[Senate Hearing 118-187]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 118-187

                         EXAMINING HEALTH CARE
                          WORKFORCE SHORTAGES:
                       WHERE DO WE GO FROM HERE?

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                                   ON

               EXAMINING HEALTH CARE WORKFORCE SHORTAGES

                               __________


                           FEBRUARY 16, 2023

                               __________

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






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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                 BERNIE SANDERS (I), Vermont, Chairman

PATTY MURRAY, Washington
ROBERT P. CASEY, JR., Pennsylvania   BILL CASSIDY, M.D., Louisiana, 
TAMMY BALDWIN, Wisconsin                 Ranking Member
CHRISTOPHER S. MURPHY, Connecticut   RAND PAUL, Kentucky
TIM KAINE, Virginia                  SUSAN M. COLLINS, Maine
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
BEN RAY LUJAN, New Mexico            ROGER MARSHALL, M.D., Kansas
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
ED MARKEY, Massachusetts             TOMMY TUBERVILLE, Alabama
                                     MARKWAYNE MULLIN, Oklahoma
                                     TED BUDD, North Carolina

                Warren Gunnels, Majority Staff Director
              Bill Dauster, Majority Deputy Staff Director
                Amanda Lincoln, Minority Staff Director
           Danielle Janowski, Minority Deputy Staff Director








                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                      THURSDAY, FEBRUARY 16, 2023

                                                                   Page

                           Committee Members

Sanders, Hon. Bernie, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Cassidy, Hon. Bill, Ranking Member, U.S. Senator from the State 
  of Louisiana, Opening statement................................     4

                               Witnesses

Herbert, James, Ph.D., President, University of New England, 
  Biddeford, ME..................................................     6
    Prepared statement...........................................     9
Hildreth Sr., James E.K., Ph.D., M.D., President and CEO, Meharry 
  Medical College, Nashville, TN.................................    20
    Prepared statement...........................................    22
    Summary statement............................................    27
Szanton, Sarah, Ph.D., RN, FAAN, Dean, Johns Hopkins School of 
  Nursing, Baltimore, MD.........................................    28
    Prepared statement...........................................    29
    Summary statement............................................    31
Seoane, Leonardo, M.D., FACP, Chief Academic Officer, Ochsner 
  Health, New Orleans, LA........................................    32
    Prepared statement...........................................    34
    Summary statement............................................    41
Staiger, Douglas, Ph.D., Professor, Dartmouth College, Hanover, 
  NH.............................................................    42
    Prepared statement...........................................    44
    Summary statement............................................    47

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Casey, Hon. Robert:
    Statement for the Record.....................................    79
    19 Stakeholders, Statement for the Record....................    83
Kaine, Hon. Tim:
    Johnson & Johnson, Statement for the Record..................    81

                         QUESTIONS AND ANSWERS

Response by James Herbert to questions of:
    Sen. Paul....................................................   258
    Sen. Tuberville..............................................   259
Response by Sarah Szanton to questions of:
    Sen. Paul....................................................   261
    Sen. Tuberville..............................................   262
Response by Leonardo Seoane to questions of:
    Sen. Paul....................................................   263
    Sen. Tuberville..............................................   264
    Sen. Budd....................................................   266









 
                         EXAMINING HEALTH CARE
                          WORKFORCE SHORTAGES:
                       WHERE DO WE GO FROM HERE?

                              ----------                              


                      Thursday, February 16, 2023

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in room 
430, Dirksen Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.

    Present: Senators Sanders [presiding], Murray, Baldwin, 
Murphy, Kaine, Hassan, Smith, Lujan, Hickenlooper, Markey, 
Cassidy, Paul, Collins, Murkowski, Braun, Marshall, Romney, 
Tuberville, and Budd.

                  OPENING STATEMENT OF SENATOR SANDERS

    The Chair. The Senate Committee on Health, Education, 
Labor, and Pensions will come to order. As I have mentioned 
before, and as everybody knows, this Committee covers a huge 
gamut of issues that impact the American people. And the 
reality is, as everybody knows, that there are going to be some 
issues where there are going to be very strong disagreements, 
and we will simply agree to disagree and hopefully do that in a 
respectful way.
    There are going to be other issues, however, that impact 
every state in this country where in fact there should be 
strong bipartisan support. And the issue we are discussing 
today is one of those issues. Let me just start off my remarks, 
then I'm going to give the mic over to Senator Cassidy, and we 
will have questions, and everybody will have their time.

    But let me start off by telling you what the panelists 
certainly know, and we thank all of them for being here today, 
and every Member here knows, and that is the United States will 
face a shortage of up to 124,000 physicians by 2034, including 
48,000 primary care physicians. By 2025, the United States will 
have a shortage of up to 450,000 nurses.

    Right now, and this is an issue we don't discuss much as a 
Nation, and I intend to see this Committee discuss it, we need 
approximately 100,000 more dentists across the United States. 
We have a major crisis in terms of access to dental care in 
Vermont, and I expect every state in this country.

    The number of people who live in areas without enough 
health care providers, I think will use the word health care 
deserts since it is the common term used, 99 million primary, 
70 million dental, 156 mental health, which everybody in this 
Committee knows is a horrendous crisis in America.

    Here is my hope, my hope that we can do what the pundits 
tell us that we can't do, and that is actually deal with the 
issues facing the American people in a serious, nonpartisan way 
because these issues impact every state in America. I want to 
thank our excellent panelists. I read the testimony and I thank 
you all for being here.

    Let me begin by saying that it is no secret to anyone that 
our Country faces many health care crises. Despite spending 
almost twice as much per capita on health care as any other 
major country, we spend $13,000 per person, man, woman, and 
child on health care, we have massive shortages in health care 
providers.

    Today, we are going to focus on that crisis. And that is 
that we simply do not have in our Nation enough doctors, 
nurses, nurse practitioners, dentists, dental hygienists, 
pharmacists, mental health providers, among other medical 
professions. And what is the impact of those health provider 
shortages? What does it mean to ordinary people?

    It means that nearly 100 million of our people live in a 
primary care desert, where they are unable to gain timely 
access to a doctor when they need it. It means that nearly 70 
million people live in a dental care desert, unable to get 
dental care while teeth in their mouths are rotting.

    It means that some 158 million Americans, nearly half our 
population, live in a mental health care desert at a time when 
this country is facing an unprecedented mental health crisis. 
Simply put, it means that a significant percentage of our 
population live in places where they cannot access the health 
care they desperately need in a timely manner.

    Got to tell you, bumped into some people in Vermont, and we 
do better than most states, I think. A guy goes in, he wants a, 
just a checkup. Four months later, he will get that checkup. 
That is in Vermont. In my view, the reality is, this reality is 
a contributing factor to the declining life expectancy we are 
seeing in many parts of our Country and the fact that our 
overall life expectancy is lower than many, many other 
countries.

    Life expectancy, as I think we all know, is not simply a 
factor of access to health care. Deals with economics, a lot of 
other things. But access to health care is an important part of 
why people are living shorter lives.

    Here is a point that you are going to hear me make over and 
over again, and that is that not only does the lack of medical 
professionals in many parts of this country lead to increased 
human suffering and unnecessary death, it is incredibly 
wasteful from a financial perspective.

    If people cannot access a primary care doctor, they may end 
up in an emergency room, which is the most expensive form of 
primary health care. Somebody goes to a community health 
center, somebody goes to an emergency room. Going to the 
community health center is 1/10th the cost to Medicaid than 
going to the emergency room.

    If their illnesses continue because they don't go to a 
doctor when they should, they may end up in a hospital running 
up tens of thousands or hundreds of thousands of dollars of 
unnecessary expenses if they got the treatment that they needed 
when they needed it.

    Study after study shows that disease prevention saves 
money. If people are able to access care when they need it, if 
there are enough medical professionals to provide that care in 
every part of this country, our health care costs go down.

    A shortage of health care personnel was a problem before 
the pandemic, and now it has gotten much worse. Health care 
jobs have gotten more challenging and in some cases more 
dangerous. Many thousands of our health care workers have died 
from COVID, we all know that doctors, nurses, others, taking 
care of the American people.

    These are genuine heroes and heroines, and we owe them more 
than we can ever pay back. According to the best estimates, 
over the next decade, our Country faces a shortage of over 
120,000 doctors, including a huge shortage of primary care 
physicians. And our goal, as long as we get more doctors, is to 
get them to the places where they are needed, often in rural 
areas, in urban areas.

    We don't need more folks on Park Avenue in New York City. 
We need them in rural areas where people can't access a doctor, 
in urban areas where the waiting lines are too long. Over the 
next 2 years, it is estimated we will need up to 450,000 more 
nurses. Today it is estimated we need 100,000 more dentists.

    In America today, there is a massive shortage and we will 
discuss this at length in another occasion, in terms of mental 
health providers. and that is psychiatrists, psychologists, 
social workers, counselors, addiction specialist, and many 
more. In addition to our overall crisis in health care 
providers, that problem is especially acute in minority 
communities, and we are going to be discussing that today.

    We desperately need more African American, Latino, and 
Native American health care personnel who are way, way 
underrepresented in the health care profession. How we address 
these crises is the subject of today's hearing and of a lot 
more future discussions that we will all be having.

    But talk and hearings, frankly, are not good enough. Our 
job is to get the best information we can as quickly as we can, 
put that information into good legislation and to pass that 
legislation. Let me very briefly talk about some of the 
thoughts that I have, others who will have different thoughts.

    First, it is a no brainer to understand that when over 
100--over 10,000 medical school graduates are unable to fill 
residency slots every year, we must significantly expand and 
improve the graduate medical education program. That is not 
within our jurisdiction. It is in the Finance Committee. But it 
is something that we have got to look at.

    Further, and in the jurisdiction of this Committee, we must 
also greatly expand the teaching health center program, another 
really good program that allows residents to work in community 
health centers and in primary care. Very important.

    Further, at a time when young people are graduating from 
medical school, dental school, and nursing school deeply in 
debt, everybody here has talked to graduates, doctors leaving 
$400,000, $500,000 in debt.

    It is pretty obvious that those people graduating with huge 
debts are not going to go to rural America, not going to go to 
urban America. They are going to go to places where they can 
make a lot of money. And that is why we must substantially, in 
my view, increase student loan debt forgiveness and 
scholarships through the National Health Service Corps Program.

    We have expanded that in recent years. We have got to do 
more. Further in terms of nursing, boy, that is an issue that I 
think impacts everybody. Despite a major nursing shortage, and 
I will tell you in my own State of Vermont, and I talked to 
Senator Collins about it, I think it is true all over this 
country.

    We in our hospital in Vermont are spending $125 million on 
traveling nurses, an insane amount of money, and yet we have 
young people in Vermont who want to become nurses. Our nursing 
schools can't accommodate them because we don't have enough 
teaching personnel or the kind of equipment that we need.

    Totally crazy, and that is an issue I look forward to us 
addressing. Well, that is about it for me. And you know, I want 
to say also a word about emergency medical services. I know in 
Vermont, rural areas, you got great people, often volunteers. 
They have to pay for their own training. I hope that that is an 
issue we deal with as well.

    Bottom line is, look, we have an issue that the American 
people want us to resolve. It should be a bipartisan issue. I 
intend to work with Republicans and Democrats to make sure that 
we get good legislation through. Senator Cassidy.

                  OPENING STATEMENT OF SENATOR CASSIDY

    Senator Cassidy. Thank you, Mr. Chairman. The COVID-19 
pandemic has strained our health care system. It has placed a 
huge burden on health care workers. So, as we come out of the 
pandemic, this hearing is to address workforce issues. Why are 
there still shortages post-pandemic? Which are most pressing? 
And how do we get the understanding to address it? There is an 
old saying in internal medicine, don't just do something, 
think.

    We must first think about what we should do. Now, 
physicians in hospitals in Louisiana tell me they need nurses. 
And speaking as a physician who had the great fortune to work 
with many incredibly talented nurses, they are essential. Goes 
without saying. There are different things we can do.

    I am going to use an example of a woman I once worked with 
to explain the concept of upskilling. Linda started off in the 
clinic as a Medical Assistant. She kept going to school and got 
her LPN. Kept going to school and got her BSN. Kept going to 
school and got her masters, and at the end was the Nurse 
Manager in the clinic in which she had begun as a Medical 
Assistant. That is upskilling.

    Along the way she improves her family, helps patients, but 
demonstrates for her children the power of education and the 
power of delayed gratification. There is a lot in that story 
that can inform what we should be doing on national policy. And 
Linda, you know who you are, wherever you are, I am talking 
about you.

    Now, something that is--by the way, this is not all 
Federal. We know that there is a shortage of nurse educators. 
But when you look at the requirements in some states, mine 
included, you have to have a master's of nursing to be a nurse 
educator. Now, I have worked with certificate nurses who have 
been by the bedside for 20 years who knew nursing. The idea 
that we cannot use someone such as she in order to educate 
others, I think doesn't acknowledge how much she knows.

    This is a way to remove a choke point which is preventing 
all these applicants from having more slots in which to go to 
fill our nursing shortage. Now, I agree with the Chair. We can 
and should work in a bipartisan way to address nursing shortage 
and other shortages aside from nursing.

    My hope for this hearing is to identify those other 
providers and those areas, as the Chair mentioned, such as 
rural areas that have critical workforce needs. But why don't 
we use the workforce we have more efficiently? I say that 
because there was a recent study, just before the pandemic, in 
the Annals of Internal Medicine that found that physicians 
spend as much as 16 minutes per patient filling out the 
electronic health record.

    Now speaking to my colleagues, many of them retire early 
because they are sick of that. It is a major cause of burnout. 
So that which has been implemented by the urging of the Federal 
Government is creating the problem of physician workforce 
shortage.

    For the patient, it is a difference between having a 
physician type on a screen as he tells you that you have cancer 
or looking into your eyes and telling you that you have hope. 
We need to give that physician the ability to communicate hope. 
This is something this Committee can look into, understand, and 
address.

    On a larger scale, the Federal Government invests billions 
toward health care workforce programs. We need to continue to 
support what is working, understand what is not, and fix that 
which is broken.

    We have to be good stewards of the taxpayers' dollars, not 
wasting money. We have to be productive. This year, the 
Committee is tasked with extending mandatory funding for 
programs like the National Health Service Corps, which offers 
loan repayment and scholarships to health care providers in 
exchange for working in a health professional shortage area. 
And the Teaching Health Centers Graduate Medical Education 
Program, which supports the cost of training medical and dental 
residents in outpatient settings.

    Additionally, we are tasked with reauthorizing the 
Children's Hospital Graduate Medical Education Program set to 
expire this year. This program, this legislation supports 
training of pediatrician and pediatric subspecialists, noting 
that nearly half of all pediatric residents train at a 
children's hospital.

    It is important that the funding for these programs is 
extended on time, in a bipartisan fashion, and that it be paid 
for. Finally, I know today's witnesses have innovative ideas on 
how hospitals and academic institutions can support the 
pipeline of health professionals.

    One of my witnesses will speak directly to that. The 
Federal Government does not play the only role in seeking a 
solution to workforce shortage. We need to hear the perspective 
of these experts as we bolster America's health care workforce 
moving forward, and while doing so, just like Linda, create 
more opportunity for the individual. Thank you.

    The Chair. Thank you, Senator Cassidy. We have a great 
panel of witnesses, and I thank them all for coming.

    Our first witness will be Dr. James Herbert, and I first 
met Dr. Herbert when Senator Collins brought him to a hearing 
that we did. I would like Senator Collins to introduce him. 
Senator Collins.

    Senator Collins. Thank you so much, Mr. Chairman. I am 
delighted to introduce Dr. James Herbert, President of the 
University of New England, located in Biddeford and Portland, 
Maine.

    Dr. Herbert has served as President of UNE since 2017. As 
the Chairman has indicated, he offered extraordinarily 
insightful testimony before the Primary Health Subcommittee in 
2021, and I thank the Chairman and the Ranking Member for 
inviting Dr. Herbert back to testify today.

    UNE is one of a handful of private universities with a 
comprehensive health education mission, including medicine, 
pharmacy, dental, nursing, and an array of allied health 
professions. UNE ranks in the top 20 of medical schools 
nationally for educating primary care physicians, particularly 
those trained in rural medicine.

    UNE is the largest provider of health professionals to the 
State of Maine, the only medical school in our state, and 
offers Northern New England's only dental college. Dr. Herbert 
holds a doctorate and master's in clinical psychology from the 
University of North Carolina at Greensboro, and a B.A. in 
Psychology at the University of Texas at Austin.

    Dr. Herbert, welcome back. I have appreciated your many 
insights that you have shared with me, and I am delighted that 
the Chairman and Ranking Member have invited you to return and 
share those insights with the Full Committee. Thank you, Mr. 
Chairman.

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

    Dr. Herbert. Thank you so much, Senator Collins. Thank you 
very much, Chairman Sanders and Ranking Member Cassidy, and 
other Members of the Committee for inviting me to speak with 
you today.

    As the Senator said, my name is James Herbert. I am from 
the University of New England in Maine. I won't repeat who we 
are because Senator Collins just told you. Thank you very much. 
I would stress that we consider ourselves a private university 
with a public mission, and we are very proud of that public 
mission.

    As you probably all know, Maine is the oldest state in the 
Nation. We have one of the oldest health care workforces, and 
we are tied with Vermont being the most rural state in the 
Nation. The challenges that we face today in Maine are 
harbingers of what the rest of the country will increasingly 
confront as our Nation ages and as urbanization creates pockets 
of underserved populations, not only in our cities, but also in 
our vast rural areas.

    I won't detail the shortage of health care professionals. 
Senator Sanders has done that very nicely, and I know you all 
appreciate the scope of the problem. What I would like to do 
today is to briefly outline six specific strategies that I 
believe can go a long way to address this crisis.

    At UNE, we are attempting to address each of these 
strategies. I don't pretend that we have all the answers, but 
we have found that what is critical to moving the needle are 
strategic partnerships between higher education, Government, 
business, nonprofits, and philanthropy. And it is that 
partnership that allows us to move forward.

    First and most fundamentally, we must increase the number 
of doctors, nurses, and other health care professionals that we 
educate. But educating more professionals is not as 
straightforward as it might seem. The biggest challenge is the 
limited availability of clinical training opportunities.

    As financial margins have tightened and clinician workloads 
have increased over the past three decades, practicing 
clinicians have less time to train students. The single most 
important thing we can do to increase the number of health care 
providers is to support partnerships between universities, and 
community, and health care entities to develop additional 
clinical training opportunities.

    This includes revision of the Center for Medicare and 
Medicaid Services' antiquated policies around funding graduate 
medical education, which Senator Sanders touched on. Tuition 
for many healthcare professional programs is high and can be an 
impediment to many students. I assure you this is not because 
greedy universities are trying to get rich on the backs of 
students.

    Rather, the cost of educating students has skyrocketed. 
Just for example, in our case, the costs of training third-and 
fourth-year medical students has increased fivefold since I 
assumed this position in 2017. Scholarship and loan repayment 
programs are critical to make health care education more 
accessible to those who would otherwise find it out of reach.

    As Senator Sanders mentioned, the National Health Service 
Corps is one example of such a program, but it is simply 
inadequate in many ways to meet current needs. Another barrier 
that has been mentioned is the difficulty in hiring and 
retaining qualified faculty members who can typically earn more 
in the private sector in direct or indirect clinical settings 
than at universities.

    Support such as that displayed by Senator Collins and 
Sanders and others for a strategic health care faculty loan 
repayment programs is critical to ensuring the future of the 
health care workforce. So, the second thing we must do is to 
intentionally recruit more students who look like the 
communities that they serve.

    It is well-established that individuals from 
underrepresented groups are more likely to seek needed health 
care services from practitioners who share their identities and 
backgrounds.

    Third, it is not enough merely to train more professionals. 
As Senator Sanders mentioned, we must address their 
maldistribution in society. That is, we must encourage them to 
practice in underserved areas following graduation, such as in 
tribal and rural and medically underserved communities.

    Like Maine, most states have vast rural areas of 
distributed population, and these communities have far less 
access to health care. Financial support in terms of loan 
repayment programs, strategic loan repayment programs to 
practice in underserved areas is critical, and I thank 
Congressional leadership for their ongoing support.

    But these programs are currently insufficient. In the case 
of physicians, for example, the loan repayment subsidies don't 
compensate for the typical salary gap between rich urban and 
suburban communities on the one hand and underserved urban and 
rural communities on the other.

    Fourth, we must leverage the power of technology to reach 
underserved communities. Telehealth and digital medicine have 
tremendous potential to help in this regard. Fifth, we need 
changes to state level regulations to allow health 
professionals to practice at the top of their scope of 
practice.

    Across the U.S., many states have laws that prevent some 
health care professionals from providing services that they are 
perfectly trained and able to provide. Many states made 
temporary changes to increase the flexibility during the 
pandemic, and such flexibility should be continued.

    The focus of scope of practice regulation should be on what 
level of regulation results in the best outcomes in terms of 
health care safety of the population, and not managing guild 
driven turf wars between professionals. Sixth, and finally, the 
most fundamental change. We must fundamentally change the 
prevailing educational model in two ways.

    First, accrediting bodies need to allow training programs 
to be more creative and innovative and flexible, without 
sacrificing educational quality, to adopt new models. This 
includes so-called career laddering, opportunities that don't 
completely remove professionals from the workplace as they are 
training to upskill.

    Accrediting bodies should also accept more high-quality 
clinical simulation hours in place of hours physically spent in 
clinical settings, and that reduces the burden on hospitals 
that I touched on earlier. The second educational reform, and I 
will conclude, involves breaking down the traditional silos 
that characterize health care training and practice.

    Anyone who has recently been in a hospital or has cared for 
a loved one in a hospital understands how siloed the practice 
of health care tends to be. In response, an educational model 
has emerged in which students are trained to work together in 
multidisciplinary teams, and this is known as interprofessional 
education.

    This model is shown to improve outcomes, improve patient 
satisfaction, decrease medical errors, and decrease provider 
burnout. So, in conclusion, successfully addressing America's 
health care workforce crisis will require not merely acting on 
each of these individual initiatives in isolation, but in 
strategically combining them.

    I am grateful for your time and consideration. Thank you.

    [The prepared statement of Dr. Herbert follows:]
                  prepared statement of james herbert
    Thank you, Chairman Sanders, Ranking Member Cassidy, and other 
Members of the Committee for the opportunity to speak with you today. 
It's an honor to share some thoughts on strategies for addressing our 
Nation's healthcare workforce crisis.

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

    As you probably know, Maine's population is the oldest in the 
nation \2\ and is tied with Vermont as being the most rural \3\ state. 
Our healthcare workers are also among the oldest in the country, with 
many practitioners approaching, or even practicing beyond, retirement 
age. \4\ The challenges we face are in some sense harbingers of what 
the rest of the country will increasingly confront as our Nation ages 
and as urbanization creates pockets underserved populations in our 
cities as well as in our vast remote rural areas.
---------------------------------------------------------------------------
    \2\  Maine has the highest median age in the U.S.: 44.7 years 
relative to the national average of 38.8 (U.S. Census Bureau, 2022). At 
21.3 percent Maine also has the highest percentage of citizens over 65 
in the U.S. (U.S. Census Bureau, 2019b).
    \3\  U.S. Census Bureau, 2019b
    \4\  At 39.3 percent, Maine ranks first in the Nation for the 
percentage of active physicians who are age 60 or older (AAMC, 2021). 
In 9 of16 Maine counties, 50 percent or more of physicians are 55 or 
older (Skillman & Stover, 2018). Over 50 percent of Maine's registered 
nurses are 50 or older (Maine Nursing Action Coalition, Center for 
Health Affairs NEONI, 2017).

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

    First, and most obviously, we must increase the number of doctors, 
nurses, and other healthcare professionals we educate to address our 
growing population, aging workforce, and many underserved communities. 
But educating more professionals is not as straightforward as it may 
seem; we at universities face a number of barriers in doing so. I will 
briefly touch on the three most important of these challenges.

    By far the most important impediment to training more healthcare 
providers is the availability of clinical training experiences in 
hospitals and clinics, which has been well documented by the Department 
of Health and Human Services Health Resources and Services 
Administration (HRSA). \5\ As financial margins have tightened and 
clinician workloads have increased over the past three decades, 
healthcare facilities and practicing clinicians have fewer resources 
and less time to devote to training students. \6\ The single most 
important thing we can do to increase the number of healthcare 
providers is to support and expand partnerships between universities 
and community healthcare settings to develop additional residencies, 
clerkships, practica, and other training opportunities. In medicine in 
particular, the Center for Medicare and Medicaid Services' (CMS) 
payment system for graduate medical education (GME; i.e., physician 
residencies) favors academic medical centers, places caps on successful 
rural residency programs making expansion difficult, and penalizes 
community hospitals that may have previously partnered with other 
institutions. In other words, CMS policy is antiquated and makes it 
very difficult to grow more residency placements. \7\
---------------------------------------------------------------------------
    \5\  U.S. Congress: Advisory Committee on Interdisciplinary, 
Community-Based Linkages. (2018).
    \6\  Benbassat, 2020; Cox & Desai, 2019; Hanna, 2019; Hatfield et 
al., 2022; Graziano et al., 2018; Konrad et al., 2010; Krehnbrink et 
al, 2020; de Villiers et al., 2018; Rodriguez, 2013
    \7\  CMS policies for GME have established caps on most existing 
residency programs and although CMS created a somewhat circuitous 
pathway for rural hospitals to expand beyond their cap, the criteria of 
the review committees of the Accreditation Council on Graduate Medical 
Education (ACGME) create significant obstacles to accredited expansion 
and the creation of new rural residency programs.

    At UNE, one way we have expanded clinical training opportunities is 
by working with partners in rural and underserved primary care sites 
and federally Qualified Health Centers. One advantage of such 
placements is that students learn how to deliver compassionate care to 
Maine's most vulnerable residents, many of whom are uninsured and also 
navigate chronic physical and mental health conditions. The precepting 
clinicians in these settings are dedicated to treating underserved 
patients, sometimes with limited access to specialized professional 
support. \8\ These settings afford students exposure to a broad range 
of conditions and allow them to perform and assist with a wide variety 
of procedures.
---------------------------------------------------------------------------
    \8\  Hempel et al., 2015; Lee et al., 2016.

    Clinical training opportunities are not the only infrastructure 
limitation to producing more healthcare professionals. Cost, both to 
educational institutions and to students themselves, is also a factor. 
Standing up new educational facilities, or expanding existing ones, 
involves considerable startup costs. One-time governmental support is 
often needed to supplement institutional investments and philanthropy. 
\9\
---------------------------------------------------------------------------
    \9\  An example of an effective public-private partnership is UNE's 
establishment of our College of Dental Medicine. Recognizing the 
region's significant unmet oral healthcare needs and the fact that 
there was no dental school in all of northern New England, in 2013 we 
partnered with both Federal and state governments, regional industry, 
non-profits, and philanthropists to establish a dental school. Senator 
Collins was critical in helping to secure Federal support for that 
project. And the people of Maine passed a $3.5 million bond to support 
not only creation of the school itself, but also community dental 
clinics around the state to help them increase their capacity to 
provide dental care and to take our students on rotation. The school 
was created with an explicit focus on addressing underserved 
populations.

    Tuition for many programs is high and can be an impediment for many 
students, especially those from poor, working class, or even middle-
class backgrounds. Contrary to certain narratives, this is not because 
greedy universities are trying to get rich on the backs of students. 
\10\ Rather, the costs to educate students have risen considerably. For 
example, the cost of training third-and fourth-year medical students 
has increased fivefold since 2017. Scholarship and loan repayment 
programs can make healthcare education accessible to those who would 
otherwise find it out of reach. The National Health Service Corps is 
one example of such a program; however, it is inadequate to meet 
current needs in many ways. Only a limited number of professions are 
covered, the competition is high with many applicants being turned 
down, the scholarship or loan reimbursement amounts are inadequate, and 
the kinds of eligible sites (FQHCs, tribal clinics, etc.) are too 
limited.
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    \10\  An exception being certain predatory foreign medical schools, 
particularly in the Caribbean, that cater to American students who 
cannot gain entry into domestic medical schools and which charge 
exorbitant tuition.

    A third barrier to training more healthcare professionals is the 
difficulty hiring and retaining qualified faculty members, who can 
typically earn more in direct care clinical settings and yet require a 
higher level of training and credentialing than those working 
clinically. \11\ Support such as that displayed by Senators Sanders, 
Collins, and others for strategic loan repayment programs targeting 
those assuming faculty positions in health professions is critical to 
ensuring the future of the healthcare workforce. Loan repayment 
programs improve access to graduate/doctoral education by encouraging 
qualified individuals to advance their education and subsequently 
become employed as faculty. \12\ Title VIII programs, such as the 
Nursing Workforce Development Programs, are an example of an important 
step in addressing this issue.
---------------------------------------------------------------------------
    \11\  Christmas et al., 2010; Feldman et al., 2015; Girod et al., 
2017; Nauseen et al., 2018
    \12\  The case of dentistry is illustrative of the problem. The 
number of dental school graduates entering an academic career 
immediately following graduation is quite low. For the Class of 2022 
graduates responding to the American Dental Education Association 
Senior Survey, 0.7 percent (13 of the 1,757 respondents) indicated they 
plan to work as a faculty/staff member at a dental school after 
graduation (Istrate et al., 2022). An additional consideration is that 
most dental schools provide little exposure to academic careers. At 
UNE's College of Dental Medicine (CDM), dental students may participate 
as teaching assistants, tutors, peer mentors in the simulation and 
patient care clinic, or conduct research with faculty to be exposed to 
elements of an academic career. To date, out of six graduating classes, 
five alumni have returned to teach as part-time adjunct faculty in the 
CDM, one is an adjunct faculty in UNE's dental hygiene program, one 
recently joined the CDM as a full-time faculty member, and eight serve 
as preceptor faculty at CDM clinical affiliation sites where fourth-
year students complete community-based externship rotations.

    In addition, in some cases practicing clinicians can be recruited 
to serve as faculty instructors in their existing workplaces. For 
example, we have developed a new accelerated nursing program, in which 
existing employees of Maine's largest healthcare system are trained 
---------------------------------------------------------------------------
onsite by a combination of our own faculty and hospital clinicians.

    Despite these challenges, at UNE we continuously seek to increase 
the number of health profession students we educate. For example, we 
have increased the size of our nursing program 300 percent over the 
last decade, and we have a grant under review with the U.S. DOL to 
further bolster our nursing training. We are currently in the process 
of increasing the class size of our medical students from 165 to 200 
per year, our dental students from 64 to 72 per year, and our graduate 
registered dietician program from 80 to 100 per year. And with these 
increases we remain focused on quality training, as evidenced by the 
fact that our students routinely score above the state and national 
means on clinical board exams, and our medical students have among the 
highest residency match rates in the Nation.

    The second strategy for addressing the Nation's healthcare 
workforce involves intentionally recruiting and training more students 
who look like the communities we need to serve. It is well established 
that individuals from underrepresented groups are more likely to seek 
out practitioners who share their identities and backgrounds. \13\ 
Studies have found that minority patients who are treated by race/
ethnic-concordant clinicians are more likely to use needed health 
services and are less likely to delay seeking care. \14\
---------------------------------------------------------------------------
    \13\  LaVeist et al., 2003; Shen et al., 2018; Takeshita et al., 
2020
    \14\  Handtke et al., 2019; LaVeist & Nuru-Jeter, 2002; Saha et 
al., 2000;

    In Maine, we have a growing immigrant population, especially from 
Central and Eastern Africa, and not surprisingly, this community 
experiences significant healthcare discrepancies relative to the 
broader population. \15\ To address this issue, not only has UNE 
increased recruitment efforts targeting students of color across the 
entire university, we recently expanded our ``Advanced Standing'' 
programs in dentistry and pharmacy, which are designed to accelerate 
the time it takes for foreign-trained immigrant professionals to 
achieve a U.S. degree and become eligible for licensure. We have also 
developed partnerships with local community colleges to matriculate 
students from our immigrant communities into certain healthcare 
programs (e.g., dental hygiene). \16\
---------------------------------------------------------------------------
    \15\  Drewniak et al., 2017
    \16\  National Academies of Sciences, Engineering and Medicine, 
2021.

