[Senate Hearing 118-188]
[From the U.S. Government Publishing Office]


                                                           S. Hrg. 118-188

                       COMMUNITY HEALTH CENTERS:
                       SAVING LIVES, SAVING MONEY

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                                   ON

                 EXAMINING THE COMMUNITY HEALTH CENTERS

                               __________

                             MARCH 2, 2023

                               __________

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

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        Available via the World Wide Web: http://www.govinfo.gov
                
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                   U.S. GOVERNMENT PUBLISHING OFFICE                    
54-461 PDF                  WASHINGTON : 2024                    
          
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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, MARCH 02, 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................................     2

                               Witnesses

Pears Kelly, Amanda, Chief Executive Officer, Advocates for 
  Community Health, Executive Director, Association of Clinicians 
  for the Underserved, Washington, DC............................     5
    Prepared statement...........................................     7
    Summary statement............................................    21
Harvey, Ben, M.A., Chief Executive Officer, Indiana Primary 
  Health Care Association, Indianapolis, IN......................    23
    Prepared statement...........................................    25
    Summary statement............................................    29
Nocon, Robert S., M.H.S, Ph.D., Assistant Professor, Kaiser 
  Permanente Bernard J. Tyson School of Medicine, Los Angeles, CA    30
    Prepared statement...........................................    32
    Summary statement............................................    45
Veer, Sue, M.B.A., C.M.P.E., President and Chief Executive 
  Officer, Carolina Health Centers, Greenwood, SC................    45
    Prepared statement...........................................    48
    Summary statement............................................    60
Farb, Jessica, M.S., Managing Director, Government Accountability 
  Office, Washington, DC.........................................    60
    Prepared statement...........................................    63


                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Casey, Hon. Robert:
    Statement for the Record.....................................   105
Sanders, Hon. Bernie:
    Statement of the American Academy of Ophthalmology...........   106
    Statement by the American Physical Therapy Association.......   108
Cassidy, Hon. Bill:
    Letter to the Hon. Gene Dodaro...............................   109

                        QUESTIONS FOR THE RECORD

Response by Amanda Pears Kelly to questions of:
    Sen. Casey...................................................   110
    Sen. Smith...................................................   111
    Sen. Hickenlooper............................................   112
    Sen. Murkowski...............................................   112
    Sen. Tuberville..............................................   113
Response by Ben Harvey to questions of:
    Sen. Casey...................................................   114
    Sen. Hickenlooper............................................   114
    Sen. Murkowski...............................................   115
    Sen. Tuberville..............................................   116
Response by Sue Veer to questions of:
    Sen. Casey...................................................   118
    Sen. Smith...................................................   119
    Sen. Hickenlooper............................................   121
    Sen. Murkowski...............................................   123
    Sen. Tuberville..............................................   129
Response by Jessica Farb to questions of:
    Sen. Murkowski...............................................   136
    Sen. Tuberville..............................................   136

 
                       COMMUNITY HEALTH CENTERS:
                       SAVING LIVES, SAVING MONEY

                              ----------                              


                        Thursday, March 2, 2023

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.

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

                  OPENING STATEMENT OF SENATOR SANDERS

    The Chairman. The Committee on Health, Education, Labor, 
and Pensions will come to order. Today, we are going to be 
taking a hard look at a major crisis in America, and that is 
that millions of our people do not have access to the health 
care that they need.

    The point that I, and I think some of our panelists will be 
making over and over again, is not only is this unfair to 
working class, to lower income Americans who cannot access a 
medical home when they need it, and we are losing over 60,000 
people a year because they don't get to a doctor on time, but 
in addition to that, from a financial and cost effective 
perspective what we have now is basically insane.

    We have a situation where when people get sick, they don't 
go to the doctor. And you know what happens when you don't go 
to the doctor and you are sick, you get sicker and maybe you 
end up in an emergency room where the cost of primary care is 
10 times or 8 times more than it is if you walked into a 
community health center.

    If you can't afford prescription drugs, you get sicker and 
you may end up in the hospital at a cost of $100,000. So, what 
we are talking today about is two things. My own personal view, 
not shared by everybody on this dais, is that health care is a 
human right and that we should emulate what goes on around the 
rest of the world and guarantee health care to all people.

    I don't have the votes to do that. But I do hope, and by 
the way I think we are making progress, in a bipartisan way at 
least saying, whether you are in rural Indiana or rural Vermont 
or Louisiana, or you may be in New Hampshire, that you do have 
the right to get into a doctor's office and save the health 
care system substantial sums of money.

    It is a funny thing. We had a hearing a couple of weeks ago 
on the crisis in the health care workforce, and it turns out 
that there was strong bipartisan support. Nobody denied the 
fact that we need more doctors, and nurses, and dentists, and 
mental health practitioners, and pharmacists.

    We all understood that. And ironically enough, I mean, to 
talk about nonpartisanship, the witness that Senator Casey 
brought was, I thought, brilliant, talking about what was going 
on in Louisiana, doing extraordinary work----

    Senator Cassidy. Cassidy not Casey----

    The Chairman. Oh, I am sorry.

    [Laughter.]

    The Chairman. Casey was good, too.

    [Laughter.]

    The Chairman. But you were better.

    Senator Cassidy. Yes.

    Senator Kaine: All the Irish guys look alike.

    The Chairman. There you go.

    [Laughter.]

    The Chairman. But the witness that Senator Cassidy brought 
from Louisiana was, I thought he was great. Could have been our 
witness. We brought Dr. James Herbert from New England 
University. It turns out I first met Dr. Herbert through Susan 
Collins. That was our witness.

    Two years ago, it was her witness. All right, why is that? 
Because I think we all understand we have got a crisis. We have 
got to work together. So, our challenge right now is to do the 
right thing for the American people and say that when you get 
sick, there will be a medical home for you to go to.

    Our other job right now is to say that in a health care 
system which spends $13,000 per person, that is an insane 
amount of money. That is double what any other major country 
does. That we understand when we invest in primary health care, 
we are going to save the system money.

    That is the struggle we have. And I am determined to do 
everything I can in a bipartisan way to make sure that we put 
together the kind of primary health care system the American 
people want us to do. So, with that, let me introduce Senator--
what is the last name? Cassidy?

    Senator Cassidy. Collins. Collins.

    [Laughter.]

                  OPENING STATEMENT OF SENATOR CASSIDY

    Senator Cassidy. Today we are discussing an important piece 
of health care infrastructure, community health centers. I am a 
doc. I worked on Louisiana Safety Net or Charity Hospital 
System for over 25 years.

    I know how community health centers provide primary care to 
low income and uninsured patients, and also provide behavioral 
health, dental services, and other care essential to those 
folks, our fellow Americans. And this is a topic we can agree 
upon. Now, I hate to be a fly in the ointment of what should be 
a good hearing, but I am a little bit upset that the majority 
chose not to work with Republicans in developing the hearing.

    There is no reason we could not have gone through the basic 
bipartisan Senate procedure to hold a bipartisan hearing. 
Republicans support this issue. Now, calling partisan hearings 
is a prerogative of the Chairman, but for issues like this 
there is no reason our staff should not be working together 
from square one.

    I raised this because last week the Chairman made a 
wonderful comment. He said that hearings should not be by 
themselves a hearing. They should be a gateway to bipartisan 
legislation. But it is difficult to have a bipartisan 
legislative agenda if the hearings that serve as a prelude are 
partisan. We can have fruitful hearings, produce meaningful 
legislation when the minority is engaged and able to 
contribute.

    But in this case, the minority must be included in the 
planning of the hearing. That said, we look forward to 
hearing--listening to our witnesses and learning more about 
what we can do to address the needs of patients who depend upon 
community health centers. In Louisiana, there is over 350 
health center sites serving over 400,000 patients per year.

    Over a third are in rural areas, and rural communities tend 
to be older and at times to have a greater disease burden with 
fewer physicians and other health care personnel available. 
These factors make community health centers work all the more 
important.

    Now, this Committee must reauthorize the Community Health 
Center Fund before September 30th. As Ranking Member, getting 
this and other reauthorizations done on time and in a fiscally 
responsible way is my priority. To do this effectively, we need 
an understanding of the full picture.

    The landscape of community health centers has changed 
significantly since the Affordable Care Act was passed, and the 
mandatory Community Health Center Fund was created. Ms. Farb 
from the Government Accountability Office will give us color on 
this from their most recent work from 2019. And here is my 
chart.

    GAO's report shows that health centers revenue more than 
doubled from 2010 through 2017. Further the GA--so here is 
where we are now, this is where we were. Further GAO's review 
raises the question, in fact points out, that community health 
centers have become less dependent upon grants as revenue from 
Medicare, Medicaid, and private payers has increased. And so 
here is Medicaid back then, here is Medicaid now.

    Much, much greater growth. Grants have grown too, but you 
can see that Medicare has gone up, private has gone up, other, 
and it is unclear to me if other includes 340B because--and Ms. 
Farb is kind of shaking your head no. And 340B is an incredible 
source of revenue that I don't even think we know how much 
there is there.

    This is not to say that increased funding for health 
centers is not needed. That is what we will discuss today. But 
to underscore the fiscal climate we are in, Americans expect 
and deserve a full and thorough review of how their tax dollars 
are spent.

    As Ms. Farb is aware, this week I requested the GAO update 
its work on sources of funding for community health centers, 
and I ask unanimous consent to insert that request into the 
record.

    The Chairman. Without objection.

    [The following information can be found on page 109 in 
Additional Material:]

    Senator Cassidy. Thank you, sir. As policymakers, this 
information is critical to making informed decisions, 
especially when speaking about mandatory spending. So, Ms. 
Farb, I thank you in advance for taking this project on.

    Last, the Community Health Center Fund reauthorization 
needs to be paid for and high protections maintained. We agree. 
As a physician, I will say an ounce of prevention is worth a 
pound of cure. If we improve health on the front end, we avoid 
costly care on the back end. The Chairman and I, we are 
together on that.

    However, we know that the Congressional Budget Office must 
operate within scorekeeping rules. More spending, from their 
perspective, is more spending. There are a lot of figures that 
will be used today about health center savings for the overall 
health care system. I have seen $24 billion, $25 billion.

    Some of these statistics are based upon data from 2006. 
Now, it is interesting to think about how CBO could account for 
savings based on prevention, but they haven't in the past, and 
I don't think any of us think that data from 2006 is a basis 
for picking amounts.

    Now, health centers do great work, but as we know in 
competing priorities, mandatory funding for health centers 
still needs to be paid for. In closing, I thank our witness 
panel. I look forward to hearing how health centers are using 
investment from the Federal Government to provide essential 
care.

    Particularly as we sit down and understand this year's 
reauthorization of the community health centers, we need your 
information. With that, I yield.

    The Chairman. Okay. Thank you very much, Senator Cassidy. I 
just wanted to briefly respond to Senator Cassidy's opening 
thoughts about this being a quote unquote, bi--part of this 
being a partisan hearing. I don't see it that way.

    I think we you and I have a disagreement is I think the 
minority has a right to invite any witness that you want. And I 
think the majority has a right to invite any witness we want. I 
don't want you to have to clear your witnesses with me. We are 
not going to clear all witnesses with you.

    I think so far, we have had wonderful witnesses on both 
sides. And I think that is the way we should proceed in a 
democratic society. All right, with that, let us hear from our 
panelists. And I thank you all very, very much for being here. 
I have read your testimony. It is, I think, very strong.

    Let's begin with Amanda Pears Kelly, who is the CEO of 
Advocates for Community Health, whose members include some 
leading--some 30 leading health centers around the country.

    Amanda is also the Executive Director of the Association of 
Clinicians for the Underserved. She has many years of 
experience working to expand access to high quality primary 
care to those who need it most. Thank you so much for being 
with us.

   STATEMENT OF AMANDA PEARS KELLY, CHIEF EXECUTIVE OFFICER, 
ADVOCATES FOR COMMUNITY HEALTH, EXECUTIVE DIRECTOR, ASSOCIATION 
       OF CLINICIANS FOR THE UNDERSERVED, WASHINGTON, DC

    Ms. Pears Kelly. Thank you so much, Chairman Sanders, 
Ranking Member Cassidy, and distinguished Members of the 
Committee. My name is Amanda Pearce Kelly. I am the Chief 
Executive Officer of Advocates for Community Health, ACH.

    ACH, as you heard, is a membership organization of 
community health centers focused on advocacy to grow integrated 
primary care and cutting-edge innovation in our field. I have 
worked with community health centers in some capacity my entire 
career. Growing up in Maine, there were times where a federally 
qualified health center was actually my primary source of care.

    I am honored to testify today on behalf of the 30 million 
patients that health centers serve, and on behalf of our 
incredible members, to shed more light on how community health 
centers save lives and save money.

    As other witnesses will testify, there has been consistent 
data over time that community health centers perform 
exceptionally well and do so at a lower cost than other 
providers in other primary care settings.

    As noted in the testimony of Dr. Robert Nocon at the Kaiser 
Permanente School of Medicine, community health centers were 
estimated to save a total of $25.3 billion for the Medicaid and 
Medicare programs in 2021.

    Community health centers have a five-decade history of 
success. But in the past few years, they have overperformed in 
five key areas that I detailed in my written testimony. Today, 
I want to highlight two.

    First, rural health care. Community health centers are 
responding to the growing health care access crisis in rural 
areas. Between 2010 and 2021, 136 rural hospitals closed. 
Research has shown that in areas previously served by a rural 
hospital, there is a higher probability of new community health 
center delivery sites post closure.

    Over time, most rural areas are seeing an increase and 
access to community health centers. And community health 
centers are not only part of the solution to preserving access 
to care in rural communities that might otherwise go entirely 
without. They are also an economic driver contributing to long 
term financial stability.

    Every community health center's workforce and governing 
board is built from the community that it serves, and these 
facilities are often among the largest employers in the 
surrounding area.

    Second, building and retaining the health care workforce. 
The foundation of community health center quality care is their 
integrated, interdisciplinary workforce, and community health 
centers proudly serve as the training ground for a country's 
primary care workforce.

    To recruit, train, and retain workers, community health 
centers leverage HRSA's health care workforce scholarships and 
education loan programs, which help train a diverse workforce, 
including the National Health Service Corps and the Teaching 
Health Center Graduate Medical Education Program.

    A critical factor I would like to call out is that 
community health centers' extraordinary growth has dramatically 
outpaced funding. From Fiscal Year 2015 to 2021, total 
community health center funding increased by 11 percent, while 
the number of patients served increased by 24 percent, from 
24.1 million to more than 30 million today.

    Similarly, the number of health center visits reached a 
record 124 million in 2021. Unfortunately, community health 
centers are facing an unprecedented set of financial 
challenges, and immediate and long-term funding is more vital 
than ever before.

