreciate that.
        Dr. Carrica. My pleasure. I will say that at our Coffee
    Break office we also have a veterans' time and we meet twice a
    month.
        Senator Boozman. Very good.
        Dr. Carrica. It is our veterans service officers as well as
    our American Legion post commanders. While the conversations
    between us and our ag community and the veterans community are
    a little bit different, the conversations always focus on
    barriers and how we can collaboratively work together in a
    sensible approach to increase access or education, or to reduce
    administrative burdens that sometimes create complexity for
    admission into services.
        How do we fast-track people in? How do we get them quickly
    evaluated so that while they are in that moment where they are
    vulnerable and willing to accept treatment--we have to take
    advantage of that moment and get them in. We cannot wait two to
    three weeks and say, you know, we will get you in then, because
    they will change their mind.
        A lot of the things that happen around those conversations
    are very organic. We will just sit around the table, and we
    will just say, what are you planting today? What are you
    planting this week? The next thing you know is they start
    talking about seed cost. They start talking about fertilizer.
    They talk about diesel fuel. They talk about their child going
    off to college and how excited they are, but in the same breath
    they talk about how they have lost some help and reliable help
    around the farm.
        Those are the organic conversations that happen around
    these coffee moments, and they are very--we are embedding those
    conversations very much into our mental health center and
    better understanding the needs and desires and how to outreach
    those prospective patients, for example.
        Quickly, on the question on inflation, I can tell you we
    started budget planning last week for July 1 through June 30th
    and right now we are projecting a 15 percent deficit, our
    expenses over revenue. That is scary. It is scary when we are
    talking about going in knowing we are going to have at least
    that type of deficit and yet knowing that human capital is
    important and we cannot start conversations around reducing
    staff.
        Then what do you do? When you have 15 offices over 10,000
    square miles, what offices do you start cutting hours? That is
    scary because that limits access. We try to be within 30
    minutes or 30 miles of very covered life, in addition to our
    iPad utilization.
        I hope that answers your question.
        Senator Boozman. No, very good.
        Dr. Carrica. Thank you.
        Senator Boozman. Again, inflation is such a difficult
    thing, you know, in so many different areas.
        Dr. Holtz-Eakin, our Committee really does not have a lot
    to do with a lot of the care provisions. Were there any care
    related provisions you are aware of that you believe would
    negatively impact quality of life in rural America that have
    come up in other committees?
        Dr. Holtz-Eakin. I think one of the concerns is the design
    of the child care subsidies actually provides tremendous
    incentives for child care price inflation. The subsidies--the
    out-of-pocket is capped for most individuals at a level where
    most folks would not care what the cost would be. If the price
    went up, it just got passed on to the taxpayer. That is a bad
    set of incentives when looking at the system as a whole.
        Senator Boozman. Right. Thank you, Madam Chair.
        Chairwoman Stabenow. Thank you very much.
        Senator Smith.
        Senator Smith. Thank you, Madam Chair. I am going to direct
    my--appreciate this hearing very much. I am going to direct my
    first question to Dr. Henning-Smith, who I believe is joining
    us remotely.
        Dr. Henning-Smith, I want to talk about rural health care
    and my Rural Moms Act. I want to thank you and the University
    of Minnesota Rural Health Research Center for collaborating
    with me on this legislation, and I am so pleased that this
    legislation, which I worked with Senator Murkowski and others,
    was signed into last just last week.
        Colleagues, what this law will do is to increase resources
    for rural providers who want to provide maternal health care.
    It expands telehealth to include prenatal and labor and
    birthing and postpartum services. It supports training for
    doctors and nurses and other providers to deliver maternity
    care in rural communities so that we have more people trained
    to take care of expectant moms during pregnancy and delivery
    and also more people who can do home visits after delivery.
        Dr. Henning-Smith, could you talk about the specific
    challenges that people face seeking maternity care in rural
    areas and how this new legislation will help in these
    communities?
        Dr. Henning-Smith. Yes. Thank you for the question, Senator
    Smith, and thank you especially for your leadership on the
    Rural Moms Act. I was delighted to see that passed into law.
        Fundamentally, rural areas do not have the access to
    obstetric care that urban areas do. Fewer than half of all
    rural counties have a hospital with an obstetric unit, and that
    has been declining over the past couple of decades. There are a
    bunch of reasons why we are losing obstetric services in rural
    areas, but regardless of the reasons the fact is that that has
    strong implications for the health and wellbeing of pregnant
    people and their babies.
        We see higher maternal mortality rates and higher infant
    mortality rates in rural communities. Within that, we see
    issues of racial justice, with the highest maternal mortality
    and infant mortality rates among rural, Black, and indigenous
    residents. We have heard harrowing stories, including from
    Minnesota, of people needing to travel hours, sometimes while
    in labor, to try to access an obstetric unit.
        In our own research from the University of Minnesota Rural