    Third, it's not enough merely to train more healthcare 
professionals, we must address their maldistribution within our 
society. That is, we must encourage healthcare providers to practice in 
underserved areas, including rural, tribal, and medically underserved 
urban communities. Like Maine, most states have vast rural areas with 
highly distributed populations, and these communities have far less 
access to healthcare. \17\ The U.S. Government has invested in 
programs, administered through the Health Resources and Services 
Administration, that provide financial support in the form of loan 
repayment to graduates who serve in disadvantaged areas. These programs 
are absolutely critical, and we thank Congressional leadership for 
their ongoing support. However, they are insufficient. For example, in 
the case of physicians, the loan repayment subsidies do not compensate 
enough for the typical salary gap between rich urban and suburban 
communities and underserved urban and rural areas. \18\
---------------------------------------------------------------------------
    \17\  The U.S. Department of Health and Human Services has 
designated nearly 248 geographic areas in Maine as health professional 
shortage areas for primary care, dental health, and mental health, as 
of December 31, 2022 (Maine Center for Disease Control & Prevention, 
2023). Maine also has 51 medically underserved areas/populations, 
defined as areas having too few primary care providers, high infant 
mortality, high poverty, and/or a high elderly population. Nearly all 
of Maine's medically underserved areas are in Maine's Congressional 
District Two, the second most rural congressional district in the 
country (U.S. DHHS, 2019).
    \18\  In addition to scholarship and loan repayment programs, 
revisions to Medicaid reimbursement schedules are needed to meet the 
needs of rural populations and to incentivize clinicians to practice in 
these areas. Rural populations tend to be more reliant on Medicaid to 
pay for healthcare. In the case of dentistry, for example, coverage and 
reimbursement rates vary by state. The low reimbursement rates and 
cumbersome preauthorization and claims processes deter many 
practitioners from accepting Medicaid insurance.

    The paucity of physicians and other healthcare providers practicing 
in rural areas is particularly acute, fueled in part by the decline of 
students from rural backgrounds pursuing healthcare education. \19\ At 
UNE, we have successfully used a three-prong strategy to encourage our 
graduates to practice in rural areas. We intentionally recruit students 
from rural areas, both from Maine and around the country. Students from 
small towns and other nonurban areas are more likely to return to such 
communities after graduation. \20\ Regardless of where they come from, 
we place students in clinical training sites in underserved rural areas 
as part of their education to give them a taste of rural practice and 
lifestyle. Each year, many graduates exposed to these crucial settings 
during rotations return for employment, inspired by the commitment to 
quality patient care they witnessed, as well as their love of small-
town life. \21\ For example, between 2013 and 2019 up to 53 percent of 
our medical students who completed a rotation in a rural community 
hospital in Maine returned to those areas to practice regardless of 
where they did their residency or where they were originally from. Our 
experience is consistent with research demonstrating a direct 
relationship between exposure to rural settings in physician residency 
training and subsequent work in rural communities. \22\
---------------------------------------------------------------------------
    \19\  Shipman, S. (2019)
    \20\  American Academy of Family Physicians, 2016; Hu et al., 2022; 
Lee et al., 2021; University of Wisconsin, 2020;
    \21\  UNE's dental school clinical model is an excellent example of 
success in this regard. UNE places students in up to two 12-week 
clinical rotations in settings throughout northern New England, working 
in collaboration with a network of FQHCs, non-profit clinics, and 
private dental offices. Students provide billable services while 
receiving supervision from the preceptor and most importantly, learning 
about the community they serve. We are grateful for the U.S. Department 
of Health and Human Services' on-going funding to Maine's network of 
health centers providing access to many of our marginalized residents, 
while also offering much-needed clinical placements to students.
    \22\  Russell et al., 2022.

    Finally, in concert with state and philanthropic partners, we have 
developed loan repayment and scholarship programs to incentivize 
practice in rural settings. These efforts have paid off; over the past 
decade we have made dramatic inroads in addressing the needs of rural 
communities. For example, 40 percent of UNE medical school graduates 
who practice in Maine do so in health profession shortage areas (HPSAs) 
designated by the U.S. Government, positively impacting the HPSA 
designation of five counties. \23\ And in our dental school's first six 
graduating classes (2017--2022), we educated 377 dentists, 27 percent 
of whom are currently practicing in Maine. Of those practicing in 
Maine, 57 percent are practicing in a Dental Health Professional 
Shortage Area (HPSA), 47 percent are enrolled as MaineCare providers or 
are in a practice that accepts MaineCare, and 17 percent practice in a 
FQHC or non-profit clinic. \24\ Nearly one in five is employed in a 
federally Qualified Health Center, a non-profit community clinic, or 
the Veteran's Administration, and four in ten are practicing in Maine's 
most disadvantaged areas. \25\
---------------------------------------------------------------------------
    \23\  NCAHD's Enhanced State Licensure Data, 2016; The Robert 
Graham Center, 2012.
    \24\  Department of Professional and Financial Regulations, Maine 
Board of Dental Practice: Provider directory; Maine Care Services, 
Provider directory; Health Resources & Services Administration, Find 
shortage areas; National Plan Provider and Provider Enumeration System, 
NPPES NPI registry.
    \25\  This is particularly noteworthy given that Maine has the 
second fewest (just ahead of New Hampshire) dental providers 
participating in Medicaid or CHIP in the entire country, according to 
the American Dental Association's Health Policy Institute (2019).

    The fourth strategy for addressing the healthcare workforce crisis 
involves technology. Specifically, we must leverage the power of 
technology to reach underserved communities. The COVID-19 pandemic 
introduced many Americans for the first time to the value of 
telehealth, as we all learned to access healthcare providers via 
videoconferencing. \26\ Telehealth and digital medicine have enormous 
potential to transform healthcare delivery, particularly in underserved 
areas. \27\ In addition to patients accessing their providers through 
secure videoconferencing platforms, primary care providers in remote 
locations can themselves access specialist colleagues in urban tertiary 
care hospitals and university health centers for expert consultation. 
And emerging digital medicine and artificial intelligence technologies 
will increasingly allow clinicians to monitor patient symptoms and even 
deliver certain treatments remotely over the internet. These 
technologies can also enhance the education of students in health 
profession programs but also the reach and effectiveness of continuing 
medical education programs. At UNE, we are integrating robust 
telehealth training for all of our health profession students in close 
partnership with our various training sites.
---------------------------------------------------------------------------
    \26\  Wosik et al., 2020
    \27\  Kichloo et al., 2020

    Fifth, changes to state level regulations that allow health 
professionals to practice at the top of their scope could help address 
health care workforce shortages. ``Scope of practice'' defines what 
services or procedures a particular type of health professional is 
trained for and is legally permitted to provide. Across the U.S., many 
states have scope of practice laws that prevent some health 
professionals from providing certain services even though they are 
trained and prepared to do so. Temporary changes to increase 
flexibility of such regulatory practices were made in many states 
around the country during the pandemic to help address the pandemic 
related workforce crisis. Continuing such flexibility should be 
seriously considered. The focus when it comes to developing scope of 
practice regulation should be on what level of regulation results in 
the best outcomes in terms of health and safety of the population, not 
on managing guild-driven turf wars between professions at the ``edges'' 
of their scope of practice. Overlap and redundancy between professions 
---------------------------------------------------------------------------
is a good thing, especially during times of workforce shortages.

    Sixth and finally, we must fundamentally change the prevailing 
educational model in two ways. First, accrediting bodies need to allow 
training programs to be more creative and flexible_without sacrificing 
educational quality of course_to develop novel training models. This 
would include so-called ``career laddering'' opportunities that do not 
completely remove the individual from the workforce while they are 
pursuing an advanced degree, such as a physician assistant or nurse 
practitioner becoming a physician, a dental hygienist becoming a 
dentist, or a certified nursing assistant becoming a registered nurse. 
In addition, accrediting bodies should accept more high-quality 
clinical simulation hours in place of hours physically spent at 
clinical sites, thereby reducing the burden on clinical sites.

    The second educational reform involves breaking down the 
traditional siloes that characterize healthcare training and practice. 
Anyone who has recently been a patient in a hospital, or who has cared 
for a hospitalized loved one, understands how siloed the practice of 
healthcare tends to be. Far too often, healthcare professionals are all 
practicing their respective crafts with scant communication and 
coordination among themselves. This siloed practice is a result, at 
least in part, of the traditional discipline-centered model of 
educating healthcare professionals. In 2001, the Institute of Medicine 
issued a groundbreaking report, Crossing the Quality Chasm: A New 
Health System for the 21st Century, which laid out the case for 
dramatic, systemic changes to health care organization and delivery. In 
response, stakeholders from academia, health systems, and government 
convened to determine how best to address the Institute's 
recommendations. In 2012, these efforts led to the development of a new 
educational model in which students from diverse disciplines are 
explicitly trained to work together, across traditional boundaries, in 
multi-disciplinary teams. Known as ``interprofessional education'' \28\ 
or ``IPE'' for short, this training model prepares students with team-
based competencies, attitudes, and skills that complement distinctive 
disciplinary knowledge. Interprofessional health care teams offer more 
than any one discipline can achieve alone, and this is especially 
critical as patients' health conditions are becoming increasingly 
complex. \29\ Growing evidence suggests that interprofessional 
collaborative practice \30\ improves clinical outcomes, \31\ reduces 
medical errors, \32\ increases patient satisfaction, \33\ and decreases 
provider burnout. \34\
---------------------------------------------------------------------------
    \28\  Interprofessional Education occurs when two or more 
professions learn about, from, and with each other to improve 
collaboration and the quality of patient care.
    \29\  Mayo & Williams-Woolley, 2016
    \30\  According to the World Health Organization, interprofessional 
collaborative practice happens when multiple health workers from 
different professional backgrounds work together with patients, 
families, care givers, and communities to deliver the highest quality 
of care (World Health Organization, 2010)
    \31\  Lutfiyya et al., 2019
    \32\  Anderson & Lakhan, 2016; Hardisty et al., 2014; Irajpour et 
al, 2019; Lygre et al., 2017; Wilson et al., 2016
    \33\  Will et al, 2019
    \34\  Cain et al., 2017; Dow et al., 2019

    The IPE training model, especially when paired with digital health 
technologies, can be instrumental in meeting the needs of underserved 
communities. \35\ The combination of IPE and telehealth allows doctors, 
mid-level clinicians, and other primary care practitioners to 
effectively expand their scope of practice, while also extending 
specialist care to those for whom it is otherwise out of reach.
---------------------------------------------------------------------------
    \35\  One particular area of healthcare that exemplifies the value 
of this kind of collaborative approach is geriatrics. Diseases of aging 
often encompass a broad scope of conditions and disciplines: heart 
disease and diabetes treated by primary care practitioners; mobility 
issues by physical and occupational therapists; isolation by social 
workers; oral health by dentists and hygienists, and so on. At UNE, we 
weave training in geriatrics throughout all of our health profession 
programs. Thanks to legislation sponsored by Senator Collins and 
supported by Maine's Junior Senator Angus King, and working closely the 
University of Maine and multiple statewide partners, UNE is one of 48 
organizations nationally to have received funding through HRSA's 
Geriatrics Workforce Education Program, which aims to create a more 
age-friendly health system by transforming primary care practices and 
engaging and empowering older adults.

    At UNE, we have been pioneers in IPE over the past decade for all 
our healthcare programs. We are currently constructing a new health 
sciences training facility on our Portland campus, which will serve as 
the new home of our medical school. By co-locating all of our health 
profession programs on a single site, we will be able enhance our 
---------------------------------------------------------------------------
training of students in this collaborative, team-based model.

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

    I am grateful for the Committee's time and attention, and 
appreciate your efforts to address our Nation's healthcare workforce 
crisis. Thank you.
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                                 ______
                                 

                               Appendix A
                                 Table 1
                       Summary of Recommendations
 
 
 
        Increase the number of         Increase the number of doctors,
       healthcare professionals   nurses, dentists, and other healthcare
                                      professionals we educate by: (1)
                                        expanding partnerships between
                                  universities and community healthcare
                                        settings to develop additional
                                    training opportunities; (2) revise
                                   antiquated CMS policies for funding
                                  GME; (3) providing targeted one-time
                                   investments in expanding healthcare
                                      training infrastructure; and (4)
                                       strategic scholarship and loan-
                                   repayment programs, including those
                                      supporting clinical educators to
                                                      increase faculty
 
                Representation    1ntentionally recruit and train more
                                  students who look like the communities
                                                            they serve
 
  Maldistribution of providers     Use a variety of tools to encourage
                                   healthcare providers to practice in
                                   underserved areas, including rural,
                                     tribal, and medically underserved
                                                     urban communities
 
                    Technology       Leverage the power of technology,
                                      including telehealth and digital
                                        medicine, to reach underserved
                                                           communities
 
             Scope of practice       Modify state level regulations to
                                  allow health professionals to practice
                                             at the top of their scope
 
    Flexibility of educational    Encourage accrediting bodies to allow
                         models   training programs to be more creative
                                     and flexible (without sacrificing
                                  educational quality) to develop novel
                                    training models including ``career
                                  laddering'' opportunities that do not
                                  completely remove the individual from
                                  the workforce while they are pursuing
                                                    an advanced degree
 
   Interprofessional Education     Promote Interprofessional Education
                                   (IPE) training models to break down
                                   traditional healthcare training and
                                                       practice siloes
 

                                 ______
                                 
                               Appendix B

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                 ______
                                 
    The Chair. Dr. Herbert, thank you very much. Our next 
witness is Dr. James Hildreth, who is President and CEO of 
Meharry Medical College, the largest private, independent, 
historically black academic health sciences center.

    Dr. Hildreth was the first African American Rhodes Scholar 
from Arkansas, and he holds a Ph.D. in Immunology from Oxford 
University. Dr. Hildreth, thanks so much for being with us.

 STATEMENT OF JAMES E.K. HILDRETH SR., PH.D., M.D., PRESIDENT 
        AND CEO, MEHARRY MEDICAL COLLEGE, NASHVILLE, TN

    Dr. Hildreth. Thank you, Chairman Sanders, Ranking Member 
Cassidy, and Members of the Committee for inviting me to give 
testimony today about our Nation's shortage of health care 
providers where we need the most, in the field of primary care, 
especially in communities without a doctor or nurse or 
physician to treat the sick in those communities.

    There are many reasons we--our Country is full of medical 
specialists but woefully lacking in primary care professionals. 
But in the time allotted me today, I would like to talk about 
ways to solve the problem and perhaps to solve it very quickly. 
I am the proud President of Meharry Medical College, as you 
heard.

    We are the Nation's four historically black academic health 
science centers. We were originally founded to train students 
that the white medical system refused to train in order that 
those students might treat patients that the white medical 
establishment refused to treat.

    Our purpose remains essentially the same today. A majority 
of the students that we attract come to us to learn primary 
care, and they intend to serve in places often ignored by 
mainstream medicine.

    I am proud to say that 80 percent of our graduates do go on 
to serve the underserved. In other words, we already trained 
exactly the professionals this country so desperately needs. 
The majority of our students do not have to be incentivized to 
switch from lucrative subspecialties to practice primary care.

    They are fully committed to working in rural communities 
and urban health care deserts. In many cases, their 
determination is borne out of personal experience. They have 
watched a family member die of untreated diabetes or some other 
chronic disease.

    They have suffered themselves from a lack of access to 
wellness checks, common in American communities. I know what 
drives them, I am one of them. I was born in rural Arkansas in 
the 1950's and watched my father die of cancer because no one 
would or could care for him.

    I have been trained at the world's most elite institutions, 
Harvard, Oxford, Johns Hopkins, yet I choose to lead Meharry 
Medical College because Meharry graduates and their 
counterparts at Howard, Morehouse, and Drew choose to care for 
people like my father, poor blacks, poor whites, poor 
Hispanics, poor Native American people who deserve to be 
healthy just like the rest of us.

    I submit to you that the Consortium of Black Medical 
Schools already has the necessary history, structure, deep 
relationships for community organizations dedicated to 
eradicate health disparities, and we have the credibility 
within disenfranchised communities to help alleviate the 
shortage.

    We have been working for decades to increase the pipeline 
of minority health care workers in our Country. We are already 
partnering with industries to support the education of minority 
physicians, dentists, nurses, researchers, and public health 
professionals. We work with neighborhood, middle, and high 
school students to introduce them to science and medicine.

    At Meharry, we are grateful to Governor Bill Lee and the 
leadership of the State of Tennessee for supporting a program 
we put in place to fast-track undergraduate students in the 
medical school who are committed to serving in rural areas in 
the State of Tennessee. But there is no simple solution to the 
health care shortage, and it is going to take a variety of 
initiatives to solve the problem.

    The HBCU Medical School Consortium is well poised to lead 
the effort, but we need your help. We have done this work for 
generations, even though we have been woefully underfunded. 
Because of my 30 plus years at prestigious majority 
institutions, I am fully aware of how the Federal Government 
sometimes choose to allocate funds to institutions that are 
deemed uniquely qualified to solve certain problems facing the 
Nation.

    Today, I submit to you that HBCU medical schools are 
uniquely poised to solve this problem. We ask your help in 
doing so. Specifically, we ask for $5 billion over the next 5 
years to improve our infrastructure, the labs, the simulation 
centers, the study spaces, the classrooms at our institutions 
that have been egregiously underfunded for decades.

    This would also allow us to dramatically expand our 
pipeline programs that are meant to get more minorities in 
health care professions. These funds, while they are certainly 
significant, are a mere drop in the bucket compared to other 
budget items and will pay media dividends to quickly expand the 
pipeline and close to health disparity gap.

    We also ask that Medicare's GME policy be amended to give 
expanded consideration to hospitals that train a large share of 
graduates from black medical schools. Finally, we ask for your 
support to ease the debt burden of students coming from poor, 
working-class families whose hard-earned health care, 
especially primary care.

    Our students who come from lower income households often 
graduate with hundreds of thousands of dollars of debt. This 
debt burden can be a deterrent from entering primary care, and 
we need those folks in the game and we need them right away.

    Our graduates are ready. They are willing. They are 
desperately needed. Our nation's HBCU medical schools have 
trained them well. We know how to reach others who want to 
serve just like they do.

    Let's do everything in our power to break down barriers 
standing in their way so that America can benefit from the care 
they will provide and reduce the barriers to care in the United 
States. Thank you, Mr. Chairman.

    [The prepared statement of Dr. Hildreth follow:]
               prepared statement of james e.k. hildreth
    Chairman Sanders, Ranking Member Cassidy, and Members of the 
Committee, thank you for the invitation to discuss the implications, 
both immediate and long-term, that the health care workforce shortage 
has on our Nation and, in particular, to communities of color and 
growing segments of the population located in rural and underserved 
areas.

    Before I begin, I'd like to thank Chairman Sanders for his work to 
significantly expand the National Health Service Corps, Community 
Health Centers, and Teaching Health Centers to hire more doctors and 
nurses of color to underserved areas and boost the Teaching Health 
Center Graduate Medical Education program to help train more African 
American primary care physicians. We have a number of Meharry students 
who are participants in the National Health Service Corps. I'd also 
like to thank Senator Cassidy and other Members of the Senate for 
passing the John Lewis National Institute on Minority Health and Health 
Disparities Research Endowment Revitalization Act. This important 
legislation will provide critical funds to Historically Black Colleges 
and Universities (HBCUs) to conduct research into and to address 
minority health disparities.

    This important conversation about the effects that the health care 
workforce shortage has on health care, health outcomes, and thus life 
opportunities of a growing segment of the U.S. population could not be 
coming at a more appropriate time. It is certainly not lost on me that 
we are addressing this critical topic both during Black History Month 
as well on the 20th anniversary of the National Academy of Medicine's 
landmark report, ``Unequal Treatment: Confronting Racial and Ethnic 
Disparities in Health Care'', a report that highlighted the startling 
fact that across similar income and education levels, insurance status, 
age and even disease type and severity, racial and ethnic minorities, 
when compared to their white counterparts, often are diagnosed later, 
and consistently have less access to the most advanced care and 
treatments, suffer worse health outcomes, and die prematurely. What a 
fitting time to draw attention to and call for action on the effects of 
our health care workforce shortage on inequities in health care and on 
health outcomes.

    I have been trained at--and served on the faculty of--some of the 
world's most prestigious institutions of higher learning. I chose to 
take the helm at Meharry because of the populations it exists to serve. 
The reason is because my life--like the lives of so many trained by 
Meharry and other HBCU academic health science centers--was shaped by 
health care disparities.

    Meharry was founded in 1876, made possible by a donation from a 
young trader of Scots-Irish descent who was traveling one night through 
rough terrain in Tennessee when his wagon became mired in a swamp. A 
Black family came to his aid, giving him food and a place to sleep, and 
helping him rescue his wagon the next morning. The man said, ``I have 
no money, but when I can, I shall do something for your race.'' He was 
as good as his word. In 1876, he and his brothers donated $15,000--a 
significant sum at that time--to establish a medical school in 
Nashville to train Black doctors the white medical establishment would 
not train, in order to care for former slaves the white medical 
establishment would not care for. The man's name was Samuel Meharry. 
The name of the family that helped him remains unknown.

    Meharry is the oldest and largest historically Black academic 
health science institution in the Nation, dedicated to educating and 
training exemplary primary care physicians, dentists, researchers, 
public health professionals, and health policy experts. As times began 
to change for the better in the mid-20th century and the American 
medical establishment began accepting people of color into its ranks, 
Meharry expanded and amplified its mission across its schools and 
programs to train medical professionals to serve all of the 
underserved--those in urban centers where the population is mostly 
Black, in rural towns where the population is mostly white, in Latino 
and immigrant communities, and on native American reservations. In 
fact, four out of every five Meharry physicians and dentists work in 
underserved rural and urban communities.
                     The Present Persistent Problem
    Meharry has made major contributions to bolstering the medical, 
dental, scientific, and public health workforce in America. 
Approximately 14 percent of Black medical doctors, 27 percent of Black 
dentists, and 15 percent of Black biomedical scientists in America 
graduated from Meharry Medical College. Collectively, with other 
historically Black health professions institutions across the United 
States, we have educated and trained half of the Black physicians in 
the country, half of the Black dentists, and 75 percent of the Nation's 
Black pharmacists and veterinarians. No other set of institutions has 
such an impressive legacy of accomplishment that is consistent with the 
national goal of improving the health status of all population groups. 
As we strive to continue to be the leading producer of diverse health 
professionals committed to bolstering access to primary care, 
eliminating health disparities in rural and urban communities, and 
improving health care quality for all, it is not lost on me that we 
have a long way to go to close the gaps in our health professions 
workforce.

    A 2021 article in the Journal of the American Medical Association 
highlighted the dearth of underrepresented minorities in many of our 
health diagnosing and treating professions. Consider, for example, that 
while White Americans account for 68.7 percent of Dentists, Black, 
Native American, and Hispanic Americans account for 4.4 percent, 0.1 
percent, and 5.7 percent respectively. Comparatively, Black Americans 
account for just 5.2 percent of physicians, with Native Americans 
accounting, once again, for 0.1 percent and Hispanic Americans 
accounting for 6.9 percent. This is in comparison to the 62.4 percent 
of physicians that identify as White Americans. The lack of diversity 
continues even when considering the other professions at a patient's 
bedside. For example, while Black Americans account for 4.5 percent of 
Physician Assistants, and Native and Hispanic Americans each account 
for 0.5 percent and 7.3 percent respectively, the overwhelming majority 
of Physician Assistants are White Americans, as represented by the fact 
that they account for 75.9 percent.

    The dearth of diverse health providers is associated with 
significant disparities in health care access, quality, and treatments, 
along with access to critical public health resources. According to the 
Association of American Medical Colleges, ``If underserved populations 
were to experience the same health care use patterns as populations 
with fewer barriers to access, the United States would need an 
additional 102,400 to 180,400 physicians.'' In addition, a recent 
research brief by the de Beaumont Foundation found that in the wake of 
the Covid-19
    pandemic, in order to provide a minimum set of public health 
services to the Nation, state and local governmental public health 
departments need an 80 percent increase in their workforce. What this 
percentage equates to in raw numbers, is a minimum of 80,000 more full-
time equivalent positions being required to provide adequate 
infrastructure and a minimum package of public health services. This 
reality is exacerbated by the fact that in the past decade alone, 
state, and local health departments lost 15 percent of their essential 
staff. Even further, while approximately 54,000 of the additional 
positions that are needed should be deployed to local health 
departments, and the remaining 26,000 to state health departments, it 
is worth noting that the most acute needs are in local health 
departments that specifically serve fewer than 100,000 people (de 
Beaumont Foundation, 2021).
            The Worsening Future Problem if We Don't Act Now
    The United States is in the midst of a moment of heightened 
awareness where greater attention is being paid to health inequities. 
And so, I look forward to working with the Members of this Committee to 
leverage this unique time in history to achieve health equity in a very 
real and meaningful way, which requires our serious efforts to address 
the health workforce shortage and the lack of diversity in the health 
care and public health arena before things get worse. It is important 
to remember that most of the recent statistics I just mentioned 
happened against the backdrop of the ongoing COVID-19 pandemic and its 
stark, disproportionate, and disparate impact on Black, Latino, 
American Indian, Asian, Native Hawaiian, and Pacific Islander 
individuals and communities. In general, low-income Latino families had 
the highest numbers of full families in poor health, followed by Black/
African American low-income families (Braveman & Barclay, 2009).

    It is hard for me to overstate the reality that these disparities 
were brought to light as racial and ethnic minorities continued to 
suffer from less access to affordable, quality health care, and 
disproportionately higher rates of incidence and prevalence, as well as 
premature death, across every chronic and acute disease and condition. 
This includes cancers, diabetes, hypertension, heart disease, asthma, 
depression and anxiety, and obesity, just to name a few. During the 
pandemic, adults reporting symptoms of mental illness quadrupled, from 
one in ten prior to four in ten. COVID exacerbated isolation and stress 
for millions during a time when families and communities continued to 
grapple with social justice issues and economic stress. This impact 
affected Black, Latino, Native Americans, Native Hawaiians, Alaska 
Natives, and Asian American adults at a much higher rate than Whites in 
the United States owing to structural barriers to health care, public 
health, family leave, and economic opportunity.

    For example, today, the maternal mortality rate among Black women 
is two to three times higher than that among White women. In fact, a 
Black woman with an advanced degree is more likely to die from 
pregnancy-related complications in the United States than a White woman 
with only a high school degree. Unfortunately, their babies do not fare 
much better: African American newborns, overall, are three times more 
likely than White newborns to die. In some communities, the number is 
even higher. Study after study confirms that racial and ethnic health 
disparities and inequities are so pervasive that they have--in some 
cases--widened over time and become the norm in the United States. 
Further adding insult to injury is a report from the Commonwealth Fund 
that found that racial and ethnic health inequities not only are 
pervasive in this country, but some of the starkest and widest 
disparities are actually in states known for having high performing 
health care systems. However, according to a ground-breaking study, in 
situations where the physician was Black, the infant mortality rates 
dropped significantly.

    These disparities carry a hefty economic cost. Research shows that 
health disparities amount to nearly $93 billion in excess medical care 
costs and another $42 billion in lost productivity each year (Laveist, 
et al.., 2009). In a study led by one of our researchers at Meharry to 
determine the economic burden of mental health inequities, the study 
showed that over a 4-year period, $278 billion could have been saved 
and reinvested into the economy, and over 116,770 lives could have been 
saved had mental health inequities become more equitable--and this is a 
conservative estimate (Dawes, et.al., 2022). Han & Ku (2019) reported 
that over two-thirds of rural counties had no psychiatrists and almost 
half of rural counties had no psychologists. Additionally, Deloitte 
also released a major study showing that if we do not address health 
disparities in the U.S. by 2040, the top five costly chronic diseases 
today will cost us $1 trillion.
            Consortium of Black Medical Schools Partnership
    The historic halls of Meharry and its fellow HBCU medical schools 
are replete with professionals who have experienced the systemic 
problem of health disparities, have dedicated their careers to treating 
this systemic problem, and are prepared to solve the systemic problems 
relative to our national health care workforce shortage.

    All four HBCU medical schools, including Meharry Medical College, 
Howard University College of Medicine, Morehouse School of Medicine and 
Charles R. Drew Medical School established the Consortium of Black 
Medical Schools (CBMS) initially to address the COVID-19 crisis, by 
providing expanded testing, contact tracing, surveillance, training of 
front-line health workers, research & drug development, and policy 
recommendations to address the unique needs of vulnerable, low income, 
African American, and other underrepresented communities that 
experienced disproportionate adverse outcomes due to the pandemic.

    Meharry and the other HBCU medical schools are uniquely qualified 
to address the shortage of health care professionals for this 
population in a way that no others are. The Consortium brings together 
the cumulative expertise of the four HBCU academic health science 
centers in primary care and subspecialties which treat diseases that 
account for the disparities heavily impacting disenfranchised 
communities of all races and ethnicities. Together we have worked with 
the White House, the Centers for Disease Control and Prevention, the 
Department of Health and Human Services, state and local legislatures, 
local health departments, faith-based organizations, and other 
community stakeholders to reduce areas of disparity in vulnerable and 
marginalized communities across the Nation.

    The CBMS has the necessary history, organizational structure, deep 
relationships with national and international organizations dedicated 
to eradicating health care disparities, and credibility within 
disenfranchised communities to scale up immediately and rapidly. 
Crucially, Black health professionals are trusted in these 
communities--trusted because we have always been there when others have 
failed them, forgotten them, or, with the best of intentions, 
misunderstood them and their needs.

    As we have done this work, we also have been woefully underfunded 
for generations. Because of my 30+ years of experience at prestigious, 
majority institutions, I am aware of how Federal funding is allocated 
to those who are deemed ``uniquely qualified'' to address a critical 
national need. This is entirely appropriate when it makes the best use 
of resources. And especially when and where a crisis is afoot.

    We, the four HBCU medical schools, are asking for those same rules 
to apply to our work. We are without a doubt ``uniquely qualified'' to 
address this growing national health crisis.

    We already are our Country's most reliable source for a well-
trained, diverse health care workforce. And the value of a diverse 
workforce cannot be underestimated. Trust, cultural competency, and a 
strong background in social determinants of health are as crucial 
during these times as medical training. We must accept that, in order 
to successfully treat at-risk African Americans and other vulnerable 
populations, we must hire and deploy a workforce that is trained to 
implement a care plan for individuals and communities that addresses 
the social forces impacting and undermining their well-being.

    Yet currently, HBCU medical schools--the most adept at training 
such a workforce--face the challenge of expanding our number of 
graduates in light of insufficient funding, an increasingly detrimental 
predicament for everyone, especially in a country whose population is 
ever-expanding and diversifying. A truly sustainable response to the 
shortage of diverse health care workers must include strategies to 
support HBCU medical schools.

    To do this work, the CBMS requires an immediate infusion of 
significant resources in order to scale up quickly, efficiently, and 
comprehensively. The CBMS anticipates the cost to develop and implement 
our plan will be $5 billion dollars over the next 5 years. We are well-
prepared and well-positioned to offer enormous benefit to the Nation at 
comparatively little cost. We plan to use the infrastructure we build 
to begin addressing the structural barriers to health in minority 
communities. Our plan will therefore have benefits that should reduce 
the overall cost of health care for the Nation.
                 Major Consortium Pipeline Initiatives
    The Consortium is now leading the national drive for greater 
pipeline diversity and is engaged in multiple initiatives to ensure a 
more equitable health care workforce in the future. It has attracted 
the interest and investment of $100+ million in public and private 
funding to support current students, as well as longer term efforts to 
educate, train and employ more Black health care workers. Notable 
funders include the National Institutes of Health, Bloomberg 
Philanthropies and Mackenzie Scott.

          The Consortium convened a gathering of 166 
        representatives from 54 of the 99 HBCUs with undergraduate 
        programs to develop a cohesive and aggressive program to 
        increase the number of Black or African American health science 
        professionals and improve educational outcomes for both STEM 
        and humanities students to ensure health science workforce 
        diversity.

          NFL Diversity in Sports Medicine Pipeline Project to 
        increase diversity in sports medicine by providing HBCU medical 
        schools the opportunity to complete a clinical rotation with 
        NFL club medical staff.

          Chan Zuckerberg Initiative to advance genomics 
        research at the four medical schools by contributing $11.5 
        million per institution over the next 5 years.

          Two-year $100 million award to the Consortium from 
        NIH's Advance Health Equity and Researcher Diversity (AIM-
        AHEAD) program.

          American Cancer Society's $12 million Diversity in 
        Cancer Research institutional advancement grants to fund a 4-
        year program to increase the pool of minority cancer 
        researchers at the four HBCU medical schools.

          Partnership between the Consortium, the Organ 
        Donation Advocacy Group and the Association of Organ 
        Procurement Organizations to initiate programs to increase the 
        number of U.S. Black organ donation and transplant 
        professionals across the Nation.