    Medicaid unwinding will lead to an estimated $2.5 billion 
loss in funding for health centers. Expiration of ARP funding 
eliminates up to 7 percent of health center bottom lines and a 
vital source of workforce funding.

    92 percent of community health centers surveyed said that 
they would have experienced additional turnover without funding 
or other benefits from the American Rescue Plan. Contract 
pharmacy limitations, PBM discrimination, and state claw backs 
has also led to significant decline in 340B revenue for health 
centers.

    Indeed, the stakes are very high, but I am here today to 
make a bold ask. HHS's vision for community health center 
funding, $30 billion by 2030, isn't rooted in dollars and 
cents. It is rooted in a vision of what we can achieve for our 
patients, our communities, and all those in need, and also 
savings across our health care system.

    We have seen what we can do with flat funding, but we want 
to push ourselves even further. Specifically, by 2030, we aim 
to serve 40 million patients, train 25,000 additional 
providers, increase the percentage of community health centers 
reaching national clinical benchmarks by 25 percent, increase 
the percentage of community health centers participating in 
value-based care by 20 percent, develop and bring to scale at 
least 15 innovative interventions to address social 
determinants of health.

    We are requesting a 5-year extension of the Community 
Health Centers Trust Fund beginning at $6.2 billion in Fiscal 
Year 2024 and scaling up to $10 billion in Fiscal Year 2028. We 
realize these are large amounts of funding in a difficult 
fiscal time for our Country, but I want to call out a few 
saving stats from my written testimony and in general.

    For every dollar invested in primary care, $13 is saved in 
downstream cost. We know that health centers specifically save 
$24 billion to the system a year. We also know that for every 
$1 invested in health centers, $3 are returned. Investing in 
health centers doesn't just save lives, it saves money.

    I hope my testimony today made the case that community 
health centers are the best place to invest scarce Federal 
resources. Not only do community health centers have a proven 
track record of savings, accountability, and positive economic 
impact, they are the breeding ground for an invaluable 
innovation to drive further savings and better health outcomes, 
all while responding to localized needs of their community.

    Congress has the opportunity to set this vital health care 
system on the right path for the future. Whether measured in 
lives or dollars, there is no better health care investment 
than the health center program.

    We look forward to working with the Committee and your 
colleagues on a bipartisan basis, and I thank you so much for 
the opportunity to testify, and welcome questions.

    [The prepared statement of Ms. Pears Kelly follows:]
                prepared statement of amanda pears kelly

    Thank you, Chairman Sanders, Ranking Member Cassidy, and 
distinguished Members of the Committee. My name is Amanda Pears Kelly, 
and I am the Chief Executive Officer (CEO) of Advocates for Community 
Health (ACH). ACH is a membership organization of community health 
centers focused on visionary and innovative policy and advocacy 
initiatives to affect positive change for community health centers, the 
patients they serve, and the Nation's health care system as a whole. 
Rooted in community health, our members are forward-thinking community 
health centers that lead the way in comprehensive, integrated primary 
care and cutting-edge innovation to help shape a rapidly evolving 
health care landscape.

    I have been working with community health centers in some capacity 
my entire career. Growing up in Maine, there were times when a 
federally qualified health center was my primary source of health care. 
I'm honored to testify today on behalf of the 30 million patients 
served by community health centers and our fantastic members, to shed 
more light on how community health centers save lives and save money.

    In my testimony, I will make the case that increasing investment in 
community health centers is the best investment you can make in health 
care--delivering cost savings, patient health, and community well-
being. I will outline the extraordinary surge in services provided by 
community health centers since the last time Congress considered the 
Community Health Center Trust Fund, how it dovetails with a perfect 
storm of financial challenges community health centers currently face, 
and how Congress can make an investment that can truly transform our 
Nation's primary care system.
                            I. Introduction
    As other witnesses will testify, there has been consistent data 
over time that community health centers perform exceptionally well and 
do so at a lower cost than other providers and other primary care 
settings. Across the board, being connected to primary care services 
leads to better outcomes and lower costs. Recent research has shown 
that, for every $1 invested in primary care, $13 is saved in downstream 
costs. \1\ Of the 4.3 trillion dollars in health spending in the U.S. 
every year, the Nation only spends 5 percent on primary care. However, 
research has shown that if the U.S. spent closer to 12 percent, \2\ it 
would cut per-patient costs and lead to a decrease in overall health 
care expenditures. And the most effective way to achieve a return on 
investment from primary care is to invest in community health centers, 
which are the gold standard of primary care--comprehensive, patient-
centered, patient-governed, accountable, competitively funded, and 
tailored to the needs of local communities. As my colleagues at the 
National Association of Community Health Centers (NACHC) found in a 
recent survey, without community health centers, 15 million more 
patients would be at risk for not having a usual source of primary 
care. \3\

    \1\  Sherril Gelmon et al., ``Implementation of Oregon's PCPCH 
Program: Exemplary Practice and Program Finding'' (Oregon Health 
Authority, September 2016), https://www.oregon.gov/oha/HPA/dsi-pcpch/
Documents/PCPCH-Program-Implementation-Report-Final-Sept-2016.pdf.

    \2\  Robert L. Phillips and Andrew W. Bazemore, ``Primary Care And 
Why It Matters For U.S. Health System Reform,'' Health Affairs 29, no. 
5 (May 2010): 806-10, https://doi.org/10.1377/hlthaff.2010.0020.

    \3\  ``Closing the Primary Care Gap: How Community Health Centers 
Can Address the Nation's Primary Care Crisis'', (National Association 
of Community Health Centers, February 2023), https://
www.hcadvocacy.org/wp-content/uploads/2023/02/Closing-the-Primary-Care-
Gap--Full-Report--2023--digital-final.

    Community health centers innovate in various ways. These 
innovations range from data infrastructure to school-based health 
centers. They include providing an emergency room, integrating 
transition of care for incarcerated patients, advancing maternal and 
child health, offering dental procedures and optometry care, 
integrating behavioral health and substance use treatment, using mobile 
units to reach patients where they live and work, and providing 
Programs of All-Inclusive Care for the Elderly for frail dual eligible 
---------------------------------------------------------------------------
beneficiaries to allow those patients to stay within their community.

    Community health centers continue to be a cost-effective option for 
both patients and the health care system alike. After controlling for 
health status, health insurance coverage, income, age, and other 
factors, patients who received a majority of their ambulatory care at 
community health centers had significantly lower annual overall medical 
expenditures (24 percent) and ambulatory expenditures (25 percent) than 
those who did not. \4\ This also held true for Medicaid patients, where 
health centers save 24 percent per patient compared to other providers, 
\5\ and Medicare patients, where costs for health centers are 10 
percent lower than physician office patients and 30 percent lower than 
outpatient clinics. \6\ As noted in the testimony of Dr. Robert Nocon 
at the Kaiser Permanente School of Medicine, community health centers 
were estimated to save a total of $25.3 billion for the Medicaid and 
Medicare programs in 2021. \7\

    \4\  Patrick Richard et al., ``Cost Savings Associated With the Use 
of Community Health Centers,'' The Journal of Ambulatory Care 
Management 35, no. 1 (March 2012): 50, https://doi.org/10.1097/
JAC.0b013e31823d27b6.

    \5\  Robert S. Nocon et al., ``Health Care Use and Spending for 
Medicaid Enrollees in federally Qualified Health Centers Versus Other 
Primary Care Settings,'' American Journal of Public Health 106, no. 11 
(November 2016): 1981-89, https://doi.org/10.2105/AJPH.2016.303341.

    \6\  Dana B. Mukamel et al., ``Comparing the Cost of Caring for 
Medicare Beneficiaries in federally Funded Health Centers to Other Care 
Settings,'' Health Services Research 51, no. 2 (April 2016): 625-44, 
https://doi.org/10.1111/1475-6773.12339.

    \7\  Robert Nocon (Kaiser Permanente Bernard J. Tyson School of 
Medicine). ``Testimony on Community Health Centers: Saving Lives, 
Saving Money before the U.S. Senate Committee on Health, Education, 
Labor and Pensions Committee.'' (March 02, 2023).

    Furthermore, not only do community health centers save the health 
care system and patients money, but they also serve as economic engines 
for under-resourced neighborhoods. In 2019, community health centers 
generated $63.4 billion in total economic activity, of which $32 
billion were indirect economic impacts generated from supporting local 
businesses. \8\ A national and local study by Capital Link has shown 
that, for every dollar of Federal funding invested in community health 
centers, $11 is generated in total economic activity through increased 
spending on related health service expenses, food services, 
---------------------------------------------------------------------------
transportation, construction, and more. \9\

    \8\  ``Community Health Centers Are Economic Engines'' (National 
Association of Community Health Centers, October 2020), https://
www.nachc.org/wp-content/uploads/2020/12/Economic-Impact-Infographic-
2.pdf.

    \9\  ``Health Centers Provide Cost Effective Care'' (National 
Association of Community Health Centers, July 2015), http://nachc.org/
wp-content/uploads/2015/06/Cost-Effectiveness-FS-2015.pdf.

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           II. Community Health Center Expansion of Services

    Community health centers have a five-decade history of success, but 
in the past few years, these hyper-local health care hubs have been met 
with new and challenging circumstances. In response to these 
unprecedented challenges, they have once again stepped up and 
demonstrated their full potential. I will highlight five areas of 
particular contribution: confronting the COVID-19 pandemic, caring for 
rural communities in the wake of decreasing access, providing critical 
behavioral health services, addressing the social determinants of 
health (SDOH), and serving as major employers and economic drivers even 
in times of economic downturn.

    It is important to note that these accomplishments exemplify the 
unique ability of community health centers to respond quickly to local 
community needs. Even in the face of nationwide trends, each community 
health center can address the particular impact on its local community 
based on the input of their consumer majority boards, which are run by 
community health center patients as required by statute.

                  1. Confronting the COVID-19 Pandemic

    Community health centers saved money and lives throughout the 
COVID-19 pandemic, serving as the single largest source of 
comprehensive primary health care for medically underserved urban and 
rural communities.

    According to the Health Resources and Services Administration 
(HRSA), community health centers provided more than 23 million 
vaccinations, nearly 70 percent of which were given to racial and 
ethnic minority patients. Additionally, community health centers served 
as trusted partners in the communities with early and consistent 
education on vaccination. They also provided 22.56 million COVID tests, 
which led to the identification of over 3 million COVID-positive 
patients. 62 percent of community health centers offered monoclonal 
antibody therapy, and 25 percent of community health centers 
distributed COVID-19 oral antiviral medication throughout the pandemic. 
\10\

    \10\  All COVID related data retrieved from Health Resources and 
Services Administration, Health Center Data Dashboard. Available 
online: data.hrsa.gov.

    To keep patients safe while maintaining access to care, community 
health centers quickly expanded access to telehealth services. In 2021, 
99 percent of community health centers offered primary care services 
via telehealth--and 21 percent of the 124.2 million patient visits 
occurred virtually. \11\ As community health centers have demonstrated 
time and time again, they were able to adjust immediately, with many 
organizations setting up full-blown telehealth operations in a matter 
of days and weeks to address the needs of their community and ensure 
continued access to care even in the most dire of scenarios.
---------------------------------------------------------------------------
    \11\  ``2021 Health Center Program Highlights Uniform Data System 
Trends,'' Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds-2021-data-trends-speakers.pdf.

    Every dollar of the funding provided by Congress through the 
American Rescue Plan went toward providing care to underserved 
patients--from retaining and recruiting the community health center 
workforce, to conducting outreach services to ensure the most 
vulnerable populations remained connected to care. In addition, as 
community health centers serve so many patients who are frontline 
workers in essential industries, health centers were responsible for 
keeping these frontline workers healthy with a consistent source of 
care, which enabled them to continue working and permitted our country 
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to continue to function.

    2. Caring for Communities in the Wake of Rural Hospital Closures

    Community health centers have also responded to the growing health 
care access crisis in rural areas. Between 2010 and 2021, 136 rural 
hospitals closed. \12\ Nineteen of these closures occurred in 2020, the 
year the COVID pandemic hit the United States. Based on the most recent 
data, community health centers serve one in five rural residents, but 
those numbers are rising. Research has shown that in areas previously 
served by a rural hospital, there is a higher probability of new 
community health centers service delivery sites post-closure. \13\ Over 
time, most rural areas are seeing an increase in access to community 
health centers. \14\
---------------------------------------------------------------------------
    \12\  ``Rural Hospital Closures Threaten Access: Solutions to 
Preserve Care in Local Communities'' (American Hospital Association, 
September 2022), https://www.aha.org/system/files/media/file/2022/09/
rural-hospital-closures-threaten-access-report.pdf.

    \13\  Katherine E. M. Miller et al., ``Access to Outpatient 
Services in Rural Communities Changes after Hospital Closure,'' Health 
Services Research 56, no. 5 (October 2021): 788-801, https://doi.org/
10.1111/1475-6773.13694.

    \14\  Nathaniel Bell et al., ``Changes in Access to Community 
Health Services among Rural Areas Affected and Unaffected by Hospital 
Closures between 2006 and 2018: A Comparative Interrupted Time Series 
Study,'' The Journal of Rural Health: Official Journal of the American 
Rural Health Association and the National Rural Health Care Association 
39, no. 1 (January 2023): 291-301, https://doi.org/10.1111/jrh.12691.

          An analysis of the economic impact of a single 
        community health center in Kansas offers insights into how 
        these impacts are felt within a community. In 2018, Mercy 
        Hospital, the sole hospital in rural Fort Scott, Kansas, closed 
        its doors. In the wake of its closure, a nearby community 
        health center, Community Health Center of Southeast Kansas, 
        stepped in to expand health services in Fort Scott, taking over 
        the hospital building and many of its clinics. Not only did the 
        community health center's expansion preserve health care access 
        for the residents of that rural town, but the transformation 
        also allowed the community health center to increase its 
        patient caseload from 47,000 in 2018 to 65,000 by 2021 and to 
        contribute $12.4 million in economic growth to the community, 
        adding 109 jobs in health care and 40 other community jobs. 
        \15\
---------------------------------------------------------------------------
    \15\  Leighton Ku et al., ``The Value Proposition: Evidence of the 
Health and Economic Contributions of Community Health Centers'' (Geiger 
Gibson/RCHN Community Health Foundation Research Collaborative, August 
2022).

    Community health centers are not only part of the solution to 
preserving access to care in rural communities that might otherwise go 
entirely without, but they also are an economic driver contributing to 
long-term financial stability. Every community health center's 
workforce and governing board is built from the community it serves, 
and these facilities are often among the largest employers in the 
---------------------------------------------------------------------------
surrounding area.