    Health Research Center, we have found in those counties that
    have lost a hospital-based obstetric unit the rate of out of
    hospital births--which might include a planned home birth and
    that might be really happy and really good, and it might
    include a birth on the side of the road or something else very
    harrowing--and the rate of births in hospitals without an
    obstetric unit, so in the emergency room, no one's ideal
    situation, both of those go up when a community loses their
    obstetric unit.
        For reasons of patient safety, of satisfaction and quality
    of life and provider wellbeing, the Rural Moms Act is so
    important.
        Senator Smith. Well, thank you. I am very excited to work
    on implementation of this bill. You know, one of the things
    that is I think cool about this bill is that we learned about--
    we put together this idea with a lot of input from rural
    providers themselves who told us that what--they really gave us
    the idea of creating these innovation networks in rural
    communities so that providers could have more colleagues and
    more opportunity to share information and experience and
    practice with one another, which is one of the challenges in
    obstetrics when you work in a community where you might only be
    delivering, you know, one baby a week or something. You do not
    have that same kind of practical work happening all the time. I
    just really appreciate the help that we got from rural
    providers on this.
        Now mostly, Madam Chair, this will be implemented at HHS,
    but I think there is an opportunity for us with USDA to think
    about how to, again, do some of the partnership that we have
    been talking about to make sure that as this gets implemented
    it is working for people in rural communities as it has been
    designed to be.
        Now I just want to followup, and I am going to bring this
    to Dr. Inwood. I just left a committee hearing at the Health,
    Education, Labor, and Pensions Committee, talking about child
    care and the deep need for child care, especially in rural
    communities. It was a big topic of conversation. We know the
    deep challenges of affordable access to child care in rural
    communities. Could you just talk to us a little bit about the
    unique challenges that we face when it comes to providing child
    care in rural communities?
        Dr. Inwood. Absolutely. I think one of the biggest
    challenges, Senator Smith, is something that you have alluded
    to many times, which is also just the distance and the low
    number of providers in those rural communities and also the
    cost. I am sorry, the quality.
        You know, one of the things I think that we really need to
    be investing in our rural communities is the quality of our
    providers. It is important to recognize it is not just in home
    providers and centers but also schools. Schools are one of the
    most important child care facilities that farmers and many
    rural entrepreneurs are relying on because it is a safe place
    that children can be in during the day. Ensuring that we have
    quality schools is another component of addressing child care
    and also economic development in our rural communities.
        Senator Smith. Absolutely. Well, thank you.
        I know Senator Braun was part of that committee hearing as
    well. Lots to work on here. Thank you very much, Madam Chair.
        Chairwoman Stabenow. Thank you so much.
        Senator Braun.
        Senator Braun. Thank you, Madam Chair. I wish we had more
    than five minutes on the initial questioning here, but---when I
    look at anything, when you have got a problem you are dealing
    with, you know, I want to make sure that we are not trying to
    fix something that is not significantly broken. In this case, I
    think there is probably the argument to be made that something
    needs to be done. Then I look at what is the long-term
    solution.
        I am going to ask my question to Dr. Holtz-Eakin
    eventually. You have got the perspective of coming back from
    being, I think, a CBO Director in the early 2000's, when the
    snapshot of our balance sheet as a Federal Government was much
    different. It was right when we started to embrace borrowing
    money, running more stuff through a Federal Government that has
    gotten, in my opinion, less and less equipped to deal with
    simply because we have not produced the results.
        When you look at rural health care, you look at health care
    in general. I have been the outspoken Senator about before you
    try to throw more government at it should we reform the system
    first. Health care is similar to agriculture in many ways,
    increasingly dominated by large corporations that have gotten
    so far away maybe from the Hippocratic Oath, that it is close
    to 20 percent of our GDP when it is delivered, 10 to 12 percent
    of GDP by 25 other countries that do things differently.
        It begs the question, why would we want to be doing more,
    and should we look at reforming the industry first, especially
    in the context that now in anything that we choose to do
    through the Federal Government we are borrowing 30 percent of
    every dollar we spend currently. In any new program, by
    definition, we are borrowing 100 percent of it. Is that a
    healthy long-term plan?
        How important is it to get at the root and maybe making
    health care transparent, competitive, getting an engaged health
    care consumer, like I did in my own business 15 years ago,
    which is immensely effective, or do you we need more government
    when we have Leader Schumer asking what more can the government
    do for another problem out there?
        Dr. Holtz-Eakin. Let me say two things, Senator. First, I
    share your concern. From the vantage point of 2003, when I was
    first the CBO Director, it was clear that the arrival of the
    retirement of the Baby Boom generation would require deep
    reforms to Social Security, Medicare, Medicaid, and we have
    done none of those things. We are four years away from the