          Beacon of Hope Partnership, a 10-year collaboration 
        of the Consortium, Novartis, Sanofi, and Merck, to create 
        programs that address the root causes of disparities in health 
        and education.

    As I testify today, I think of Samuel Meharry. His gift in 1875 was 
nominal relative to his total wealth. But he had been the beneficiary 
of selfless compassion from an African American family. He gave in 
order to allow that compassion to exert the maximum influence possible 
during that time and in that world, where slavery had been abolished in 
name only. I also think of my father, who--generations later--would 
succumb to health care disparities as much as he succumbed to cancer. I 
think of my mother, who urged me to respond by serving those who are 
perennially left out and left behind. I think of Black physicians and 
other professionals from the past who because of redlining and 
structural racism could not build wealth for their families and 
communities. I think of my colleagues across the Nation who could share 
similar stories with you of family members and friends locked into 
legacies of poor health.

    For more than a century, the responsibility for educating Black 
doctors, dentists, researchers, and health care professionals in the 
U.S. has largely rested on the institutions dedicated to that purpose: 
our Nation's four HBCU Medical Schools. Charles R. Drew University of 
Medicine and Science in Los Angeles, Howard University College of 
Medicine in Washington, DC, Meharry Medical College in Nashville, and 
Morehouse School of Medicine in Atlanta have long prioritized the need 
for more diversity in medical careers while other colleges and 
universities ignored the issue. For years, we have worked individually 
in our own communities and together, as a Consortium, on larger 
initiatives in the United States and Africa to advance the diversity of 
the workforce and the health of the patients they served.

    We, the Consortium of Black Medical Schools, are ready. We only 
need your endorsement and a modicum of the Nation's resources to make a 
profound difference. Let us take our place in this fight. We already 
are well-prepared and well-trained. But we must be well-armed. Please 
arm us by supporting the policy recommendations outlined below. Thank 
you for your time.
                         Policy Recommendations
          $5 billion for infrastructure for Improving Research 
        and Development Infrastructure for academic health science 
        centers at Historically Black Graduate Institutions as defined 
        under Section 326(e) of Title III of the Higher Education Act.

           $500 million to maintain and expand programs to 
        increase research capacity at minority-serving institutions (as 
        described in sections 371(a) and 326(e)(1) of the Higher 
        Education Act.

          Amend/Expand the Medicare GME policy to add a 
        priority criterion for hospitals that have a sponsoring 
        institution for their GME programs that is a Minority-Serving 
        Institution (to include Historically Black Graduate 
        Institutions), as well as add ``non-contiguous area'' to the 
        ``rural'' criterion.
                                 ______
                                 
               [summary statement of james e.k. hildreth]
                           Meharry Background
    Meharry is the oldest and largest historically Black academic 
health science institution in the Nation, dedicated to educating and 
training exemplary primary care physicians, dentists, researchers, 
public health professionals, and health policy experts.

    Meharry has made major contributions to bolstering the medical, 
dental, scientific, and public health workforce in America. 
Approximately 14 percent of Black medical doctors, 27 percent of Black 
dentists, and 15 percent of Black biomedical scientists in America 
graduated from Meharry Medical College.
                           Focus of Testimony
    A 2021 article in the Journal of the American Medical Association 
highlighted the dearth of underrepresented minorities in many of our 
health diagnosing and treating professions. Consider, for example, that 
while White Americans account for 68.7 percent of Dentists, Black, 
Native American, and Hispanic Americans account for 4.4 percent, 0.1 
percent, and 5.7 percent respectively. Comparatively, Black Americans 
account for just 5.2 percent of physicians, with Native Americans 
accounting, once again, for 0.1 percent and Hispanic Americans 
accounting for 6.9 percent. This is in comparison to the 62.4 percent 
of physicians that identify as White Americans.

    These disparities carry a hefty economic cost. Research shows that 
health disparities amount to nearly $93 billion in excess medical care 
costs and another $42 billion in lost productivity each year (Laveist, 
et al.., 2009). In a study led by one of our researchers at Meharry to 
determine the economic burden of mental health inequities, the study 
showed that over a 4-year period, $278 billion could have been saved 
and reinvested into the economy, and over 116,770 lives could have been 
saved had mental health inequities become more equitable. Han & Ku 
(2019) reported that over two-thirds of rural counties had no 
psychiatrists and almost half of rural counties had no psychologists. 
Additionally, Deloitte also released a major study showing that if we 
do not address health disparities in the U.S. by 2040, the top five 
costly chronic diseases today will cost us $1 trillion.
            Consortium of Black Medical Schools Partnership
    For more than a century, the responsibility for educating Black 
doctors, dentists, researchers, and health care professionals in the 
U.S. has largely rested on the institutions dedicated to that purpose: 
our Nation's four HBCU Medical Schools. Charles R. Drew University of 
Medicine and Science in Los Angeles, Howard University College of 
Medicine in Washington, DC, Meharry Medical College in Nashville, and 
Morehouse School of Medicine in Atlanta have long prioritized the need 
for more diversity in medical careers.

    Meharry and the other HBCU medical schools are uniquely qualified 
to address the shortage of healthcare professionals for this population 
in a way that no others are. The Consortium brings together the 
cumulative expertise of the four HBCU academic health science centers 
in primary care and subspecialties which treat diseases that account 
for the disparities heavily impacting disenfranchised communities of 
all races and ethnicities.
                Recommendations to Senate Help Committee
    $5 billion for infrastructure for Improving Research and 
Development Infrastructure for academic health science centers at 
Historically Black Graduate Institutions as defined under Section 
326(e) of Title III of the Higher Education Act.

    $500 million to maintain and expand programs to increase research 
capacity at minority-serving institutions (as described in sections 
371(a) and 326(e)(1) of the Higher Education Act.

    Amend/Expand the Medicare GME policy to add a priority criterion 
for hospitals that have a sponsoring institution for their GME program/
s that is a Minority-Serving Institution (to include Historically Black 
Graduate Institutions), as well as add ``non-contiguous area'' to the 
``rural'' criterion.
                                 ______
                                 
    The Chair. Well, thank you very much, Dr. Hildreth. Our 
next witness is Dr. Sarah Szanton. She is dean of the John 
Hopkins School of Nursing and an Advanced Nurse Practitioner 
and has published more than 200 papers. Dr. Szanton, thanks so 
much for being with us.

STATEMENT OF SARAH SZANTON PH.D., RN, FAAN, DEAN, JOHNS HOPKINS 
                SCHOOL OF NURSING, BALTIMORE, MD

    Dr. Szanton. Chairman Sanders, Ranking Member Cassidy, and 
Members of the Committee, thank you for the opportunity to 
describe some of the factors contributing to our national 
nursing crisis and to offer some solutions for your 
consideration.

    As you mentioned, I am a Professor, a Nurse, and the Dean 
of the Johns Hopkins School of Nursing. I have spent 25 years 
at Johns Hopkins teaching nurses, nurse scientists, making 
house calls in the community, and conducting research.

    I state for the record the opinions expressed here today 
are my own and do not necessarily reflect the views of the 
Johns Hopkins University or the Johns Hopkins health system. As 
we have discussed, our Country is perilously short of nurses, 
and those we do have are often not working in the settings that 
could provide the most value. This was true before the 
pandemic, as you mentioned, and has become more acute.

    One thing that has not been mentioned is the average age of 
nurses today is 54 years old, and 19 percent of them are 65 or 
older. So, you can imagine we are worried about the future as 
well. And that, coupled with an aging population that has more 
and more chronic conditions as well.

    There are 4.5 million nurses and nurses are often 
considered the oxygen of any health care setting. So as a 
country, we need people to become new nurses and we need to 
retain current nurses, and there are many steps to both.

    To become a nurse, one needs to first be able to imagine 
oneself as a nurse, to apply and be accepted to a nursing 
school, and have the resources to pay tuition, food, housing, 
and perhaps childcare while in the program.

    One needs to have dedicated time and space to learn and 
then pass the nursing boards. For the school to be able to 
admit that student, it needs enough faculty, adequate 
facilities, clinical settings in which to place nursing 
students for experience, and scholarships to offer. And then to 
stay in nursing, nurses need supportive, safe work 
environments, a career ladder, and for some, the ability to 
return to school to develop the science behind prevention and 
care.

    If we take each factor separately, as a field, nursing has 
historically been composed of predominantly women, so men have 
a hard time seeing themselves in the role. Another 
misperception is that nursing is all hospital based, when the 
reality is that only 60 percent is.

    Turning to nursing schools, 90,000 qualified applications 
are turned down from nursing schools each year, as you 
mentioned in Vermont, due to lack of space. There is not enough 
scholarship and loan repayment money to support nursing 
students. And as was mentioned, the nursing shortage is in 
large part a nurse faculty shortage.

    The country is shy about 2,100 nurse faculty. We need to 
increase the number of highly educated nurses who can be 
faculty and retain them by paying them as much as their 
clinical counterparts would receive.

    I mentioned the schools also struggle to find nurses 
outside of school willing to precept nurses in training, and 
this has been mentioned across the board. Like medical school, 
nursing education combines classroom learning with hands on 
clinical training, and that clinical training relies on 
established nurses willing to precept students. And it has been 
mentioned about graduate medical education.

    There is nothing similar for graduate nursing education. 
There is a small pilot that has ended that was successful. So, 
at a time when nurse shortages are glaring, nurses with a full 
clinical workload, who are often overtaxed, struggle to take on 
students on top of that. Finally, some schools have offices, 
classrooms, practice spaces, and simulation areas that are 
arcane. So as leaders in nursing, we prepare for both current 
and future challenges.

    The current we have discussed. But we also need to prepare 
people for the health system of the future in which most 
encounters will happen at home, online, in clinics, in schools, 
and in businesses.

    As you consider solutions to the crisis, I want to 
acknowledge the vital work Congress has done to strengthen and 
grow the Title VIII Nursing Workforce Development Programs and 
the CARES Act of 2020. I urge the Committee to support the 
Future Advancement of Academic Nursing Act, or FAAN Act, when 
it is reintroduced by Senator Merkley, and Congresswoman 
Underwood, and co-sponsors.

    It would address all of the areas that I have mentioned, 
solving barriers for students, preceptors, faculty, and 
enhancing infrastructure. And in closing, I would like to 
highlight two additional principles to guide this body's 
deliberations. First, as a Nation, we must strive to make 
nursing more disability inclusive.

    27 percent of our Country has a disability, both ethically 
and practically. We should tap the strengths and skills of 
people with disabilities. Second, robust support for preventive 
health care approaches could also save money, reduce poor 
health outcomes, and thus require fewer nurses. With a more 
deliberate emphasis on a preventive health care system, we 
might no longer have a nursing shortage.

    Models delivered at home, like the capable program I 
spearheaded, for instance, would allow older adults to age in 
the community. Today, nurse scientists are developing many 
models that may soon provide health care for a nation that is 
both better and less expensive. Thank you. I would be pleased 
to answer any questions that you have.

    [The prepared statement of Dr. Szanton follows:]
                  prepared statement of sarah szanton
    Chairman Sanders, Ranking Member Cassidy and Members of the 
Committee.

    Thank you for the opportunity to describe some factors contributing 
to our national nursing crisis--and to offer some solutions for 
consideration.

    My name is Sarah Szanton. I am a professor, a nurse and the dean of 
the Johns Hopkins School of Nursing. I have spent 25 years at Johns 
Hopkins, teaching nurses and nurse scientists, making house calls in 
the community, and conducting research. I now lead the Nursing school.

    I state for the record that the opinions expressed here today are 
my own and do not necessarily reflect the views of The Johns Hopkins 
University or the Johns Hopkins Health System.

    Our country is perilously short of nurses, and those we do have are 
often not working in the settings that could provide the most value. 
This was true before the COVID pandemic, and has become more acute 
since COVID struck. According to the McKinsey Institute, the Nation 
needs at least 200,000 more nurses--and perhaps closer to a half 
million.

    The average age of U.S. nurses today is 54 years old. Fully one 
fifth of working nurses are at least 65 years old! The nurse shortage 
will only grow more severe over time, as these nurses approach 
retirement at the same time as COVID's long-term disabilities become 
clearer, and the aging population encounters more chronic diseases.

    Nurses are the largest component of the health care workforce--4.5 
million strong. Nurses are often considered the oxygen of any health 
care setting.

    As a country, we need people to become new nurses and to retain 
current nurses. And there are many steps to both.

    To become a nurse, one needs to be able to imagine oneself as a 
nurse, to apply and be accepted by a nursing school, to have the 
resources to pay tuition, food, housing and perhaps childcare while in 
the program. One needs to have dedicated time and space to learn. And 
then pass the nursing boards. For the school to be able to admit that 
student, it needs: enough faculty; adequate facilities; clinical 
settings in which to place nursing students for experience; and 
scholarships to offer.

    To stay in nursing, nurses need: supportive, safe work 
environments, a career ladder and, for some, the ability to return to 
school to develop the science behind prevention and care.

    Let's take each factor separately--As a field, nursing has 
historically been composed of predominantly women, so men have a hard 
time seeing themselves in the role. Another misperception is that 
nursing is all hospital-based, when the reality is that only 60 percent 
is.

    As for nursing schools, about 90,000 qualified applications are 
turned down from nursing schools each year due to lack of space, and 
there is not enough scholarship and loan repayment money to support 
nursing students. The nursing shortage is, in large part, a nurse 
faculty shortage. This country is shy about 2,100 nurse faculty. We 
need to increase the number of highly educated nurses who can be 
faculty in the U.S. To retain them, we need to pay them on par with 
what they can earn clinically.

    I mentioned that schools also struggle to find nurses outside of 
school willing to precept nursing students-in-training. Like medical 
school, nursing education combines classroom learning with hands-on 
clinical training in hospitals and clinics. That clinical training 
relies on established nurses willing to precept students. In medicine, 
there's a paid mechanism through Medicare to support medical education, 
but not so in nursing. At a time when nurse shortages are glaring, 
nurses with a full clinical workload are often overtaxed and struggle 
to take on students, too.

    Finally, some schools have offices, classrooms, practice spaces, 
and/or simulation areas that are arcane or inadequate.

    As leaders in nursing, at Johns Hopkins, we prepare for both 
current and future challenges. We prepare nursing students for today's 
acute care-focused medical system, and we must prepare them for the 
health system of the future, in which most encounters will happen at 
home, online, in clinics, at schools, or in businesses.

    As you consider solutions to the crisis, I want to acknowledge the 
vital work Congress has done to strengthen and grow the Title VIII 
nursing workforce development programs through annual appropriations 
and the CARES Act of 2020.

    I urge the Committee to support the Future Advancement of Academic 
Nursing Act (Or FAAN Act) when it is reintroduced by Senator Merkley 
and Congresswoman Underwood, and cosponsors. It would address all the 
areas I have mentioned, specifically, solving barriers for students, 
preceptors, faculty, and enhancing infrastructure.

    In closing, I highlight two additional principles to guide this 
body's deliberations.

    First, as a Nation, we must strive to make nursing more disability-
inclusive. Twenty 7 percent of the country has a disability. Both 
ethically and practically, we should tap the strengths and skills of 
people with disabilities.

    Second robust support for preventive health care approaches could 
also save money, reduce poor health outcomes and, thus, require fewer 
nurses. With a more deliberate emphasis on a preventive healthcare 
system, we might no longer have a nursing shortage. Models delivered at 
home, like the CAPABLE program I spearheaded, for instance, would allow 
older adults to age in the community. Today, nurse scientists are 
developing many models that may soon provide health care for our Nation 
that is both better AND less expensive.

    Thank you and I would be pleased to answer any questions you may 
have.
                                 ______
                                 
                  [summary statement of sarah szanton]
              Johns Hopkins School of Nursing and Its Dean
      Johns Hopkins School of Nursing, in Baltimore, MD, is a 
leading school of nursing that educates nurses from all over the 
country to become nurses as well as nurse practitioners, nurse 
anesthetists, and PhD level nurse scientists.

      Sarah Szanton is a professor, nurse and dean of the Johns 
Hopkins School of Nursing, where she has spent 25 years teaching nurses 
and nurse scientists, making house calls in the community, and 
conducting research.
                            Testimony Focus
      The nursing shortage has been exacerbated by COVID with 
likely 200,000-400,000 RNs short by 2025.

      The average age of the 4.5 million U.S. nurses 
is54.Twenty percent of working nurses are at least65 years old.

      The nurse shortage will grow more severe as these nurses 
approach retirement, and the aging population encounters more chronic 
diseases.

      There are barriers to becoming a nurse both from the 
student perspective and the school perspective.

      Schools turn down over 90,000 qualified applications each 
year due to shortage of both faculty and clinical preceptors who 
provide hands on training, inadequate facilities, and financial aid 
shortages.

      To stay in nursing, nurses need supportive work 
environments, career ladders and for some--opportunity to return for 
advanced education.

      It's important to simultaneously prepare nursing students 
for today's acute care-focused medical system, and the health system of 
the future, in which most encounters will happen at home, online, in 
clinics, at schools, or in businesses.

      We acknowledge the vital work Congress has done to 
strengthen and grow the Title VIII nursing workforce development 
programs through annual appropriations and the CARES Act of 2020.
                Recommendations to Senate Help Committee
      Support the Future Advancement of Academic Nursing Act 
(FAAN Act) when reintroduced which would address student enrollment and 
retention, support modernization of curricula including mental health 
of patients and communities, address faculty and precept or shortage 
while diversifying the field, enhance outdated infrastructure and train 
more nurse scientists.

      Improve recruitment and retention of people with 
disabilities to be nurses and doctors; this can improve health care and 
decrease workforce shortage.

      Consider preventive healthcare approaches to improve 
health outcomes, save money and possibly require fewer nurses.
                                 ______
                                 
    The Chair. Dr. Szanton, thank you very much. Senator 
Cassidy is going to introduce our next witness. Senator 
Cassidy.

    Senator Cassidy. Dr. Szanton, first let me compliment you. 
You finished just at--your time ran out. It was just like a 
gymnast getting her feet down perfectly.

    [Laughter.]

    Senator Cassidy. My pleasure to introduce Dr. Leo Seoane. 
And on a note of personal pride, this is, I think, the fifth or 
sixth time one of my former students has testified. I think the 
first time I have actually invited. So, you have done very 
well, Dr. Seoane.

    I think you would say your success is despite your 
instructor, not because of. But anyway, my pleasure to 
introduce Dr. Leo Seoane, the Executive Vice President and 
Chief Academic Officer of Ochsner Health System.

    He is a graduate of LSU Medical School, and he joined 
Ochsner in 2001 and has served in a variety of leadership 
roles, overseeing both medical care and medical education. As 
Chief Academic Officer, Dr. Seoane leads Ochsner's partnership 
with Loyola regarding nursing, Loyola of New Orleans, and 
Xavier of New Orleans, which is soon to join Meharry, becoming 
the sixth historically black college and university in the 
Nation to have a medical school. He is also currently serving 
as interim Chief Executive Officer at Ochsner System, North 
Louisiana, which has a wide rural catchment area.

    For decades, Dr. Seoane has worked to improve the quality 
of care for Louisiana families, including partnering with other 
academic institutions for workforce development initiatives 
within Ochsner, so that future Louisiana health care providers 
have access to the best education possible.

    As a doctor and educator in Louisiana, Dr. Seoane 
understands the challenges that rural and underserved 
communities face when it comes to health care shortages. He 
also understands the importance of having an educated and 
diverse health care workforce to close the health gap and 
provide quality care. I look forward to Dr. Seoane's insights 
on how to address these issues.

    STATEMENT OF LEONARDO SEOANE M.D., FACP, CHIEF ACADEMIC 
            OFFICER, OCHSNER HEALTH, NEW ORLEANS, LA

    Dr. Seoane.

    [Technical problems]--Chairman Sanders, and thank you, 
Senator Cassidy. I am almost as nervous as I was on rounds with 
you when I was----

    [Laughter.]

    Dr. Seoane [continuing]. and distinguished Members of the 
Committee. I am the lead of the medical education programs at 
Ochsner in my role as Chief Academic Officer. As Senator 
Cassidy said, I lead the partnerships with our universities and 
colleges. Headquartered in New Orleans, Ochsner is one of the 
Nation's leading nonprofit, clinically integrated academic 
health centers.

    We deliver care to urban, suburban, and rural communities 
throughout the Gulf Coast. Over the last 14 years, in 
partnership with the University of Queensland, we have helped 
train 800 new physicians for the United States. We also 
annually train more than 330 residents and fellows through our 
31 ACGME accredited residency programs.

    Today's hearing comes at a critical time for us. Like 
providers across the Nation, Ochsner faces an alarming shortage 
of nurses, doctors, and health professionals. As Senator 
Cassidy knows very well, we face a significant challenge in 
that Ochsner serves patients who come from low income, rural, 
and historically underserved communities.

    Ochsner has undertaken dozens of proactive and innovative 
initiatives to recruit and develop a pipeline of doctors, 
nurses, and allied health professionals. But despite these 
efforts, today, we have 1,200 open nursing positions throughout 
our system. In addition, we are also experiencing a physician 
shortage.

    Last year, the American Association of Medical Colleges 
projected that over the next decade, as Senator Sanders pointed 
out, Louisiana will be the third worst in physician shortages 
of all 50 states. And our neighbor Mississippi will be the 
worst.

    During the past 6 months, these shortages have forced us to 
close more than 100 beds across the health system, resulting in 
the need to hold more patients in the emergency departments 
that are already constrained. There are two main causes for our 
nursing shortages in our region.

    First, a lack of training and educational capacity that is 
preventing us from developing the adequate pipelines needed to 
fill our current nursing positions. Second, these shortages are 
putting an enormous strain on our current workforce and in turn 
leading to loss of our bedside clinical nurses. This has been 
exacerbated by the pandemic.

    Moreover, these shortages have led to rising costs and 
increased competition for qualified health professionals. Since 
2019, our non-agency labor costs have grown just under 60 
percent. In comparison, over the same period, our contracted 
staffing costs for nurses and allied health has increased 
nearly 900 percent.

    Ochsner is committed to addressing the workforce shortages 
today and developing the next generation of health care 
providers. We know solutions are multifaceted and require 
partnerships with Government, and universities and colleges. We 
are trying to do our part. In 2022, we invested more than $5 
million to operate dozens of different workforce programs, 
impacting more than 1,200 individuals.

    We are seeking to grow the pipeline of high school and 
college students entering health care careers and provide 
career advancement opportunities for existing employees by 
offering earn as you learn programs. We in the Gulf Coast 
regularly experience and survive hurricanes. This makes us 
resilient and innovative. And we have brought these traits to 
solving our workforce shortages.

    My written testimony provides greater details, but here are 
two examples. In 2021, Ochsner invested $20 million to launch a 
partnership with the Delgado Community College in New Orleans 
to train the next generation of nurses and allied health 
professionals. The resources cover a new training facility and 
full-time tuition for Ochsner employees pursuing a nursing or 
allied health career.

    We also provide tuition support for physicians that are 
committed to working in primary care and behavioral health, as 
well as tuition support for nurses that are committed to 
working throughout the Gulf Coast at the Ochsner system post-
graduation. We take--we understand and take real responsibility 
that we need to train a more diverse workforce that represent 
the diverse communities of Louisiana and Mississippi.

    To that end, in January, Ochsner partnered with the Xavier 
University, one of our premiere HBCUs, to announce plans to 
create the Xavier Ochsner College of Medicine, with the 
explicit mission to increase the number of underrepresented 
physicians in the U.S. We appreciate that Congress has taken 
several steps to address health care workforce gaps. However, 
additional efforts are needed to bolster local efforts like the 
ones we have undertaken.

    My written testimony provides a range of ideas, including 
investments to help scale our proven local solutions, 
increasing the number of GME slots, and providing more stable 
Medicare and Medicaid reimbursement climate for our physicians.

    In conclusion, on behalf of Ochsner and all the communities 
we have the privilege of serving, thank you again for this 
opportunity. We stand ready to work with you and your 
colleagues through public, private partnerships to ensure 
access to quality care for the patients across the Gulf Coast 
and our Nation.

    [The prepared statement of Dr. Seoane follows:]

                 prepared statement of leonardo seoane
    Chairman Sanders and Ranking Member Cassidy, I am Dr. Leonardo 
(Leo) Seoane of Ochsner Health, where I serve as Executive Vice 
President and Chief Academic Officer; Associate Vice-Chancellor of 
Academics for LSU Health Shreveport; and Professor of Medicine for 
University of Queensland. On behalf of Ochsner Health (Ochsner) and our 
nurses, physicians, and other professionals who provide comprehensive, 
quality care to families and communities throughout Louisiana and 
Mississippi, thank you for the opportunity to present testimony to you 
and your colleagues on the Senate Health, Education, Labor, and 
Pensions Committee.

    Since joining Ochsner in 2001, I have supported Ochsner's continuum 
of education, including undergraduate, graduate and continuing medical 
education programs, as well as all research initiatives. Additionally, 
I oversee Ochsner's partnerships with the University of Queensland 
Ochsner Clinical School, Xavier University of Louisiana (Xavier), and 
Loyola University of New Orleans. I am particularly proud to serve as 
our executive champion for Healthy State by 2030, Ochsner's commitment 
to building a healthier Louisiana for all people. As a Cuban American, 
this vision and our efforts to create health equity for the diverse 
communities we serve are professionally and personally meaningful to 
me. I graduated from Loyola University in New Orleans with a Bachelor 
of Science in Biological Sciences and earned my Doctor of Medicine 
degree at Louisiana State University School of Medicine. I am certified 
by the American Board of Internal Medicine in internal medicine, 
pulmonary care, critical care, and palliative medicine.

    Over the last several years, Congress has taken meaningful steps to 
address health care workforce gaps and improve patient access to care. 
This includes the support and expansion of various graduate medical 
education programs, Health Resources and Services Administration (HRSA) 
grants provided to strengthen and expand access to care in rural and 
underserved areas, and resources to enhance and facilitate the use of 
telehealth. Moreover, substantial resources were provided temporarily 
to a wide range of health care providers during the COVID-19 public 
health emergency (PHE). However, although the Federal PHE will soon 
expire, we know that the pandemic has had a lasting impact on the U.S. 
health care system. As I will discuss in greater detail, Ochsner has 
undertaken numerous initiatives to retain health care workers and 
expand the future pipeline for doctors, nurses, and other allied health 
professionals. However, it is clear that additional efforts are needed 
in both the public and private sectors. This hearing--the first for the 
HELP Committee this Congress--could not be happening at a better time. 
We thank the Committee for its leadership and look forward to 
contributing to this important examination of policies and programs 
that can help improve patient access to care by addressing current and 
anticipated workforce challenges.

    We are honored to have this opportunity to share with you our 
experience with the current health care workforce shortage and discuss 
several initiatives to develop and retain existing health professionals 
and build a pipeline of the next generation of caregivers. Ochsner 
stands ready to be a resource for the Committee and your colleagues in 
Congress as you explore ways in which the Federal Government may help 
address the current and anticipated shortage of nurses, physicians, and 
other health professionals. Working together, we can ensure the 
patients of today and tomorrow receive the primary, specialty, urgent, 
and emergency care they need and deserve.
                             About Ochsner
    Ochsner, headquartered in New Orleans, is one of the Nation's 
leading clinically integrated not-for-profit academic health systems. 
Ochsner's mission is to Serve, Heal, Lead, Educate and Innovate. As a 
leader in value-based care and delivery system innovation, we provide a 
comprehensive range of services across 90 specialties and 
subspecialties. This is done through our clinically integrated network 
of 4,600 affiliated and employed physicians and 47 owned, managed, and 
affiliated hospitals. Of these hospitals, eight are critical access 
hospitals located in medically underserved rural areas in Louisiana, 
Mississippi, and Alabama. We are proud that our innovative partnership 
model through the Ochsner Health Network (OHN) allows many communities 
to maintain local ownership and control of their hospitals, while 
bringing to bear the benefit of experience and breadth of the Ochsner 
clinical and operational teams. Each year we serve more than one 
million individual patients who come from every state in the Nation and 
more than 70 countries. Ochsner educates thousands of health care 
professionals annually. With our partner, LSU Health Shreveport, we are 
the leading educator of physicians in Louisiana. For the past 14 years, 
Ochsner has been training medical students through a partnership with 
University of Queensland, resulting in more than 800 new physicians for 
America. In addition, Ochsner is a leader in graduate medical education 
(GME) programs with 31 ACGME accredited residency and fellowship 
programs, through which we train more than 330 residents and fellows 
each year.
              Louisiana's Health Care Workforce Shortages
    Louisiana and Mississippi historically are the lowest-performing 
states for health outcomes in the U.S. Illustrating the myriad 
challenges facing the states that we serve, the United Health 
Foundation's America's Health Rankings 2022 Annual Report ranked 
Louisiana as 50th and Mississippi 49th. \1\ The leading drivers of poor 
health for both states are economic hardship, high rates of chronic 
disease and premature death, and low high school graduation rates as 
compared to other states. Moreover, while Louisiana has expanded 
Medicaid and overall numbers of uninsured have decreased, a significant 
proportion of the individuals and families we serve are underinsured. 
According to the American Community Survey reflecting 2016-2020, 
Mississippi and Louisiana are among the top five states and territories 
with the highest percentage of the population living in poverty. The 
COVID-19 pandemic has had disproportionately large impacts on minority 
communities, uninsured populations, and rural communities--all of which 
are found in Louisiana and Mississippi. Ochsner was the first to 
document the disproportionate impact of COVID-19 on African American 
communities in the New England Journal of Medicine in May 2020.
---------------------------------------------------------------------------
    \1\  https://assets.americashealthrankings.org/app/uploads/
allstatesummaries-ahr22.pdf

    Louisiana has been especially hard hit by the pandemic. The 
Louisiana Department of Health's COVID-19 dashboard reports over 1.55 
million cases to date in Louisiana and more than 18,600 deaths. This 
impact has been further exacerbated by the five named hurricanes that 
have made landfall in Louisiana since the pandemic began. Louisiana's 
health care workforce has played a critical role in the delivery of 
life-saving clinical care throughout the pandemic, but it has placed a 
tremendous strain on the entire health care delivery system and our 
---------------------------------------------------------------------------
workforce.

    Ochsner, like other health care providers throughout Louisiana and 
the Nation, continues to face an alarming shortage of nurses practicing 
in our communities. Despite multiple efforts to address these 
shortages, we currently have nearly 1,200 open registered nurse 
positions to fill. Unfortunately, the pipeline of available nurses 
being educated in Louisiana is not keeping pace with demand. The 2022 
Louisiana State Board of Nursing's Education Capacity Report shows that 
more than 1,200 qualified students were denied admission to the pre-RN 
licensure schools in 2021 due to insufficient training capacity.

    A 2017 study by the U.S. Department of Health and Human Services 
(HHS) estimated that the Nation would need 3.6 million nurses by 2030--
or approximately 50,000 new registered nurses each year from 2017 
through 2030. \2\ More recently, in September 2022, the U.S. Bureau of 
Labor Statistics reported that the Nation will have approximately 
203,000 annual openings for new registered nurses through 2026, due to 
nurses retiring or otherwise leave the nursing field. \3\ The nursing 
shortage was once due to a lack of individuals interested in the field, 
but the challenge now is there is lack of nursing school capacity to 
support the matriculation of all interested and qualified students. 
Inadequate nursing school capacity is due to several factors, including 
lack of qualified and available faculty, insufficient funding to 
support enough faculty positions, and faculty salaries that are 
significantly lower than bedside, management, or administrative nursing 
positions. Without numerous interventions to address these issues, 
Louisiana will continue to lose interested and qualified nursing 
students.
---------------------------------------------------------------------------
    \2\  https://www.usnews.com/news/health-news/articles/2022--11--01/
the-state-of-the-nations-nursing-shortage
    \3\  https://www.bls.gov/ooh/health care/registered-nurses

    In addition to the severe shortage of nurses, we also face a 
shortfall in physicians--both in Louisiana and across the Nation. In a 
2021 report, the American Association of Medical Colleges projected 
that ``physician demand will grow faster than supply, leading to a 
projected total physician shortage of between 37,800 and 124,000 
physicians by 2034.'' \4\ AAMC estimates that Louisiana will rank third 
in the Nation for shortage of physicians by 2030. Louisiana's 
population estimate for 2030 is 4.6 million. Therefore, the estimated 
shortage of physicians comes to 100 per every 100,000 people. 
Neighboring Mississippi is projected to have the worst physician 
shortage in the Nation by 2030, with 120 physicians needed for every 
100,000 people. Rural and underserved communities throughout Louisiana 
and Mississippi are expected to be the hardest hit.
---------------------------------------------------------------------------
    \4\  https://www.aamc.org/media/54681/download
---------------------------------------------------------------------------
       Impact of the Nursing Shortage on Ochsner and Our Patients

    The ongoing nursing workforce challenge has created a nationwide 
reliance on agency nurses, which significantly drives the cost of 
delivering care. The number of unique job postings in the U.S. for 
travel nurses more than doubled from January 2019 to January 2022 and 
the average amount staffing agencies charge hospitals and pay their 
nurses has increased from 15 percent in January 2019 to 62 percent. \5\
---------------------------------------------------------------------------
    \5\  https://www.fiercehealth care.com/providers/aha-Federal-funds-
needed-offset--20-patient-increase-hospital-expenses--2019

    The operational and financial impact of staff shortages and nursing 
and allied health staff agency costs on the Ochsner system pre-pandemic 
to today has been dramatic. Our contract staffing costs alone increased 
by 892 percent since 2019. During the same period, non-agency labor 
costs grew 59 percent. Ochsner currently contracts with approximately 
600 agency registered nurses. In addition to the increased costs, 
relying on high numbers of agency nurses can impact the effectiveness 
of care delivery teams. Hospital-based health care delivery is centered 
on a team-based approach and high functioning teams require consistency 
among the team members and iterative practice to assure highly 
---------------------------------------------------------------------------
reliable, safe care.