          Columbia Basin Health Association \16\ serves a rural 
        area of Washington state. In 2020, even at the height of the 
        COVID-19 pandemic, the organization was still able to provide 
        $136,000 in community support, including migrant worker 
        outreach, Thanksgiving food baskets, and COVID testing events. 
        The health center also held 50 community events, volunteered 
        2700+ hours for community events, and offered $8,000 in 
        scholarships through their Healthy Future program.
---------------------------------------------------------------------------
    \16\  "CBHA 2020 Annual Report" (Columbia Basin Health Association, 
2020), https://www.cbha.org/documents/Annual-Reports/CBHA-Annual-
Report-2020.pdf.

                  3. Providing Behavioral Health Care
    Community health centers are one of the most important access 
points for quality behavioral health care in the United States, and 
they were called to this mission even more so during the pandemic.

    First, community health centers actively integrate behavioral 
health and primary care to improve health outcomes among low 
socioeconomic status and underserved communities by addressing the 
social needs of patients. Community health centers are significantly 
more likely than other safety net practices and non-safety net 
practices to offer early, late, or weekend appointments, provide 
medication-assisted treatment for opioid use disorders, offer 
behavioral health services, and screen patients for SDOH. \17\

    \17\  Valerie A. Lewis et al., ``FQHC Designation and Safety Net 
Patient Revenue Associated with Primary Care Practice Capabilities for 
Access and Quality,'' Journal of General Internal Medicine 36, no. 10 
(October 1, 2021): 2922-28, https://doi.org/10.1007/s11606-021-06746-0.

    Second, community health centers' integrated staffing models drive 
behavioral health integration. Many centers use paraprofessionals for 
behavioral care management, which helps reduce staffing shortages and 
promotes patient-centered care, as Commonwealth Fund's Reggie Williams 
testified at a March 2022 U.S. Senate Finance Committee Hearing on 
``Behavioral Health Care When Americans Need It: Ensuring Parity and 
Care Integration.'' \18\ Additionally, a recent report demonstrated 
that National Health Service Corps (NHSC) behavioral health staff at 
community health centers improves care and reduces costs. On average, 
each additional Full-Time Equivalent NHSC behavioral health staff was 
associated with a savings of $3.55 per visit in Community Health 
Centers; in rural areas, there were greater savings of $7.95 per visit. 
\19\
---------------------------------------------------------------------------
    \18\  Reginald D. Williams II, ``Testimony: Ensuring Access to 
Behavioral Health Care--Making Integrated Care a Reality,'' 
Commonwealth Fund, March 30, 2022, https://doi.org/10.26099/h4n0-p508.

    \19\  Xinxin Han, Patricia Pittman, and Leighton Ku, ``The Effect 
of National Health Service Corps Clinician Staffing on Medical and 
Behavioral Health Care Costs in Community Health Centers,'' Medical 
Care 59 (October 2021): S428, https://doi.org/10.1097/
MLR.0000000000001610.

    Third, community health centers have leveraged telehealth to reach 
more patients in need. A 5-year Patient-Centered Outcomes Research 
Institute study highlighted how several rural community health centers 
successfully use telehealth for mental health services. The study 
looked at two models of care: linking patients to specialists via 
telehealth or integrating telehealth into primary care services. Both 
groups ``reported substantially and statistically significant 
improvements in perceived access to care, decreases in their mental 
health symptoms and medication side effects, and improvements in their 
---------------------------------------------------------------------------
quality of life.'' \20\

    \20\  John C. Fortney et al., ``Comparison of Teleintegrated Care 
and Telereferral Care for Treating Complex Psychiatric Disorders in 
Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial,'' 
JAMA Psychiatry 78, no. 11 (November 1, 2021): 1189-99, https://
doi.org/10.1001/jamapsychiatry.2021.2318.

          ``Since the onset of the pandemic, we have seen an 
        increase in mental health related issues impacting our 
        students,'' said the Director of Behavioral Health at Camarena 
        Health in rural Central Valley, California. ``We are hopeful 
        (that) with . . . funds we will continue to provide the much-
        needed mental health services to our students, specifically to 
        the students and families in our rural communities where mental 
        health (services) is difficult to access.'' \21\
---------------------------------------------------------------------------
    \21\  ``Camarena Health 2021 Annual Report'' (Camarena Health, 
2021), https://www.camarenahealth.org/wp-content/uploads/2022/09/CAM-
2021AnnualReport-Web-AZ.pdf.

    From this foundation, community health centers across the country 
were able to leverage those models to meet the unprecedented need 
during the pandemic. Mental health and substance use disorder services 
exceeded pre-pandemic levels in 2021. Overall, the number of visits for 
mental health issues rose by 19 percent from 2019 to 2021. There was a 
particularly notable increase in the number of patients experiencing 
anxiety disorders; in 2021, three million patients, or 10 percent of 
all community health center patients, had an anxiety disorder 
diagnosis, an increase of 17 percent from 2019. The number of patients 
receiving medication-assisted treatment (MAT) for opioid use disorder 
also increased substantially; in 2021, more than 180,000 patients 
received MAT representing an increase of 29 percent from pre-pandemic 
---------------------------------------------------------------------------
levels.

    In addition to growing demand during the pandemic, these increases 
also reflect growth in community health centers' capacity to provide 
mental health and SUD services. For example, a survey of community 
health centers in late 2021 found that roughly two-thirds (64 percent) 
of community health centers added a new mental health or SUD service, 
including services that community health centers were newly able to 
provide via telehealth. In 2021, community health centers served 2.7 
million patients for mental health needs and provided substance use 
disorder services to 286,000 patients. Community health centers had an 
increase of 138,000 patients seeking mental health and substance use 
disorder services between 2020 and 2021. \22\
---------------------------------------------------------------------------
    \22\ Jessica Sharac et al., "Changes in Community Health Center 
Patients and Services During the COVID-19 Pandemic,'' KFF (blog), 
December 21, 2022, https://www.kff.org/Medicaid/issue-brief/changes-in-
community-health-center-patients-and-services-during-the-covid-19-
pandemic/.

    Unfortunately, the current need is far greater than the existing 
capacity to provide these services. Given our Nation's current mental 
health and substance use disorder challenges, more must be done to care 
for those in need. Community health centers have demonstrated not only 
effectiveness in providing this type of care and responding directly to 
the needs of their community, but they have also done so in a highly 
cost-effective manner--one that ultimately saves lives and our health 
---------------------------------------------------------------------------
care system money.

            4. Addressing the Social Determinants of Health

    Community health centers are uniquely positioned to address SDOH 
and improve population health outcomes. According to Healthy People 
2030, SDOH are ``the conditions in the environments where people are 
born, live, work, play, worship, and age that affect a wide range of 
health, functioning, and quality-of-life outcomes and risks.'' \23\ 6 
in 10 of adults have one chronic disease and 4 in 10 adults have 
multiple chronic diseases. \24\ Evidence shows that social and 
behavioral factors are significantly associated with the development of 
chronic diseases such as hypertension and diabetes, and often these 
SDOH are manageable or treatable. \25\ Even worse, disparities in SDOH 
exacerbate chronic diseases, especially in certain communities, and 
limit ways for people to live a healthy, fulfilled life. \26\ The 
COVID-19 pandemic exacerbated SDOH challenges; compared to before the 
pandemic, over half of the community health centers said they saw an 
increase in the number of patients seeking housing services (69%), food 
and nutrition services (63%), and transportation services (53%). \27\
---------------------------------------------------------------------------
    \23\ ``Social Determinants of Health--Health People 2030,'' Office 
of the Assistant Secretary of Health, n.d., https://health.gov/
healthypeople/priority-areas/social-determinants-health.

    \24\ ``Chronic Diseases in America,'' Centers for Disease Control 
and Prevention, December 13, 2022, https://www.cdc.gov/chronicdisease/
resources/infographic/chronic-diseases.htm.

    \25\ Vishal Vennu et al., ``Associations between Social 
Determinants and the Presence of Chronic Diseases: Data from the 
Osteoarthritis Initiative,'' BMC Public Health 20, no. 1 (August 31, 
2020): 1323, https://doi.org/10.1186/s12889-020-09451-5.

    \26\ Paula Braveman and Laura Gottlieb, ``The Social Determinants 
of Health: It's Time to Consider the Causes of the Causes,'' Public 
Health Reports 129, no. 1--suppl2 (January 1, 2014): 19-31, https://
doi.org/10.1177/00333549141291S206.

    \27\ Jessica Sharac et al., ``How Community Health Centers Are 
Serving Low-Income Communities During the COVID-19 Pandemic Amid New 
and Continuing Challenges,'' KFF (blog), June 3, 2022, https://
www.kff.org/Medicaid/issue-brief/how-community-health-centers-are-
serving-low-income-communities-during-the-covid-19-pandemic-amid-new-
and-continuing-challenges/.

    As of 2021, 74 percent of community health centers collected social 
risk data to help design and execute critical interventions. \28\ Of 
the 26 percent of community health centers that don't currently collect 
social risk data, 80.7 percent of these community health centers (or 21 
percent overall) plan on collecting social risk data in the future. 
\29\ In response to the needs they are seeing, community health centers 
have implemented a variety of solutions to address the wide range of 
SDOHs that their patients experience. The following examples highlight 
ways community health centers have tackled food insecurity, housing 
instability, and linguistic diversity--all services that are above and 
beyond what is required by community health centers under the 330 
statute.
---------------------------------------------------------------------------
    \28\ ``2021 Health Center Program Highlights Uniform Data System 
Trends,'' Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds-2021-data-trends-speakers.pdf.

    \29\ ``2021 Health Center Program Highlights Uniform Data System 
Trends,'' Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds2021-data-trends-speakers.pdf.

---------------------------------------------------------------------------
    Food Insecurity:

    In 2021, 32.1 percent of households with incomes below the Federal 
poverty line were food insecure, \30\ meaning the issue presents itself 
at our country's community health centers every single day. Each center 
tailors its programs to the needs of its local community.
---------------------------------------------------------------------------
    \30\ ``Food Security and Nutrition Assistance,'' United States 
Department of Agriculture, October 18, 2022, https://www.ers.usda.gov/
data-products/ag-and-food-statistics-charting-the-essentials/food-
security-and-nutrition-assistance/.

          East Boston Neighborhood Health Center in 
        Massachusetts takes a four-pronged approach to addressing food 
        insecurity: (1) Food Access programs increase access to healthy 
        foods at Farmers' Markets; (2) the center's Community Resource 
        and Wellness Center serves over 700 families each week with 
        groceries and necessities; (3) an onsite kitchen makes more 
        than 2,000 prepared meals each week for elderly enrolled in its 
        home-delivered meals program through the Senior Care Options or 
        Program of All-Inclusive Care of the Elderly programs; and (4) 
---------------------------------------------------------------------------
        an onsite WIC program supports thousands of families each year.

          Peninsula Community Health Services (PCHS) in 
        Bremerton, Washington, screens all patients for SDOH, including 
        food security. In 2022 they screened 40,007 patients across 
        88,701 visits and identified 303 patients who needed referrals 
        for food as an immediate need. As a part of their process, PCHS 
        provides emergency food boxes inside their clinic--a service 
        they offer without any designated funding. Those patients were 
        then also sent to work with PCHS Community Health Workers for 
        434 ``touches,'' during which the community health center works 
        to coordinate more stable food resources, another non-billable 
        service the community health center shouldered to ensure their 
        patients' needs are met.

    Housing Instability:

    Without stable housing, it is near impossible for a patient to care 
for basic health and human needs. A person without stable housing 
lives, on average, 27.3 fewer years than the average housed person. 
\31\ With nearly 1.3 million patients at community health centers 
nationwide experiencing homelessness, housing instability and 
homelessness are key issues that community health centers must tackle. 
\32\
---------------------------------------------------------------------------
    \31\  Travis P. Baggett et al., ``Mortality Among Homeless Adults 
in Boston: Shifts in Causes of Death Over a 15-Year Period,'' JAMA 
Internal Medicine 173, no. 3 (February 11, 2013): 189-95, https://
doi.org/10.1001/jamainternmed.2013.1604.
    \32\  ``2021 Health Center Program Highlights Uniform Data System 
Trends,'' Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds-2021-data-trends-speakers.pdf.

          At Jordan Valley Health Care in Missouri, all 
        patients are screened for whether or not they have a regular 
        place to live or are at risk of losing their housing. Based on 
        the screening findings, specialists onsite work to identify 
---------------------------------------------------------------------------
        housing assistance and patient options as soon as possible.

          Lifelong Medical Care in California serves 
        transitional housing residents in single-resident occupancy 
        housing--often the final stepping stone from homeless to stable 
        housing--working to stabilize more than 500 patients annually 
        onsite.

    Data shows a return on investment through securing stable housing, 
including fewer emergency room visits, lower health costs, and improved 
health outcomes and quality of life. \33\ Community health centers play 
an integral role in ensuring stable housing, ongoing access to care, 
and bridging gaps in other SDOH, all leading to healthier, more 
stabilized patients.
---------------------------------------------------------------------------
    \33\  Mekdes Tsega et al., ``ROI Calculator for Partnerships to 
Address the Social Determinants of Health: Review of Evidence for 
Health-Related Social Needs Interventions'' (The Commonwealth Fund, 
n.d.), https://www.commonwealthfund.org/sites/default/files/2019-07/
ROI-EVIDENCE-REVIEW-FINAL-VERSION.pdf.

---------------------------------------------------------------------------
    Linguistic Access

    Patients with limited English proficiency are among the most 
vulnerable populations. A 2001 Robert Wood Johnson Foundation report 
found that 94 percent of providers cite communication as the most 
important priority for delivering care. However, more than 70 percent 
of providers reported that language barriers compromise patients' 
understanding of care and treatment, leading many to skip care 
altogether. \34\ Part of providing comprehensive care at community 
health centers includes providing culturally sensitive and 
linguistically competent care. About 1 in 4 patients served by 
community health centers in 2021 are best served in a language other 
than English. \35\
---------------------------------------------------------------------------
    \34\  Robert Wood Johnson Foundation. 2001. New survey shows 
language barriers causing many Spanish-speaking Latinos to skip care. 
[Online]. Available: www.rwjf.org/news.
    \35\  ``2021 Health Center Program Highlights Uniform Data System 
Trends,'' Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds-2021-data-trends-speakers.pdf.

    This problem is especially challenging in the Asian American 
community. In 2019, about 3 in 10 (30.8 percent) Asian American adults 
and 1 in 8 (12.1 percent) Native Hawaiian/Pacific Islander (NHPI) 
nonelderly adults had low English proficiency (LEP), compared with 32.9 
percent of Hispanic adults, 3.1 percent of Black adults, and 1.4 
percent of white adults. An estimated 14.9 percent of Asian American 
adults lived in a household where all members aged 14 and older 
reported having LEP. AANHPI adults with LEP were more likely than those 
proficient in English to have economic disadvantages such as lower 
incomes, lower levels of education, and higher uninsurance rates. \36\
---------------------------------------------------------------------------
    \36\  Jennifer M. Haley et al., ``Many Asian American and Native 
Hawaiian/Pacific Islander Adults May Face Health Care Access Challenges 
Related to Limited English Proficiency,'' Urban Institute, December 12, 
2022, https://www.urban.org/research/publication/many-asian-american-
and-native-hawaiianpacific-islander-adults-may-face-health.