    exhaustion of the Hospital Insurance Trust Fund. We are 10
    years from the exhaustion of the Social Security Trust Fund. We
    have had to patch the Disability Insurance Trust Fund.
        Over that period, we did not take care of known problems
    and we instead added new programs and are proposing new
    programs yet again. Many of them are not fully covered by taxes
    and thus financed with borrowed money. That pattern is not
    sustainable, and it should be a deep concern to everyone.
        On the health care front, health care is the single most
    important Federal cost. It is across the entire spectrum of
    activities, from the Veterans Administration to Medicare,
    Medicaid, and things like that. One of the most important
    things about the way we run these programs is there is an open
    ended draw on the Treasury. You would love to run a business
    where you had an open-ended draw on the taxpayer if things did
    not go----
        Senator Braun. Or the printing press in the basement.
        Dr. Holtz-Eakin. Or both. Until there is some attempt to
    more broadly use things like bundles of payment that say, this
    is what you can have to do this episode of care and there is a
    quality measure composed on that, we will continue to have the
    problems of the legacy of fee-for-service medicine, which is
    very expensive and not particularly high quality.
        Senator Braun. That is a good point. I must point out as
    well that the marquee Federal Government health care
    initiative, Medicare--we have been paying into it as employers
    and employees since the 60's--goes completely broke here in 4.5
    years. I believe it is real close to 18 percent benefit cuts.
    Of course, what we will do is borrow more money because we can
    do it in the current.
        It really begs the question of why do we want more Federal
    Government to be involved in any of this, particularly when the
    health care industry is broken to begin with.
        Dr. Holtz-Eakin. I would really encourage you to look hard
    at Medicare where you get the opportunity. Prior to the
    pandemic, so before all the emergency borrowing we have seen in
    the past two years, Medicare alone was responsible for one-
    third of Federal debt outstanding. That is a cost center that
    needs to be addressed.
        Senator Braun. You know, I think that is obvious. I
    remember the first year I was on the Budget Committee. We
    actually got together as a Budget Committee back then. We did
    not at all this year. It was one of the Senators on the other
    side of the aisle, when I bemoaned that question of why don't
    we do budgets, do deficits and debt make any difference
    anymore, and why don't we preemptively fix something that
    actuarially we have known for decades with Medicare and Social
    Security. ``Senator Braun, we just do not have the political
    will to do it.'' That was an interesting early committee
    meeting that has played out unbelievably to be the dynamic that
    drives this place.
        Thank you.
        Chairwoman Stabenow. Thank you very much. A lot of
    important things to debate on all of these subjects. Thank you
    very much.
        I believe Senator Thune has arrived and will be our last
    questioner unless somebody else arrives. Senator Thune.
        Senator Thune. I will bet these guys are very relieved to
    know that they are finally at the end.
        Chairwoman Stabenow. That is right.
        Senator Thune. Thank you, Madam Chair, and I want to thank
    everybody for participating.
        Let me just ask Dr. Holtz-Eakin, we have seen inflation
    hitting all aspects of the economy. Food prices are up. Gas
    prices are up. What is inflation's effect on the health care
    system, and does it result in more cost shifting for workers
    who have insurance through their jobs? Maybe can you touch on
    how that affects Medicare and Medicaid?
        Dr. Holtz-Eakin. All good questions, Senator. The health
    care system is going to face rising input costs like everyone
    else. We have got transportation costs for the supplies. We
    have got wage costs for the employees. Facilities costs. You
    know, shelter is now a central part of the inflation problem.
    That is going to spread to commercial real estate.
        Broadly, input costs are going to rise. People are going to
    face budget deficits in their planning. Certainly, that is
    something that I worry about in my business. You have to find a
    way to accommodate that. Will it be cutting off care, or will
    it be raising the cost of that care? Neither is a particularly
    attractive option. Then the health care sector is going to face
    a lot of that over the next year.
        For workers, they are getting wage increases, but those
    wage increases are not enough to keep up with inflation. If
    their health insurance goes up, the typical response of
    employers is to minimize the amount of wage increases they give
    to sort of cover the benefit bill, and you just do not get a
    cash increase. That exacerbates the problem they face. That is
    a cost shifting onto workers that will be prevalent over the
    next two or three years. I think that will be quite clear.
        Senator Thune. As you know, I come from a rural State, and
    naturally I am very concerned about the closure of hospitals
    and nursing homes in rural America, which is why I find the
    Biden administration's position on nursing home mandates and
    staffing to be so perplexing. As it is, nursing homes are
    competing with fast-food restaurants and, in bigger cities,
    Amazon warehouses to find workers.
        Let me be clear. We all want nursing homes to be safe and
    our loved ones to have quality care, but the President just
    proposed new requirements on staffing and potential enforcement
    penalties that make me wonder if anyone is thinking about how
    rural nursing homes are going to be able to make it. USDA's
    Rural Development initiatives can be helpful here, but they
    cannot be a substitute for other policies that fail to consider
    the needs of rural America.