    While we have worked hard to reduce this number and convert these 
positions to full time roles, the latest report from the Louisiana 
Nursing Supply and Demand Council indicates that nursing shortages will 
continue to grip the state unless we remove barriers to meet the demand 
and undertake more significant interventions.

    Of serious concern is that these staffing shortages and the rising 
costs, coupled with a growing senior population with multiple chronic 
conditions, are impacting our ability to meet current and anticipated 
demand for primary, specialty, preventative, urgent, and emergency 
care. For example, across our system, we have closed 100 beds, 
resulting in the need to hold patients in non-traditional care settings 
like emergency departments that are already constrained. While Ochsner 
has a very advanced patient flow center that manages transfers across 
the state, over the past several months nearly all our 47 locations 
have been on inpatient and specialty diversion.
            Ochsner's Efforts to Address Workforce Shortages
    Ochsner is committed to addressing the workforce shortages of today 
and developing the next generation of health care providers and front-
line staff for tomorrow. We know that the solution to this statewide 
and national problem is multi-faceted and requires efforts from all 
stakeholders, including providers and state and local government. To 
that end, we have developed several programs and partnerships dedicated 
to workforce development in New Orleans and across Louisiana.

    We are proud that last year we invested more than $5 million to 
operate more than 29 different workforce programs, serving over 1,200 
individuals. We have focused efforts on increasing the supply of 
nurses, growing the pipeline of high school and college students 
entering health care training programs, and advancing existing 
employees by offering ``earn as you learn'' programs to incumbent 
employees. The following provides several examples of our current 
offerings and strategies.

          Delgado Community College Investment. In February 
        2021, Ochsner launched a partnership with Delgado Community 
        College (Delgado) to train the next generation of nurses and 
        allied health professionals, forming the Ochsner Center for 
        Nursing and Allied Health. Delgado is the largest educator of 
        nurses and allied health professionals in Louisiana. Together, 
        Delgado and Ochsner will meet critical workforce demands, 
        providing more opportunities for local graduates in high-wage 
        careers, and proactively pursue the career development of 
        minority and disadvantaged students. Ochsner's $20 million 
        investment in the center covers full-time tuition for Ochsner 
        employees pursuing a nursing or allied health certificate or 
        degree at Delgado and matching funds for a new state-of-the-art 
        facility on its City Park Campus. In addition to RN and LPN 
        programs, the facility will host Radiologic Technologist, 
        Respiratory Therapy, Physical Therapy Assistant, Occupational 
        Therapy Assistant, Surgical Technologist, Medical Laboratory 
        Technologist, and Pharmacy Technologist programs.

          Ochsner Nurse Scholars offers a tangible solution to 
        growing a diverse nursing workforce in Louisiana and 
        Mississippi by providing funding support and professional 
        development for current LPN, ADN, BSN, MSN nursing students 
        attending accredited Louisiana and select Mississippi nursing 
        schools full-time. In exchange for the funding, students are 
        required to work at Ochsner as a nurse upon graduation for 1-3 
        years, depending on which degree they are pursuing. There are 
        currently 364 active nurse scholars and an additional 44 who 
        have already graduated and joined Ochsner. Over 65 percent of 
        Ochsner's nurse scholars are demographically diverse with a 90 
        percent retention rate of program participants. Students are 
        attending one of 35 academic partners across Louisiana (28) and 
        Mississippi (7).

          Ochsner Nursing Pre-Apprenticeship launched in 2021 
        in partnership with Delgado Community College and the Louisiana 
        Department of Education (LDOE). It provides high school 
        sophomores and community college students an opportunity to 
        apprentice as nurses. This LDOE-approved Fast Forward Pathway 
        serves high school students across Jefferson, Orleans, St. 
        Bernard and the River Parishes and also supports students in 
        St. Bernard in partnership with Nunez Community College. The 
        program will soon expand to students in Shreveport, Lafayette, 
        Monroe and Baton Rouge. With more than 350 students currently, 
        the program seeks serve more than 600 students over the next 2 
        years.

          Ochsner Facilities Pathway Pre-Apprenticeship 
        launched in 2022 in partnership with Delgado Community College 
        and includes a high school pathway for the skilled trades 
        (plumbing, light electrical, etc.) as well as an incumbent 
        apprenticeship pathway. While the high school pathway is new in 
        2023, in partnership with Jefferson Parish Public Schools, the 
        incumbent pathway has seven apprentices who will graduate in 
        May 2023 from Delgado. This pathway has been submitted for 
        recognition as a registered apprenticeship.

          The Ochsner Catalyst Summer Internship Program 
        (Catalyst) build awareness of career opportunities in the 
        health care industry. In its 3d year, Catalyst draws college 
        students pursing an undergraduate or graduate degree for an 8-
        week paid summer internship. The program provides 1:1 
        mentorship, hands-on experience, peer networking and 
        developmental training sessions and assists students in 
        identifying non-clinical health care career opportunities, 
        while providing economic security. More than 500 students 
        applied for the 100 opportunities.

          Ochsner's Medical Assistant to Licensed Practical 
        Nurse (LPN) Apprenticeship recently celebrated the pinning of 
        31 LPNs. In partnership with LCTCS colleges, North Shore 
        Technical Community College, and Delgado Community College, the 
        registered apprenticeship offers tuition-free career growth to 
        current Ochsner Medical Assistants. Plans are underway to scale 
        the program into the Shreveport and Lafayette areas.

          Ochsner's LPN to Registered Nurse Apprenticeship 
        celebrated its first cohort in 2022-23. This earn as you learn 
        registered apprenticeship provides an opportunity for LPN to 
        advance in the nursing profession to ADN while sustaining their 
        living. While in an Ochsner apprenticeship, benefits are 
        subsidized allowing the apprentice to pursue education while 
        continuing to earn a living wage. Seven students were part of 
        the inaugural cohort.

          IMPACT Essential Skills Builder trained over 200 
        incumbent environmental services, patient escort, supply chain 
        dock workers and certified nursing assistants in ethical 
        decisionmaking, interpersonal communication, and critical 
        thinking skills. Participants are given opportunity to meet 
        with a career coach to shape a personal career development plan 
        that aligns them to opportunities ranging from apprenticeship 
        pathways to nurse scholars to tuition reimbursement for 
        college.

          MA Now, first launched in 2013, is our signature 
        community-facing program that links unemployed and 
        underemployed to a nursing pathway. Students earn several 
        industry-aligned credentials including the certified clinical 
        medical assistant, phlebotomy, ED Tech Monitor, and EEG 
        pathways. More than 250 MA Now graduates have been trained and 
        employed by Ochsner. Graduates regularly move into leadership, 
        LPN, and RN positions as they advance their careers.

          PAR Now, modeled on the highly successful MA Now, is 
        Ochsner's community-facing Patient Access Representatives or 
        PAR Now program. It prepares un-and underemployed for positions 
        as a clerical medical assistant in the Revenue Cycle job 
        family. Like MA NOW graduates, PAR NOW graduates earn stackable 
        credentials that open multiple doors for the graduates.

          Community Health Worker (CHW) is helping to build a 
        diverse workforce to service community clinics and support 
        health equity initiatives at the neighborhood level. In 2022, 
        nearly 50 CHWs were trained by Delgado Community College, in 
        partnership with Clover (previously Kingsley House in New 
        Orleans) and funded by a grant from Blue Cross Blue Shield.

          Patient Care Assistant (PCA) to Certified Nursing 
        Assistant (CNA) is a 8-week pathway program for those with a 
        strong desire for bedside caregiving who lack a credential. New 
        hires enter an ``earn as you learn'' pathway that includes 
        didactic training at a local community college while students 
        supplement the ancillary staff in the hospital as they build 
        their skills. Students graduate as a Certified Nursing 
        Assistant and enter a pathway to progress to LPN and then on to 
        RN.

          In-Patient Bedside Coding is a 2-year program to 
        build the knowledge and capacity for an individual to serve as 
        an in-patient coder. This highly sought-after talent is in 
        short supply across our Nation. The complexity of in-patient 
        coding requires advance training. Our apprenticeship allows 
        students the opportunity to grow their knowledge, skills, and 
        abilities to successfully compete in this high demand 
        occupation. Ochsner has successfully trained two cohorts, 
        including one that progressed during the height of the COVID-19 
        pandemic.
 Ochsner's Efforts to Strengthen and Diversify the Physician Workforce
    Ochsner is proud of our long-standing commitment to train the next 
generation of primary care and specialty physicians. We are working 
diligently to create more resident and fellowship opportunities 
throughout the region by building new GME programs in Lafayette and the 
Greater New Orleans Area. We are proud to have developed Ochsner's 
Program to Introduce Medicine to Underrepresented Students (OPTIMUS), 
which provides education about career options in medicine, hands-on 
simulations and experiments. Ochsner also sponsors the Ochsner 
Academics Summer Internship for Students (OASIS) program. OASIS 
provides formative experiences to undergraduate students interested in 
pursuing a career as a physician, physician assistant, or researcher in 
the biomedical sciences with a focus on supporting African American and 
Hispanic students, as well as students of Ochsner employees.

    Although Black and African American populations account for 13 
percent of U.S. residents, according to the AAMC, representation of 
African Americans within medicine lags, as they comprise only 5 percent 
of all U.S. doctors. Research shows an urgent need for a Historically 
Black College and University (HBCU) medical school. Recognizing this 
significant and growing need, in January 2023, Ochsner and Xavier 
University announced plans to create the Xavier Ochsner College of 
Medicine.

    Together, Xavier and Ochsner will create a new curriculum and use 
facilities, personnel, and administrative processes of both 
institutions to support the new school of medicine. Xavier's College of 
Pharmacy, established in 1982, is the oldest in Louisiana and has for 
years been among the top in the Nation in producing African American 
graduates with Doctor of Pharmacy degrees. The new Xavier Ochsner 
School of Medicine will build upon this strong legacy and result in 
greater diversity and representation among medical practitioners, which 
is critical to improving health outcomes by increasing quality of care, 
access, and patient trust in their health care providers.
      Other Investments to Build A Diverse and Inclusive Workforce
    Ochsner recognizes that an essential component to advancing equity 
and reducing health disparities is ensuring that our own workforce and 
that of the Nation reflect our diverse communities and society. To that 
end, in November 2020, Ochsner announced the creation of the Ochsner-
Xavier Institute for Health Equity and Research (OXIHER) to focus on 
five key strategies to address health inequity in Louisiana, including 
recruiting, educating, and training a diverse health care workforce. 
OXIHER trains health care workers to lead and innovate in health 
equity. Ochsner is pursuing this strategy through several initiative 
including the following:

          In addition to the new medical school and OXIHER, 
        Xavier and Ochsner also have worked to improve diversity within 
        the health sciences by establishing a new Physician Assistant 
        (PA) Program. In May 2022, Ochsner and Xavier celebrated the 
        first graduating class of 37 students in the full-time graduate 
        PA Program with a 93 percent completion rate. The program leads 
        to a master's degree in health sciences and trains the next 
        generation of providers to make a meaningful impact on health 
        care. In 2021, Ochsner and Xavier also established a Bachelor 
        of Arts in Medical Laboratory Science Program. Genetic 
        counseling and health informatics programs will be available in 
        the near future and will be offered to students through 
        classroom instruction at Xavier and clinical rotations at 
        Ochsner facilities. Xavier will be the first university in 
        Louisiana to offer a genetic counseling training program. It 
        will be the only such program based at an HBCU.

          NextOp and Ochsner have been awarded a $1.1 million 
        grant to help transition military and veteran talent in the 
        Mississippi River Delta area. The Workforce Opportunity for 
        Rural Communities Initiative Grant from the U.S. Department of 
        Labor and the Delta Regional Authority will be used to help 
        qualified applicants find careers in the health care industry. 
        Over the course of 3 years, the goal is to hire 300 veterans 
        into clinical and non-clinical careers with Ochsner.

 Innovations to Reduce Workforce Strain, Boost Care Delivery, Increase 
            Teaching Capacity, and Enhance Workplace Safety
    Nurses have experienced unprecedented strain, stress, exhaustion, 
and anxiety since the start of the PHE and the resulting, 
understandable burnout has contributed to the numbers leaving bed-side 
nursing. To help reduce the strain on our workforce and address 
burnout, we have undertaken a number of steps and launched new efforts, 
including the following initiatives:

          We are leveraging certified nursing assistants who 
        can perform functions like taking vital signs, freeing nurses 
        to engage in the provision of other care and services aligned 
        with their training and allowing them to practice at the top of 
        their licenses. Similarly, we are bringing more LPNs to general 
        medical surgical areas in the inpatient setting so they can 
        provide care and assistance in a manner consistent with their 
        state scope of practice and training.

          Through innovationOchsner, we have a long history of 
        successfully leveraging technology to solve access to care 
        challenges, as seen through our successful digital hypertension 
        and diabetes health offerings, Connected MOM, telehealth 
        platform, eICU, and the virtual care program Ochsner Connected 
        Anywhere. Utilizing our experience with these initiatives, we 
        currently are piloting a Virtual Nursing Program at our Ochsner 
        Medical Center Kenner location. There, we have a bunker with a 
        cadre of nurses who work a 12-hour shift but are not directly 
        located on an inpatient unit. The Virtual Nurse Program, which 
        provides 24-hour virtual nursing support to the patient care 
        team, is an innovative staffing model focused on patient-
        centered care and safe distribution of workload across an 
        integrated team of virtual and bedside nursing personnel. The 
        bunker contains a bank of computers and a high-tech early 
        warning system through EPIC, which together allow for the 
        monitoring of up to 20 patients at a time.

          The pilot has already improved risk adjustment mortality 
        index and turnover rates and we are in the process of expanding 
        the program to other Ochsner campuses. Further, the bunker 
        technology allows the remote nurses to virtually enter certain 
        patient rooms to assist with clinical and administrative 
        matters, such as discharge paperwork, which often can be 
        burdensome to the bedside nurse and can cause delays in getting 
        patients home or to the next care setting. This approach allows 
        bedside nurses to focus on direct care and leverages the bunker 
        nurses--via technology hook-ups--to manage non-direct care 
        matters--resulting in more efficient care delivery, a better 
        patient discharge experience, and less strain on the bedside 
        nurse.

 
------------------------------------------------------------------------
         Roles and Responsibilities in Virtual Nurse Care Model
-------------------------------------------------------------------------
           Virtual Nurse               Mutual/Shared    Beside Care Team
------------------------------------------------------------------------
   Admission Documentation    Educate   Conduct
                                      patients          physical
                                                        assessments
                 Care Plan    Monitor   Conduct
                                      patients          Bedside Handoff
       Discharge Education              Hourly
                                      Document Care     Purposeful and
                                                        Safety Rounds
    Transfer Documentation    Respond   Provide
                                      to patient/       Direct Patient
                                      family            Care (med
                                      questions         administration,
                                                        treatments, care
                                                        plan)
          Proactive rounds              Manage
                                      Collaborate       discharge
                                      with              process
                                      interprofession
                                      al care team
 Conduct real-time quality                      All
          surveillance (nightshift)                     ``hands-on''
                                                        care
  Document emergent/urgent
           Code Blue/Rapid Response
      24-hour chart checks
      Review trends (early
 intervention for deterioration: AI
                             alerts
------------------------------------------------------------------------


          We are also leveraging technology by providing 
        patients with MyChart Bedside on personal tablets to help 
        connect them with their care and their care team. MyChart 
        Beside puts Ochsner's integrated, electronic health record in 
        patients' hands, giving them real-time access to lab results, 
        medications, and treatment plans. Patients also can order 
        meals, call housekeeping, and have other non-clinical needs 
        addressed. This reduces the burden and demand on nurses to 
        handle non-clinical concerns for patients, allowing them to 
        focus their time, efforts, and expertise on clinical matters.

          Recognizing that our nursing schools have limited 
        capacity due to insufficient numbers of teaching faculty, we 
        are supporting several of our full-time employed Ochsner nurses 
        in stepping out of their clinical roles 2 days a week to serve 
        as clinical adjunct faculty at colleges of nursing. Ochsner 
        continues to pay their salaries in full, which provides schools 
        of nursing with faculty at no cost.

          There is nothing more important to Ochsner than the 
        safety and security of our employees and our patients and their 
        family members. Tragically, workplace violence against health 
        care workers has been escalating and disruptive or violent 
        incidents in hospitals--many involving hostile visitors--are on 
        the rise, including in our own system. As part of our 
        commitment to the mitigation of workplace violence we have 
        deployed a multifaceted approach. A key component of this 
        effort is our multidisciplinary Workplace Violence Committee, 
        which is focusing on patients, employees, and visitors. Within 
        our internal communication daily safety escalation huddles 
        workplace safety is discussed for each campus and as a system, 
        in addition to patient safety. We are providing education for 
        our employees on workplace violence and offer support programs 
        for employees who have been victims. Further, we are 
        implementing enhanced security solutions and improving our 
        tracking of incidents and analysis of related data. During the 
        previous session of Congress, we were proud to lend our support 
        to Congressman Troy Carter's resolution condemning violence 
        against health care workers and the bipartisan Safety from 
        Violence for Healthcare Employees (SAVE) Act, which would 
        establish legal penalties for assaulting or intimidating 
        hospital employees.
       Recommendations for Federal Policy, Programs, and Funding
    We sincerely appreciate you prioritizing the health care workforce 
and thank you for your interest in working with Ochsner to advance 
solutions for Louisiana and the Nation. We offer the following ideas 
for the Committee's consideration. We note that some of these policies 
fall squarely within the jurisdiction of this Committee, while other 
initiatives will require programmatic changes to Medicare, Medicaid, 
and other programs, which may be in the purview of other Senate 
Committees:
                    Health Care Workforce Shortages
          Provide funding to non-profit health systems and 
        academic partners working together to increase the pipeline of 
        physicians, nurses, and allied health professionals. Prioritize 
        efforts that demonstrate a commitment to addressing economic 
        and health disparities in the health care workforce.

          Address nursing shortages by investing in nurse 
        faculty salaries and hospital training time, including 
        reimbursement for hospitals and health systems that make their 
        nurses available as faculty to colleges of nursing.

          Authorize and fund new programs to support and scale 
        innovative solutions that reduce the burden on bedside nurses 
        and other clinicians, like our Virtual Nurse Program.

          Boost the Nation's ability to leverage availability 
        of international physicians and nurses. Increase the visas 
        available through proposals like the bipartisan Health Care 
        Workforce Resilience Act which allows for recapture from 
        previous fiscal years unused immigrant visas for physicians 
        (15,000) and nurses (25,000), exempts these visas from country 
        caps, and directs State Department and Department of Homeland 
        Security to expedite these processing of these recaptured 
        visas.
                             Access to Care
          Increase the number of physician residency slots and 
        safeguard GME funding from reductions.

          Establish new scholarships for minority health 
        professional students in return for work in rural or safety net 
        hospitals, or those in federally designated health professional 
        shortage areas.

          Provide additional Medicare funding to hospitals 
        experiencing extraordinary inflationary pressures caused by the 
        pandemic, including a fix to the hospital market basket update 
        to correct for lag times.

          Prevent further reductions to Medicare and Medicaid 
        physician payments, which may have a negative impact on patient 
        access to certain services, and support adjustments for 
        inflation and rising input costs.

          Make permanent Medicare coverage of certain 
        telehealth services made possible during the pandemic, 
        including lifting geographic and originating site restrictions, 
        expanding practitioners who can provide telehealth, and 
        allowing hospital outpatient billing for virtual services.

          Redesign current Medicare coverage and payment 
        policies for remote patient monitoring to remove barriers--such 
        as cost-sharing--that thwart patient access to innovative care 
        delivery models shown to improve patient health outcomes and 
        reduce the overall cost of care for patients.
                               Conclusion
    On behalf of the nurses, physicians, and other professionals who 
serve the more than one million individuals we care for each year, 
thank you again for this opportunity to present testimony regarding the 
current health care workforce challenges we face and for allowing us to 
discuss ways in which the shortages can be addressed. We are confident 
that through public-private partnerships we can together recruit, 
train, educate, and retain a diverse and robust health care workforce 
to ensure access to quality primary and specialty care for patients 
across the Nation. We are eager to work with you on this national 
imperative and welcome the opportunity to discuss our experience 
further and answer any questions.
                                 ______
                                 
                 [summary statement of leonardo seoane]
                          About Ochsner Health
      Ochsner, headquartered in New Orleans, is a clinically 
integrated not-for-profit academic health system with a network of 
4,600 affiliated and employed physicians and a combination 47 of owned, 
managed, and affiliated hospitals throughout Louisiana, Mississippi, 
and Alabama.

      Ochsner serves as the top health care educator in 
Louisiana, maintaining the state's largest group of GME programs with 
31 accredited residency and fellowship programs, through which more 
than 330 residents and fellows are trained each year.
                           Focus of Testimony
      Louisiana and Mississippi face unique challenges in 
health care delivery, as historically the lowest-performing states in 
terms of health outcomes in the U.S.

      Staffing shortages have had a tremendous impact on the 
Ochsner health care workforce and overall patient care. Despite 
multiple efforts to address these shortages, Ochsner currently has 
nearly 1,200 open registered nurse positions. By 2030, Louisiana will 
rank third in the Nation for shortage of physicians and Mississippi is 
projected to have the worst physician shortage in the Nation. Rural and 
underserved communities throughout Louisiana and Mississippi are 
expected to be the hardest hit.

      Main causes of nursing shortages in the states Ochsner 
serves include lack of training capacity, impact of shortages on 
burnout and premature retirement, and skyrocketing system costs.

      Ochsner has led multiple efforts to train and expand a 
diverse health care workforce through the Ochsner-Xavier partnership, 
specifically the Xavier Ochsner School of Medicine and Institute for 
Health Equity and Research (OXIHER), and other workforce development 
programs aimed at increasing the participation of persons from 
historically underrepresented and underserved backgrounds.

      Ochsner has led initiatives to reduce health care 
workforce strain, improve patient care, and enhance workplace safety, 
including leveraging CNAs and LPNs, making its clinical nurses 
available as faculty to colleges of nursing, deploying technology in 
innovative ways to enhance delivery of inpatient care, and providing 
employee education and support programs related to workplace violence.
                Recommendations to Senate Help Committee
      Support efforts to address health care workforce 
shortages, including investing in nurse faculty salaries, hospital 
training time, and non-profit health systems and academic partners 
working to increase the health care workforce pipeline, among other 
suggested initiatives.

      Advance initiatives to expand access to care, including 
increasing the number of physician residency slots, safeguarding GME 
funding from reductions, establishing new scholarships for minority 
health professional students, providing additional Medicare funding to 
hospitals experiencing extraordinary COVID-19 related-inflationary 
pressures, preventing further reductions in physician payments, and 
making permanent Medicare coverage of certain telehealth flexibilities 
granted under the PHE, among other suggested policy and programmatic 
changes.
                                 ______
                                 
    The Chair. Dr. Seoane, thank you very much for your 
testimony. Our final witness will be Dr. Douglas Staiger, 
Professor at Dartmouth College. Dr. Staiger received this Ph.D. 
in economics from MIT and has served as faculty at Stanford and 
Harvard before joining Dartmouth in 1998. Dr. Staiger, thanks 
for being with us.

   STATEMENT OF DOUGLAS STAIGER PH.D., PROFESSOR, DARTMOUTH 
                      COLLEGE, HANOVER, NH

    Dr. Staiger. Thanks, Chairman Sanders, Ranking Member 
Cassidy, Members of the Committee. It is an honor to be here 
this morning. No group of workers has been touched more 
directly and deeply by the COVID-19 pandemic than frontline 
health care providers, particularly nurses.

    I am going to focus my comments on nurses this morning, and 
I am an economist, so I am going to focus on data about 
employment and earnings in nurses. The U.S. has enjoyed steady 
growth in the registered nurse workforce, doubling the number 
of RNs per capita over the last four decades.

    However, since the start of the COVID-19 pandemic, RN 
workforce has been in flux. So, developing effective policies 
to strengthen the current and future RN workforce requires 
timely data. Over the last 20 years, I have worked with the 
research team to identify emerging trends in the health care 
workforce and forecast the future supply of RNs. And based on 
our recent and ongoing research, we see three key issues going 
forward.

    First, after a sharp decline in 2021, our unemployment 
recovered in 2022 and now is nearly 5 percent above where it 
was in 2019 before the pandemic, so there has been strong 
growth. RN earnings have grown slightly faster than inflation 
during the pandemic, whereas earnings in other occupations have 
grown more slowly than inflation.

    Encouragingly, as of 2022, both RN employment and earnings 
are at or above their pre-pandemic trends. But the big change 
that we have seen during the pandemic has been a shift of RN 
employment away from hospitals and into other settings, such as 
outpatient clinics, physician offices, schools, etcetera.

    All of the growth in RN employment since 2019 occurred 
outside of hospitals, and that is very unusual. We haven't seen 
that in years before. This helps to explain why hospitals are 
reporting shortages of RNs, right. If this trend continues, 
actions will be needed to improve the work environment and 
attract RNs back to working in hospitals.

    Otherwise, hospitals will need to develop strategies and be 
supported to better utilize a smaller RN workforce. Second key 
issue for the future supply of RN s is the educational 
pipeline. Application to nursing schools dipped in 2020 but 
rebounded strongly in 2021 and have continued their upward 
trend.

    Today are as high as they have ever been. However, the 
pandemic decreased academic preparedness of high school 
students entering nursing programs, which threatens to slow 
their educational progression and entry into the workforce.

    Similar patterns are seen in nurses taking the licensure 
exam, continued steady growth in numbers taking the exam, but a 
notable decline in pass rates, from 88 percent pre-pandemic to 
about 81, 82 percent in the last couple of years.

    These trends paralleled the decline in academic achievement 
during the pandemic for students in K-12 education, 
particularly those attending high poverty schools who lag 
roughly half a grade level behind pre-pandemic achievement 
levels.

    Nursing schools and employers realize they have to provide 
their nursing students and new nursing employees with 
additional training, and this may need Federal support. Third 
question key issue is the adequacy of the rural RN workforce, 
which I know is a concern of Members of the Committee.

    The number of RNs per capita in rural areas is actually 
comparable to urban areas and projected to steadily grow amidst 
declining rural physicians and limited rural nurse 
practitioners. So, it is actually quite different from 
physicians, where physicians in rural areas are definitely 
underrepresented.

    However, rural RNs are markedly less diverse than the 
population they serve, and only half of rural RNs have a 
bachelor's degree or higher, compared to over 70 percent for 
urban RNs, a recommendation 10 years ago from the National 
Academy of Medicine that 80 percent of RNs have bachelor's 
degrees by 2020.

    The Department of Health and Human Services has recently 
announced large investments in the rural health workforce, 
which could be used for programs such as the scholarship and 
loan forgiveness, that increase bachelor's degrees among rural 
RNs and help achieve greater diversity among RNs in rural 
communities.

    Putting all this evidence together, we have updated our 
forecasts and actually continue to forecast strong growth in 
the RN workforce. Forecast that there will be an additional 
million RNs over the next decade in the workforce, on top of 
the current workforce, employed workforce of about 3.5 million.

    The main concerns that need to be addressed in the near 
term are the shift of our own workforce away from the hospital, 
decreased preparedness of students entering and exiting nursing 
schools, and the need to diversify the rural workforce and 
increase bachelor's degrees among rural RNs.

    Finally, as I stated at the beginning, effective workforce 
planning and policymaking requires timely data and analysis. It 
would be valuable if there was a Federal effort to coordinate 
collection of better data on health care workforce that could 
be used to monitor the lingering effects of COVID-19 pandemic. 
This was something also that was recommended in the earlier 
National Academy of Medicine report. Thank you.

    [The prepared statement of Dr. Staiger follows:]
                 prepared statement of douglas staiger
                              Introduction
    The U.S. has enjoyed steady growth of the registered nurse (RN) 
workforce since the 1970's, providing the backbone of the Nation's 
growing and evolving health care delivery systems. Now, 3 years into 
the COVID-19 pandemic the RN workforce is very much in flux. The acute 
needs of the first 2 years of the pandemic placed extraordinary demands 
on health care workers and health care institutions, with registered 
nurses often at the center of the crises. Reported shortages of key 
nursing personnel have been widespread, leading to cancellation of 
elective care, bed closures, and severe strain on the provision of both 
essential acute and long-term care services. These strains on the 
nursing workforce have led to reports of burnout, early retirement, and 
workplace dissatisfaction.

    Developing effective strategies to strengthen the current and 
future RN workforce requires timely data on challenges facing the 
current workforce and forecasts of where the workforce is heading over 
the next decade. In the next three sections of this testimony, I 
summarize recent and ongoing research on the nursing workforce by me 
and others that is particularly relevant to understanding the state of 
the current RN workforce. In the final section, based on this evidence, 
I provide some recommendations on where we go from here.

    The analyses that I discuss here focus on economic impacts using 
data collected in Federal surveys of the Nation's workforce that 
include RNs, including many analyses that are currently under way and 
not yet publicly available. This research describes the current nurse 
workforce, compares nurse workforce trends before and during the 
pandemic, identifies changes in where RNs were working during the 
pandemic, and builds on our 20-year record of forecasting the future 
growth of the RN workforce. However, these federally collected surveys 
do not gather information about the non-economic impacts of the 
pandemic on RNs. The COVID-19 pandemic has exerted an enormous toll on 
nurses, physicians, and other health care workers, particularly in 
hospitals that were impacted initially by the pandemic and by ensuing 
strains and waves of the Corona virus. For that broader context, I 
defer to others to offer insights on the non-economic impact of the 
pandemic on the RN workforce in the U.S.
                   Employment and Earnings of RNs \1\
---------------------------------------------------------------------------
    \1\  This section draws largely from: Auerbach, Buerhaus, Donalan, 
and Staiger, ``A worrisome Drop in the Number of Young Nurses,'' Health 
Affairs Forefront, April 13, 2022; Buerhaus, Staiger, Auerbach, Yates, 
and Donalan, ``Nurse Employment During the First Fifteen Months of the 
COVID-19 Pandemic,'' Health Affairs, January 2022; and Auerbach, 
Buerhaus, and Staiger, ``Implications of the COVID-19 pandemic for the 
future supply of registered nurses,'' unpublished manuscript, 2023.

    Over the last four decades the RN workforce grew steadily from just 
over one million RNs in 1982 to 3.2 million in 2020. Today, the number 
of per capita RNs in the U.S. is either on par with or higher than most 
other OECD countries, in contrast with the number of physicians, which 
is among the lowest of these nations. In 2000 there were projections of 
looming RN shortages as large numbers of RNs were nearing retirement 
age and few younger people were entering the profession. \2\ In 
response to these projections numerous initiatives and public awareness 
campaigns generated increased interest in nursing as a career among 
younger people, resulting in continued steady growth of the workforce.
---------------------------------------------------------------------------
    \2\  Buerhaus, Staiger, and Auerbach, ``Implications of an Aging 
Registered Nurse Workforce,'' JAMA, June 14, 2000.