          North East Medical Services (NEMS) in San Francisco, 
        California provides many languages and dialects as a standard 
        part of their culturally competent care, including English, 
        Cantonese, Mandarin, Toishan, Vietnamese, Burmese, Korean, 
        Spanish, and Hindi. \37\ The NEMS health center also helps 
        improve health literacy by providing health education resources 
        in other languages. \38\ Resources are available for asthma, 
        high blood pressure, childhood immunization schedules, 
        diabetes, mental health, and nutrition.
---------------------------------------------------------------------------
    \37\  ``About Us,'' North East Medical Services, n.d., https://
nems.org/about-us/.

    \38\  ``Health Education Resources,'' North East Medical Services, 
n.d., https://nems.org/resources/health-education-resources/.

    Community health centers of all sizes provide language services, 
and centers use different modalities to fit the needs of their 
patients. Centers often have bilingual health providers and nonclinical 
staff, provide interpreters, and/or use video services to assist in 
providing care. \39\ During the pandemic, language often was a barrier 
for telemedicine. However, a recent qualitative study showed that 
audio-only visits with bilingual staff improved patient experience and 
access to care at community health centers. \40\ The audio-only visits 
also removed barriers to broadband and connectivity issues.
---------------------------------------------------------------------------
    \39\  ``Serving Patients with Limited English Proficiency: Results 
of a Community Health Center Survey'' (National Health Law Program, 
June 16, 2008), http://nachc.org/wp-content/uploads/2015/06/
LEPReport.pdf.

    \40\  Denise D. Payn et al., ``Telemedicine Implementation and Use 
in Community Health Centers during COVID-19: Clinic Personnel and 
Patient Perspectives,'' SSM--Qualitative Research in Health 2 (December 
1, 2022): 100054, https://doi.org/10.1016/j.ssmqr.2022.100054.

    Providing culturally and linguistically competent care is a 
cornerstone of the community health center model, and is a fundamental 
part of continued access to care for the 30 million patients served by 
community health centers. It's important to note that true access to 
care must consider and incorporate patient needs to yield positive 
health outcomes, which ultimately yield savings and demonstrable 
returns on investments across the health care system as a whole.
          5. Building and Retaining the Health Care Workforce
    The foundation of community health center quality care is their 
integrated, interdisciplinary workforce, and community health centers 
proudly serve as the training ground for our country's primary care 
workforce. Community health centers naturally embrace the National 
Academy of Sciences, Engineering, and Medicine's recommendation for 
Implementing High-Quality Primary Care: Train primary care teams where 
people live and work. \41\ Between 2020 and 2021, community health 
centers increased their full-time employees by 7 percent, especially to 
improve maternal health outcomes. \42\
---------------------------------------------------------------------------
    \41\  ``Implementing High-Quality Primary Care: Rebuilding the 
Foundation of Healthcare,'' National Academy of Sciences, Engineering, 
and Medicine, n.d., https://www.nationalacademies.org/our-work/
implementing-high-quality-primary-care.

    \42\  ``2021 Health Center Program Highlights Uniform Data System 
Trends,'' Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds-2021-data-trends-speakers.pdf.

    To recruit, train and retain workers, community health centers 
leverage HRSA's health care workforce scholarships and education loan 
programs which help train a diverse workforce, including dentists, 
dental hygienists, mental health professionals, community health 
workers, nurses, midwives, primary care professionals, and faculty. 
\43\ These programs provide care in community-based settings to the 
most vulnerable patients, and help retain a workforce who are most 
likely to serve those communities after training. These vital programs 
include:
---------------------------------------------------------------------------
    \43\  ``Bureau of Health Workforce Field Strength and Students and 
Trainees Dashboards,'' Health Resources and Services Administration, 
n.d., https://data.hrsa.gov/topics/health-workforce/field-strength.

---------------------------------------------------------------------------
          National Health Service Corps

          Health Careers Opportunity Program

          Scholarships for Disadvantaged Students

          Teaching Health Center Graduate Medical Education 
        Program.

    In total, in 2021-2022, there were over half a million participants 
nationwide and over 368,000 graduates across these programs. \44\ Among 
these, over 42,000 participants reported being from an underrepresented 
minority, disadvantaged, or rural background. Over 25,000 participants 
focused on the Department of Health and Human Services (HHS) priority 
of health equity and SDOH. 69 percent of recent graduates now practice 
in a medically underserved community, primary care setting, or rural 
area. NHSC providers represent a diverse group of clinicians. 33 
percent of the Nation's total population identifies as Black or 
Hispanic/Latino. This same population only represents 11 percent of 
physicians in the U.S. However, roughly 25 percent of physicians 
serving through the NHSC identify as Black or Hispanic/Latino, a key 
indication that the NHSC is successfully driving clinician diversity. 
\45\
---------------------------------------------------------------------------
    \44\  ``Health Professions Training Programs,'' Health Resources 
and Services Administration, n.d., https://data.hrsa.gov/topics/health-
workforce/training-programs.
    \45\  Association of Clinicians for the Underserved. ``2023 Fact 
Sheet: National Health Service Corps Program.'' [online]. https://
clinicians.org/wp-content/uploads/2023/02/NHSC-2023-Fact-Sheet.pdf.

    In addition, many community health centers run paraprofessional 
education training programs, which employ many minorities and women and 
contribute to the 1.5-2.5x return on investment to their community. Two 
---------------------------------------------------------------------------
community health centers in Massachusetts exemplify this well:

          East Boston Neighborhood Health Center (EBNHC) in 
        Massachusetts has its own Education and Training Institute that 
        establishes career ladders for the community health center's 
        existing and future professionals, managers, and leaders and 
        provides the education and skill training needed for individual 
        growth and advancement. By bringing education and training 
        opportunities to the community, community health centers 
        address both sides of a vital employment issue. The community 
        health center provides employees and community members with the 
        education and skills needed to obtain well-paying jobs in 
        health care, which in turn creates a source of qualified 
        employees to meet EBNHC's staffing requirements. From entry-
        level skills to professional development, the community health 
        center is developing a range of training and advancement 
        courses and seminars in such a way as to recognize the complex 
        lives and needs of community members and entry-level EBNHC 
        employees.

          Lowell Community Health Center in Massachusetts works 
        with the city to give patients a voice in how Federal funding 
        is allocated. The community health center leads most 
        discussions because it is the trusted voice within the 
        community, ensuring that any economic impact is distributed 
        equitably.

    Community health centers in Massachusetts are more likely to employ 
people from the area, and the state's community health centers added 
more than 21,500 jobs in 2021. In Massachusetts alone, community health 
centers saved $1.1 billion for Medicaid and $1.9 billion for the U.S. 
health system. \46\
---------------------------------------------------------------------------
    \46\  Internal report from Capital Link. Data available upon 
request.

    Much like the consumer majority board, which ensures the community 
health center is driven by and responsive to the community's needs, 
much of the community health center workforce is also built of the 
community they call home. Often among the largest employers in the 
communities they serve, community health centers have been deliberate 
in designing career pathways and training opportunities to respond to 
and support the needs of their patients and their workforce. Data has 
also shown that care provided by caregivers with a shared experience 
leads to better health outcomes, a factor community health centers take 
into account as they seek to develop their own homegrown workforce and 
---------------------------------------------------------------------------
cultivate true community transformation.

          Camarena Health, in rural Central Valley California, 
        illustrates this with one of their Behavioral Health 
        Navigators. One of their employees started as a behavioral 
        health case manager and climbed into the navigator position. He 
        is a Madera native, and his lived experiences help him 
        understand and serve his community at the health center. \47\

    \47\  ``Camarena Health 2021 Annual Report'' (Camarena Health, 
2021), https://www.camarenahealth.org/wp-content/uploads/2022/09/CAM-
2021AnnualReport-Web-AZ.pdf.

          Nieves Gomez, the CEO of Columbia Basin Health in 
        rural Washington state, grew up in a family of migrant workers. 
        He experienced the community health center first as a patient, 
        then professionally, and now leverages his experience and 
---------------------------------------------------------------------------
        knowledge in his current leadership role.

    We would be pleased to share with the Committee examples of similar 
stories and pathways within the community health center network. These 
testimonials demonstrate the unique opportunities and commitment 
community health centers have made to support the health and 
professional development of not just patients, but their workforce who 
hail from within the community as well.
   III. Community Health Center Performance: Expanding Patient Care, 
                           Increasing Quality
    Community health centers provide these services and more while 
caring for a growing patient population from a wide range of 
backgrounds. Community health centers are required to integrate their 
patient voice into their governance. \48\ At least 51 percent of 
community health center board members must be patients served by the 
community health center, ensuring local buy-in, collaboration, and 
direct knowledge of community needs. Additionally, community health 
centers must complete needs assessments every 3 years to ensure an 
ongoing understanding of the unmet needs of their community and improve 
the delivery of care. While these needs assessments often try to 
understand causes of morbidity and mortality, these reports often 
assess SDOH, such as housing, the physical environment, and cultural/
ethnic factors.

    \48\  ``Health Center Program Compliance Manual'' (Bureau of 
Primary Health Care, Health Resources and Services Administration, 
August 20, 2018), https://bphc.hrsa.gov/sites/default/files/bphc/
compliance/hc-compliance-manual.pdf.

    In 2021, HRSA-funded community health centers provided 
comprehensive primary care to a record 30.2 million patients, a 43 
percent increase over the past 10 years. \49\
---------------------------------------------------------------------------
    \49\  "2021 Health Center Program Highlights Uniform Data System 
Trends," Bureau of Primary Healthcare, Health Resources and Services 
Administration, August 9, 2022, https://bphc.hrsa.gov/sites/default/
files/bphc/data-reporting/uds-2021-data-trends-speakers.pdf.

          Rural/Urban: 20.7 million patients were served by 
        urban community health centers, and 9.5 million patients were 
---------------------------------------------------------------------------
        served by rural community health centers.

          Racial/Ethnic: 63 percent of patients identified as a 
        member of a racial/ethnic minority group.

          Socioeconomic: 90 percent of patients had incomes at 
        or below 200 percent of Federal Poverty Guidelines.

          Veterans: Almost 390,000 veterans served, a 3.3 
        percent increase from 2020 to 2021.

          Insurance Status: 48 percent Medicaid, 11 percent 
        Medicare, and 20 percent uninsured.

          Language: 24 percent of patients were best served in 
        a language other than English.

          Age: 8.6 million patients aged 0-17 (29 percent), 
        18.3 million patients aged 18-64 (60 percent), and 3.3 million 
        patients aged 65+ (11 percent).

    As Vermont Community Health Center CEOs Josh Dufresne and Jeff 
McKee state, ``Health centers cannot keep doing more with less.'' \50\ 
The present trajectory is unsustainable, and the Federal funding for 
health centers is not keeping pace with rising medical costs and 
patient population growth. \51\ Community health centers' extraordinary 
growth has dramatically outpaced funding. From Fiscal Year 2015 to 
Fiscal Year 2021, total community health center funding increased by 11 
percent ($5.1B to $5.7B) while the number of patients served increased 
by 24 percent (24.1 million to 30 million). \52\ Similarly, the number 
of health center visits reached a record 124 million in 2021. \53\
---------------------------------------------------------------------------
    \50\  Josh Dufresne and Jeff McKee, "Dufresne & McKee: Health 
Centers Cannot Keep Doing More with Less," VTDigger, January 18, 2023, 
https://vtdigger.org/2023/01/18/dufresne-mckee-health-centers-cannot-
keep-doing-more-with-less/.
    \51\  Matrix Global Advisors. The Overlooked Decline in Community 
Health Center Funding. 2022. https://acrobat.adobe.com/link/
review?uri=urn:aaid:scds:US:58b05b79-f372-30b3-aa7c-874ee1517dec.
    \52\  Julia Paradise et al., "Community Health Centers: Recent 
Growth and the Role of the ACA," KFF (blog), January 18, 2017, https://
www.kff.org/medicaid/issue-brief/community-health-centers-recent-
growth-and-the-role-of-the-aca/.
    \53\  Jessica Sharac et al., "Changes in Community Health Center 
Patients and Services During the COVID-19 Pandemic," KFF (blog), 
December 21, 2022, https://www.kff.org/medicaid/issue-brief/changes-in-
community-health-center-patients-and-services-during-the-covid-19-
pandemic/.

    Also notable, the quality of care provided by community health 
centers has not altered or been sacrificed in the face of growth. 1,058 
community health centers (77 percent) have achieved Patient-Centered 
Medical Home (PCMH) recognition, and community health centers have an 
eight times greater odds of attaining PCMH certification compared to 
other types of health care practices. \54\ The PCMH model of care 
enables community health centers to have strong patient outcomes at 
lower costs despite treating patients who are often sicker, with more 
complex health care needs, and those who come from a poorer population 
than in other health care settings. 79 percent of community health 
centers met or exceeded one or more national clinical benchmarks in 
2020, with more than half (55 percent) reporting improvements in 5 or 
more clinical quality measures (CQMs) and 1 in 6 community health 
centers nationwide (16 percent) reporting clinical quality measures 
(CQMs) and 1 in 6 community health centers nationwide (16 percent) 
reporting improvements in 8 or more CQMs. \55\
---------------------------------------------------------------------------
    \54\  "Community Health Center Chartbook 2022" (The National 
Association of Community Health Centers (NACHC), 2022), https://
www.nachc.org/wp-content/uploads/2022/03/Chartbook-Final-2022-Version-
2.pdf.
    \55\  ``Health Center Program: Impact and Growth,'' Bureau of 
Primary Health Care, Health Resources and Services Administration, 
August 2022, https://bphc.hrsa.gov/about-health-centers/health-center-
program-impact-growth.

          Chief of Information Services Dave Perkins at Yakima 
        Valley Farm Workers Clinic in western Washington, describes 
        community health centers' commitment to quality: ``Tearing down 
        barriers between patients and their care has been a cornerstone 
        of our organization from its inception. We hope to continue 
        that trend by ensuring their health information is always at 
        our patients' fingertips.'' \56\ Yakima is working with CMS on 
        advancing health equity metrics for all community health 
        centers. Additionally, as highlighted in the Washington Health 
        Alliance's 2022 Community Checkup Report, the clinic had the 
        fourth-best composite percentage in Washington state, 
        representing an overall score that represents four areas: 
        prevention and screening, chronic disease care, coordinated and 
        cost-effective care, and appropriate and cost-effective care. 
        \57\
---------------------------------------------------------------------------
    \56\  ``Report to Our Communities 2021'' (Yakima Valley Farm 
Workers Clinic, 2021), https://www.yvfwc.com/wp-content/uploads/2022/
07/119-220711-RTOC-Web-Single-8.5x11-Pages.pdf.
    \57\  ``2022 Community Checkup Report'' (Washington Health 
Alliance, 2022), https://wahealthalliance.org/wp-content/uploads/2022/
03/2022-community-checkup-report-Improving-Care-in-WA-state.pdf.