        Could you tell me your perspective on how Federal mandates
    are going to affect access to care in rural America?
        Dr. Holtz-Eakin. I certainly think this is a concern in the
    specific in rural America. These mandates on the nursing homes
    to have, you know, fewer multi-patient rooms, more single
    rooms, higher staffing requirements, these are all costs of
    doing business. They are going to be mandated cost increases
    that are not obviously easy to cover given the business model.
        Again, unpleasant choices will be present. Do we raise the
    prices? Do we close different branches to make things go? That
    is inevitable.
        This is a general problem with the regulatory State, which
    is that we have programs that fund things but with the other
    hand we are raising the cost of doing those very activities.
    The Biden administration finalized $200 billion worth of
    regulatory costs in its first year in office. That is the
    largest number of any administration since we started tracking
    this, and it is raising the cost of business at a time when
    inflation is already pressing people and making things
    difficult.
        Senator Thune. Yes. Well, let me just say, because it is
    National Ag Day today, that I want to thank profoundly farmers
    and ranchers in South Dakota and across the country for their
    tireless efforts to feed and clothe the world.
        I want to express my frustration at the fact that I do not
    believe we are focusing enough on the numerous challenges that
    rural Americans are currently facing as a result of high
    inflation. You have got rising food and energy costs. There is
    a lot of global commodity market uncertainty and volatility.
        I think those are the types of things that I would like to
    see the Committee, Madam Chair, focus on. I again would urge
    the Committee to follow through on a request that Senators
    Marshall, Ernst, and I have made to hold a hearing on the
    current agricultural supply chain challenges and ideas for
    improving the situation for our producers. We all hear it.
    Input cost, does not matter what it is, diesel fuel,
    fertilizer, equipment, everything is going through the roof. I
    think we are going to really see the results of that in the ag
    economy in this next season as they start planting crops and
    harvesting those crops. I hope we can have a hearing on that
    subject.
        I thank all of you for being here today, and with that, I
    will yield back my time. Thank you.
        Chairwoman Stabenow. Well, thank you very much, Senator
    Thune.
        Let me just say, in closing, that there is no question that
    costs are up. Good news is prices are up; the economy is
    strong. Bad news is input costs are up.
        I am very pleased as a result of funding that we put in the
    American Rescue Plan that the Biden administration is moving
    forward now as it relates to fertilizer inputs. We need to be
    making those in America, not relying on other countries.
        Same thing with the supply chains, we need to have more
    resiliency in our supply chains. That is why the money we put
    in the American Rescue Plan to help support small-and medium
    size meat processing operations, to create competition, to make
    sure we are not relying on the big four companies. They are
    primarily international. It is really important. There is no
    question on supply chains.
        Again, coming out of a global pandemic. We hope we are
    coming out of this. With supply chains broken down, the economy
    shut down in America, as well as all over the world, I am not
    surprised that our generation, which is facing something we
    have not faced in our generation, is now having to figure out
    how we put all these pieces back together and match them up. We
    have got a lot of challenges.
        Prices are going up, and we have got to continue to do
    everything we can to support our growers and our families to
    bring those down, which brings us back to today because that
    also relates to the things that directly relate to families who
    want to live in rural Michigan, who want to live in rural
    America. Certainly it is what is happening on inputs on the
    farm. It is also what is happening for families. It is also
    child care. It is also care for our moms and dads and grandpas
    and grandmas. It is also not driving three counties away for
    mental health help or health help, and all the other things
    that we need so that folks will want to live, so that the next
    generation of farmers, young people, farmers will want to come
    and stay. I want them to stay in rural Michigan. That is what
    this is all about.
        We have heard from our witnesses today that the care
    economy is important and needs to be supported as part of the
    whole picture. Whether that is child care, elder care, or
    health care, mental health, physical, behavioral health, our
    rural families' ability to access quality of life care is
    important, is key to economic prosperity for all of us.
        There is a lot of great work that is being done. We
    appreciate what you are doing. I look forward to continuing our
    strong relationship with the USDA and rural communities across
    our country as we work to improve access to quality care
    services at all stages of life.
        In addition, we will--at this point, the record will remain
    open for five business days for members to submit additional
    questions and statements.
        With that, the hearing is adjourned. Thank you very much.

        [Whereupon, at 12:19 a.m., the Committee was adjourned.]

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                                A P P E N D I X

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                       DOCUMENTS SUBMITTED FOR THE RECORD

                                 March 22, 2022

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                             QUESTIONS AND ANSWERS

                                 March 22, 2022

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