    Since the start of the COVID-19 pandemic the RN workforce has been 
in flux. Recently published data found that the total employment of RNs 
declined by more than 100,000 between 2020 and 2021, the largest such 
decline since at least 1980. However, RN employment recovered 
dramatically in 2022 and is now nearly 5 percent above where it was in 
2019. Hourly earnings of RNs (adjusted for inflation) were relatively 
unchanged in the decade before the pandemic, but have grown slightly 
faster than inflation since 2019, while earnings across all occupations 
have grown more slowly than inflation. \3\ Thus, as of 2022, both RN 
employment and erning have grown at or above their pre-pandemic trends.
---------------------------------------------------------------------------
    \3\  The number of nurses working for employment agencies--
including travel nurses--has nearly doubled during the pandemic. While 
these nurses are paid more than other nurses, they remain a small 
fraction of the workforce, accounting for less than 3 percent of the RN 
workforce in 2022.

    The most notable development during the pandemic has been a shift 
of RN employment away from hospitals and into other settings such as 
outpatient clinics, MD offices, schools, etc.: All of the growth in RN 
employment between 2019 and 2022 occurred outside of hospitals. This 
helps to explain why hospitals continue reporting shortages of RNs 
despite robust growth of the overall RN workforce. Why this has 
occurred, and whether this trend will continue, is less clear. The 
shift away from hospital employment was particularly dramatic for older 
RNs, consistent with reports of increased stress and difficult working 
conditions exacerbated by the pandemic: A recent Medscape survey found 
that 40 percent of RNs said that COVID-19 had negatively impacted their 
career satisfaction. Actions will be needed to improve the workplace 
environment and attract RNs back to working in hospitals. Otherwise, 
hospitals will need to develop strategies to better utilize a smaller 
RN workforce.
                        The Nursing Pipeline \4\
---------------------------------------------------------------------------
    \4\  Data on applications to BSN programs and NCLEX discussed in 
this section come from the National Council of State Boards of Nursing 
and the American Association of Colleges of Nursing.

    A key factor in understanding the future supply of RNs is the 
educational pipeline. The number of applications to baccalaureate 
nursing programs has risen rapidly over the past 20 years (more than 
doubling). While application growth slowed in 2020, it accelerated 
again in 2021, allaying concerns of declining interest in a nursing 
career. However, the pandemic decreased the academic preparedness of 
high school students entering nursing programs, which threatens to slow 
their educational progression and entry into the workforce. \5\
---------------------------------------------------------------------------
    \5\  https://www.prnewswire.com/news-releases/amid-a-national-
nursing-shortage-prospective-nursing-students-say-lack-of-academic-
preparedness-is-the-driving-decision-to-delay-or-forego-nursing-
school--301621715.html

    Similar patterns have occurred in annual graduations from nursing 
education programs and the number of NCLEX test-takers (the RN 
licensure exam), which have grown steadily through the pandemic and 
have never been higher. However, pass rates on the NCLEX declined 
sharply during the pandemic, from 88 percent in 2018 and 2019 to 81-82 
percent in 2021 and 2022, again suggesting decreased preparedness of 
graduates to enter the workforce. Pass rates are likely to fall further 
with the introduction of the more difficult NextGen NCLEX coming later 
this year. Developing strategies to reverse these trends is essential.
                            Rural Nurses \6\
---------------------------------------------------------------------------
    \6\  This section draws from Yates, Auerbach, Staiger & Buerhaus, 
``Characteristics of rural registered nurses and the implications for 
workforce policy,'' The Journal of Rural Health, 2023.

    Rural RNs play an integral role in providing care for an 
underserved population with worse health outcomes than urban 
counterparts. In contrast to physicians, the number of RNs per capita 
in rural areas is comparable to urban areas. While the number of 
physicians serving rural populations has decreased in recent years, and 
rural nurse practitioners (NPs) remain in short supply, rural RNs have 
steadily grown in numbers at a rate comparable to urban RNs. Moreover, 
young rural nurses appear on pace with urban nurses to adequately 
---------------------------------------------------------------------------
replace older nurses and continue to grow the workforce.

    While the numbers of rural RNs appear to be sufficient, the 
characteristics of the workforce do not align with the needs of the 
rural population. Rural RNs in 2019 were markedly more likely to be 
white, non-Hispanic (89.1 percent) than either urban RNs (68.4 percent) 
or the rural population they serve (77.3 percent). In 2011, the 
Institute of Medicine recommended that 80 percent of RNs have a 
bachelor's degree by 2020, yet only half of rural RNs had a bachelor's 
degree or higher in 2019 compared to over 70 percent of urban RNs. The 
Department of Health and Human Services has recently announced 
``record-setting investments'' to bolster the rural health workforce, 
including RNs, and to advance equity and ensure access to care. These 
burgeoning investments in the rural health workforce present 
opportunities to help diversify, increase educational access, and 
further rural readiness for RNs moving forward.
                       Where Do We Go from Here?
    While 100,000 RNs left the workforce in 2021, the RN workforce 
rebounded in 2022 and is back on track with pre-pandemic projections. 
In ongoing work with David Auerbach and Peter Buerhaus building on our 
20-year record of forecasting the future growth of the RN workforce, we 
have estimated updated forecasts of growth in the RN workforce that 
incorporate these trends through 2022. Over the next decade we project 
the national RN workforce to not only replace the expected retirement 
of an estimated 500,000 RNs but further expand by nearly 1 million RNs, 
with growth in RNs serving both rural and urban populations.

    Nevertheless, there are three main concerns looking ahead:

          1. Addressing the shift of the RN workforce away from the 
        hospital. While the exact reasons for this shift are not yet 
        clear, the trend is consistent with reports of increased stress 
        and difficult working conditions in hospitals exacerbated by 
        the pandemic. Improving the workplace environment will require 
        constructive engagement with nurses to identify supportive 
        characteristics of an organization's culture and reset trusting 
        relationships with administrative and executive leaders. Much 
        work has been done that hospitals and other organizations can 
        draw from to frame and guide these conversations, particularly 
        the National Academy of Medicine's National Plan for Health 
        Workforce Well-Being (2022). Maximizing the services provided 
        by the remaining RNs in the hospital will require redesigning 
        of care delivery models and removal of unnecessary restrictions 
        on nurses' scope of practice.

          2. Addressing the decreased academic preparedness of students 
        entering and exiting nursing schools. The decline in academic 
        preparedness of students exiting nursing school may be short-
        lived if it is driven by remote instruction during the 
        pandemic. However, it may continue for many years as students 
        graduating from high school suffer the lingering effects of the 
        pandemic. Recent estimates suggest that students in all grades, 
        particularly those attending high poverty schools, lag roughly 
        half a grade level behind pre-pandemic achievement levels. \7\ 
        In either case, at least in the short term, nursing schools and 
        employers will need to develop "booster" programs to provide 
        their nursing students and new nurse employees with needed 
        training. Otherwise, the pipeline of incoming nurses will be 
        both fewer in number and less well prepared. It would be 
        appropriate for the federal government to provide some support 
        for this training through pandemic relief funds.
---------------------------------------------------------------------------
    \7\  https://projects.iq.harvard.edu/cepr/education-recovery-
scorecard
---------------------------------------------------------------------------
          3. Addressing the need to diversify the rural workforce and 
        increase bachelor's degrees among rural RNs. The American 
        Rescue Plan and CARES acts directed a new Health Workforce 
        Strategic Plan from the Department of Health and Human 
        Services, in which increased rural access to care and workforce 
        diversity are critical goals. Because RNs represent a large and 
        growing proportion of health care providers serving rural 
        communities, policymakers should consider directing some of 
        these resources toward the RN workforce to increase bachelor's 
        degrees among rural RNs and help achieve greater diversity 
        among the RN providers in rural communities. For example, 
        scholarships that require subsequent service in rural hospitals 
        (like loan forgiveness but without the negative connotations 
        associated with debt) could be used to encourage under-
        represented groups to become rural RNs or to encourage rural 
        RNs with an associates degree to obtain a baccalaureate degree.

    Finally, as I stated at the beginning, developing effective 
strategies to strengthen the current and future RN workforce requires 
timely data. One of the 4 key messages in the Institute of Medicine's 
2011 report The Future of Nursing: Leading Change, Advancing Health was 
that ``Effective workforce planning and policymaking requires better 
data collection and an improved information infrastructure.'' The ACA 
created the National Health Care Workforce Commission and the National 
Center for Workforce Analysis to, among other things, coordinate the 
collection of data and analysis of the health care workforce. This 
would be an opportune time to use those existing structures to support 
better data collection and continued analysis for monitoring the 
lingering effects of the COVID-19 pandemic on the health care 
workforce.
                                 ______
                                 
                 [summary statement of douglas staiger]
    In my written testimony, I summarize recent and ongoing research on 
the nursing workforce by me and others that is particularly relevant to 
understanding the state of the current RN workforce, and then provide 
some recommendations on where we go from here. Recent evidence suggests 
the following:

          1. After a worrisome decline in 2021, registered nurse (RN) 
        employment has recovered in 2022 and is nearly 5 percent above 
        where it was in 2019. RN earnings have grown slightly faster 
        than inflation, whereas earnings across all occupations have 
        grown more slowly than inflation. But the big change during the 
        pandemic has been a shift of RN employment away from hospitals 
        and into other settings such as outpatient clinics, MD offices, 
        schools, etc.: All of the growth in RN employment between 2019 
        and 2022 occurred outside of hospitals. This helps to explain 
        why hospitals are reporting shortages of RNs.

          2. Applications to nursing schools dipped in 2020 but 
        rebounded strongly in 2021 and continue their steady upward 
        trend. However, there are concerns about decreased academic 
        preparedness of entering students. Similar patterns are seen in 
        nurses taking the licensure exam--continued steady growth, but 
        a notable decline in the pass rates in 2021.

          3. The number of RNs per capita in rural areas is comparable 
        to urban areas and is projected to steadily grow amidst 
        declining rural physicians and limited rural Nurse 
        Practitioners (NPs). However, rural RNs are markedly less 
        diverse than the populations they serve and only half of rural 
        RNs have a bachelor's degree or higher compared to over 70 
        percent for urban RNs.

    Putting this evidence together, we continue to forecast strong 
growth in the RN workforce over the next decade. The main concerns 
looking ahead are (1) a shift of the RN workforce away from the 
hospital, (2) decreased preparedness of students entering & exiting 
nursing schools, and (3) a need to diversify the rural workforce and 
increase bachelor's degrees among rural RNs.
                                 ______
                                 
    The Chair. Thank you very much. Let me begin the 
questioning, and I will give the mic over to Senator Cassidy, 
and we will go around the table.

    As I mentioned earlier, in my state, in our largest 
hospital, we have seen a huge expenditure of $125 million for 
traveling nurses at a time when we have more young people who 
want to become nurses but can't accommodate them in our nursing 
schools.

    Dr. Herbert, is that in fact just a Vermont problem or is 
that a main problem? Is that a national problem?

    Dr. Herbert. Senator Sanders, it is very much a national 
problem. The traveling nurse situation that you described, you 
are exactly right. We are seeing the exact same thing in Maine. 
There's a number of reasons for it.

    But I think what you are hearing from the panel today, 
there is consistency in terms of the nurse educator problem. 
But there's also hospitals are really strapped with the 
workload issues that I that I described earlier in terms of 
reimbursements.

    It is complicated, but the clinical training sites like 
hospitals need support to be able to accommodate more trainees, 
which will help with the problem.

    The Chair. Okay. Dr. Szanton, how are we going to--give me 
some specific ideas as to how we get more nurse educators out 
there so we can accommodate the number of young people who want 
to become nurses?

    Dr. Szanton. If we can increase all the programs through 
HRSA, like the nurse corps, that would be a really concrete 
suggestion. Currently, almost none of our students are able to 
get the nurse corps because we are a master's program.

    I think solving all the problems that we talked about and 
having more simulation passing the FAAN Act would be ways of 
quickly trying to increase the nurse faculty abilities of this 
country.

    The Chair. Okay. Dr. Hildreth, it is widely recognized, not 
debated, that African Americans, Latinos, and Native Americans 
are underrepresented in the health care profession and debates 
that what is the impact of that. You know, people say, so what 
is the difference? You know, so you have a white doctor, a 
black doctor who cares? Is there a difference? What is the 
difference?

    Dr. Seoane. Thank you, Senator Sanders. The data is very 
clear, as my colleague referenced earlier, that when the health 
care workforce reflects the population, they care for, outcomes 
are better. That is not to say that a white doctor can't 
provide great care to a black patient.

    That happens every single day in our Country and vice 
versa. But when the provider team looks like the population 
they are caring for, the outcomes are better. That has been 
demonstrated over and over again. That is what we lose by not 
having a diverse workforce, the best outcomes for communities.

    The Chair. Thanks very much. Dr. Seoane, you talked about 
large areas of Louisiana, in fact, all over this country, not 
having enough physicians, nurses, etcetera.

    It is a little bit outside of the scope of this hearing, 
although I am going to get back to it because we have 
jurisdiction over the community health center program. Do you 
think that expanding community health centers in rural areas in 
America would make a lot of sense?

    Dr. Seoane. Thank you for that question, Senator Sanders. I 
do. I think they are important. Ochsner is starting 13 
community health centers throughout Louisiana. They serve an 
important need.

    The Chair. Are these federally qualified community health 
centers?

    Dr. Seoane. These are our own. We have gone outside the 
federally qualified centers. So, we partnered with federally 
qualified health centers, and we are starting our own community 
health centers, too. We are meeting all the Federal health 
qualified center guidelines, but it was quicker to get there 
into our communities to serve.

    The Chair. Would it be advantageous if they were FQHCs? 
Would it work well for you or not?

    Dr. Seoane. It would be advantageous if we could work with 
the Government to make health centers like Ochsner be able to 
start these federally health qualified centers and spread them 
more quickly.

    The Chair. Good. Let me ask, go back to Dr. Herbert. One of 
the areas that we do have jurisdiction over, and I am very 
strongly in support of, teaching health centers, GME. And that 
is an opportunity to get residents out of teaching hospitals 
and into primary health care facilities. Perhaps you and Dr. 
Hildreth can say a word about that. Is that a good idea to 
expand those programs?

    Dr. Herbert. That is a very good idea. And because of the 
caps on GME funding from the Federal Government, states have 
actually stepped in and done some creative things. I mean, for 
example, the State of Georgia has done that.

    We are now working with colleagues in Maine to establish, 
trying to get some legislation through the State of Maine to 
actually directly fund GME through partnerships based in 
community hospitals, but in partnerships with the teaching 
hospitals.

    There are some creative things that can be done. Could be 
done much more fast, much more quickly if the CMS rules were 
changed in the way they fund GME. But there is innovative, 
other innovative ways of doing it.

    But we absolutely need more GME. This is critical not only 
for primary care but for some specialty care as well. Senator 
Sanders and I worked--Senator Collins, and I apologize. We are 
talking this morning about obstetrics and the closure of 
obstetric units in rural hospitals and community hospitals.

    Again, GME is really the key to addressing these various 
issues.

    The Chair. Dr. Hildreth, do you agree or--?

    Dr. Hildreth. I definitely agree. And as you referenced 
earlier, Senator Sanders, we want to make health care happen in 
the lowest cost setting possible, and that is certainly 
outpatient setting for primary care. I definitely agree that 
more GME in those settings would be great.

    The Chair. Great, good.

    Dr. Hildreth. Thank you.

    The Chair. Thank you very much.

    Senator Cassidy.

    Senator Cassidy. I am going to defer to Senator Paul.

    The Chair. Senator Paul.

    Senator Paul. Thank you. Dr. Szanton, are you pro-choice 
with regard to patients making individualized medical choices?

    Dr. Szanton. Broadly, thank you, yes.

    Senator Paul. Are you aware that your university doesn't 
allow choice with regard to vaccination, that you require all 
of your students to have three vaccines in order to be 
students?

    Dr. Szanton. Yes.

    Senator Paul. It is sort of choice, but not so much when 
regarding vaccination. Are you aware of the increased risk of 
myocarditis with the COVID vaccine, particularly with 
successive COVID vaccinations in males between the ages of 16 
and 24?

    Dr. Szanton. Senator, thank you for the question. I am 
prepared to talk about the nursing crisis, and that we have 
vaccine requirements across the board for----

    Senator Paul. Here is the problem, if you exclude everybody 
from being a nurse who believes in basic immunology, you are 
going to include a lot of smart people, people who believe that 
you can get immunity from both vaccination as well as 
infection.

    If you say, well, we are just not going to take the people 
who believe in that old fashioned infection thing, providing 
immunity, we are only going to take the people who will do as 
they are told. I mean, do you think individuals should be 
treated the same when they come to the emergency room?

    If you have got an 18-year-old with chest pain and a 68-
year-old obese diabetic with chest pain, you think they get 
treated the same in the emergency room? There are differences 
based on age. We used to always make differences even on the 
flu vaccine. We advise it for people at risk. We have done this 
forever.

    This is the first time we have done it. We are now doing it 
with an experimental vaccine, one that has not been approved. 
Do you think that prior infection affects your immunity?

    Dr. Szanton. Senator, I am not--I don't make the choices 
about the vaccinations. That is a Johns Hopkins University----

    Senator Paul. Right, but you are a leader at Johns Hopkins 
University and you could well have your opinion stated. Dr. 
Marty Makary is there, and Dr. Marty Makary has been very 
active in this. He has looked at the incidence of myocarditis 
and he says it is 28 times more likely to get myocarditis from 
the vaccine than from COVID for a particular cohort of young 
men. Women, this also applies to, but more men and women.

    I assume you have men and women in your nursing program. 
This is a big deal and it might affect them. It affects the 
Marines. It affects everybody else. We finally fixed it with 
the Marines. We are not making them do it anymore. But the 
thing is, is you are at an institution of higher learning. We 
should have questions.

    I know sometimes we have to do as we are told, but you are 
also dean of the school. You have a voice. And we should be 
curious about things. In Britain, France, Germany, Norway, 
Sweden, Denmark, they don't have university mandates on this. 
Some countries don't recommend it for children at all.

    There really is a debate and discussion. You can have an 
opposite debate, but if you believe in choice, when something 
has a debate and there are arguments on both sides, you would 
give people the choice. So, the CDC did a study of a million 
patients. That is a pretty big study. It is an observational 
study, but it is a large study. And they asked, what are the 
chances that you will go to the hospital? And they divided into 
different groups.

    One group was vaccination, and it showed a 20 times, and 
this has been repeated a lot, 20 times lowering of your rate of 
going to the hospital if you have been vaccinated. I think most 
people accept that.

    Now, it doesn't stop transmission. So, when you mandate 
this, you can't make any arguments about protecting other 
people. It is only about you at this point. But what they also 
found in this study of a million people was that people who had 
not been vaccinated but had been infected on a prior occasion 
by COVID were 57 times less likely to go to the hospital. So 
really it isn't an argument against vaccination.

    I mean, if you haven't been infected, you ought to be 
vaccinated, but you got to have a choice. You are not giving 
people any choice. And actually, this applies to all your 
universities. None of your universities--I think we all mandate 
three vaccines. And frankly, I think the literature actually 
shows it to be malpractice.

    That is why you should all have a voice in this. A large 
study in Israel shows that the rate of myocarditis among 
vaccinated is about 1 in 3,000 to 1 in 6,000. There is another 
study that shows it is 40 times greater. So, between 28 and 40 
times. And this isn't an argument against vaccination, it is an 
argument for thinking and understanding the people of different 
ages could respond differently.

    My hope, and what I would offer to all of you is that 
people should speak up. We are living in a world where 
everybody sticks your head in the sand and says, do as you are 
told, take three vaccines. And there are people with 
myocarditis that are seriously ill currently. I mean, think 
about this.

    Here is a question, your 15-year-old kid has had COVID, 
takes the vaccine, and has myocarditis enough to be 
hospitalized. What would you do? Would you give him another 
vaccine?

    Dr. Szanton. Thank you. I am not--I will take into 
consideration what you have said and I will bring it back----

    Senator Paul. Well, it is an individual decision, and you 
ought to be able to answer. At least be honest and look 
backward. The thing is, the CDC says if your kids had 
myocarditis, got sick and went to the hospital, as soon as he 
gets better, give him another one. I think most parents in the 
country would say that is a stupid idea and defies all common 
sense and they would resist this.

    But when the Government tells you to do it and it is a 
really stupid idea that defies common sense, guess what, people 
lose trust in Government. People--we want to have trust in the 
people running our medical schools and our nursing schools. But 
somebody needs to ask these questions.

    Dr. Marty Makary is doing it. Dr. Vinod Prasad is doing it 
out at UC San Francisco. And it is a growing movement, but I 
would hope that you all will open your minds to at least 
thinking about the choice of the individual in medicine.

    The Chair. Okay. Thank you, Senator Paul.

    Senator Hassan.

    Senator Hassan. Well, thank you very much, Mr. Chair and 
Ranking Member Cassidy, for this hearing. And thank you to all 
of our witnesses. I greatly appreciate what all of you do. Dr. 
Staiger, I wanted to start with a question to you.

    Thank you again for being here and for sharing your 
expertise on the workforce shortages facing health systems in 
New Hampshire and all around the country. As we work to address 
this shortage, we don't want nurses or other health care 
workers to have to leave their jobs to get a degree or 
credential that they need to advance their career.

    Last Congress, I worked with Senator Young to introduce the 
Upskilling and Retraining Assistance Act, which would double 
the amount of tax-free educational assistance that workers can 
receive as a benefit from their employers.

    Dr. Staiger, would offering tax free education benefits 
help keep health care workers in the field and ease the labor 
shortages facing hospitals and other providers?

    Dr. Staiger. I actually think that is quite a good idea. It 
is--I think of it as scholarships from your employer, right. 
These are often offered with the agreement that you have a 
commitment to the employer afterwards, which is a good way, 
rather than doing a loan, to support this.

    You keep them in, they tend to take a day off here or 
there, and they stay connected. I especially think these are if 
you had to target this, it should be targeted in places that 
are--where we have particular need, sure.

    Senator Hassan. That makes sense. Let me turn to Dr. 
Herbert. When I visited with health care leaders at Memorial 
Hospital in North Conway last month, they told me about the 
challenges that they face every day as a result of the nursing 
shortage.

    While it is essential that we train more registered nurses, 
we also need these nurses to continue to practice in rural 
areas of states like New Hampshire and Maine and Vermont after 
they get their license. So how can we encourage nurses trained 
in rural states to stay and practice there after graduating?

    Dr. Herbert. Thank you very much for the question. We use a 
three-pronged approach that we found helpful. The first is we 
try to attract students from rural areas. And what we found is 
students from rural areas are more likely to go and practice in 
a rural area, even if it is not their same hometown.

    That is the first key. Second, and this is very important, 
regardless of where they come from, during training, placing 
them in clinical sites in rural areas, very, very important. 
They get a taste of rural life and many of them actually really 
like small town and rural life and prefer to work in those 
settings.

    Third and most importantly is something I mentioned before, 
which is either scholarship or loan repayment programs with 
strings attached, with a commitment to practice in those areas.

    You can do it on the front end of scholarships, on the back 
end as loan repayment, but there needs to be an incentive 
because, as Chairman Sanders said, if you are looking at a big 
debt that you need to pay off and there is a major hospital in 
Boston that will give you x additional salary, we need to at 
least--even if we don't even if we don't make up the entire 
amount, we need to offset that enough to incentivize people to 
practice in rural areas. That three-pronged approaches, we 
found it helpful for not only nurses but dentists and other 
professionals.

    Senator Hassan. Well, I thank you for that response. I will 
add that the other piece of the conversation that came up in 
North Conway and has come up all around my state, is just the 
need for housing for employees, especially in rural New England 
right now, Northern New England.

    Dr. Herbert. Couldn't agree more.

    Senator Hassan. Dr. Szanton, I wanted to ask you a 
question. In response to the growing shortage of licensed 
nursing assistants, New England College has created a joint 
nursing education program with Eliot Hospital in Manchester.

    The college's students earned 25 percent of their college 
credits working as licensed nursing assistants at Eliot 
Hospital. They graduate with a Bachelor of Science in Nursing. 
How can we encourage these kinds of innovative partnerships and 
other efforts to train and develop more licensed nursing 
assistants?

    Because what we are finding is these nursing assistants are 
doing the work they need at the bedside, but they are also 
getting critical clinical experience with oversight from nurses 
in a clinical setting.

    Dr. Szanton. Absolutely. I think that is a wonderful idea. 
And we have such a shortage, especially in the hospitals, that 
it is going to take it all of the above kind of strategy, and 
some training in the clinical places, and some in the 
universities. And that sounds like a wonderful idea.

    Senator Hassan. Thank you. Dr. Seoane, in December, 
Congress funded the training of 200 new physicians, including 
at least 100 psychiatrists or addiction medicine specialists, 
building off a bill that Senator Collins and I did, called the 
Opioid Workforce Act.

    Dr. Seoane, how will additional psychiatrists help meet the 
existing behavioral health crisis, and what more can we do to 
continue developing the behavioral health workforce?

    Dr. Seoane. Thank you for that question. There is a 
critical shortage of psychiatrists in the U.S., and in 
particular in my state. That is why at Ochsner we have our 
scholarships around primary care and psychiatrists. And 
psychiatrists are part of a team.

    They are psychologists, nurse practitioners, and others 
that can participate in that. But that program is essential to 
growing the workforce. And psychiatrists are they are the 
spearhead to help be part of the solution for this mental 
health crisis that we are facing in the United States.

    Senator Hassan. Thank you very much, thank you, Mr. Chair.

    The Chair. Thank you, Senator Hassan.

    Senator Cassidy.

    Senator Cassidy. I will once again defer this time to 
Senator Collins.

    Senator Collins. Thank you very much, Senator Cassidy. Dr. 
Herbert, I do want to follow-up with you on the issue of the 
shortage of nursing faculty. It just is astonishing to me that 
at last, I guess it was in 2021, almost 92,000 applications for 
baccalaureate and graduate nursing programs were turned away, 
with faculty shortages cited as the top reason. And the 
University of Maine this year had 1,239 applications for only 
80 slots.

    I think there is this misperception that people don't want 
to become nurses when in fact we have a ton of applicants from 
people who do want to enter the field of nursing, but we don't 
have the professors to teach them. And that is why the Chairman 
and I and the Ranking Member have been working hard to come up 
with a solution.

    I want to--more with you on how we bridge the faculty gap. 
You mentioned in your testimony, Dr. Herbert, that in some 
cases, practicing clinicians can be recruited to serve as 
faculty instructors in their existing workplaces. Could you 
give the Committee an example of how UNE is working with an 
academic institution or a hospital to expand training capacity?

    Dr. Herbert. Thank you very much, Senator Collins. We are 
doing exactly that. First of all, I agree with everything you 
said. It is a real problem. And you are also right that there 
is a lot of demand out there for people who want to become 
nurses and other health care professionals, and, but with 
limitations on what we can do. At UNE, we have increased the 
number of nurses.

    We trained 300 percent in the past 10 years, so we are 
continuously looking how we can expand that. A program along 
the lines that you are describing is something we are doing in 
partnership with MaineHealth. MaineHealth is Maine's largest 
health care network of providers, and also has branches in New 
Hampshire as well, Southern New Hampshire.

    We, what we are doing is we are actually using the faculty 
onsite, using nurses onsite. We provide professional 
development and support from the university to have them train 
people onsite, in the MaineHealth hospitals, hospitals system. 
So, using clinicians, this is part of that laddering approach.

    We are also training the nurses, upskilling the nurses, 
going from LPNs to RNs, RNs to BSNs, BSNs to nurse 
practitioners onsite, in partnership with MaineHealth. And we 
are looking to expand that program with other health care 
programs as well. So, trying to find creative ways of 
addressing the faculty shortage.

    Senator Collins. Thank you. Dr. Staiger, I saw you nodding. 
Did you have something to add?

    Dr. Staiger. I was just going to say I--there has been such 
strong growth in the number of people going through nursing 
schools. Applicants have outpaced that, so that is why there--
the thing and so we shouldn't be surprised there are faculty 
shortages.

    It has been chronic because we have tripled the number of 
students going through nursing programs in the last 25 years. 
That, nobody thought that could happen 25 years ago. It has 
been heroic what the nursing schools have done.

    It is, it is a chronic problem. I also think it is a 
problem that the nursing schools have been able to solve with 
help, and I am optimistic going ahead.

    Senator Collins. But we have still got this huge gap. Dr. 
Hildreth, I was very moved by your testimony, and I was 
reminded of the fact that one reason UNE has been so successful 
in getting its graduates to practice in rural areas is they do 
that third-year program in rural areas. So, do you do something 
similar to that in order to encourage people to return to 
underserved areas?

    Dr. Hildreth. Thank you, Senator Collins. I mentioned 
earlier that we are really happy that the Governor of 
Tennessee, Governor Lee, and his leadership helped us create a 
program where we recruit students from rural areas to come to 
university there, and they are admitted into medical school at 
the same time.

    It is an accelerated program in which their tuition is 
paid, both undergraduate and medical school, and they have 
committed to go back and work in the communities they come 
from. I think that is a model that should be repeated all over 
the country. Thank you.

    Senator Collins. Thank you.

    The Chair. Thank you very much, Senator Collins.

    Senator Hickenlooper.

    Senator Hickenlooper. Thank you, Mr. Chair. And thank all 
of you for your work and your commitment to this at a time 
when, as both the Chair and the Ranking Member made so clear in 
their opening statements, this is an emergency and you all 
share that sense of urgency. Dr. Seoane, while I was Governor 
in Colorado, we worked hard to expand youth apprenticeship 
opportunities.

    I was moved to read the testimony about the different ways 
Ochsner is using apprenticeships to foster interest in medicine 
and as a workforce solution. Especially enthusiastic to learn 
about the Ochsner Nursing Pre-Apprenticeship Program, which is 
open to high school sophomores hoping to serve more than 600 
students over the next 2 years.

    That really is incredible. Have any of your pre-
apprenticeship program graduates remained with Ochsner or 
stayed in the field, and has opened these programs to high 
school students helped--you know, do you see an impact in terms 
of addressing your challenges?

    Dr. Seoane. Thank you very much for that question, Senator. 
It is early in the program. We started in 2021. We have 
currently about 350 apprenticeships in the program. By this 
fall, we will have 600 students in the program.

    It is early in the program. But we--but this grew out of 
another program, the MA Now Program, which is a program where 
we went into our communities, underserved communities, where 
they had high unemployment rates, partnered with our local 
community partners there to identify applicants for MA Now 
Program. And then we certified those programs.

    There is 6 months training. We trained them, they got a 
certificate program to be an MA. Now we have over 600 of those 
MA we hired through that program. The apprenticeship program 
for us is very important as we launched our Healthy State 
Initiative, which is Ochsner's initiative to do a collective 
impact in Louisiana to improve our health rankings from 50th, 
which unfortunately is where we have been, 50th or 49th for the 
last 30 years, to 40th over the next 10 years.

    High school graduation rate is one of the key factors for 
our poor health rankings. So, this apprenticeship program 
really gets at two components. One, can we get to our 
sophomores in high school, keep them in high school by allowing 
them to work as apprentices to nurses, and therefore pay them 
some during high school, and then they get a free year of 
community college when they finish high school, and then they 
are an LPN.

    We are early on in the program, Senator, but we are very 
enthusiastic about it.

    Senator Hickenlooper. Great. I am very excited about it as 
well. I have talked to both Cassidy and Senator Sanders about 
the value of apprenticeships, looking at that on a broader 
scale in health care. The pandemic showed us how important it 
is to address the shortage of public health workers.

    Colorado offers a first of its kind state program called 
Colorado Public Health Works that connects AmeriCorps 
volunteers with a registered apprenticeship program run by the 
Trailhead Institute.

    This allows AmeriCorps members to gain valuable, on the job 
apprenticeship experience while helping meet our public health 
needs at the same time. Dr. Staiger, how can we build out 
programs like this to help address our larger public health 
workforce needs?

    Dr. Staiger. Not sure I have great concrete advice on that. 
I think these kind of programs are critical. Everyone has 
talked about the step step programs and people going there 
wasn't--didn't used to be a career ladder here for people to 
get trained and gradually move up from medical assistant to RN 
to NP, etcetera.

    I think the more we can encourage that, the better. I still 
think this is best done by providers, right. They are the most 
close to the ground. They can figure this out. So, providing 
them with the resources and incentives to develop these 
programs.

    Senator Hickenlooper. All right. But facilitating also, I 
think using resources like AmeriCorps and making sure that you 
can facilitate that connection.