              IV. Community Health Center Financial Crisis
    Unfortunately, even as community health centers continue to 
leverage successes and look to expand to meet the increasing needs of 
patients in new and existing communities, they are facing an 
unprecedented set of financial challenges.

                           Medicaid Unwinding

    States have begun the process of redetermining eligibility for 
every beneficiary covered under Medicaid, a process that was on hold 
during the Public Health Emergency. While the number of Medicaid 
enrollees who may be disenrolled during the ``unwinding'' period is 
highly uncertain, it is estimated that millions will lose access to 
Medicaid coverage. The Kaiser Family Foundation estimates that between 
5.3 million and 14.2 million people will lose Medicaid coverage once 
the continuous enrollment provision ends. \58\
---------------------------------------------------------------------------
    \58\  Jennifer Tolbert and Meghana Ammula, ``10 Things to Know 
About the Unwinding of the Medicaid Continuous Enrollment Provision,'' 
KFF (blog), February 22, 2023, https://www.kff.org/Medicaid/issue-
brief/10-things-to-know-about-the-unwinding-of-the-Medicaid-continuous-
enrollment-provision/.

    Community health centers expect that the end of the Public Health 
Emergency and continuous Medicaid coverage will pose a significant risk 
to community health centers, as Medicaid provides health care coverage 
to over 48 percent of community health center patients \59\--or about 
15 million patients--and made up 41 percent of community health center 
revenue in 2021. \60\ A new report from the Geiger Gibson/RCHN 
Community Health Foundation Research Collaborative at the George 
Washington University Milken Institute School of Public Health puts the 
facts into a stark reality: up to 2.5 million community health center 
patients could lose their Medicaid coverage once continuous enrollment 
ceases. \61\ HHS estimates that 56 percent of those losing coverage 
will be due to loss of eligibility and will need to transition to 
another source of coverage. 44 percent will lose Medicaid coverage 
despite still being eligible (``administrative churning''), although 
HHS is taking steps to reduce this outcome. Community health centers 
will continue to care for these patients regardless of their status. 
But without additional resources, they will face enormous financial 
challenges to sustain everything from workforce recruitment and 
retention, to continued programming to address SDOH, to community 
outreach to keep patients healthy.
---------------------------------------------------------------------------
    \59\  ``National Health Center Program Uniform Data System (UDS) 
Awardee Data,'' Health Resources and Services Administration, 2021, 
https://data.hrsa.gov/tools/data-reporting/program-data/national.

    \60\  KFF. ``Community Health Center Revenues by Payer Source,'' 
December 5, 2022. https://www.kff.org/other/state-indicator/community-
health-center-revenues-by-payer-source/.

    \61\  Leighton Ku et al., ``The Potential Effect of Medicaid 
Unwinding on Community Health Centers,'' Geiger Gibson Program in 
Community Health, GW Milken Institute School of Public Health, January 
19, 2023, https://geigergibson.publichealth.gwu.edu/potential-effect-
Medicaid-unwinding-community-health-centers.

    This widespread coverage loss could trigger a deficit of $1.5 
billion to $2.5 billion in patient revenue for community health 
centers, which amounts to between 4 percent and 7 percent of total 
community health center revenue nationally. By law, community health 
centers must ``provide comprehensive, high-quality primary care and 
preventive services regardless of patients' ability to pay.'' However, 
a revenue impact of this size means that community health centers, the 
Nation's largest primary care system for medically underserved rural 
and urban communities, could be faced with increasing challenges to 
serve between 1.2 million and 2.1 million patients; and with this sharp 
reduction in resources, community health centers also could lose the 
ability to employ or retain 10,700 to 18,500 of their staff. The study 
is based on estimates of the unwinding's impact prepared by the Urban 
Institute and data on community health centers from the 2021 Uniform 
Data System data. \62\ The study's authors report that these estimates 
likely are low, since they are based on 2021 community health center 
data and the number of patients served by community health centers 
---------------------------------------------------------------------------
likely increased over the 2022-2023 period.

    \62\  Leighton Ku et al., ``The Potential Effect of Medicaid 
Unwinding on Community Health Centers,'' Geiger Gibson Program in 
Community Health, GW Milken Institute School of Public Health, January 
19, 2023, https://geigergibson.publichealth.gwu.edu/potential-effect-
Medicaid-unwinding-community-health-centers.

    Even in a normal year, community health centers confront the 
natural churn of Medicaid patients, which can result in access barriers 
as well as additional administrative costs. When individuals who remain 
eligible for coverage are disenrolled, they may experience gaps in 
coverage that could limit access to care and lead to delays in getting 
needed care. Research indicates that enrollees who experience 
fluctuations in coverage are more likely to report difficulties getting 
medical care and are more likely to end up in the hospital with a 
preventable condition. \63\ In addition, there are administrative costs 
associated with disenrolling an enrollee and then subsequently 
processing a new application. \64\ Community health centers are ready 
to serve additional patients, but centers are burdened with additional 
administrative barriers to help patients keep or transition to the 
proper health insurance coverage.
---------------------------------------------------------------------------
    \63\  U.S Government Accountability Office. ``Medicaid: States Made 
Multiple Program Changes, and Beneficiaries Generally Reported Access 
Comparable to Private Insurance,'' November 15, 2012. https://
www.gao.gov/products/gao-13-55.
    \64\  Katherine Swartz et al., ``Evaluating State Options for 
Reducing Medicaid Churning,'' Health Affairs 34, no. 7 (July 2015): 
1180-87, https://doi.org/10.1377/hlthaff.2014.1204.

    As the Commonwealth Fund points out, community health centers and 
safety-net providers will play a critical role after the unwinding. 
\65\ Community health centers not only serve patients, but also serve 
as navigating partners to help patients maintain or find insurance 
coverage and connect patients to community-based organizations and 
agencies. This includes connecting members to Supplemental Nutrition 
Assistance Program, Special Supplemental Nutrition Program for Women, 
Infants, and Children, assistance for victims of interpersonal and 
family violence, and other clinically and health-related social needs 
network services. 37 percent of community health centers expanded 
enrollment assistance staff, and 42 percent were scheduling advanced 
appointments for high-risk patients. \66\ To re-engage patients, 
regardless of insurance status, community health centers must conduct 
linguistically and culturally appropriate outreach in some of the most 
hard-to-reach communities.
---------------------------------------------------------------------------
    \65\  Sara Rosenbaum, Caitlin Murphy, and Rebecca Morris, ``When 
Medicaid's COVID-19 Pandemic Continuous Enrollment Guarantee Unwinds, 
Safety-Net Providers Will Play a Critical Role,'' Commonwealth Fund, 
July 7, 2022, https://doi.org/10.26099/f09x-dp94.
    \66\  Jessica Sharac et al., ``How Community Health Centers Are 
Serving Low-Income Communities During the COVID-19 Pandemic Amid New 
and Continuing Challenges,'' KFF (blog), June 3, 2022, https://
www.kff.org/Medicaid/issue-brief/how-community-health-centers-are-
serving-low-income-communities-during-the-covid-19-pandemic-amid-new-
and-continuing-challenges/.

          At Cumberland Family Medical Center (CFMC) in 
        Kentucky, one patient eloquently captures the expertise and 
        understanding community health center staff provide. ``I am a 
        widow and am on a fixed income. I cannot afford insurance if it 
        was not for the ACA. I tried signing myself up, but was unable 
        to get the application completed, but with the help of CFMC's 
        KyNectors, I now have insurance and can afford to go to the 
        doctor when I need to. The KyNectors were so helpful and any 
        time I have a question I still call her. She even called after 
        I was enrolled to make sure I had received my insurance card. 
        Thank you CFMC for caring about your patients and going above 
        and beyond to make sure they have the best care 
        possible.''received my insurance card. Thank you CFMC for 
        caring about your patients and going above and beyond to make 
        sure they have the best care possible.''received my insurance 
        card. Thank you CFMC for caring about your patients and going 
        above and beyond to make sure they have the best care 
        possible.'' \67\
---------------------------------------------------------------------------
    \67\  ``Outreach Stories & Patient Testimonials,'' Cumberland 
Family Medical Centers, n.d., https://www.cumberlandfamilymedical.com/
media/outreach-stories-patient-testimonials.aspx.

    Without additional resources to support community health centers to 
continue to provide care to those in need and help patients navigate 
coverage gaps, access and health outcomes could suffer as a result.
                Expiration of Supplemental COVID Funding
    The expiration of supplemental COVID funding will be an additional 
challenge, as it made up 7 percent of community health center revenues 
in 2021. \68\ While much of the COVID funding was used for non-
recurring expenses specific to the COVID pandemic, in a survey of our 
members, we found that community health centers were forced to use this 
funding to fill critical gaps, especially in the area of the workforce. 
\69\ Due to the years of flat funding in the community health center 
program, our centers have been unable to make additional investments in 
workers at all levels. With this supplemental funding, community health 
centers were able to prioritize recruitment and retention. As it goes 
away, they are once again faced with flat budgets against dramatically 
increasing needs and market rates. Simply put, community health centers 
do not have the resources to compete with some privately held 
practices, hospital systems, or corporate-owned or financially backed 
practices, causing severe challenges for both recruiting and retaining 
staff. To put this issue into greater context, if community health 
centers lack the funding and resources necessary to retain and recruit 
staff at all levels, access to care will suffer.
---------------------------------------------------------------------------
    \68\  Jessica Sharac et al., ``Changes in Community Health Center 
Patients and Services During the COVID-19 Pandemic,'' KFF (blog), 
December 21, 2022, https://www.kff.org/Medicaid/issue-brief/changes-in-
community-health-center-patients-and-services-during-the-covid-19-
pandemic/.
    \69\  Internal ACH survey data available upon request.

---------------------------------------------------------------------------
                      Erosion of the 340B Program

    Making an already dire situation worse, the 340B program, a vital 
revenue stream for federally qualified community health centers, is 
slowly being eroded by the actions of state policymakers, 
pharmaceutical companies, and pharmacy benefit managers. In national 
studies of the 340B program, 92 percent of community health centers 
utilize 340B savings to increase access for low-income and/or rural 
patients by maintaining or expanding services in underserved 
communities. \70\ A study of a regional network of community health 
centers found that the number of community health center patients who 
are 65 and older is twice as high in rural communities as in urban 
communities, who more often have complex medication regimens and higher 
costs. \71\ The 340B program enables community health centers to manage 
more clinical complexity for these patients.
---------------------------------------------------------------------------
    \70\  ``Summary of NACHC's Report on 340B: A Critical Program for 
Health Centers'' (National Association of Community Health Centers, 
June 2022), https://www.nachc.org/wp-content/uploads/2022/06/NACHC-
340B-Report-Summary-June-2022.pdf.
    \71\  OCHIN. ``How Affordable Prescription Medication Program 
Supports Care for Low-Income Patients,'' July 5, 2022. https://
ochin.org/blog/affordable-prescription-medication-program-supports-
care-low-income-patients.

    Unfortunately, the revenue they have to make these investments is 
shrinking. States across the country, including California, have taken 
back community health centers' 340B revenue--taking it for general 
state funds, without the reinvestment guardrails by which community 
health centers must abide. Pharmaceutical companies refuse to honor 
discounts at contract pharmacies, which decreases 340B savings and cuts 
off access to medications. And finally, both Pharmacy Benefit Managers 
and insurers discriminate against 340B entities by targeting them with 
lower reimbursement. Taken together, these actions place a consistent 
source of revenue for community health centers at risk.
                          Workforce Shortages
    In a recent NACHC survey, 92 percent of community health centers 
surveyed say they would have experienced additional turnover without 
funding and other benefits from the American Rescue Plan. Rates of 
estimated additional turnover are highest among rural community health 
centers. 97 percent of community health centers surveyed believe that 
additional Federal funding would help employee retention and 
recruitment. \72\ As mentioned above, community health centers are at a 
significant disadvantage when it comes to retaining and recruiting the 
health care workforce. While anecdotally, hospitals and larger systems 
report losing between $100,000--$200,000 annually per primary care 
physician, they can make that money back through specialty referrals 
and other high-cost services. Community health centers have no ability, 
nor is their model such, that they can recoup revenue via specialty 
referrals or other services--a critical difference in understanding the 
financial structures under which Community Health Centers function. 
It's important to note that community health centers' quality of care--
measured through vaccinations, cancer screenings, and control of 
diabetes--decreases health care costs while limiting the centers' 
ability to recoup costs. Therefore, programs like the National Health 
Service Corps and others offer community health centers tools to 
recruit and retain providers, and ensure that primary care growth 
continues in medically underserved areas.
---------------------------------------------------------------------------
    \72\  ``Current State of the Health Center Workforce: Pandemic 
Challenges and Policy Solutions to Strengthen the Workforce of the 
Future'', (National Association of Community Health Centers, March 
2022), https://www.nachc.org/wp-content/uploads/2022/03/NACHC-2022-
Workforce-Survey-Full-Report-1.pdf.

    At a time when the health care workforce is already severely 
strained, and recruitment and retention strategies like loan repayment 
programs, competitive salaries, training, education and career pathways 
are vital, community health centers cannot afford to take a step 
backward and further batter an already weary workforce. Burnout comes 
with a cost. Turnover in the primary care physician workforce costs the 
United States $979 million; $260 million of that (27 percent) is 
attributable to burnout. \73\ Community health centers are poised to 
serve millions of additional patients, but this is dependent on 
critical investments and expansion of community health center funding 
to both stabilize and grow the community health center workforce.
---------------------------------------------------------------------------
    \73\  Christine A. Sinsky et al., ``Health Care Expenditures 
Attributable to Primary Care Physician Overall and Burnout-Related 
Turnover: A Cross-Sectional Analysis,'' Mayo Clinic Proceedings 97, no. 
4 (April 1, 2022): 693-702, https://doi.org/10.1016/
j.mayocp.2021.09.013.

