[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.]

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


                            A P P E N D I X

                             March 22, 2022

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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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


                   DOCUMENTS SUBMITTED FOR THE RECORD

                             March 22, 2022

=======================================================================
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



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


                         QUESTIONS AND ANSWERS

                             March 22, 2022

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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]