    Dr. Staiger. Yes, that is exactly----

    Senator Hickenlooper. Dr. Hildreth, as I do--well, I will 
leave that. I will go on to the next one. I can get carried 
away. Dr. Herbert, I was going to ask you about the IPE and 
that effort. Well, let's just--I will give that a written 
question. Just know that I am very attracted to and, appreciate 
the IPE model, and I think the collaboration and what it allows 
providers is a big thing.

    I will go to Dr. Hildreth, and you have spoken about the 
critical needs in terms of how important it is to increase 
diversity. I have been on a number of roundtables where the 
small numbers of not just doctors but midwives, in terms of how 
expectant mothers are taken care of, really, the women of color 
don't get offered the same choices, right.

    The only way we are going to change that is really to 
change the makeup of who are tending to them. How can we foster 
programs that encourage early exposure, this kind of early 
exposure at the Federal level that make sure that younger kids 
see a role for them in health care?

    Thank you, Senator, for the question. What we have done at 
Meharry is we have adopted two middle schools. And what we do 
is we make sure that our student in medical school, dental 
school, and our graduate programs are present with those kids 
to show them that it is possible for them because they see 
students in professional programs that look like them, and we 
think this is a very powerful way to get students engaged early 
on and keep them engaged by having our students interact with 
them. Thank you for the question.

    Senator Hickenlooper. Thank you. I yield back.

    The Chair. Senator Cassidy.

    Senator Cassidy. I will defer to Senator Romney.

    Senator Romney. Thank you, Senator Cassidy. I was struck by 
the Chairman's opening comments that we spend so much per 
person in this country and health results are not that much 
different. We spend almost double as much as the people in the 
average developed nation in health care.

    Sometimes we in Washington think, well, the answer is to 
spend more. But I would suggest that there must be a different 
approach. If we are already spending almost twice as much as 
everybody else, then there has got to be some other reason that 
we are not able to provide the quality at a reasonable cost 
that we would like to do.

    I note that my prior experience in the private sector 
showed that almost everything that we buy gets better and 
better, better quality and lower cost in real terms over time, 
and that productivity increases over time.

    The exception to that are really three major areas, health 
care, education, and the military. Those happen to be three 
areas that are dominated by Government. I think I have an idea 
as to where the problem lies and would suggest the right answer 
is, is not more Government.

    In this case, I think we can look at health care and say, 
we have--what is the old Pogo cartoon? I have met the enemy and 
the enemy is us. And one aspect of that enemy relates to 
immigration. My understanding is that typically almost 20 
percent of the nurses and medical professionals this country 
come from foreign countries. But the backlog of medical 
professionals that want to come into this country has become 
enormous.

    We required them to be interviewed, and given our security 
needs, it is appropriate that they be interviewed about the 
State Department. But apparently, the State Department is still 
so concerned about COVID that they are not interviewing these 
people.

    Places like the Philippines, where there are some 30,000 
people who want to come here and serve as nurses, we can't get 
those nurses in. Are you aware of this feature, given by the 
President of college at the University of New England, are you 
aware of the fact that our Government is just not doing the 
interviews necessary to bring people in that would help 
dramatically reduce our nursing shortage?

    Dr. Herbert. Senator Romney, I'm going to be honest with 
you, I am not aware of that. I am not up on that particular 
issue with the interviews. But if I--I am going to be happy to 
speak to because I agree with you about the importance of 
immigrants in our health care workforce.

    More broadly, if I can just very quickly say, one of the 
things we need is programs like we are doing at UNE in our 
pharmacy school and our dental school, which are programs that 
are accelerated programs that take foreign trained dentists or 
pharmacist or doctors for that matter, and then help them 
become eligible for American licensure.

    To meet the requirements so they can sit for their exams 
and become eligible. So, these accelerated programs are very 
valuable. And because we have professionals who are legal, they 
have green cards, they are in some cases citizens, and who 
could work but can't work in their field that they were 
trained.

    They may have been a surgeon for 20 years in a foreign 
country, but and these are often people of color from the 
developing world. So, we have developed programs in that 
regard. But then you also have, and just in the case of Maine, 
to give you an example, we have a lot of asylum seekers from 
Africa and they are sitting in hotel rooms and can't work and 
they want to work.

    Senator Romney. Yes. Let's interview these people. Let's 
stop allowing our Government workers to work from home saying, 
because they have COVID, we can't allow you to come back to the 
workplace. You can't do the interviews of these people who want 
to come to our Country and fill the desperate needs we have in 
health care.

    If we have a nursing shortage and a doctor shortage, let's 
let those who are in line that are qualified come here. I agree 
with you with regards to the education programs. I note with 
regards to educating our own citizens here, the work that you 
are doing in your respective institutions is critical.

    There is one in the Western part of our Country called 
Western Governors University. You are probably familiar with 
it. It graduates more nurses than any other institution of 
higher learning in the country. Its tuition, Mr. Chairman, is 
$6,700 every 6 months, very reasonable tuition compared to the 
cost in most places. 126,000 students at Western Governors 
University.

    It is a not for profit. It was established by former 
Governor Mike Leavitt and the Governors of five other western 
states. We have a capacity to educate. They can take on more 
students at reasonable cost. So, the approach is that we can 
learn from one another and expand the best practices that we 
are seeing in some places.

    But legal immigrants, following the legal process, where 
the State Department does the job, they need to do and doesn't 
stay home because of COVID, will allow us to dramatically 
reduce the shortage that we are seeing in this country. Thank 
you, Mr. Chairman.

    The Chair. Senator Kaine.

    Senator Kaine. Thank you, Mr. Chairman. Chair Sanders and 
Ranking Member Cassidy, thank you for making this the first 
hearing of this Committee in the 118th Congress. I think this 
issue is huge and challenging, but one that is very amenable to 
some bipartisan work that can be done.

    Senator Romney beat me to the punch, not the first time, 
because I wanted to talk about immigration. I was interested in 
none of the opening testimony was this put on the table as a 
potential solution, although I think in some of your written 
testimony, a couple of you mentioned it. Just to give you a 
numbers on this.

    According to the Migration Policy Institute, as of 2018, 
the foreign born comprise almost 18 percent of the 14.7 million 
people in the U.S. who work in health care, nearly 1 in 5. The 
foreign born make up a disproportionate share of certain both 
high and low skilled health care workforces.

    28 percent of our physicians and surgeons are foreign born, 
and 38 percent of our home health aides were born outside the 
United States. And this isn't just about employment-based 
immigration, it is also focused on family and humanitarian 
immigration systems.

    Another statistic, more than 310,000 health care workers, 
12 percent of the immigrants who are employed in health care 
occupations are not here on work related visas, they are here 
for humanitarian reasons, resettled refugees, asylees, special 
immigrant visa holders, TPS recipients, and Cuban and Haitian 
entrants.

    President Herbert, you have already addressed this with 
Senator Romney, but what could we do with an immigration reform 
that is focused on health care or other critical workforce 
areas that would make all of your jobs easier in educating a 
diverse and sufficiently sized health care workforce?

    Dr. Herbert. Senator Kaine, thank you very much. First of 
all, I should say I am not an immigration expert. I make no 
pretends to be, but I echo your concerns. I think that there is 
no question that immigrants disproportionately go into health 
care at various levels. They are very hard workers. They want 
to work.

    I can tell you from personal experience, at least locally, 
what I see is a lot of folks who want to work, they are here 
legally, but they are not able to work because of arcane 
regulations that really should be changed. And so, yes, we 
need--and we think we need to encourage immigration.

    In a state like Maine, where we are losing native 
population and the only way our population is staying stable 
and even growing is through immigration. And there are many new 
Mainers who want to work and are not able to.

    Senator Kaine. My perception, and I don't have the data on 
this, but my perception in Virginia is that the foreign-born 
health care workforce is also more likely to work in rural 
Virginia.

    If I talk to the physicians in Appalachia, they are more 
likely to be foreign born than if I am doing it where I live in 
Richmond or metropolitan--other metropolitan areas of the 
state. I have other topics I want to get to, but is anyone else 
want to weigh in on immigration? Yes, Dr. Hildreth.

    Dr. Hildreth. Senator Kaine, thank you for the question. I 
have nothing against bringing in foreign born folks to work in 
our health care enterprise. We have lots of talent we have not 
tapped into in our own country here.

    For example, it used to be that 26 percent of all the black 
students who went to medical school came from HBCUs. It is now 
less than 10 percent. Why is that? Because we have 
underinvested, under-resourced those schools.

    I would submit to you, but that by properly resourcing the 
schools we have, we can fill a lot of that gap with native born 
talent right here in the United States.

    Senator Kaine. I have a piece of legislation that is called 
the Expanding Medical Education Act, which I am going to 
reintroduce this Congress, I introduced that in the last, that 
is very focused on HBCUs and other minority serving 
institutions. In your testimony and in doctor--is at Seoane.

    Dr. Seoane's testimony, you both laid out some innovative 
programs you are doing and the need for additional investment. 
I completely agree with that. Let me ask a question about the 
direct care workforce shortage or just bring it to the 
attention of the Committee. Our direct care workforce shortage 
is often left out of the conversation about health care 
workforce shortages.

    Direct care professionals make an average of $11.75 an 
hour. They are some of the lowest paid workers in the economy, 
but they provide difficult hands-on care to seniors and people 
with disabilities. And this workforce shortage kind of 
compounds other shortages.

    I go to hospital emergency rooms and they say we have to 
keep people in hospitals longer because the direct care 
workforce shortage means that there are no placements where we 
can discharge someone from a hospital to a long-term care 
setting or to appropriate home health care.

    I hope as we look at this problem, we will focus on the 
direct care workforce. Finally, Mr. Chairman, I would like to 
introduce a letter for the record. Johnson and Johnson wrote a 
letter to thank Senator Cassidy and the whole Committee for a 
bill we passed, the Lorna Breen Health Care Provider Protection 
Act, which is to provide mental health resources to frontline 
health care workers.

    One of the ways we will keep a robust health care workforce 
is making sure that they have the resources they need to be 
resilient. I would like to introduce that letter for the 
record, if I could.

    The Chair. Without objection.

    [The following information can be found on page 81 in 
Additional Material:]

    Senator Kaine. Thank you. I yield back.

    The Chair. Thank you very much, Senator Kaine.

    Senator Cassidy.

    Senator Cassidy. I will defer to Dr. Marshall, who for the 
first time in 2 weeks, is not wearing Kansas City Chiefs 
colors.

    [Laughter.]

    Senator Marshall. Well, thank you, Ranking Member and 
Chairman. I want to just remind folks that Kansas has two 
nationally ranked basketball teams in the top 10 and it is time 
to move on to basketball season. But I am honored to be here 
today to talk about an issue near and dear to my heart.

    This is the dream, the nightmare that I have lived the last 
40 years of my life. There has been a physician shortage in 
rural America for at least 40 years. There has been a nursing 
shortage in rural America for at least 20 years. So, the 
challenge before me as a person operating a private practice in 
rural America has been to recruit doctors, and then as running 
a hospital, is recruiting nurses.

    Myself, I went back to rural America. One of the reasons 
is, was I had a scholarship, a state sponsored tuition 
scholarship if I would go back to an underserved area. My 
partner was a recipient of a National Health Service Corps loan 
as well and was able to repay it. So those are certainly some 
of the things that are working.

    I want to talk about nursing shortage for just a second. 80 
percent of the nurses could come from community colleges. Let 
me say that a different way. 80 percent of the jobs in health 
care can be done with community college nurses.

    Community colleges are the answer to the nursing shortage. 
Those folks are typically from a small town. They are going to 
go to that small town community college, are more likely to 
stay in that small town.

    Of all the students from my hometown that went off to the 
university medical school, I could maybe count on my hand the 
ones that came back. There was a 4-year program in Fort Hays, 
more of a rural community program. Those folks were more likely 
to stay back. But once those young nurses tasted life in the 
big city, they like it and they stay there.

    As we think about going forward, I hope we can come back 
and talk to the community colleges nursing programs a little 
bit more. What can we do to accentuate them and the small 
colleges as well? There are quite a few small colleges with 
good 4-year programs as well.

    By the way, their student debt is maybe a fourth or a fifth 
of what a person who went to a university would be. Talk about 
physician shortages for a second. We will go on the other end 
of the spectrum. A lot of our physicians are leaving the market 
right now because of burnout. Issues like prior authorization, 
surprise billing.

    Our ER doctors have just been overworked and underpaid, if 
you will, but mostly they are burned out. They are getting 
burned out on that with the surprise billing issues and just 
frankly, just the COVID epidemic just overwhelmed the system.

    Those folks are leaving, leaving like we have never seen 
them before. Nurses again we forced them to take a vaccine. 
Some of them didn't like that. And certainly, they were burned 
out as well. Anyone want to speak to burnout in the profession? 
Just one of you go ahead.

    Dr. Seoane. I will speak to it. Thank you for that 
question, Senator Marshall. Look, I think what sometimes we 
forget when we are not on the front lines of health care every 
day is that the pandemic for us, for many of us, we can go and 
turn off our TV and go back home or work from home or work from 
our offices, and we can get away from the pandemic.

    We can get away from those stressors. For those frontline 
nurses and those frontline physicians, they can never get away 
from the pandemic. It is day in, day out, and it takes a toll. 
It is an impact on ill people, death and dying, and it has been 
a marathon for them, not a sprint.

    That marathon continues. I think we have got to work on 
ways that we can improve the working environment. And it has 
been a more violent working environment as there has been more 
verbal and physical assaults on health care providers.

    To that end, I think at Ochsner, we have really taken the 
approach of we have a wellness office. We have provided a lot 
of wellness programs for our nurses and physicians. We also 
worked with our State Legislators and State of Louisiana to 
make violence in the health care workplace a felony.

    Also training our workforce on de-escalation techniques. 
But we have to be proactive in this area. And then I think the 
other thing, and speaking with the nursing programs, is we got 
to develop innovative new ways to think of respite for our 
frontline nurses. So, one of the things----

    Senator Marshall. I am sorry, I am running out of time. I 
am. Sorry. So those are--I mean would you quickly talk, though 
about residency programs. Where Kansas loses our doctors and 
our medical students is residency programs. We don't have, 
specifically our primary care doctor slots.

    One of the challenges I see is that the orthopedic 
residencies are a moneymaker for hospitals, so the hospitals 
are willing to fund them, but primary care is not a moneymaker 
for hospitals, and consequently they don't want to fund them. 
They want more Government funding.

    Just--I am sorry, I am over time, quickly address just how 
big medical center hospitals look at primary care residencies 
as opposed to, say, a specialty residency that makes money?

    Dr. Seoane. Well, primary care doctors are essential for 
any large health system. And especially a group practice 
integrated health system like ours, primary care doctors are 
key. So, we value them as much as we value our orthopedists.

    As Senator Sanders already mentioned, I think being able to 
fund community-based clinic, primary care to expand our funding 
for primary care residencies, we would be very excited about 
that.

    Senator Marshall. Thank you. I yield back.

    The Chair. Thank you, Senator Marshall.

    Senator Markey.

    Senator Markey. Thank you, Mr. Chairman, very much. And 
thanks to our witnesses, and thanks for focusing upon the 
critical health care issues that are facing our Country today. 
Massachusetts is renowned for its top research institutions and 
its second to none health care system.

    It creates an ecosystem for innovation and for care. But at 
the same time, even in Massachusetts, there are 19,000 
positions sitting empty in acute care at hospitals. Half of all 
licensed practical nurse positions at acute care hospitals sit 
empty.

    But home care aides, mental health workers, social workers, 
paramedics, 1 in 3 of those jobs is empty in Massachusetts. I 
appreciate the concerns I am hearing from more rural states, 
but we have the exact same set of issues.

    It is an urgent crisis. Patients are facing long wait times 
for an annual well visit. Kids are sitting in adult emergency 
rooms for hours, days, weeks, waiting for mental health 
treatment in Massachusetts.

    People trying to get help meet deadly delays in access to 
opioid use disorder treatment like methadone medication, and 
the health care system strained under the weight of surges like 
the COVID pandemic and natural disasters.

    Meanwhile, our health care heroes who get into their 
careers to help people, in their greatest hour of need are 
facing their own hour of need. The current system is forcing 
them to make impossible choices when faced with huge caseloads, 
immense pressure, intense burnout.

    Advocates in health care unions across the country are 
fighting to make sure we can keep our workers on the job 
through better pay and safer working conditions. But without 
enough of these critical workers, health care centers are 
closing their doors, turning people away, happening in 
Massachusetts, are forcing patients to wait in line for care.

    We have to make sure that we care for our health care 
workers. So let me ask you, Dr. Herbert. I am hearing over and 
over again that children are waiting for behavioral health 
services or people are having trouble getting treatment for a 
substance use disorder.

    For people in rural communities, in Western Massachusetts 
or in Northern New England, obviously these problems are very 
real. Can you talk about that and what you would recommend as a 
solution?

    Dr. Herbert. Absolutely. And let me begin by saying that I 
completely agree with you. My comments are largely focusing on 
rural, the underserved areas and rural areas. They are 
absolutely, and as the Chairman entered it in his introductory 
comments mentioned, there are underserved areas in urban areas 
as well that are just as acute and problematic.

    In terms of behavioral health, we need--there is a number 
of things that we need. The first thing I would say is there is 
a critical shortage of psychiatrists, but we are not--we are 
never going to train enough psychiatrists to meet the 
psychiatric needs of underserved areas. It is just, I just 
don't see it happening in the next decade. There are answers, 
though, for example, nurse practitioners.

    We can train more nurse practitioners in psychiatric--to be 
psychiatric nurse practitioners, and we are developing 
precisely one of those programs right now. So, there is--we 
need the full range of behavioral, investments in the full 
range of behavioral health services, all the way from 
psychiatry, nurse practitioners, down to in some states like 
Maine, there are opportunities for a credential for 
undergraduates with an undergraduate degree to work in 
behavioral health.

    Most states don't have that. We do. I think more states 
should so that you can actually at entry level mental health 
position, behavioral health in nursing homes, and in various 
kinds of community settings, schools with just a bachelor's 
degree, and so we need investments across the board.

    Senator Markey. Yes, no question. My wife is a 
psychiatrist, so I appreciate this mental health crisis that we 
have in our Country right now. We have a climate crisis as 
well. And climate can impact upon a community's health care 
resources. Dr. Seoane, could you talk about that in Louisiana.

    Dr. Seoane. You know, unfortunately, because of our 
geographic location, we are no strangers to hurricanes. And we 
have dealt them--I grew up in New Orleans, so I have dealt with 
them for a long time, and we continue to deal with them. It is 
unfortunately part of our way of life down on the Gulf Coast, 
and we just look at ways to be resilient and adaptive.

    Senator Markey. How difficult is it, given the sometimes 
catastrophic events that you have to deal with?

    Dr. Seoane. I think it is quite obvious that we deal with 
this. I will say it brings the community together, and of 
course, it is difficult, yes.

    Senator Markey. Okay. Thank you, thank you, Mr. Chairman.

    The Chair. Thank you, Senator Markey.

    Senator Cassidy.

    Senator Cassidy. I will defer to Senator Budd.

    Senator Budd. I thank the Chair. Thank the Ranking Member. 
I have heard firsthand from patients, doctors, nurses, and 
hospitals all around North Carolina about ongoing workforce 
challenges.

    I think we need to focus on preparing future health care 
workforce. For example, Wake Forest, Early College of Health 
and Sciences, partners with Wake Tech, Community College, and 
WakeMed to provide students with hands on experience, 
certifications, and even college credit. So, in the House of 
Representatives, I led the Critical Health Care Careers Act.

    The bill would help community colleges prepare the next 
generation of health care workers. Students should have the 
opportunity to gain on the job experience to prepare them for 
careers in health care.

    Dr. Seoane, what steps is your health system in Louisiana 
taking to offer new credentials and educational opportunities 
for workers to join the health care workforce?

    Dr. Seoane. Thank you for that question. I mentioned the MA 
Now Program, which is one where we partner with our 
communities, where there is high unemployment or 
underemployment to introduce workers into the health system 
through the medical assistant job.

    Then it is about upskilling, as Senator Cassidy has 
mentioned. We like to call it earn as you learn or the ladders, 
and then taking those MAs and then working with our community 
colleges to be able to, as their work, support them, give them 
free tuition, to be able then to become LPNs, associate 
degrees.

    Then now we are working with our university partners for 
them to be able to have bachelor's degree. That story that 
Senator Cassidy shared with us is exactly what we are trying to 
do by getting more entry level into health care and then being 
able to meet our health care needs. And it is a win, win across 
the board, right.

    We are leveraging the human capital of the State of 
Louisiana and Mississippi, but we are also giving people a 
living wage for them to raise their family.

    Senator Budd. Thank you. So earlier in your testimony, I 
understand that you mentioned using non-physician providers 
like CNAs, licensed practical nurses. Do you agree that 
maintaining access to services delivered by non-physician, such 
as testing, treatment, vaccinations at local pharmacies, do you 
think that is an important part of addressing the health care 
workforce shortage?

    Dr. Seoane. You know, medicine is a team. It is a team 
effort. Physicians are a very important part of that team, but 
many other providers are also extremely important part of that 
team, so I agree.

    Senator Budd. Yes. So, what steps do you think institutions 
should take? I know you are from the Louisiana perspective, but 
as you think about all the way to North Carolina, what can 
institutions do to better prepare health care workers to serve 
patients outside of a traditional hospital setting? I am 
thinking in-home telehealth, community health centers, or 
anything else.

    Dr. Seoane. You know, health care is shifting to 
outpatient. And one of the things we need to do is to be able 
to be innovative about how we care for more patients. And it 
has already been mentioned at this Committee at lower cost 
settings.

    As we can transition an inpatient stay to a home stay, as 
we can leverage a medical home model where we can have digital 
tools, telehealth tools to--for patient who may have stayed in 
the hospital 3 days now could stay 2 days.

    That obviously opens up more hospital beds to care for more 
acute patients, but it is also a more family, patient friendly 
model as we transition toward this medical home model. So, we 
would agree with that, and we currently are pursuing innovative 
models that we can do that.

    Senator Budd. Thank you very much. I would like to yield 
back to the Ranking Member.

    The Chair. Thank you very much.

    Senator Baldwin.

    Senator Baldwin. Thank you, Mr. Chairman. Thank you to our 
panel of witnesses. Really appreciate the conversation that we 
are having today. I wanted to start and raise once again an 
issue that came up in previous questioning relating to violence 
and harassment faced by health care providers, and how that 
impacts the question that we are tackling today.

    A recent study found that more than two-thirds of nurses 
reported experiencing verbal abuse, and 44 percent reported 
being subject to physical violence. Last year, I was proud to 
reintroduce the Workplace Violence Prevention for Health Care 
and Social Service Workers Act.

    This Act would require health care and social service 
employers to write and implement workplace violence prevention 
plans to prevent and protect their employees from violent 
incidents Violence against health care workers is totally 
unacceptable, and we need, I think, to do more to provide 
protection.

    Dr. Szanton, I would like to ask you to reflect on how 
violence against health care workers contributes to reduction 
of staffing levels, burnout, and the consequences of reduced 
staffing for patient safety. But since Dr. Seoane also raised 
this, I would like to call on you additionally to comment.

    Dr. Szanton. Thank you for the question, Senator. 
Absolutely, it is an issue. I think we are in the middle of the 
mental health crisis and a substance use crisis, and the way 
that the country feels more and more fractured.

    I think all of those together add to--you know, I talk to 
nurses who say I used to be the hero walking into their room 
and I used to have this respect based on being a nurse, and now 
I don't always get that.

    Suffer verbal abuse and sometimes physical abuse. I do 
think that it has been mentioned that hospitals are going to 
shrink and become more and more operating rooms and intensive 
care units and that almost everything else will happen out in 
the community.

    I do think that when people are at home and in their 
community, and in lower cost settings, and more family centered 
settings, that some of that will dissipate.

    Senator Baldwin. Thank you.

    Dr. Seoane.

    Dr. Seoane. Yes. I will say it is 28 years of practicing 
medicine, including my training, and I have never seen such a 
charged environment as every day throughout our health system, 
at our safety huddle, our daily safety huddle, there is an 
issue around either verbal and physical abuse to our health 
care provider. So, it is a true crisis.

    We have like I said, we have been working with our State 
Legislators to make sure that it is a felony. We have put up 
signage. And also, it is not just the, as you have pointed out, 
the physical abuse, but the verbal abuse.

    Part of that state bill was that if you interrupt the 
ability to deliver health care by being verbally abusive, that 
that also is now a crime, so.

    Senator Baldwin. Well, and it also sounds like you said 
your health care system is taking proactive steps. We want to 
see that more uniform around the country. I also, turning to a 
different topic, I have been proud to lead the bipartisan 
Palliative Care and Hospice Education and Training Act with my 
colleague, Senator Capito.

    The bill would grow, improve, and sustain the palliative 
and hospice care workforce. It addresses each aspect of the 
health care workforce pipeline. Importantly, the bill provides 
grants to schools of medicine and teaching hospitals to train 
physicians who plan to teach and establishes fellowship 
programs to give providers the opportunity to learn more about 
providing palliative and hospice care.

    Dr. Seoane, could you briefly describe why it is important 
for academic health systems to provide physicians with both 
training, to teach, and opportunities to build their skills, 
upskill. And as a follow-up, how does additional training 
support or alleviate burnout?

    Dr. Seoane. Senator Baldwin, thank you very much for that 
question, because 15 years ago, I created a course to train 
residents in the intensive care unit around death and dying and 
palliative care.

    In that course, we taught residents with real cases, cases 
that they experienced during their month in the intensive care 
unit. And we had a debrief at the end where we went through 
what they learned, but really kind of an emotional reset for 
them.

    There were some real critical learnings from that. One of 
them was, while we were teaching them skills about having--how 
to have difficult conversations and how to manage patients that 
are critically ill, we quickly learned that one of the most 
important parts of the course was actually the benefit to the 
residents would be able to debrief, the mental health and 
wellness for the residents to be able to be able to speak about 
what they had experienced in that month.

    Because remember, for many of these young medical students 
are residents. That is their first experience with death and 
dying. So, it has an incredible benefit to the wellness of our 
health care workers. I have experienced that firsthand through 
that course.

    I want to thank you for putting that legislation forward. 
We are trying to start our own fellowship in palliative care. 
That is the next program that we actually are going to start. 
And it is critically important for the way we practice 
medicine.

    As our population ages, it is critically important, not 
just for health care providers, that we be able to provide the 
appropriate care for patients in their time of need.

    The Chair. Thank you, Senator Baldwin.

    Senator Murkowski.

    Senator Murkowski. Thank you, Mr. Chairman. Thank you for 
this hearing today. As you and I have discussed, workforce 
within health care is something that is critically important.

    We both come from rural states, and when I think about the 
challenges that we face in providing health care in a big state 
geographically with a small population and the many challenges 
that we face, we can overcome a lot of that, but if we don't 
have the trained workforce, it just doesn't come together.

    Don't take my lack of Chair time here as an indicator that 
I am not interested in addressing the challenges that we face 
in this. We have got competing hearings this morning, and so I 
have been jumping in between.

    But one of the ways that we have been trying to facilitate 
better access to care in a remote place like Alaska, where 80 
percent of our communities are not connected by a road, is 
telehealth. We are working on the broadband to connect 
everybody so that that telehealth actually is more than just 
the device, but it actually works.

    I know that this subject has been raised, but I would ask 
you, Dr. Seoane, apparently you had mentioned a pilot program 
for virtual nursing education. So, in other words, this is a 
big challenge for us in Alaska.

    We got a nursing program, but how you get the teachers to 
teach it. Can more be done with the nursing education programs 
for telehealth as opposed to just how we are thinking about 
telehealth generally?

    Dr. Seoane. Yes. Thank you for that question, Senator 
Murkowski. Look, telehealth is a critical component for how we 
reach our rural communities and address some of this, including 
on mental health, where there are many good models.

    With the pandemic, we saw about a 400, 500 percent increase 
in telehealth used in a pandemic. And we are able to 
demonstrate effective care for many patients using telehealth. 
I think we have learned a lot from the pandemic.

    On the nursing side, our virtual nursing program really is 
a, not an education program, although there are some learnings 
for the bedside nurse, as it is a patient facing program. And 
so, there is a bunker where we 24 hour monitor the patients and 
that allows the nurse then to be at the clinics--at the 
bedside, caring for the patient, and all of that electronic 
health, medical records, and all of that administrative work 
can be done by the nurses in the bunker.

    For instance, a good example would be upon discharge, which 
could be an arduous process of all the paperwork to discharge, 
the bunker can do a lot of the administrative and all the 
discharge work while the bedside nurse can just do the clinical 
work and we can quickly facilitate transitions from a patient 
from the hospital to their home.

    We haven't done a lot of on the telehealth education on the 
nursing side other than that program. And like I said, the 
good--the education component is that bunker also can work with 
the bedside nurse as an education part.

    Senator Murkowski. Let me ask a little bit different 
question. And again, it speaks to some of the ways that we are 
addressing health care challenges in Alaska. We rely a lot on 
EMS, EMTs. I was just visiting with a woman from Chicken, 
Alaska. Chicken has probably never been a population of more 
than a 100 people.

    Probably--but her son is an EMT there, and basically what 
they do is they work to make sure that anybody, anybody out 
there can be trained in emergency services. But I understand 
that right now we have a significant shortage of EMS 
professionals.

    Studies have found that less than 20 percent of EMS 
organizations, at least in Alaska, have an adequate level of 
staff across the Nation. Turnover of EMS professionals hovers 
near 30 percent.

    Very few stay in their role long enough to establish the 
stability that they need. What more do we need to do in this 
area? We have been talking about everything else, but what 
about emergency medical services? Dr. Herbert, you are nodding. 
I don't know who to direct this to, so I will just throw it out 
there.

    Dr. Herbert. Thank you. I was just agreeing with you. I 
tend to nod. I am not a good poker player, so.

    Senator Murkowski. I am a nodder too. That is okay.

    Dr. Herbert. But I will--first of all, I completely agree 
with you about EMS. And so, there are many of us, I am sure my 
colleagues on the panel are responding by strengthening our 
programs in that regard. And we have a robust program at my 
university. But if I could speak briefly about the telehealth 
piece, because I completely agree with you. We face the same 
challenges in Maine.

    The last time you and I talked was in Reykjavik, and there 
are people in Iceland and in Scandinavia that are really 
leading the world in terms of telehealth developments. And so, 
we have a lot to learn from those folks.

    Telehealth is exploding in terms of beyond just telehealth, 
digital medicine, being able to monitor chronic conditions 
remotely and feed that information back in real time to 
providers. And then in terms of rural settings, people think of 
telehealth being from the provider to the patient, but it is 
also the provider back to the tertiary care medical center to 
get the consultation that they need.

    Tremendous work going on in this. What I would simply add 
is that we need to make sure that our regulations, the state 
level regulations, licensing boards, accrediting bodies, 
Government reimbursement, that it keeps up.

    We saw some positive changes during the pandemic. We need 
to make sure that those are sustained. But there is--my concern 
is that with the incredible innovation that is going on, and 
this really is going to be transformative over the next 10 
years, that these entities are going to fall behind, and this 
creates tension and delays the full utilization of telehealth 
and digital medicine.

    Senator Murkowski. Thank you. I am well over my time, so 
thank you all. And we will probably be following up on some of 
the telehealth conversations. Thank you so much.

    Senator Lujan. Thank you, Senator.

    Senator Smith, you are recognized for questions.

    Senator Smith. Thank you, Chair Lujan. And thank you to all 
of you for being here. I want to just note my good friend, 
Senator Murkowski, and I have worked a lot on rural health care 
issues together, so I appreciate your questions about that.

    Both of us have large areas of rural communities in our 
state. Though I think Alaska trumps Minnesota in some ways on 
that. I just want to thank you for your questions there. I am 
grateful for this hearing and the bipartisan spirit of this 
hearing. I would like to start by focusing on the mental health 
care workforce.

    You know, even before the pandemic, we knew that there was 
a growing need for mental health services. And the pandemic 
has, I think, shone a light on the deep need and made the need 
bigger.

    HRSA estimates that by 2025, we will need an additional 
250,000 mental health professionals, from psychiatrist and 
mental health and substance abuse, substance use disorder 
specialists, school psychologists, school counselors.

    Of course, as Senator Murkowski is pointing out, rural 
communities are much more likely to have a shortage of mental 
health professionals, and people of color are much, much more 
likely to live in places where there is a shortage of mental 
health care. So today we are talking about the barriers that 
are facing people who want to get into this field, and one of 
them is money.