---------------------------------------------------------------------------
                 V. Conclusion: The Case for Investment

    Community health centers work tirelessly to meet the evolving needs 
of their patients. With the right investment, community health centers 
can fulfill their mission as hyper-local health care hubs--treating the 
full range of patients' needs, supporting community transformation, and 
achieving true health equity. ACH's vision for community health center 
funding--$30 billion by 2030--isn't rooted in dollars and cents. It's 
rooted in a vision of what can be achieved for our patients, our 
communities, and all those in need. We seek to push ourselves further, 
achieving better outcomes for patients and eliminating health care 
disparities, including between rural and urban communities. 
Specifically, by 2030, we aim to:

          Serve 40 million patients

          Train 25,000 additional providers

          Increase the percentage of community health centers 
        reaching national clinical benchmarks by 25 percent

          Increase the percentage of community health centers 
        participating in value-based care by 20 percent

          Develop and bring to scale at least 15 innovative 
        interventions to address the SDOH

    We urge Congress to scale investment in community health center 
funding, including infrastructure, workforce, and innovation. We 
request a 5-year extension of the Community Health Center Trust Fund, 
with the following annual funding amounts: fiscal year 2024: $6.2 
billion; fiscal year 2025: $6.98 billion; fiscal year 2026: $7.87 
billion; fiscal year 2027: $8.87 billion; and fiscal year 2028, $10 
billion.

    We realize these are large amounts of funding in a difficult fiscal 
time for our country. But I hope my testimony today made the case that 
community health centers are the best place to invest scarce Federal 
resources. As has been documented over and over again, the savings 
yielded by the community health resources. As has been documented over 
and over again, the savings yielded by the community health center 
program are immense.

    Not only do community health centers have a proven track record of 
savings, accountability, and positive economic impact, they are the 
breeding ground for invaluable innovation to drive further savings and 
better health outcomes, all while responding to the localized needs of 
their community. The Health Center Program is a shining example of a 
vital Federal investment with localized control and impact, and massive 
system-wide returns in the form of savings, employment, and economic 
stimulation in otherwise underserved communities.

    Community health centers are required to serve every patient who 
walks through their doors, regardless of their insurance status or 
ability to pay. But to do so, we need an investment from the Federal 
Government that matches our communities' needs. This comprehensive, 
culturally, and linguistically competent care also requires a strong 
community health center workforce. Rather than disinvest in community 
health centers and force them to pull back, we need to reinvest to 
allow them to expand and offer more people their high-quality, low-cost 
services. Investing in community health centers allows us to accomplish 
the following:

          Focus on providing access and care without worrying 
        about piecemealing funding

          Fully provide patient-centered, holistic models of 
        care that incorporates social needs

          Allow agility in providing emergency/pandemic care

          Reinvest in providing care and medication to our 
        uninsured population

          Provide robust outreach to underserved patients

    As we have established in this testimony, community health centers 
have significantly increased services and expanded the number of 
patients served--all while facing damaging financial headwinds. Yes, we 
have proven we can do a great deal with limited resources; but we could 
do even more with meaningful investment. Community health centers are 
poised to care for our Nation's underserved, innovate and drive new 
models of care, produce healthier patients and communities, and save 
our health care system scarce resources.

    I'm fortunate to have conversations daily with community health 
center leaders who can easily tell me about the long list of programs, 
services, expansions, and new models they'd like to bring to fruition 
if only they had the resources to do so. Congress has the opportunity 
to set this vital health care system on the right course for the 
future. Whether measured in lives or dollars, there is no better health 
care investment than the Health Center Program.
                                 ______
                                 
               [summary statement of amanda pears kelly]
    Increasing investment in community health centers (CHCs) is the 
best investment Congress can make in health care--delivering cost 
savings, patient health, and community well-being. Access to primary 
care at health centers leads to better outcomes and lower costs--up to 
$30 billion annually in Medicare and Medicaid combined. Health centers 
are the gold standard of primary care--comprehensive, patient-centered, 
patient-governed, accountable, competitively funded, and tailored to 
the needs of local communities. Since Congress last considered the 
Community Health Center Trust Fund, community health centers have 
demonstrated particular capacity in the following areas:

          COVID-19: CHCs provided tens of millions of 
        vaccinations and COVID tests and access to monoclonal antibody 
        therapy and antiviral medication. They quickly expanded access 
        to telehealth services and conducted important outreach 
        services, provided employment, and kept frontline workers 
        connected to health care.

          Rural Health Care: Health centers serve one in five 
        rural residents, and those numbers are rising. In areas 
        previously served by a rural hospital, there is a higher 
        probability of new CHC service-delivery sites post closure. 
        Over time, most rural areas are seeing an increase in access to 
        CHCs. Health centers are an economic driver contributing to 
        long term financial stability in rural areas.

          Behavioral Health: CHCs actively integrate behavioral 
        health and primary care to improve health outcomes, and 
        leverage staffing strategies and telehealth services to improve 
        care. There has been unprecedented need for mental health and 
        substance abuse disorder services during and after the 
        pandemic; the current need is far greater than existing 
        capacity to provide these services.

          Social Determinants of Health: The majority of CHCs 
        collect social risk data to help design and execute critical 
        interventions, and many have successfully implemented solutions 
        to address patient needs.

          Workforce: CHCs are the training ground for our 
        country's integrated, interdisciplinary primary care workforce. 
        CHCs have workforce programs and policies to help train and 
        retain providers who are most likely to serve those communities 
        after training. They also provide career ladders for staff and 
        students interested in healthcare. Much of the health center 
        workforce comes from the communities they serve.

    In 2021, HRSA-funded health centers provided comprehensive primary 
care to a record 30.2 million patients, a 43 percent increase over the 
past 10 years. Health centers' extraordinary growth has dramatically 
outpaced funding. As the need continues to increase, CHCs face an 
unprecedented set of financial challenges, including the ongoing 
Medicaid unwinding, the expiration of supplemental COVID funding, 
continued erosion of 340B program revenue, and dire workforce 
shortages.

    The Case for Investment: ACH's vision for health center funding--
$30 billion per year (including discretionary and mandatory funding) by 
2030--is rooted in a vision for what we can achieve for our patients, 
for our communities and for all those in need. We seek to push 
ourselves further, achieving better outcomes for patients and 
eliminating health care disparities, including between rural and urban 
communities. We urge Congress to scale investment in health center 
funding, including infrastructure, workforce, and innovation. We 
request a 5-year extension of the Community Health Center Trust Fund, 
with the following annual funding amounts: fiscal year 2024: $6.2 
billion; fiscal year 2025: $6.98 billion; fiscal year 2026: $7.87 
billion; fiscal year 2027: $8.87 billion; and fiscal year 2028, $10 
billion.

    Not only do health centers have a proven track record of savings, 
accountability, and positive economic impact, they are the breeding 
ground for invaluable innovation to drive further savings and better 
health outcomes, all while responding to the localized needs of their 
community. Whether measured in lives or dollars, there is no better 
health care investment than the Health Center Program.
                                 ______
                                 
    The Chairman. Thank you very much, Ms. Pears Kelly. Our 
next witness will be Ben Harvey. Mr. Harvey is the CEO of the 
Indiana Primary Health Care Association. He will be introduced 
by Senator Braun of Indiana.

    Senator Braun. Thank you, Chairman Sanders, and Ranking 
Member Cassidy. A pleasure to introduce Ben Harvey, fellow 
Hoosier, graduate of Taylor University back in Indiana. Heads 
our Indiana Primary Health Care Association. Great job at doing 
it.

    Previously served in a senior role with the Missouri 
Department of Health and Senior Services. His work has helped 
increase the number of community health centers throughout 
Indiana and modernized the state's telehealth laws, which is 
going to become increasingly important, I think, down the road 
in health care, resulting in greater access to quality care for 
many Hoosiers.

    Greatly appreciate your willingness to come and share your 
Hoosier practicality with all of us here and look forward to 
hearing what you have to say.

STATEMENT OF BEN HARVEY, M.A., CHIEF EXECUTIVE OFFICER, INDIANA 
       PRIMARY HEALTH CARE ASSOCIATION, INDIANAPOLIS, IN

    Mr. Harvey. Well, thank you, Senator Braun, for the 
introduction. It is an honor to be here. It is an honor to be 
in this room. Honored to be introduced by a distinguished 
Hoosier like yourself, so thank you for that.

    Chairman Sanders, Ranking Member Cassidy, Members of the 
Committee, thank you for the invitation to be here to discuss 
community health centers. I would like to specifically thank 
you, Mr. Chairman, for your work to expand the National Service 
Core, Community Health Centers, Teaching Health Center Program.

    Your leadership is appreciated by health centers in my 
state, across the country, so thank you for that. I would also 
like to thank Senator Braun, Senator Young, the Senators from 
Indiana, for their longstanding support of Indiana's community 
health centers.

    Before I begin, I just want to note that I have a very 
personal connection to health centers and the work that they 
do. I grew up in a rural, medically underserved part of 
Indiana, Grant County, and I have seen firsthand the impacts of 
a lack of medical services on individual lives. So, the concept 
deaths of despair, that idea that young adult Americans are 
dying earlier, that is a very real thing to me.

    I have seen friends and family die of substance use 
disorders, suicide, chronic diseases. These are very real. So, 
I stand as a witness not only to the impact that health centers 
have on the health care system, but also on the impact they 
have on individual Americans and the people that they serve.

    Health centers, like Amanda mentioned, are nonprofit, 
patient governed organizations that provide high quality, 
comprehensive primary health care to people living in medically 
underserved areas. In 2021, health centers nationally reached 
the historic milestone of serving 30 million Americans in a 
single year.

    In Indiana, we have 350 clinical delivery sites that serve 
a little over 600,000 Hoosiers, 90 percent of whom are below 
200 percent of the Federal poverty level, and 65 percent of 
whom are below the poverty level. Health centers in Indiana 
have established themselves as the safety net for Indiana's 
communities.

    A recent example of this is the response to health centers, 
Southern Indiana Community Health Centers and Indiana Health 
Centers, had to a closure over a hospital in Bedford. Both 
SICHC and IHC stepped into that situation, which you are all 
aware of, when a rural hospital closes. It can have pretty 
detrimental impacts to health.

    It can also have a detrimental impact to the economy. Both 
of those health centers stepped into that void to provide 
continuity of services, to work with the other existing 
critical access hospital, and to support the local community.

    In addition to that, we know CHCs positively impact the 
economies of the communities in which they operate, which are 
oftentimes economically distressed, in addition to being 
medically underserved. In Indiana, the total economic impact is 
over $1 billion annually, and that number is certainly much 
larger at a national level.

    Health centers additionally impact their local economies by 
providing employment and workforce development opportunities in 
areas that are impacted by higher rates of unemployment.

    For example, Eskenazi Health Center on Central Indiana has 
created their own medical assistant training program, which 
allows the training of existing non-clinical staff. It also 
allows Eskenazi Health Center, it gives them the ability to 
work with local community groups, like the Goodwill of Central 
and Southern Indiana, to identify potential candidates from the 
community for job training.

    It is well established and well noted that integrated team 
based primary care services improve health care quality and 
cost outcomes. Decades of research like, those done by Dr. 
Nocon, have consistently shown health centers create cost 
savings despite serving populations who are at higher risk of 
poor overall health and chronic conditions.

    Health centers save at least $24 billion a year. It is a 
well-established number. Health center patients have lower 
rates of multi-day hospitalizations, hospital admissions, lower 
rates of ED utilization, lower rates of specialty care visits, 
and lower numbers of inpatient bed days. And research again has 
shown that health center patients have about 24 percent lower 
overall costs than patients receiving primary care in other 
settings.

    Access to primary care, like those found at health centers, 
can be improved and sustained through strategic investments. We 
know that the portion of Americans with identified source of 
primary care is decreasing.

    In Indiana, HRSA and the CDC, two Federal agencies, 
estimate there are more than 2 million Hoosiers in health 
professional shortage areas and roughly 800,000 Hoosiers who 
report lacking a usual place to go for medical care.

    Additional Federal investments in health centers would 
extend their reach into the underserved communities in Indiana 
and deepen their existing service lines, creating greater 
access to maternal and newborn health, mental and behavioral 
health care, and oral health care.

    Federal funding, Senator Cassidy just showed an image on 
this, which is generally less than 20 percent of health 
centers' overall budget, provides critical funding to stabilize 
operations and provide startup funding for new services or new 
service sites in underserved areas.

    Again, in conclusion, the Community Health Center Program 
is a cornerstone of the U.S. health care system and Indiana's 
health care system. Health centers are a cost effective, high 
quality, highly efficient form of primary care, which save 
billions of dollars every year and improve the lives and health 
of millions of Americans, many of whom I know.

    Health centers need continued sustained funding and are 
primed to meet the ongoing and expanded needs of the patients 
in the communities they serve. And again, thank you for the 
invitation to testify, and I look forward to your questions.

    [The prepared statement of Mr. Harvey follows:]
                    prepared statement of ben harvey
    Chairman Sanders, Ranking Member Cassidy, and distinguished Members 
of the Committee, thank you for the invitation to discuss the impact of 
Community Health Centers (CHCs) on the health of people across America, 
in addition to CHCs economic impact, ability to lower health care 
costs, and the opportunity for further investment in CHCs.

    I would like to specifically thank Chairman Sanders for his 
dedicated efforts to significantly expand the National Health Service 
Corps, Community Health Centers, and Teaching Health Centers. Your 
leadership is much appreciated by CHCs across the country. I would also 
like to thank the Senators from Indiana, Sen. Braun, who sits on this 
prestigiuous Committee, and Sen. Young, for their long-standing support 
of Indiana's CHCs.

    Before I begin I would like to note the very personal connection I 
have with CHCs. Born and raised in a medically undeserved part of rural 
Indiana, I have seen firsthand the costs of limited access to care and 
poor health. ``Deaths of despair'' the expression describing the 
decreasing life expectancy of young-adult Americans, is very real to 
me, having seen too many friends succumb to substance use disorders, 
suicide, and chronic disease. I stand as a witness not only to the 
impact CHCs have on the overall health care system, but also as a 
witness to the impact they can and do have on the individual Americans 
they serve.

    CHCs are nonprofit, patient-governed organizations that provide 
high-quality, comprehensive primary health care to people living in 
medically underserved areas. Serving 1 in 11 people nationwide, CHCs 
are committed to providing care to all patients, regardless of income 
or insurance status. In 2021, CHCs marked the historic milestone of 
serving 30 million Americans in a single year.

    Established in 1982, the Indiana Primary Health Care Association 
(IPHCA) is the membership body for Indiana's CHCs and CHC Look-A-Likes. 
IPHCA supports a membership that includes Indiana's 27 CHCs and 12 
Look-A-Likes who collectively have over 350 clinic sites across Indiana 
that provide primary medical, dental, and behavioral health care to 
over 600,000 Hoosiers, 90 percent of whom are below 200 percent of the 
Federal Poverty Level (FPL), and 65 percent of whom are below the FPL.

    CHCs in Indiana range from large, urban-centered CHCs who serve 
more than 50,000 patients annually, to small rural CHCs who serve less 
than 5,000 patients annually. Collectively, more than 50 percent of 
patients at Indiana's CHCs identify as a racial and/or ethnic minority, 
with 16 percent of patients being best served in a language other than 
English.