    This morning, I reintroduced my bipartisan bill, the Mental 
Health Professionals Workforce Shortage Loan Repayment Act. You 
do not need to remember the name, just remember the idea. With 
Senators Murkowski and Hassan.

    What our bill would do is to provide student loan repayment 
for mental health professionals who want to practice in places 
where there are shortages. Dr. Herbert, if I could start with 
you.

    Could you talk about the importance of loan repayment 
programs? You said how important it was that they were 
strategic in your opening remarks. I would like you--I would 
like to hear more about that and tell us what you think we 
should have in our minds as we design and move these student 
loan repayment programs.

    Dr. Herbert. Well, thank you, Senator, for the question. I 
completely agree with you about the mental health crisis. And 
it is important that--there is a number of things to say about 
this.

    First of all, we need to make sure that we train people in 
primary care who are not mental health specialists to do mental 
health first aid, to be able to--people in our schools, for 
example, teachers, to be able to recognize and be able to make 
appropriate referrals. So that is one piece that is there.

    In terms of loan repayment programs, these can work very, 
very well if they are done strategically. So just to give you 
one example, the Chairman mentioned dentistry before, and we 
haven't talked a lot about that today.

    We have an incredible partnership with Delta Dental, 
Northeast Delta Dental for loan repayment programs for dental 
graduates who decide to set up shop in underserved rural areas. 
And we have been able to place in the 5-years, five graduating 
classes of our new dental school, we have been able to place 
about 20 dentists in very, very remote rural communities that 
didn't have dentists before.

    With regard to mental health, it is the exact same thing. 
We just need to make sure that we are targeting--that there is 
a strong contingency where they need to practice in underserved 
areas, either rural or urban areas, and it is not just--I mean, 
I am great about loan repayment programs in general, but to be 
maximally effective, they have to target underserved areas.

    Senator Smith. Yes, exactly. I appreciate your comment 
about training in primary care, because our brains and our 
bodies are connected. It is one person, one body, and we too 
often segment out our mental health care from our physical 
health care in ways that are not good for our overall health 
care.

    Thank you for that. Dr. Hildreth, I so appreciated your 
testimony, which I was able to hear before I went off to other 
committees, about the crucial role that historically black 
medical schools play, and the assets that you have when it 
comes to relationships, and expertise, and trust.

    I wonder if you could just--and also, I mean, you very well 
pointed out the disparities that you experienced in terms of 
the resources that you have available to build on your mission. 
I wonder if you could talk a bit more about that.

    Maybe I care a lot and have focused a lot on the great 
disparities in maternal health care, maternal morbidity, the 
disparities between black women and white women, and how that 
kind of pans out as you think about the practices and the 
people that you work with.

    Dr. Hildreth. Senator Smith, thank you for the question. 
And clearly, as we have alluded to earlier, when the provider 
can relate to the patient in terms of culture, race, and all of 
that, the outcomes are better.

    There are studies to show that black women who are cared 
for by black OBs have better outcomes, and our babies do as 
well. But it all comes back to what I said earlier. We are--
have been training health care professionals who are really 
competent and skilled, connected to their communities for 
decades, but our challenge is the infrastructure we have to do 
that. What we teach and how we teach it has changed 
dramatically.

    Majority institutions have been able to keep up with that 
change, but we don't have the resources, for example, to do 
small group teaching as opposed to on a stage. Standing in 
front of 100 students in a lecture hall is a great way to 
teach, but it is a terrible way to learn.

    We need to change how we teach this. We like to do that at 
our institutions, but we don't have the resources to do it. I 
would just submit again that if you gave us those resources, 
the payoff would be tremendous for the country. But thank you 
for the question.

    Senator Smith. Thank you very much, thank you.

    Senator Cassidy. I will defer to Senator Braun.

    Senator Braun. Thank you, Mr. Chair. I come from the world 
of fixing issues. I ran a company for 37 years that was so 
little, many of the issues didn't even come to the forefront 
because you were worried about turning the lights on in the 
morning, off in the evening, and all the stuff that happened in 
between.

    Lucky enough to take a little hard scrabble company and 
turn it into a national distribution logistics company. Biggest 
thing I wrestled with once we got larger was the high cost of 
health care. And now, we have not only got that to contend 
with, we have got the issue of how are you going to get people 
into the business of it when it is the largest sector of our 
economy. Travel, 92 counties in Indiana, workforce, workforce, 
workforce.

    It was a bigger issue now than it was pre-COVID, and that 
is what I heard mostly pre-COVID. I can say one thing, if you 
give good benefits, you pay your people well, folks come to 
your door to work there. I weigh in on those issues a lot, and 
every company is going to find its own way to do that. But 
let's look at this issue.

    I don't think that we would want to look to the Federal 
Government to take on something so granular when currently we 
borrow 30 percent of every dollar we spend here. I don't know 
if you know that. It was about 20 percent when I got here just 
4 years ago. Terrible long term business plan.

    We are not going to be able to solve anything by borrowing 
money from our kids and grandkids, and that is what this place 
does. Let me turn my attention to what I think would work. I 
think companies, I think the health care industry, let's focus 
in on what we are talking about, has now become so top heavy 
where doctors, the practitioners are wondering if it was even 
worth it to get their degree.

    Nurses as well, analogous to farmers in big Ag. Had a 
startup recently in Indiana where a bunch of anesthesiologists 
and surgeons wanted to start their own practice. It was almost 
impossible to do. Most of them got fired from their hospital 
they were working for. Let me tell you what they were able to 
do. They were able to take a gallbladder removal that cost 
$21,000 in Indiana if you were covered with insurance, $32,000, 
that is bizarre, if you didn't have insurance but could afford 
to pay for it. They are doing it for $8,000.

    They are going to pay themselves twice as much in terms of 
fees. That is what is got to change, basically, or else you are 
not going to have anybody wanting to get into the industry. And 
until you fix the industry itself with competition, 
transparency, removing the barriers to entry, making it 
entrepreneurial, the whole idea of getting people to work 
within it is almost going to be a secondary consideration.

    Now let's get to the matter of what we are talking about 
here, workforce in a broken industry, how do you improve upon 
it? Well, No. 1, I wouldn't look to this place. That ought to 
be something that would be easy among the people in the 
business.

    If you are occupying 18 to 20 percent of our GDP, you ought 
to be making some effort to do workforce through your own 
businesses, which now is mostly hospitals, over 40 percent, 
pharma is 15 percent, practitioners are shrinking because they 
are going on the payroll of hospitals, and then you have got 
insurance, which is kind of the Darth Vader of the whole 
industry in terms of getting to any of this getting fixed.

    I would say, because I wrestled and I was on our school 
board locally for 10 years, this ought to be something we are 
doing better in K-12. Look at the parents that regret that they 
didn't have some guidance somewhere along the way in high 
school or back in middle school that, don't pursue a 4-year 
degree when only 35 percent of the jobs need it.

    I get 10 people show up for that one. I got one open. I am 
lucky on a Friday if three people come in for a job that would 
pay as much as most 4-year degrees. But they show up on Monday, 
and we got to get that figured out.

    Better guidance in high school. Starting to take high 
demand, high wage jobs, which nurses would be one of them. 
Doctors, if you can put up with how long it takes to be 
educated and not to be frustrated once you become one, we need 
to do that back there, where you live within your means and you 
get results.

    Dr. Seoane, I would like you to comment and anybody else 
fairly briefly, should we be doing more here, or is a solution 
getting better value when they are in K-12, essentially middle 
school through high school, for the problems we are dealing 
with and talking about here?

    Dr. Seoane. I think partnerships are important. I think we 
need to work together. And we have done some of the programs 
you have described. That is exactly what we have kind of done 
with.

    We have got the high school apprenticeship, going to our 
high schools, partnering with our high schools, creating that 
nurse apprenticeship program to keep them to graduate high 
school and then become LPNs, and then move up.

    Those programs that I describe in my statement have all 
been supported through the Ochsner health system. But to scale 
them, we need support from our universities, we need support 
from our community colleges, we need support from our 
Government. I do think it is a partnership.

    Senator Braun. Good news. I see that happening back in my 
own home state. And anybody else want to weigh in on that? Yes, 
sir.

    Dr. Hildreth. Thank you. I want to make a point that is 
often missed, which is our health care is actually sick care. 
And if we focused on keeping people without the need to see a 
doctor, to be hospitalized, that is the solution. And some of 
that $4.3 trillion we spend on sick care, if we reduce that by 
10 percent, we would have $400 billion to invest in public 
health, and that is exactly what we should be doing, in my 
humble opinion.

    Senator Braun. Amen to that, because I will part with this, 
back 15 years ago, when I was sick and tired of hearing how 
lucky I was that it is only going up 5 to 10 percent each year, 
I was large enough to self-insure, I found out they were making 
25 percent profit margins on the plan I had in place, and the 
insurance companies told me just what you said.

    An ounce of prevention worth a pound of cure, avoid the 
business we are in. I took it to heart. Paid for 100 percent of 
wellness. Skin in the game from dollar one. We have not had a 
premium increase in 15 years and I got a healthier profile of 
employees. Thank you.

    The Chair. Okay. Thank you very much, Senator Braun. If you 
see people running in and out, it is not lack of interest, it 
is a vote on the floor.

    Senator Lujan.

    Senator Lujan. Thank you, Mr. Chairman. I want to thank 
everyone for being here today as well. In rural areas like New 
Mexico, primary care providers serve as vital lifelines for all 
health care needs.

    That is why the Project Echo Model, which was developed at 
the University of New Mexico by Dr. Sanjeev Arora, is so 
critical. Dr. Herbert, Project Echo, as you know from the 
University of New England, Maine's own effort is a 
telementoring model that gives health care providers access to 
the tools and mentoring they need to treat complex medical 
cases.

    Project Echo was found to be effective at equipping primary 
rural providers to screen for skin cancer when patients don't 
have access to dermatologists, as just one example. Dr. 
Herbert, as we work to address the shortage of health care 
providers in rural areas, how can we better utilize and 
innovate models like Project Echo to expand access to 
lifesaving medical care?

    Dr. Herbert. Excellent question. Thank you very much. And 
we do have a Project Echo project at our university as well, so 
I appreciate the question. I think it touches on a number of 
issues.

    First of all, the importance of prevention that we were 
just talking about. Early assessment and intervention of 
problems. Training primary care professionals to stretch their 
scope of practice. So earlier today we were talking about scope 
of practice laws that are overly limiting in terms of what 
primary care can do.

    Universities have a role in making sure not just in 
training new students, but in providing continuing education 
and professional development for existing providers using tools 
like Project Echo.

    But also, other kinds of continuing education tools to make 
sure that our primary care workers, physicians and others, are 
equipped to address a broader range of concerns. Because there 
is no way in a rural state, we are going to be able to place 
highly trained specialists of every kind in every community.

    Senator Lujan. I appreciate that very much. Mr. Chairman, 
we have already seen and witnessed the benefits of Echo models 
for health delivery. We are starting to see more and more 
benefit for educational opportunities as well with the Echo 
model, so I am hoping that we will see expansion.

    Dr. Hildreth, this will be for you, sir. Despite the 
growing need for behavioral health services, the behavioral 
health workforce has unfortunately been hemorrhaging workers.

    More than 122 million Americans and 65 percent of New 
Mexicans live in areas with mental health professional 
shortages. While training and education are critical to build 
on behavioral health workforce, I want to focus on keeping the 
providers we have. Dr. Hildreth, how would dedicated retention 
efforts for behavioral health workers impact this vital 
workforce?

    Dr. Hildreth. I think the retention is a really important 
part of our strategy. But I would also say that getting more 
training in behavioral health to primary care physicians who 
are at the front lines of this.

    We are not going to be able to train enough psychiatrists 
to solve this problem, but by bolstering the training of 
primary care doctors in behavioral health, that is going to be 
a big part of the solution.

    Again, one of the things I worry about is, they play such 
an important role in our health care system, but they are, to 
me, underpaid for what they do because they are the frontline 
in bringing down the costs.

    Because if you can catch someone early with a chronic 
disease and get them into care, that is going to reduce the 
long-term cost for the country. I would just suggest that 
training primary care doctors in behavioral health has to be a 
part of the solution. Thank you.

    Senator Lujan. I very much appreciate that. Doctor, thank 
you. Dr. Szanton, how can we explore promoting utilization of 
services to include midwife expansion and benefits?

    I have been a big proponent and having to explain to so 
many that the services that midwives provide is not just 
delivering babies to many communities.

    This is the only care that they have and they are the 
primary care providers in the area. So, in that respect, how 
can we explore promoting utilization of these services to not 
only support these families, but strengthen the health care 
workforce as well?

    Dr. Szanton. Thank you. Yes. Nurse midwives provide vital 
care throughout the postpartum period, pre-partum, and during. 
And they work often with doulas. And I think there has been a 
lot of emphasis today about rural areas.

    I think that focusing also on the infrastructure we do have 
in rural areas like postal workers like daycare centers, like 
Meals on Wheels, that we have got a lot of infrastructure we 
can take advantage of for the health of the Nation.

    But back to the midwives, they are just really essential 
components, often under looked, and can provide really 
comprehensive tailored care.

    Senator Lujan. I appreciate that response. Mr. Chairman, in 
my closing time, Senator Murkowski was asking some questions 
around EMS providers as well, which I very much appreciate the 
attention there.

    As some of you may know, I survived a stroke a year ago. My 
sister, who took me to the hospital from a rural community 30 
minutes or so away from Santa Fe to where I live, had the 
foresight to stop at a local fire department because they were 
washing vehicles as she was passing by.

    That was 5 minutes from my home. Those EMS providers 
provided incredible care to me, immediately being able to 
provide stabilization, and I know communicating with that 
emergency room before I arrived. Had it not been for them, I 
don't know that I would be here today.

    I hope that we will see more support and attention with 
this kind of service, and especially acknowledging some local 
governments and communities across the country, their budgets 
don't allow for that kind of investment. I thank you for that 
as well.

    The Chair. Well, thank you, Senator. I did mention that in 
my opening remarks, and we are going to get back to that. 
Senator Cassidy has been a true gentleman, scholar, gentleman 
allowing his colleagues to go before him. Senator Cassidy.

    Senator Cassidy. Yes. I have lots of questions, but even 
though I am last, limited time, so I will go a little rapid 
fire.

    It has been a fantastic panel, by the way. I don't know if 
we have ever seen this much kind of participation from Members, 
and congrats to the Chair. I think it has just gone very well 
and you have all been really good.

    Dr. Seoane, happy Mardi Gras to all of those who are not as 
blessed as you and I to live in New Orleans and for this 
upcoming weekend. We have got to do something relatively 
quickly. Facilities for HBCUs, nursing, the pipeline, it is 
actually kind of okay.

    It finally gets there. One of the things that I have been 
thinking about how we could initially, boom have an impact, 
aside from immigration change, which would be huge, Dr. Seoane, 
you mentioned the press of people coming to ERs and even the 
violence associated with.

    I have read that we have an absence of medication assisted 
therapy clinics. I am assuming there are a fair number of 
people come to ERs. Dr. Hildreth, you are in an urban area as 
well. Oh, my gosh.

    Dr. Szanton, oh my gosh, that if we had effective MAT, in 
which we were keeping people from coming to the ER because they 
were less likely to be an overdose or withdrawal, that that 
could be something that could be relatively quickly implemented 
to have a relatively rapid response. Dr. Seoane.

    Dr. Seoane. Senator Cassidy, thank you for that question. 
Look, I couldn't agree more. I think those are critical and 
important. I think it goes beyond just the medication 
assistance therapies programs.

    There is other interventions like it was mentioned digital 
medicine, digital monitoring, but there is actually digital 
management programs, digital hypertension, digital diabetes.

    We did a pilot in 3,000 Medicaid patients in rural areas 
where we manage their diabetes or their hypertension through 
the digital program.

    We showed in 1 year, in a Medicaid population, decreased 
hospitalizations and decreased ER visits. So I think you are 
right, Senator Cassidy, we need to move care into the community 
to prevent the ER visits.

    Senator Cassidy. That has been a theme from all of you. Dr. 
Staiger, I have been just chomping at the bit to ask you this 
question. Are you ready? The sophistication of your research, 
you say that the pass rate of licensing exam is down. Now, you 
have done some sort of multivariate analysis.

    Is it--who is less likely to pass? Is it the online school? 
Is it the for profit school? Is it the person who graduated 
during the pandemic? Is it poor preparation prior to coming to 
school? What are the variables that can be affected?

    Dr. Staiger. We are working on that. I don't have--Oh, come 
on.

    [Laughter.]

    Dr. Staiger. But I can--I have some answers. The people who 
are not passing the licensure exam are people who were in 
nursing school during the pandemic. And all belief is that it 
was the, you know----

    Senator Cassidy. So that cuts across the institution. Johns 
Hopkins, all the way to your community college?

    Dr. Staiger. Well, I can't say Johns Hopkins specifically, 
but they are seeing it across the board in terms of the 
declining pattern.

    Senator Cassidy. Let me ask you then, online nursing 
instruction, which I will come back to you, ma'am. Online 
nursing instruction, I am out by the bedside person and your 
quote, I will steal it, Dr. Hildreth.

    In fact, I will attribute it the first time, but then after 
that, I will just forget you. Speaking to 100 people is a great 
way to teach, but a bad way to learn. So online seems like a 
great way to teach, but a bad way to learn for nursing skills. 
Am I right or am I wrong?

    Dr. Staiger. Well, I think the challenge has been 
particularly for clinical skills, right, that bedside skills. 
And the exam, and it is changing in April is--focuses 
increasingly on clinical skills and clinical experience for the 
nurse licensure exam.

    That is becoming--you know, the belief is that the pass 
rates are going to get much worse this year this next year 
because of that.

    Senator Cassidy. Because there has been a lack of 
preparation for clinical.

    Dr. Staiger. Lack of the clinical experience----

    Senator Cassidy. So let me move on. Dr. Szanton, I suspect 
you are chomping at the bit. Now, I endorse what Marshall said, 
the woman or the man that goes to the community college, I 
think is probably more likely to stay in her community.

    I will just say from my personal experience as a physician, 
certificate nurses, the one that I worked with for 30 years, 
she was just fantastic. There is a clear bias toward BSNs, but 
it seems more expensive, it seems a longer pipeline to get them 
out, and again, as he says, there may be a predisposition for 
those folks to stay where they were trained at the university 
town as opposed to their community.

    We got a couple of things to throw before you. One, what 
about that, the Marshall issue? Dr. Staiger, what about this 
kind of clinical skills gap? And what should we be thinking 
about in terms of online training and what I would intuitively 
think would make them less prepared?

    Dr. Szanton. Thank you very much for those questions. About 
the online training, so at Johns Hopkins, I can't speak for all 
nursing schools, but at Johns Hopkins, when we talk about an 
online program, what they mean is that the some of the didactic 
portion when you are learning about pathophysiology and you are 
learning about how the heart works, and that that can be online 
modules.

    But they come to campus multiple times a year and they have 
clinical experiences wherever they are. There is--at least at 
Johns Hopkins, there is no such thing as online only nursing 
program. To your point, that wouldn't make sense.

    Senator Cassidy. I know that there is some online only 
classes? Do I know that? Some universities all do 100 percent 
online. Dr. Staiger, did you know that.

    Dr. Szanton. Classes----

    Dr. Staiger. During the pandemic, and there was--typically, 
no, right. They all----

    Dr. Szanton. For example, at Johns Hopkins March 2020, 
everything shut down briefly, but we pivoted quickly and people 
were back doing clinical hours. Sometimes they were more out in 
the community than in the hospital, for example. But people got 
really hands on clinical experiences during the pandemic. I 
want to just mention about RN, I wouldn't call it a bias 
respectfully, toward BSN education.

    There are decades of evidence, and I am sure you can back 
me up, showing that health systems that have a higher 
proportion of BSNs have better health outcomes for the 
patients.

    Of course, you need a team of all different kinds of 
people, but there is a lot and a lot of evidence that we would 
be happy to share over time about the need for the BSNs.

    Senator Cassidy. Now, the choice is between the marginal 
increase in outcome, which again, you want a multivariate 
analysis to look at that, as opposed to having a shortage of 
nurses. Which would be more impactful, more nurses or more of 
them being BSNs?

    Dr. Staiger. You know, nurses first, right, then skills, 
then upskilling. And you know the evidence--the National 
Academy of Medicine came out and this was their recommendation, 
so I won't argue with that. It is not perfect evidence, but it 
is good evidence. I think the key to the associate degree 
nurses is the entry in the career steps.

    You know, it is a way for people to get in with 2 years, 
but then have a career ahead of them where they can get trained 
up to be a bachelor's nurse. And the key is facilitating that. 
That is how you get people to enter at these lower wage jobs, 
is they see the career ahead.

    Senator Cassidy. With upskill, can I have one more 
question? Dr. Hildreth, you alluded to, Dr. Szanton spoke 
specifically, that if we address the burden of chronic disease, 
we can decrease our utilization.

    Dr. Seoane mentioned an innovative program in terms of 
digital health. We are going to have some hearings on 
pharmaceuticals, but whatever we say about pharmaceuticals, 
they have been incredibly innovative.

    We know the burden of metabolic disease disproportionately 
falls upon the poor, and that if we do something about the 
metabolic syndrome, then we are going to decrease renal 
failure, hypertension, diabetes, heart disease, stroke.

    I say that, I am not sure there is a question there, but 
just an observation, that there has been a consistent refrain 
that if we do something about the burden of chronic disease, 
that we can decrease the demand upon our health care 
facilities, if you will, a more fundamental way to address the 
shortfall as opposed to just more nursing schools, which we 
also need. Any comment on that, sir?

    Dr. Hildreth. Thank you, Senator Cassidy. I will just 
repeat what I said earlier. Our health care system is actually 
a sick care system.

    We need to be focused on the social determinants of health, 
where you live, where you work, how much money you make, your 
educational attainment, all of those things contribute much 
more to your health than going to see a doctor.

    Now, in my job, I am in the business of training doctors, 
dentists, researchers, but the reality is that what we need 
more of this investment in public health.

    I would argue that re-integrating public health in primary 
care is the best way forward, so we can actually get better 
outcomes for communities, not one person at a time. Thank you.

    The Chair. Thank you, Senator Cassidy. Look, I agree with 
Senator Cassidy. I thought this, Senator Cassidy, was an 
extraordinary hearing.

    I think we had the attendance of virtually every Member 
here on both sides, which tells--should tell us and tell all of 
us, rural, urban, no matter where you are from, we have got a 
major crisis in health care workforce.

    This has been a great panel and I want to thank each and 
every one of you for being here. We are going to get back to 
you. We are going to produce legislation. I don't do hearings 
for the sake of hearings.

    All of you have been invaluable in your contributions. So, 
let's work together. Let's do something for the American people 
and thank you very much.

    For any Senators who wish to ask additional questions, 
questions for the record will be due in 10 business days, March 
3rd at 5.00 p.m.

    Finally, I ask unanimous consent to enter at the record a 
statement from Senator Casey and 19 statements from stakeholder 
groups sharing their health care workforce priorities. So, 
ordered.

    [The following information can be found on page 79 and 83 
in Additional Material:]

    The Chair. The Committee stands adjourned.

                          ADDITIONAL MATERIAL

         senator robert p. casey, jr., statement for the record
    I regret that I was unable to attend the Committee on Health, 
Education, Labor, and Pensions (HELP) hearing on Thursday, February 16, 
2023 due to medical leave. This hearing covered a critical and timely 
matter: health professional shortages and their impact on the health 
care system.

    The COVID-19 pandemic placed an immense strain on the health care 
workforce across the field, from outpatient to intensive care. While 
the world went into lockdown, health care facilities and the personnel 
that staff them remained open, fielding the swell of patients 
exhibiting the symptoms of a virus the medical community was only 
beginning to understand. The data suggest that one in five health care 
workers quit their jobs during the pandemic. Working long hours, often 
without adequate personal protective equipment, health care providers 
were steadfast in their commitment to serving their communities.

    We must apply lessons learned during the acute phases of the COVID-
19 pandemic to future policy. I look forward to working with my 
colleagues on both sides of the aisle this Congress to reauthorize the 
Pandemics and All Hazards Preparedness Act to fortify our health care 
system against future public health threats. It will be vitally 
important to prioritize building supports for our frontline health care 
personnel, so they are able to provide the best care possible when it 
is needed most.

    There are a number of Federal programs aimed at building the health 
workforce pipeline, including the National Health Service Corps (NHSC) 
and Medicare Graduate Medical Education (GME) payments to support 
residency slots to train new doctors. In Pennsylvania, loan repayment 
programs like the NHSC are especially important for our rural health 
care facilities who may otherwise struggle to attract new providers 
without incentives like loan repayment. I was pleased to see that the 
Consolidated Appropriations Act, 2023 included an expansion of GME 
slots, but systemic underinvestment in these--and similar--programs can 
limit their impact.

    There are further considerations for specialty providers, who 
receive extra training. I have led efforts to reauthorize the 
Children's Hospital Graduate Medical Education program for many years. 
This program supports the pediatric health care workforce and addresses 
shortages in pediatric specialty care by supporting residency slots at 
freestanding children's hospitals. I look forward to working on the 
reauthorization of this important program this Congress.

    As it stands, our health care workforce does not reflect the 
diversity of the communities they serve. My bill, the Allied Health 
Workforce Diversity Act, recently passed with the Consolidated 
Appropriations Act, 2023. This legislation authorizes $8 million per 
year over the next 5 years for a new grant program aimed at recruiting 
a diverse body of professionals in the allied health fields, including 
occupational therapists, physical therapists, speech-language 
pathologists, and audiologists.

    Our work is not done once a health care worker is hired, though. 
Health care workers consistently face elevated rates of workplace 
violence, and I am proud to support Senator Baldwin's work in 
addressing this serious issue. There was an outpouring of support for 
our health care professionals during the acute phases of the COVID-19 
pandemic, in recognition of their truly heroic work. We must continue 
to show up for our providers, and I look forward to working with my 
colleagues on the HELP Committee this Congress to develop new, 
innovative ways to build this critical workforce.

    Pennsylvania's world-class medical community will be part of these 
developments, and I will continue to work on behalf of our health care 
providers to make sure we have the proper resources to keep up with the 
changing health care landscape without sacrificing care quality.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                        QUESTIONS FOR THE RECORD

  Response by James Herbert to questions of Senator Paul and Senator 
                               Tuberville

                              senator paul
    Question 1. The American Nurses Association reports that the 
average age of a nurse is 52 years old and that at least a fifth of all 
U.S. nurses will be retiring in the next 5 years. The U.S. Department 
of Labor says that there are in excess of 200,000 open RN positions 
right now and that number is expected grow. Nurses are reporting 
record-high levels of stress because of severe workforce shortages. 
This data implies that the nursing shortage is about to get much worse. 
What is being done to combat these workforce shortages and alleviate 
the immense stress being suffered by nurses?

    Answer 1. Nurse stress, burnout, and compassion fatigue are 
collectively contributing to the departure of nurses in the workforce. 
In order to combat this reality, healthcare systems need to analyze and 
address the root causes of nurse stress. At an organizational or micro 
level, these issues are varied and often co-occurring. It is vital for 
institutions to establish appropriate staffing levels reflective of 
patient complexity and acuity, the number of admissions or discharges 
within a given assignment, and the availability of support personnel. 
The work environment itself needs to be assessed and determined to be 
safe and free from harm. Nurses are encountering increasing acts of 
aggression, both verbal and/or physical, and health systems need to 
promote a 24-hour safe setting for nurses to execute their work. 
Compensation structures for nurses need to be reevaluated, along with 
ensuring that nurses are able to practice to the full extent of their 
academic preparation, experience, and professional licensure/
credentialing.

    At a macro-disciplinary level, a number of professional 
organizations are working to combat nurse stress and fatigue. For 
example, the American Nurses Association (ANA) launched the Healthy 
Nurse/ Healthy Nation initiative. This social action endeavor aims to 
enhance the health and well-being of the 4 Million registered nurses in 
the U.S., and in so doing, favorably impact the health of the Nation. 
The program offers ANA members health and wellness assessments, tool 
kits to improve focus areas such as sleep, activity, nutrition, stress 
management, and vehicles for establishing support/connections with 
others.

    Finally, as I discussed in my testimony with respect to healthcare 
professionals more generally, we need to facilitate the training of 
more nurses, including both new, entry-level nurses as well as programs 
to upskill lower-level providers to become nurses. The primary 
bottlenecks in this regard are insufficient clinical training sites and 
the paucity of nurse educators. Many institutions (including my home 
university, the University of New England) are doing creative things to 
address both of these issues, but these could be facilitated with 
additional state and/or Federal support.

    Question 2. For the last 15 years, nursing school enrollment has 
not kept up with hospital demand for nurses. The primary barriers to 
accepting all qualified students at nursing schools continue to be 
insufficient clinical placement sites, faculty, preceptors, and 
classroom space. How are we increasing nursing opportunities for U.S. 
students?

    Answer 2. Increasing nursing school enrollment is a complex and 
multifaceted issue. The lack of appropriately prepared nurse faculty, 
limitations in expanding clinical placement sites, and modernizing 
nursing education infrastructure illustrate these vexing challenges. 
This can be best addressed by investing in nursing education. The re-
authorization of the Title VIII Nursing Workforce Development Program 
as part of the CARES Act was an essential first step. Ongoing 
congressional funding is essential to continue to support opportunities 
to grow nursing education faculty, imagine innovative models for 
clinical education, and modernize nursing education facilities. The 
interest of the U.S. Department of Labor is also essential in solving 
this issue. Individual states play a role as well, providing funding 
opportunities to support the expansion of graduate medical education 
and creation of novel clinical rotational opportunities.

    Embarking on new, innovative partnerships is also essential for 
addressing these challenges. This may involve creation of unique health 
system/academic institution alliances, or public/private educational 
institutions working in concert to co-create nursing education programs 
responsive to local or regional needs.

    Question 3. Fifteen percent of U.S. nurses are foreign-trained, 
meaning that thousands of new U.S. nurses per year are foreign workers. 
Retrogression of visas is expected in 2024. If this pool of nurses were 
to run out, stress on nursing staff would be unsustainable, likely 
leading to even earlier retirements. Since visa retrogression will 
happen in 2024 and no foreign nurses will be able to enter the U.S., 
what steps are being taken to maintain foreign nurses' entry into the 
U.S.?

    Answer 3. Entry into the United States and visa issuance is a 
legislative issue. Credentialing of foreign trained nurses and 
conferment of licensure is a nursing regulatory matter. The National 
Council of State Board of Nursing (NCSBN) is a not-for-profit 
organization through which nursing regulatory bodies (i.e., each of the 
50 state boards of nursing) confer and act and together on issues 
impacting public health, safety, and welfare, including the licensure 
of nurses. The NCSBN is a member organization of the international 
center for regulatory scholarship, uniting nine member nursing 
organizations around the world to promoting research and data sharing 
to influence policy impacting the health, safety, and welfare of the 
public.

    Foreign trained nurses applying for licensure in the United States 
need to be credentialed through the Commission on Graduates of Foreign 
Nursing Schools (CGFNS). This process verifies and authenticates the 
credentials for an internationally educated applicant. Foreign trained 
nurses may need to initially complete a qualifying examination and/or 
demonstrate English language proficiency. Foreign trained nurses may or 
may not be required to successfully pass the National Council Licensing 
Examination (NCLEX-RN). This is dependent upon their prior preparation. 
Each state board of nursing has its own requirements in determining 
educational and experiential comparability for individuals trained 
outside of the United States.
                           senator tuberville
    Question 1. In addition to doctors and nurses, the current health 
worker shortage includes technicians, assistants, pharmacy personnel, 
home health aides, nursing home staff, and more. America is 
experiencing shortages across every aspect of America's health care 
systems--not just the jobs requiring high-level and post-grad degrees. 
We need to train people throughout the care team, all across the 
industry. Not everyone desiring to pursue a career in health care wants 
to go to a full 4-year college or nursing or medical school.

    Question 1(a). Please highlight what other opportunities outside 
traditional 4-year college settings are available to interested 
students?

    Question 1(b). What training and incentive programs are out there?

    Answer 1. There are an abundant number of essential health care 
roles that do not require 4-year baccalaureate education or graduate 
study. Certified nursing assistants (CNA's), home health aides (HHA's), 
medical assistants (MA's), licensed practical nurses (LPN's), X-ray 
technicians, and phlebotomists are examples of vital paraprofessional 
roles. Educational requirements differ depending upon the role, ranging 
from a few weeks to a year to complete training. Credentialing also 
varies, ranging from certification to licensure. Each state determines 
rules and regulations for these positions. Licensed practical nurses 
(LPN's) are governed by NSCBN (described above) and must successfully 
pass the NCLEX-PN to practice.

    Public K-12 education is often also engaged in paraprofessional 
training, providing secondary students with health care ``tracks'' or 
``concentrations'' leading to nursing assistant credentialing. Many 
community, technical, or vocational colleges offer this training in a 
post-secondary manner. Municipalities have become increasingly involved 
in this arena through adult education, offering nursing assistant 
training to community residents to enhance the regional workforce. 
Health care systems have also assumed an educational role, creating 
paid training programs in an effort to ``grow their own'' workforce. 
These models commonly pay an individual to complete the specified 
training, and once successfully completed, require future employment 
for a specified number of years. There are abundant opportunities for 
innovative higher education/health system partnerships to expand this 
essential workforce. Federal and state funding initiatives are critical 
to support the workforce growth needed in this arena.

    Question 2. I have been contacted in particular by EMS 
professionals in Alabama who are sounding the alarm about their own 
individual shortages. Specifically, I recently heard from an EMS 
company in the state, NorthStar EMS. They are providing vital 911 
emergency and interfacility ground ambulance services in both rural and 
urban counties in Alabama. Their organization, and every other 
ambulance service provider in Alabama, is facing an unprecedented 
workforce shortage. NorthStar noticed this issue several years prior to 
the pandemic and started their own training academy in order to make 
EMT education more accessible to people desiring to enter the field. 
When the pandemic started, interest in attending EMT school dropped. 
Not many people wanted to put themselves into a front-line position, 
which made the problem worse. However, the ones who wanted to get into 
the profession at that time turned out to be some of the best students 
and workers they have had in years. They have finally started to see an 
uptick in interest from prospective students, but nowhere near where 
they need to be in order to get back to pre-pandemic levels, which 
leaves them far short of where they need to be.

    According to NorthStar, a recent survey on the EMS workforce 
shortage--involving nearly 20,000 employees working at 258 EMS 
organizations--found that overall turnover among paramedics and EMTs 
ranges from 20 to 30 percent annually. With percentages that high, 
ambulance service providers face 100 percent turnover within a 4-year 
period. Staffing shortages compromise their ability to respond to 
health emergencies, especially in rural and underserved parts of the 
country. In several rural counties in Alabama, only one ambulance is 
staffed most days of the week--not because that is what the service 
wants to do, but because there are no staff to cover the open shifts.

    The EMS workforce shortage has continually worsened over a period 
of several years with the pandemic exacerbating the current shortage 
and highlighting the need to better understand the drivers of workforce 
turnover.

    Question 2(a). From your perspective, what can be done to correct 
the training and staffing pipeline of EMS workers, especially in rural 
areas?

    Answer 2. Emergency management services (EMS) are part of the 
healthcare ecosystem and involve public safety (police and fire), 
public health, and regional healthcare delivery systems. EMS is 
generally organized around four (4) levels of care or responders to 
include: Emergency Medical Responder (EMR); Emergency Medicine 
Technician (EMT-B); Advanced Emergency Medical Technician (EMT-A); and 
paramedic (EMT-P). Each of these require different levels of education 
and preparation. The delivery of acute, complex, and life-threatening 
care optimally requires intervention at the EMT-A and paramedic level.

    There are many drivers that threaten the current and future EMS 
workforce and pipeline. The impact of the pandemic on personal health 
and well-being has influenced the entire health care workforce, to 
include EMS. EMS compensation structures remain persistently low, 
rendering the role unattractive. According to the Bureau of Labor 
statistics, the 2021 median annual wage for emergency medical 
technicians was $35,470; and the 2021 median annual wage for paramedics 
was $46,770. The provision of EMS services requires 24-hour coverage, 
and staffing shortages commonly necessitate mandatory overtime to 
ensure appropriate community coverage. Career mobility is limited with 
few opportunities for professional growth and advancement.

    The delivery of EMS services is complex and differs from region to 
region. A variety of entities including municipal fire departments, 
rescue squads, hospitals, and private companies all represent the 
numerous ways that EMS care is delivered. Rurality presents unique 
challenges to the EMS industry. The workforce itself, particularly at 
the higher levels of practice, is in scare supply. Response times in 
rural regions are significantly longer, and the public is more likely 
to survive a life-threatening event if care is rendered by an EMT-A or 
paramedic. In addition to longer response times, transport times are 
also lengthy, thus taking an ambulance out of service for another 
possible call. Ground ambulance costs have increased steadily over the 
past 5 years, and CMS reimbursement rates commonly do not cover the 
cost of services and transport. This results in a financial deficit for 
the EMS system, be it administered by a municipality, private company, 
and/or hospital.

    Innovative educational programs to increase student interest and 
enrollment are needed to expand the pipeline of EMS provider. Federal 
and state funding should be allocated to support student scholarships 
and/or loan repayment once credentialed. CMS reimbursement rates must 
be re-examined to ensure the sustainability of the EMS system.

    Question 3. In your testimony, you mention how critical is that we 
leverage the power of technology to reach underserved communities. In 
Alabama, we used Federal authority to make telehealth much more 
effective and feasible for patients and doctors during COVID. Providers 
in rural states were able to reach more patients with fewer health care 
workers using virtual visits and follow-ups. It was a lifeline in many 
rural areas and helped lift the burden placed on brick-and-mortar 
health care centers.

    Question 3(a). What can we do to encourage further use and 
innovation in telehealth, especially in rural states and communities?

    Question 3(b). How can it be best utilized to help address the 
current workforce shortage?

    Answer 3. Telehealth is dependent upon the availability of 
appropriate tools and resources to achieve successful and sustainable 
telehealth practices. Reliable Internet, inclusive of broadband, is 
essential to support video chat capability, visual imaging, and two-way 
exchange. Federal and state funding is critical to ensure such 
infrastructure is regionally in place.

    As noted, telehealth can provide vital patient care services, 
thereby improving access to care and health outcomes. Telehealth can 
also include telemonitoring, as with home care services which monitor 
and collect patient status data (e.g., self-care for heart failure 
programs). Telemonitoring can also be employed with respect to hospital 
inpatient unit oversight, such as an offsite clinician observing real 
time patient data and alerting facility-based staff regarding changes 
(e.g., virtual telemetry monitoring). Telehealth has additionally been 
impactful in creating virtual learning communities of health 
professionals and subject matter experts to inform best practices in 
care delivery (e.g., Project ECHO). Telehealth can also be employed 
with tele-precepting, uniting expert faculty with rural-based learners 
in supervising specialized patient care.

    Academic preparation of today's health profession student needs to 
include didactic exposure and clinical experience with telehealth. 
Students need to be oriented to telehealth practices, examination 
strategies, approaches for building positive relationships with 
patients, appropriate documentation, and legal and policy implications. 
Faculty development is often needed, as telehealth is a new and 
evolving field. The integration of telehealth into health care 
curricula promotes graduate workforce readiness in this growing arena.

    Question 4. Dental practices across the country are experiencing a 
significant shortage of hygienists and dental assistants.

    Question 4(a). Are dental schools working with community colleges 
and career and technical training programs to come up with ways they 
can collectively encourage increased interest in those careers?

    Question 4(b). What can we do at the Federal level to support those 
efforts?

    Answer 4. Dental medicine and dental hygiene programs are actively 
partnering with community colleges to create educational pathways and 
promote student interest in the field of oral health. Community college 
graduates who earn an Associate Degree in health science are well 
qualified for entry into baccalaureate level dental hygiene education. 
For example, the University of New England has robust articulation 
agreements with regional community colleges for this very purpose. Each 
year, the dental hygiene program admits approximately 12 new community 
college graduates who will then study four additional semesters to earn 
the Bachelor of Science Dental Hygiene and eligibility for licensure. 
Innovative, accelerated pathways also exist for students seeking to 
attain dental medicine degrees (DDS, DMD).

    Federal and state funding level can support these initiatives by 
enhancing scholarship opportunities to incentivize students into these 
careers. Additionally, loan repayment programs are another effective 
approach, especially for retaining graduates in documented regions with 
few oral health providers.
                                 ______
                                 

  Response by Sarah Szanton to questions of Senator Paul and Senator 
                               Tuberville

                              senator paul
    Question 1. The American Nurses Association reports that the 
average age of a nurse is 52 years old and that at least a fifth of all 
U.S. nurses will be retiring in the next 5 years. The U.S. Department 
of Labor says that there are in excess of 200,000 open RN positions 
right now and that number is expected grow. Nurses are reporting 
record-high levels of stress because of severe workforce shortages. 
This data implies that the nursing shortage is about to get much worse. 
What is being done to combat these workforce shortages and alleviate 
the immense stress being suffered by nurses?

    Answer 1. Thank you for the question. We are agree that the stress 
and shortages are a major problem. The FAAN act (Senate bill 246 from 
117th Congress) which has not yet been re-introduced in this Congress 
would go a long way to solving many of the shortages, including 
addressing shortage of preceptors, financial aid for students and 
increasing the number of faculty members in nursing schools.

    Question 2. For the last 15 years, nursing school enrollment has 
not kept up with hospital demand for nurses. The primary barriers to 
accepting all qualified students at nursing schools continue to be 
insufficient clinical placement sites, faculty, preceptors, and 
classroom space. How are we increasing nursing opportunities for U.S. 
students?

    Answer 2. Thank you. The FAAN act described above would address 
each of these issues.

    Question 3. Fifteen percent of U.S. nurses are foreign-trained, 
meaning that thousands of new U.S. nurses per year are foreign workers. 
Retrogression of visas is expected in 2024. If this pool of nurses were 
to run out, stress on nursing staff would be unsustainable, likely 
leading to even earlier retirements. Since visa retrogression will 
happen in 2024 and no foreign nurses will be able to enter the U.S., 
what steps are being taken to maintain foreign nurses' entry into the 
U.S.?

    Answer 3. That's a great question. It is outside of my area of 
expertise as a Nursing School Dean so I do not have the technical 
expertise to provide the Senator the answer his important question 
deserves.
                           senator tuberville
    Question 1. In addition to doctors and nurses, the current health 
worker shortage includes technicians, assistants, pharmacy personnel, 
home health aides, nursing home staff, and more. America is 
experiencing shortages across every aspect of America's health care 
systems--not just the jobs requiring high-level and post-grad degrees. 
We need to train people throughout the care team, all across the 
industry. Not everyone desiring to pursue a career in health care wants 
to go to a full 4-year college or nursing or medical school.

    Question 1(a). Please highlight what other opportunities outside 
traditional 4-year college settings are available to interested 
students?

    Question 1(b). What training and incentive programs are out there?

    Answer 1. Thank you for the question. I completely agree that not 
everyone wants to go to a full 4-year collage or nursing or medical 
school. One of the wonderful things about the health professions is 
that there are many rungs to jump onto to be able to serve patients, 
their families and communities. These include many community college 
programs for 2 year degrees and shorter than that for some fields. I am 
less aware of what incentive programs there are for other professions 
because I am a nursing school Dean and don't have technical expertise 
in the other professions.

    Question 2. I have been contacted in particular by EMS 
professionals in Alabama who are sounding the alarm about their own 
individual shortages. Specifically, I recently heard from an EMS 
company in the state, NorthStar EMS. They are providing vital 911 
emergency and interfacility ground ambulance services in both rural and 
urban counties in Alabama. Their organization, and every other 
ambulance service provider in Alabama, is facing an unprecedented 
workforce shortage. NorthStar noticed this issue several years prior to 
the pandemic and started their own training academy in order to make 
EMT education more accessible to people desiring to enter the field. 
When the pandemic started, interest in attending EMT school dropped. 
Not many people wanted to put themselves into a front-line position, 
which made the problem worse. However, the ones who wanted to get into 
the profession at that time turned out to be some of the best students 
and workers they have had in years. They have finally started to see an 
uptick in interest from prospective students, but nowhere near where 
they need to be in order to get back to pre-pandemic levels, which 
leaves them far short of where they need to be.

    According to NorthStar, a recent survey on the EMS workforce 
shortage--involving nearly 20,000 employees working at 258 EMS 
organizations--found that overall turnover among paramedics and EMTs 
ranges from 20 to 30 percent annually. With percentages that high, 
ambulance service providers face 100 percent turnover within a 4-year 
period. Staffing shortages compromise their ability to respond to 
health emergencies, especially in rural and underserved parts of the 
country. In several rural counties in Alabama, only one ambulance is 
staffed most days of the week--not because that is what the service 
wants to do, but because there are no staff to cover the open shifts.

    The EMS workforce shortage has continually worsened over a period 
of several years with the pandemic exacerbating the current shortage 
and highlighting the need to better understand the drivers of workforce 
turnover.

    Question 2(a). From your perspective, what can be done to correct 
the training and staffing pipeline of EMS workers, especially in rural 
areas?

    Answer 2. Thank you for the question. EMS workers are essential to 
providing Americans with emergency care. With new models, some are also 
providing important community based care such as check-ins for 
loneliness and whether people have enough food. As a nursing school 
dean, however, I do not have the technical expertise to provide the 
Senator the answer his important question deserves.
                                 ______
                                 

   Response by Leonardo Seoane to questions of Senator Paul, Senator 
                      Tuberville, and Senator Budd

                              senator paul
    Question 1. The American Nurses Association reports that the 
average age of a nurse is 52 years old and that at least a fifth of all 
U.S. nurses will be retiring in the next 5 years. The U.S. Department 
of Labor says that there are in excess of 200,000 open RN positions 
right now and that number is expected grow. Nurses are reporting 
record-high levels of stress because of severe workforce shortages. 
This data implies that the nursing shortage is about to get much worse. 
What is being done to combat these workforce shortages and alleviate 
the immense stress being suffered by nurses?

    Answer 1. The nursing shortage--and its strain on our existing 
workforce--is a significant concern to Ochsner Health. With over 1,200 
open nursing positions across our system, and the cost of contract 
nursing having increased more than 800 percent since 2019, steps must 
be taken to grow the number of nurses in the health care workforce. At 
Ochsner, we have committed significant resources to the training and 
retention of nurses and implemented numerous programs to alleviate 
provider stress and prevent burnout.

    Ochsner and our partners have developed nursing workforce programs 
that are accessible to individuals at all stages of their nursing 
career. We offer nursing pre-apprenticeship programs to high school and 
community college students, tuition reimbursement programs to full time 
community college and university nursing students, as well as ``earn as 
you learn'' apprenticeship programs for individuals already working as 
a Medical Assistant who want to become and LPN. We also offer 
scholarships and other financial assistance to employees who want to 
advance their careers by way of our career pathway programs. Finally, 
we have provided significant capital funds to build a new nursing 
program at a local community college, as well as providing Ochsner 
clinical nurses to serve in faculty positions at various nursing 
schools at no cost to the school.

    At Ochsner, the mental health and well-being of our employees is of 
utmost importance, and we understand the strain and pressure the PHE 
put on our employees, but particularly bedside providers. We are 
particularly concerned that our clinicians are facing a more violent 
working environment; there has been more verbal and physical assaults 
on health care providers, including in our system. To help reduce the 
strain on our workforce and address burnout, we have undertaken a 
number of steps and launched new efforts in the clinical setting. We 
have a wellness office for our nurses and physicians. Other efforts 
include expanding the bedside care team to include more nursing 
assistants and LPNs in addition to RNs, all practicing within the scope 
of their licensure, to spread the workload and reduce pressure on the 
care team more evenly. Ochsner is also leveraging its long history of 
digital innovation to address provider stress through the 
implementation of the Virtual Nurse Program. This program, which 
provides 24-hour virtual nursing support to the patient care team, is 
an innovative staffing model focused on patient-centered care and safe 
distribution of workload across an integrated team of virtual and 
bedside nursing personnel. This approach allows bedside nurses to focus 
on direct care and leverages the bunker nurses--via technology hook-
ups--to manage non-direct care matters--resulting in more efficient 
care delivery, a better patient discharge experience, and less strain 
on the bedside nurse. We worked with the Louisiana state legislature to 
make violence against health care workers a crime and we urge Congress 
to take similar action to provide the same safeguards to health care 
workers as are afforded airline employees.

    Question 2. For the last 15 years, nursing school enrollment has 
not kept up with hospital demand for nurses. The primary barriers to 
accepting all qualified students at nursing schools continue to be 
insufficient clinical placement sites, faculty, preceptors, and 
classroom space. How are we increasing nursing opportunities for U.S. 
students?

    Answer 2. Ochsner has made significant investments in educational 
opportunities for health care students. As the largest health care 
provider in Louisiana, Ochsner is proud to serve as a clinical training 
site for numerous programs in the region. Additionally, Ochsner's $20 
million investment in the Ochsner Center for Nursing and Allied Health 
at Delgado Community College provides matching funds for a new state-
of-the-art facility on its campus in New Orleans, and covers full-time 
tuition for Ochsner employees pursuing a nursing or allied health 
certificate or degree at Delgado. Finally, we recognize that our 
nursing schools have limited capacity due to insufficient numbers of 
teaching faculty, and we are supporting several of our full-time 
employed Ochsner nurses in stepping out of their clinical roles 2 days 
a week to serve as clinical adjunct faculty at colleges of nursing. 
Ochsner continues to pay their salaries in full, which provides schools 
of nursing with faculty at no cost.

    Question 3. Fifteen percent of U.S. nurses are foreign-trained, 
meaning that thousands of new U.S. nurses per year are foreign workers. 
Retrogression of visas is expected in 2024. If this pool of nurses were 
to run out, stress on nursing staff would be unsustainable, likely 
leading to even earlier retirements. Since visa retrogression will 
happen in 2024 and no foreign nurses will be able to enter the U.S., 
what steps are being taken to maintain foreign nurses' entry into the 
U.S.?

    Answer 3. Ochsner agrees that maintaining a supply of well trained 
nurses who have a legal pathway to work in the U.S. is essential to 
helping us address workplace shortages and critical to closing the gap 
between patient demand and nursing need. We would support efforts to 
increase the visas available through proposals like the bipartisan 
Health Care Workforce Resilience Act which allows for recapture from 
previous fiscal years unused immigrant visas for physicians (15,000) 
and nurses (25,000), exempts these visas from country caps, and directs 
State Department and Department of Homeland Security to expedite these 
processing of these recaptured visas.
                           senator tuberville
    Question 1. In addition to doctors and nurses, the current health 
worker shortage includes technicians, assistants, pharmacy personnel, 
home health aides, nursing home staff, and more. America is 
experiencing shortages across every aspect of America's health care 
systems--not just the jobs requiring high-level and post-grad degrees. 
We need to train people throughout the care team, all across the 
industry. Not everyone desiring to pursue a career in health care wants 
to go to a full 4-year college or nursing or medical school.

    Question 1(a). Please highlight what other opportunities outside 
traditional 4-year college settings are available to interested 
students?

    Question 1(b). What training and incentive programs are out there?

    Answer 1. Ochsner is proud that last year we invested more than $5 
million to operate more than 29 different workforce programs, serving 
over 1,200 individuals. We have worked hard to ensure that these 
programs are accessible to individuals in both traditional educational 
pathways and those who choose alternate routes. Most of these programs 
are provided free of charge or include tuition assistance. Employment 
opportunities also await individuals finishing these programs. Ochsner 
offers nursing pre-apprenticeship programs to high school and community 
college students, as well as ``earn as you learn'' apprenticeship 
programs for individuals already working as a Medical Assistant who 
want to become and LPN. We also offer scholarships and other financial 
assistance to employees who want to advance their careers by way of our 
career pathway programs. We also have programs focused on individuals 
who are either un-or underemployed or lack proper credentials but wish 
to pursue opportunities within the health care system. MA Now is our 
signature community-facing program that links unemployed and 
underemployed to a nursing pathway. Students earn several industry-
aligned credentials including the certified clinical medical assistant, 
phlebotomy, ED Tech Monitor, and EEG pathways. More than 250 MA Now 
graduates have been trained and employed by Ochsner. Graduates 
regularly move into leadership, LPN, and RN positions as they advance 
their careers. We also offer non-clinical opportunities including In-
Patient Bedside Coding. This program is a 2-year program to build the 
knowledge and capacity for an individual to serve as an in-patient 
coder. This highly sought-after talent is in short supply across our 
Nation. The complexity of in-patient coding requires advance training. 
Our apprenticeship allows students the opportunity to grow their 
knowledge, skills, and abilities to successfully compete in this high 
demand occupation.

    Specifically, with respect to students attending 2-year community 
college we have a number of programs.

          In February 2021, Ochsner launched a partnership with 
        Delgado Community College (Delgado) to train the next 
        generation of nurses and allied health professionals, forming 
        the Ochsner Center for Nursing and Allied Health. Delgado is 
        the largest educator of nurses and allied health professionals 
        in Louisiana. Together, Delgado and Ochsner will meet critical 
        workforce demands, providing more opportunities for local 
        graduates in high-wage careers, and proactively pursue the 
        career development of minority and disadvantaged students. 
        Ochsner's $20 million investment in the center covers full-time 
        tuition for Ochsner employees pursuing a nursing or allied 
        health certificate or degree at Delgado and matching funds for 
        a new state-of-the-art facility on its City Park Campus. In 
        addition to RN and LPN programs, the facility will host 
        Radiologic Technologist, Respiratory Therapy, Physical Therapy 
        Assistant, Occupational Therapy Assistant, Surgical 
        Technologist, Medical Laboratory Technologist, and Pharmacy 
        Technologist programs.

          Ochsner Nursing Pre-Apprenticeship launched in 2021 
        in partnership with Delgado Community College and the Louisiana 
        Department of Education (LDOE). It provides high school 
        sophomores and community college students an opportunity to 
        apprentice as nurses. This LDOE-approved Fast Forward Pathway 
        serves high school students across Jefferson, Orleans, St. 
        Bernard and the River Parishes and also supports students in 
        St. Bernard in partnership with Nunez Community College. The 
        program will soon expand to students in Shreveport, Lafayette, 
        Monroe and Baton Rouge. With more than 350 students currently, 
        the program seeks serve more than 600 students over the next 2 
        years.

          Ochsner Facilities Pathway Pre-Apprenticeship 
        launched in 2022 in partnership with Delgado Community College 
        and includes a high school pathway for the skilled trades 
        (plumbing, light electrical, etc.) as well as an incumbent 
        apprenticeship pathway. While the high school pathway is new in 
        2023, in partnership with Jefferson Parish Public Schools, the 
        incumbent pathway has seven apprentices who will graduate in 
        May 2023 from Delgado. This pathway has been submitted for 
        recognition as a registered apprenticeship.

          Ochsner's Medical Assistant to Licensed Practical 
        Nurse (LPN) Apprenticeship recently celebrated the pinning of 
        31 LPNs. In partnership with LCTCS colleges, North Shore 
        Technical Community College, and Delgado Community College, the 
        registered apprenticeship offers tuition-free career growth to 
        current Ochsner Medical Assistants. Plans are underway to scale 
        the program into the Shreveport and Lafayette areas.

          Patient Care Assistant (PCA) to Certified Nursing 
        Assistant (CNA) is a 8-week pathway program for those with a 
        strong desire for bedside caregiving who lack a credential. New 
        hires enter an ``earn as you learn'' pathway that includes 
        didactic training at a local community college while students 
        supplement the ancillary staff in the hospital as they build 
        their skills. Students graduate as a Certified Nursing 
        Assistant and enter a pathway to progress to LPN and then on to 
        RN.

    Question 2. I have been contacted in particular by EMS 
professionals in Alabama who are sounding the alarm about their own 
individual shortages. Specifically, I recently heard from an EMS 
company in the state, NorthStar EMS. They are providing vital 911 
emergency and interfacility ground ambulance services in both rural and 
urban counties in Alabama. Their organization, and every other 
ambulance service provider in Alabama, is facing an unprecedented 
workforce shortage. NorthStar noticed this issue several years prior to 
the pandemic and started their own training academy in order to make 
EMT education more accessible to people desiring to enter the field. 
When the pandemic started, interest in attending EMT school dropped. 
Not many people wanted to put themselves into a front-line position, 
which made the problem worse. However, the ones who wanted to get into 
the profession at that time turned out to be some of the best students 
and workers they have had in years. They have finally started to see an 
uptick in interest from prospective students, but nowhere near where 
they need to be in order to get back to pre-pandemic levels, which 
leaves them far short of where they need to be.

    According to NorthStar, a recent survey on the EMS workforce 
shortage--involving nearly 20,000 employees working at 258 EMS 
organizations--found that overall turnover among paramedics and EMTs 
ranges from 20 to 30 percent annually. With percentages that high, 
ambulance service providers face 100 percent turnover within a 4-year 
period. Staffing shortages compromise their ability to respond to 
health emergencies, especially in rural and underserved parts of the 
country. In several rural counties in Alabama, only one ambulance is 
staffed most days of the week--not because that is what the service 
wants to do, but because there are no staff to cover the open shifts.

    The EMS workforce shortage has continually worsened over a period 
of several years with the pandemic exacerbating the current shortage 
and highlighting the need to better understand the drivers of workforce 
turnover.

    Question 2(a). From your perspective, what can be done to correct 
the training and staffing pipeline of EMS workers, especially in rural 
areas?

    Answer 2. Ochsner Health cannot fulfill our vision and mission 
without our EMS partners. Whether they are delivering a 911 emergency 
patient to our emergency departments (ED) or emergently transporting 
our patients between facilities in order to provide them the level of 
care needed, EMS is an essential component of our health care system. 
We have definitely felt the significant impact of the shortage of EMS 
staffing. Because of delays in EMS response to 911 calls due to 
shortages, our patients are arriving to us sicker. Our patients are 
facing delays in care due to a lack of available resources to transport 
critically ill or injured patients from a smaller facility to one that 
has the available resources and expertise to manage their conditions.

    We value and appreciate what our EMS colleagues bring to patient 
care. We recently implemented an ``EMS Timeout'' initiative where we 
provide EMS professionals with an opportunity to present their patients 
to us upon arrival in the ED in a respectful, attentive environment. 
When these health care professionals are seen as peers and 
counterparts, it leads to improved patient care.

    We also recognize that being a field EMT is physically demanding, 
and many are forced to seek alternative jobs due to the physicality of 
the profession. Ochsner Health has provided an additional avenue for 
paramedics who might have otherwise left the profession completely, 
leading to retention of experienced paramedics to continue practicing 
in their chosen field, albeit in the hospital setting, where they have 
become an integral part of our on campus care team. We work closely 
with our EMS partners and state entities to ensure EMS interests are 
supported and maintained at the highest level of excellence to arrive 
at the best possible patient outcomes. We also have an elite helicopter 
EMS program, Ochsner Flight Care, with intense, ongoing advanced skills 
training as another avenue for paramedics to pursue. We have a parish-
based 911 EMS Service, St. Charles Parish EMS, that operates from one 
of our facilities.

    We believe that providing our EMS colleagues with additional 
opportunities for employment will help to bring more interest to the 
profession. We strive to promote EMS as a lifelong career, rather than 
simply as a stepping stone, while also supporting paramedics who wish 
to continue their education to become nurses, advanced practice 
providers, or physicians.
                            senator ted budd
    Question 1. Dr. Seoane, how can health systems better partner with 
high schools and community colleges to develop and credential students 
for in-demand health careers?

    Answer 1. Community colleges play a critical role in Ochsner's 
efforts to grow the health care workforce in our region. We are 
fortunate to have developed partnerships with excellent community 
colleges across Louisiana who educate and train Ochsner's current and 
future employees and providers in high quality programs in high demand 
fields. In return, Ochsner is proud to support our partners through 
capital investments, assistance with curriculum development, financial 
support for clinical faculty, and tuition assistance for students.

    Specifically, with respect to students attending 2-year community 
college we offer the following programs:

    Answer 1(a). In February 2021, Ochsner launched a partnership with 
Delgado Community College (Delgado) to train the next generation of 
nurses and allied health professionals, forming the Ochsner Center for 
Nursing and Allied Health. Delgado is the largest educator of nurses 
and allied health professionals in Louisiana. Together, Delgado and 
Ochsner will meet critical workforce demands, providing more 
opportunities for local graduates in high-wage careers, and proactively 
pursue the career development of minority and disadvantaged students. 
Ochsner's $20 million investment in the center covers full-time tuition 
for Ochsner employees pursuing a nursing or allied health certificate 
or degree at Delgado and matching funds for a new state-of-the-art 
facility on its City Park Campus. In addition to RN and LPN programs, 
the facility will host Radiologic Technologist, Respiratory Therapy, 
Physical Therapy Assistant, Occupational Therapy Assistant, Surgical 
Technologist, Medical Laboratory Technologist, and Pharmacy 
Technologist programs.

    Ochsner Nursing Pre-Apprenticeship launched in 2021 in partnership 
with Delgado Community College and the Louisiana Department of 
Education (LDOE). It provides high school sophomores and community 
college students an opportunity to apprentice as nurses. This LDOE-
approved Fast Forward Pathway serves high school students across 
Jefferson, Orleans, St. Bernard and the River Parishes and also 
supports students in St. Bernard in partnership with Nunez Community 
College. The program will soon expand to students in Shreveport, 
Lafayette, Monroe and Baton Rouge. With more than 350 students 
currently, the program seeks serve more than 600 students over the next 
2 years.

    Ochsner Facilities Pathway Pre-Apprenticeship launched in 2022 in 
partnership with Delgado Community College and includes a high school 
pathway for the skilled trades (plumbing, light electrical, etc.) as 
well as an incumbent apprenticeship pathway. While the high school 
pathway is new in 2023, in partnership with Jefferson Parish Public 
Schools, the incumbent pathway has seven apprentices who will graduate 
in May 2023 from Delgado. This pathway has been submitted for 
recognition as a registered apprenticeship.

    Ochsner's Medical Assistant to Licensed Practical Nurse (LPN) 
Apprenticeship recently celebrated the pinning of 31 LPNs. In 
partnership with LCTCS colleges, North Shore Technical Community 
College, and Delgado Community College, the registered apprenticeship 
offers tuition-free career growth to current Ochsner Medical 
Assistants. Plans are underway to scale the program into the Shreveport 
and Lafayette areas.

    Patient Care Assistant (PCA) to Certified Nursing Assistant (CNA) 
is a 8-week pathway program for those with a strong desire for bedside 
caregiving who lack a credential. New hires enter an ``earn as you 
learn'' pathway that includes didactic training at a local community 
college while students supplement the ancillary staff in the hospital 
as they build their skills. Students graduate as a Certified Nursing 
Assistant and enter a pathway to progress to LPN and then on to RN.

    A newer addition to our workforce offerings, is Ochsner's 
partnership with school districts and high schools around the state to 
offer their students an opportunity to experience working in the health 
care system during a particularly important time in their educational 
career. These unique programs offer high school students the 
opportunity to start a paid job in a high demand career field while 
still in high school, with the promise of free college tuition and a 
job upon completion of the program.

    Specifically, with regards to high school students, we offer the 
following programs:

    Ochsner Nursing Pre-Apprenticeship launched in 2021 in partnership 
with Delgado Community College and the Louisiana Department of 
Education (LDOE). It provides high school sophomores and community 
college students an opportunity to apprentice as nurses. This LDOE-
approved Fast Forward Pathway serves high school students across 
Jefferson, Orleans, St. Bernard and the River Parishes and also 
supports students in St. Bernard in partnership with Nunez Community 
College. The program will soon expand to students in Shreveport, 
Lafayette, Monroe and Baton Rouge. With more than 350 students 
currently, the program seeks serve more than 600 students over the next 
2 years.

    Ochsner Facilities Pathway Pre-Apprenticeship launched in 2022 in 
partnership with Delgado Community College and includes a high school 
pathway for the skilled trades (plumbing, light electrical, etc.) as 
well as an incumbent apprenticeship pathway. While the high school 
pathway is new in 2023, in partnership with Jefferson Parish Public 
Schools, the incumbent pathway has seven apprentices who will graduate 
in May 2023 from Delgado. This pathway has been submitted for 
recognition as a registered apprenticeship.

    A key aspect of scaling these types of programs is the availability 
of funding. Ochsner spends significant resources on developing and 
operating these programs, which limits the size and scope of any self-
funded program. To encourage the growth in coordination between the 
Nation's academic institutions and health-systems, we would urge 
Congress to provide funding to support entities working together to 
increase the pipeline of physicians, nurses, and allied health 
professionals. We would also encourage funding to be prioritized for 
efforts that demonstrate a commitment to addressing economic and health 
disparities in the health care workforce.
                                ------                                


    [Whereupon, at 12:30 p.m., the hearing was adjourned.]


                            [all]