                   The Direct Economic Impact of CHCs

    Within the US health care system, the main role of CHCs is to 
provide high-quality primary health care with a particular focus on 
serving vulnerable populations. CHCs, in particular, provide care to 
low-income patients and those who are uninsured or under insured. In 
this role as a health care safety-net provider, CHCs offer a 
comprehensive array of health care services which include primary care, 
behavioral health, chronic disease management, preventive care, as well 
as other specialty, enabling, and ancillary services such as radiology, 
laboratory, dental, transportation, translation, and social services.

    CHCs are a specifically defined type of health care organization. 
CHCs must offer services to anyone, regardless of their ability to pay; 
have a sliding fee system; be a nonprofit or public organization; be 
community-based with a board of directors composed primarily of 
patients; provide services in areas that are medically underserved or 
to an underserved population; offer comprehensive primary care 
services; and have an ongoing quality assurance program.

    CHCs positively impact the economies of communities in which they 
operate, which are often times economically distressed in addition to 
being medically vulnerable. In late 2020, the Center for Health Policy 
at the Indiana University, Richard M. Fairbanks School of Public Health 
conducted a once in a decade study of the economic impact of CHCs in 
Indiana. The total economic impact of CHCs in Indiana was nearly $1 
billion annually. This is an increase of $800 million, up from a $195 
million annual impact in 2009. Every dollar spent on CHC operations, 
supplies, and personnel generates an additional $.81 for the overall 
state economy, up from $.54 in 2009.

    Investments in CHCs generate not only direct economic benefits for 
the local economies in which they operate (e.g., hiring of staff, 
materials, physical plant), but also two types of economic spin-off 
benefits: (1) indirect economic benefits to the businesses that support 
the operation of the CHCs (e.g., the suppliers of materials, 
construction firms), and (2) induced economic benefits to the local 
economy from the increased spending by persons who have received either 
direct or indirect benefits from the operation of CHCs. The size of 
these ``ripple effects" can sometimes exceed the original direct 
benefit, particularly when the local economy is depressed or when 
unemployment is high, which is often the case in communities in which 
CHCs are located.

    CHCs in Indiana provided 2,910 direct jobs to employees who support 
the operation of CHCs and another 3,082 jobs to workers in the larger 
economy who provide the goods and services purchased by CHCs and 
through income generated directly or indirectly by the CHCs. The impact 
on jobs has increased substantially since 2009 by contributing an 
additional 2,049 direct jobs and another 2,496 indirect jobs to 
Indiana's economy.

    CHCs additionally impact their local economies by providing 
workforce development opportunities in areas that are impacted by 
higher rates of unemployment and poverty. By partnering with local 
schools of higher education, community partners, public schools, or 
even developing their own training programs, CHCs create the 
opportunity to improve local labor conditions and create a newly 
skilled workforce.

    In 2021, Indiana University's Bowen Center for Health Workforce 
Research and Policy, conducted an analysis of health professional 
education and training efforts being undertaken by Indiana's CHCs. The 
analysis recognized CHC's response to workforce challenges, and 
alignment with organizational missions to serve their community, to 
train the next generation of the health workforce and engage in health 
professional education and training as a part of their engagement, many 
CHCs serve as training sites for health professions students of all 
types, with a particular emphasis on occupations that are in high-
demand. These high-demand occupations, many of which would not exist in 
the community except for CHCs, consist of wide range of specialties and 
offer unique services pertinent to serving underserved communities.

    A CHC in Northwest Indiana, HealthLinc, offers a grow-your-own 
Medical Assistant (MA) program, operated in partnership with the 
National Institute of Medical Assistant Advancement, which hosts MA 
students enrolled in local training programs. Supported by the Indiana 
Department of Workforce Development's Next Level Jobs Workforce Ready 
Grants, HealthLinc has focused on ``upskilling'' existing non-clinical 
employees by enabling them to participate in on-the-job training. Due 
to the success of the MA trainings, and their commitment to improving 
their community through the creation of employment opportunities, 
HealthLinc plans to expand their program to include training Dental 
Assistants.

    HealthLinc's work is not an outlier. Eskenazi Health Center in 
Central Indiana, has created their own MA training program, which 
allows the training of existing non-clinical staff. The program also 
gives Eskenazi Health Center the ability to work with local community 
groups, such as Goodwill of Central & Southern Indiana, to identify 
potential candidates from the community for job training. This training 
extends both the capacities of Eskenazi Health Center, related to their 
own workforce needs, and the individual community member or employee, 
who has now developed a highly sought-after and marketable skill set 
they may not otherwise have the opportunity to develop.

    CHCs have also established themselves as the safety-net for 
Indiana's communities. One very recent example in Indiana is the 
response of Southern Indiana Community Health Center (SICHC) and 
Indiana Health Centers (IHC), to the closure of Ascension St. Vincent 
Dunn Hospital in Bedford, IN, in December 2022. A hospital closure in a 
community can lead to devastating gaps in access to care, and have 
ripple effects, include short and long-term negative economic effects, 
across the community. This was particularly true in Bedford, as Dunn 
Hospital was the only hospital with a labor and delivery unit.

    Recognizing the needs of the Bedford community, SICHC and IHC both 
boldly stepped forward to fill the void for primary care services, 
particularly OB services, created by the hospital closure. Both CHCs 
worked with the community to create continuity of care, fill access 
gaps created by the closure, and to create new partnerships, such as a 
collaboration with a local Critical Access Hospital, to support the 
newly vulnerable community.

               Health Care Cost Savings Generated by CHCs

    High-quality primary care services are a critical component of the 
U.S. health care system. It is well established that integrated, team-
based primary care services improve health care quality and cost 
outcomes. CHCs in particular are a cost-effective, high-quality, and 
highly efficient form of primary care, in part due to the comprehensive 
and integrated nature of the services CHCs provide.

    Research shows CHCs provide comparable and oftentimes higher 
quality care compared to other health entities, particularly for the 
most vulnerable Americans. A 2013 brief from The Kaiser Commission on 
Medicaid and the Uninsured found that when comparing data collected 
from CHCs to HEDIS data, CHCs often outperformed MCOs in key chronic 
care metrics, including A1c control for diabetics and blood pressure 
control for hypertensive patients. Indiana data tells a similar story; 
CHC patients are more likely to have chronic diseases like hypertension 
and diabetes under control compared to the general population of 
Medicaid recipients in the state.

    CHCs provision of community-based, relationship oriented care for 
basic health needs, chronic disease management, substance use 
disorders, and many other services in an integrated, enabling and 
collaborative fashion across the health care system creates substantial 
reductions in overall cost. Decades of research have consistently shown 
CHCs create cost savings, despite serving populations who are a higher 
risk of poor overall health and chronic conditions. CHCs save at least 
$24 billion in costs annually for the health care system. It is 
estimated that it is between $500-$2,300 less expensive for a Medicaid 
patient to receive primary health care at a CHC than at another 
provider.

    CHCs help lower the cost of medical care by providing the types of 
primary and preventive services that reduce the need for costlier 
medical care such as preventable emergency room visits and in-patient 
hospital care. CHC patients have lower rates of multi-day hospital 
admissions, lower rates of ED utilization, lower rates of specialty 
care visits and lower numbers of inpatient bed days. Research has shown 
that health center patients have 24 percent lower overall costs than 
patients receiving primary care in other settings.

    A recent study conducted on the impact of funding for CHCs on 
utilization and emergency department visits in Massachussetes provides 
a clear demonstration of the effect of CHCs on health care cost 
drivers. The study found that areas in Massachusetts which had greater 
funding increases provided to CHCs resulted in increased growth in 
patient visits, and reductions in the number of people with visits to 
the emergency department, especially for conditions that do not require 
immediate emergency care. This reduction in visits to the emergency 
department was unique to areas with increases in health center funding, 
and provides evidence for the impact CHCs have on patients by providing 
a usual option for primary care.

    As one CHC leader was quoted as saying in the report conducted by 
the previously mentioned analysis conducted by the Indiana University, 
Fairbanks School of Public Health:

        ``We really feel like our niche is safety net care. So, we 
        really look for those opportunities in the community to pickup 
        the vulnerable and marginalized populations. We've got a couple 
        of different programs that we feel like really get at the heart 
        of that. One of those programs is an emergency department 
        follow-up program. If folks are seen in the emergency 
        department and they don't have somewhere to follow-up, we will 
        see them. An example would be if I had a primary care provider 
        and I got stitches in the emergency department today [and] my 
        primary care provider couldn't get me in, I could come to [the 
        CHC] for follow-up.''

         Opportunities and Need for Further Investment in CHCs

    Access to primary care can be improved through sustained and 
strategic investments in CHCs. The health center model ensures access 
to primary care for all individuals, that is patient-center, community-
based, and high-quality.

    The reach and impact of the health center program has grown 
substantially, and has demonstrated the ability for continued growth. 
Since 2015, the number of federally funded CHCs has remained relatively 
constant, with no Federal grant adjustments to keep pace with inflation 
or other costs. Yet, the number of clinic sites operated by CHCs across 
the Nation has increased from 10,000 in 2015 to over 14,000 in 2021. 
The number of patients served by CHCs has also increased, growing by 6 
million, or 24 percent during the same time period. In Indiana, this 
expansion has resulted in an increase from 100 clinic sites in 2015, to 
over 350 at the time of this Hearing. The number of Hoosiers served by 
CHCs also increased by over 150,000 from 2015 to today.

    Despite the successful expansion of CHCs, we know that the portion 
of Americans with an identified source of primary care is decreasing, a 
trend further investment in CHCs can help reverse. This is partially 
related to the ongoing, chronic shortage of primary care access. In 
Indiana, according the Health Resources and Services Administration 
(HRSA), there are currently more than 2 million Hoosiers in primary 
care Health Professional Shortage Areas. It is not surprising then that 
based on national estimates, roughly 800,000 Hoosiers report lacking a 
usual place to go for medical care.

    Specifically focusing on a population CHCs serve extensively, the 
medically uninsured, paints a similar picture of an opportunity to 
address unmet need. Among the non-elderly population in Indiana in 
2021, there were nearly 600,000 uninsured Hoosiers, who we know 
traditionally face limited access to health care services. In 2021, 
nearly half (46.7 percent) of nonelderly uninsured adults reported not 
seeing a doctor or health care professional in the past 12 months 
compared to 18.2 percent with private insurance and 13.1 percent with 
public coverage. Of the nearly 600,000 uninsured Hoosiers, 150,000 are 
served by Indiana's CHCs which, with additional Federal funding serving 
as a catalyst, is a number that would certainly increase and help to 
address the issue of access to care for uninsured Hoosiers.

    Additional Federal investments in CHCs would extend their reach 
into underserved communities across Indiana, and deepen their existing 
service lines, creating greater access to maternal/newborn health care, 
mental and behavioral health care, and oral health care. The last time 
a competition for CHC New Access Points was held by HRSA in 2019, 
approximately 500 applications were submitted nation-wide. However, due 
to limited funding, only 77 organizations were funded.

    According to the National Association of Community Health Centers, 
a commitment by Congress to allocate an additional $500 million over 5 
years will enable over 750 new CHCs to reach approximately 4 million 
new patients. Federal funding, which is generally less than 20 percent 
of a CHCs overall budget, provides critical funding to stabilize 
operations and provide start-up funding for new services or service 
sites.

                               Conclusion

    The health center program is a cornerstone of the U.S. health care 
system and Indiana's health care system. CHCs are a cost-effective, 
high-quality, and highly efficient form of primary care, which save 
billions of dollars every year and improve the health of millions of 
Americans. CHCs need continued, sustained funding, and are primed to 
meet the ongoing and expanded needs of the patients and communities 
they serve.

                               References

    A Roadmap to Expanding Health Professions Education and Training 
Programming in Indiana CHCs. The Indiana University, Bowen Center for 
Health Workforce Research and Policy. October 2021, Accessed at https:/
/www.indianapca.org/wp-content/uploads/2022/04/FINAL-Roadmap-to-
Expanding-HPET-in-Indiana-Health-Centers-3.pdf.

    Access to Health Care, Fast Stats. Centers for Disease Control and 
Prevention, National Center for Health Statistics. December 2022, 
Accessed at https://www.cdc.gov/nchs/fastats/access-to-health-care.htm.

    Closing the Primary Care Gap, How Community CHCs Can Address the 
Nation's Primary Care Crisis. National Association of Community CHCs 
and HealthLandscape at the American Academcy of Family Physicians. 
February 2023, Accessed at https://www.nachc.org/focus-areas/policy-
matters/closing-the-primary-care-gap/.

    Dor, A., Pylypchuck, Y., Shin, P., and Rosenbaum, S. (2008). 
Uninsured and Medicaid patients' access to preventive care: Comparison 
of health centers and other primary care providers (Geiger Gibson/RCHN 
Community Health Foundation Research Collaborative policy research 
brief no. 4). Washington, DC: George Washington University, School of 
Public Health and Health Services, Department of Health Policy.

    Finegold K, Conmy A, Chu RC, Bosworth A, and Sommers, BD. Trends in 
the U.S. Uninsured Population, 2010-2020. (Issue Brief No. HP-2021-02). 
Washington, DC: Office of the Assistant Secretary for Planning and 
Evaluation, U.S. Department of Health and Human Services. February 11, 
2021.

    Health Workforce Shortage Areas. Health Resources and Services 
Administration. Dec. 2022, Accessed at https://data.hrsa.gov/topics/
health-workforce/shortage-areas.

    Key Facts about the Uninsured Population. Kaiser Family Foundation. 
Dec. 2022, Accessed at https://www.kff.org/uninsured/issue-brief/key-
facts-about-the-uninsured-population/.

    Levine DM, Linder JA, Landon BE. Characteristics of Americans With 
Primary Care and Changes Over Time, 2002-2015. JAMA Intern Med. 
2020;180(3):463-466. doi:10.1001/jamainternmed.2019.6282

    Myong C, Hull P, Price M, Hsu J, Newhouse JP, et al. (2020) The 
impact of funding for federally qualified CHCs on utilization and 
emergency department visits in Massachusetts. PLOS ONE 15(12): 
e0243279. https://doi.org/10.1371/journal.pone.0243279.

    National Academies of Sciences, Engineering, and Medicine. 2021. 
Implementing High-Quality Primary Care: Rebuilding the Foundation of 
Health Care. Washington, DC: The National Academies Press. https://
doi.org/10.17226/25983.

    Nocon RS, Lee SM, Sharma R, Ngo-Metzger Q, Mukamel DB, Gao Y, White 
LM, Shi L, Chin MH, Laiteerapong N, Huang ES. Health Care Use and 
Spending for Medicaid Enrollees in federally Qualified CHCs Versus 
Other Primary Care Settings. Am J Public Health. 2016 Nov;106(11):1981-
1989. doi: 10.2105/AJPH.2016.303341. Epub 2016 Sep 15. PMID: 27631748; 
PMCID: PMC5055764.

    Quality of Care in Community Health Centers and Factors Association 
With Performance. The Kaiser Commission on Medicaid and the Uninsured. 
June 2013, Accessed at: https://www.kff.org/wp-content/uploads/2013/06/
8447.pdf.

    The Impact of Indiana's Community CHCs, The Center for Health 
Policy at the Indiana University Richard M. Fairbanks School of Public 
Health. Nov. 2020, Accessed at: https://www.indianapca.org/resource/
resource-link/impact-analysis-of-indiana-CHCs/.
                                 ______
                                 
                   [summary statement of ben harvey]
    Community Health Centers (CHCs) are nonprofit, patient-governed 
organizations that provide high-quality, comprehensive primary health 
care to people living in medically underserved areas. In 2021, CHCs 
marked the historic milestone of serving 30 million Americans in a 
single year, 600,000 of whom were Hoosiers.

    CHCs are a specifically defined type of health care organization. 
CHCs must offer services to anyone, regardless of their ability to pay; 
have a sliding fee system; be a nonprofit or public organization; be 
community-based with a board of directors composed primarily of 
patients; provide services in areas that are medically underserved or 
to an underserved population; offer comprehensive primary care 
services; and have an ongoing quality assurance program.

    In Indiana, CHCs have a direct economic impact of nearly $1 
billion. CHCs also impact their local economies by providing workforce 
development opportunities in areas that are typically impacted by 
higher rates of unemployment and poverty.

    Research has consistently shown health center patients covered by 
Medicaid and Medicare routinely have lower annual costs than patients 
seen by other providers. CHC patients have lower rates of multi-day 
hospital admissions, lower rates of ED utilization, lower rates of 
specialty care visits and lower numbers of inpatient bed days. CHCs 
save at least $24 billion in costs annually for the health care system.

    Access to primary care can be improved through sustained and 
strategic investments in CHCs. The health center model ensures access 
to primary care for all individuals, that is patient-center, community-
based, and high-quality.

    CHCs are a cost-effective, high-quality, and highly efficient form 
of primary care, which save billions of dollars every year and improve 
the health of millions of Americans. CHCs need continued, sustained 
funding, and are primed and ready to continue, and expand, to meet the 
needs of the patients and communities they serve.
                                 ______
                                 
    The Chairman. Mr. Harvey, thank you very much for your 
testimony. Our next witness is Dr. Robert Nocon, who is an 
Assistant Professor at Kaiser Permanente School of Medicine, 
who prior to that was a researcher at the University of 
Chicago. Dr. Nocon, thanks a lot for being with us.

     STATEMENT OF ROBERT S. NOCON, M.H.S, PH.D., ASSISTANT 
    PROFESSOR, KAISER PERMANENTE BERNARD J. TYSON SCHOOL OF 
                   MEDICINE, LOS ANGELES, CA

    Dr. Nocon. Chairman Sanders, Ranking Member Cassidy, and 
distinguished Members of the Committee, thank you for the 
opportunity to testify on the topic of community health centers 
today.

    As was mentioned, I work as an Assistant Professor at the 
Kaiser Permanente Bernard J. Tyson School of Medicine, and I am 
a health services researcher who studies the financing and 
organization of care in the safety net.

    I state for the record that my views today are my own as a 
researcher and do not necessarily represent the views of Kaiser 
Permanente or the KP School of Medicine. As others have noted, 
community health centers have long played a critical role in 
providing access to comprehensive, high quality primary care 
across the United States.

    There is also a long history of academic research on 
community health centers and the care they provide. I will be 
focusing my comments on research that assesses the cost and 
utilization of care for community health center patients, and I 
will specifically highlight an ongoing series of studies that I 
conduct along with my collaborators at the University of 
Chicago.

    In these studies, our group uses national Medicaid and 
Medicare administrative claims data, drawing from data from 
2012 to 2016. We use the claims data to identify patients who 
receive most of their primary care in community health centers, 
and comparison patients who mainly get their primary care in 
other settings.

    We conduct separate studies for general populations of 
adults, children, and individuals duly eligible for Medicaid 
and Medicare, as well as more focused studies on individuals 
with opioid use disorder and those with diabetes.

    By using these national claims data sets, we are able to 
study a range of different types of health care utilization and 
cost, not only the types of services that community health 
centers provide, but also the services that occur downstream of 
primary care, such as emergency department use and 
hospitalization.

    Across these studies, we find that health center patients 
have greater use and cost for primary care services, but 
generally less use and cost of other services. When we add up 
those costs across all services, we find that health center use 
is associated with lower total costs of care, on average, 15 
percent lower for adults and 22 percent lower for children.

    In terms of quality of care, while specific results vary by 
disease area, we mostly find that health centers have similar 
or better levels of performance on quality measures, such as 
prevention of unnecessary hospitalizations, and completion of 
recommended well-child visits.

    Applying our estimates of cost savings to the national 
population of health center patients in 2021, we estimate that 
health centers resulted in a cost savings of over $25 billion, 
from reduced payments from Medicaid and Medicare, over a 1-year 
period. Beyond our own research group studies, our findings are 
consistent with multiple studies over time that have found 
community health centers to be associated with lower total 
costs.

    Dr. Leighton Ku of George Washington University shared his 
own estimates in assessment of the literature, which I appended 
to my testimony. Notably, much of Dr. Ku's work has used a 
completely different dataset, national surveys of patients, and 
observed similar levels of cost savings associated with health 
centers.

    Across different populations, data sets, years, and 
research groups, several studies have described this pattern of 
health center care being associated with lower total costs, and 
comparable or better quality.

    Overall, these studies provide a large body of evidence 
that support the case for health center value. Given the 
Committee's consideration of future Federal health center grant 
funding, I will close by highlighting one additional theme from 
our work, which is the particular importance of this grant 
funding to health center operations.

    Recently published studies from our group have shown that 
health center staffing and service volume are particularly 
sensitive to changes in Federal health center grant levels, and 
these grants are associated with stronger overall financial 
health as an organization.

    Other witnesses today have and will continue to speak 
eloquently about the supportive services and advance care model 
that health centers provide. Our research suggests that this 
model of care contributes to value through lower Medicaid and 
Medicare costs for other types of utilization, and the 
community health center grant funding under consideration by 
this Committee is particularly important to maintaining this 
program and the benefits it provides to our most medically 
underserved communities.

    Thank you for the opportunity to testify today, and I look 
forward to your questions.

    [The prepared statement of Dr. Nocon follows:]
                   prepared statement of robert nocon
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
                  [summary statement of robert nocon]
          My statement describes research on cost and 
        utilization of care for patients of community health centers.

          Community health centers serve a critical role in 
        providing access to comprehensive, high quality primary care in 
        areas of high health care need across the United States.

          A large body of research, dating back over 30 years, 
        has studied how care for patients who use health centers 
        differs from patients who use other types of primary care 
        providers.

          Research conducted along with my collaborators at the 
        University of Chicago has used national administrative claims 
        data from Medicaid and Medicare to analyze this topic. We find 
        that health center patients have greater use and cost for 
        primary care services, but generally less use and cost of other 
        services ``downstream'' of primary care, such as inpatient 
        hospitalization.

          Accounting for all types of medical care utilization, 
        we find that health center use is associated with lower total 
        costs of care. Health center patient total cost is 15 percent 
        lower for adults and 22 percent lower for children, compared to 
        similar patients who go to other settings for their primary 
        care.

          In terms of quality of care, while specific results 
        vary by disease area, we mostly find that health centers have 
        similar or better levels of performance on quality measures 
        such as prevention of unnecessary hospitalizations or 
        completion of recommended well-child visits.

          Applying our estimates of cost savings to the 
        national population of health center patients in 2021, we 
        estimate that health center care resulted in a cost savings of 
        over $25 billion to Medicaid and Medicare over a 1-year period.

          Our research findings are consistent with numerous 
        studies over time that have found community health centers to 
        be a cost-efficient way of strengthening the health care safety 
        net.
                                 ______
                                 
    The Chairman. Thank you, Dr. Nocon, for your testimony. Our 
next witness is Sue Veer, President and CEO of Carolina Health 
Centers in South Carolina, where she has served since 2006. Ms. 
Veer has over 35 years of experience supporting the development 
and leadership of health centers and primary care associations.

    She also serves on the Board of Directors of the National 
Association of Community Health Centers. Ms. Veer, thank you so 
much for being with us.

 STATEMENT OF SUE VEER, M.B.A., C.M.P.E., PRESIDENT AND CHIEF 
   EXECUTIVE OFFICER, CAROLINA HEALTH CENTERS, GREENWOOD, SC

    Ms. Veer. Thank you, Chairman Sanders. Chairman Sanders, 
Ranking Member Cassidy, and Members of the Committee, I want to 
thank you for this opportunity to testify about the important 
work of community health centers.

    As the Senator said, my name is Sue Veer. I am the 
President and CEO of Carolina Health Centers, which is a 
federally qualified health center that serves as the primary 
care medical home for over 25,000 patients in rural South 
Carolina.

    My career has spanned 35 years in several different 
settings of care, but one constant has been a commitment to 
ensure that everyone, regardless of demographic or 
socioeconomic barriers and circumstances, has access to 
appropriate and effective health care that is delivered with 
respect, dignity, and compassion, and there is no better fit 
for that commitment than community health centers.

    Health centers manage their patients across not just the 
continuum of care, but oftentimes the entire spectrum of their 
lives. We provide access to comprehensive primary and 
preventive care, but also address social determinants of health 
by tackling really difficult challenges like homelessness, 
joblessness, domestic violence, parenting skills, food 
insecurity, transportation, the list goes on.

    Access to these programs and services drives more 
appropriate and effective use of health care services and 
improved health outcomes, resulting in cost savings across the 
entire health care delivery system. And while cost prevention 
may not count in the scoring of Congressional funding, it 
matters in real life. It matters in reality.

    Health centers also have a significant financial impact or 
economic impact, and you are going to hear a lot of that and 
you have had a lot of that in writing. A study with Carolina 
Health Centers that was completed by Capital Link in 2020 
indicated $24 million in savings to the overall health care 
system, and 456 jobs generated, and $53 million in direct and 
indirect spending in our communities.

    Our primary service area, as I said, covers 3,708 square 
miles and 7 rural counties. We were established in 1977, and we 
now operate 12 medical practice sites, 3 of which are 
pediatric, 2 community pharmacies, and we provide agricultural 
farmworker services during the growing season.

    Behavioral health and substance use disorder services are 
particularly important and they are provided through 
integrated, in-house behavioral health services and 
collaboration with the local mental health and substance use 
agencies. It is a particular challenge, however, due to the 
lack of third-party reimbursement or any other source of 
funding.

    In a Medicaid non expansion state, few adults have 
coverage, and consequently we estimate that 80 percent of those 
needing services have no source of third-party reimbursement. 
This challenge extends to our ability to provide substance use 
disorder because behavioral health is an incredibly important 
component of medication assisted treatment.

    Our pharmacy includes two entity owned pharmacies which are 
both open retail and 340B, and we also provide prescriptions 
through several contract pharmacy arrangements necessary due to 
both geographic barriers and limited payer networks.

    Our clinical pharmacists are also part of the treatment 
team, and oral health is provided through a contract--a network 
of contract dentists, and we subsidize that care for our low 
income, uninsured, and underinsured patients.

    In the time I have remaining, I really want to introduce 
three initiatives that contribute to our ability to effectively 
manage the care of our patients. The first is those integrated 
models of care. But here I want to focus on early childhood 
services as it is a bit unique to Carolina Health Centers.

    We operate an early childhood service department that 
includes four evidence-based programs, three of which are home 
visitation programs. They also provide a range of care 
coordination to make sure the needs of all families are met. 
They--you have an outline of the criteria for all those 
programs, but what is important is the impact for families, as 
well as across the health care delivery system.

    On more than one occasion, home visiting nurses have 
identified pre-term labor, preventing possible death of either 
mother or baby, or preventing premature delivery, which would 
have resulted in a costly NICU visit. We have seen countless 
stories of parents who have ended abusive relationships, 
finished high school, gone back to college.

    Also, our pediatricians attest to the fact that these 
parents are often the most adherent to treatment protocols 
well-child checks, and not using the emergency room for 
ambulatory sensitive conditions.

    These success stories really speak to the impact on health 
and well-being of our families, but behind the scenes, it is 
really about the resources they have saved, not to mention the 
fact that these families can now make meaningful contributions 
in their communities. I have very little time left.

    I do want to mention, and you have in writing, an outline 
of our Quality and Population Management Department, which 
really works to close gaps in care, making sure people use care 
effectively, and second, manage the medical loss ratio, which 
is a measure of how much of the MCO managed care company's 
capitated rate is spent on direct patient care.

    We operate right around an 80 percent range, which is 
extremely cost effective. We are also a member of the OCHIN 
Health Center Controlled Network and Collaborative, which is 
200 health centers that are a learning collaborative that 
optimizes the use of technology to manage care.

    The last thing and in closing that I will mention is we 
have one site that is quite unique because it is located within 
the walls of a hospital contiguous to an emergency room. And 
over the how many ever years, it has been open I think now 12 
years, and it has shown a dramatic reduction of use in the E.R.

    Thank you very much. I look forward to your questions and 
the continuing discussion.

    [The prepared statement of Ms. Veer follows:]
                     prepared statement of sue veer
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
                    [summary statement of sue veer]
    My name is Sue Veer, and I am the President and CEO of Carolina 
Health Centers, Inc. My career in health care spans 35 years and 
includes working in community hospitals, a major academic medical 
center, private practices, and now, the community health center world. 
Though my work environment has varied, the one constant has been my 
strong commitment to advocating on behalf of patients and their 
families--a commitment to ensure that everyone, regardless of 
demographic or socio-economic circumstances, has access to appropriate 
and effective health care that is delivered with dignity and 
compassion.

    In my testimony I plan to share an overview of my health center and 
examples that outline how access to the programs and services at a 
community health center drives more appropriate and effective use of 
health care services and results in improved health outcomes. This, in 
turn, results in cost-effectiveness and increased capacity within the 
health care system. As acknowledged in the announcement of this 
hearing, Community Health Centers save (and improve) lives and save 
money, and those savings accrue not just to the health centers but 
across the entire delivery system.

    Carolina Health Centers, Inc. (CHC is a federally Qualified Health 
Center (FQHC) that serves as the primary care medical home for 25,770 
patients in the rural area of South Carolina known as the Lakelands. 
CHC's primary service area covers 3,708 square miles and includes the 
seven rural counties of Abbeville, Edgefield, Greenwood, Laurens, 
McCormick, Newberry, and Saluda. Established in 1977, CHC now operates 
12 medical practice sites, two community pharmacies, and provides 
agricultural farmworker health services during the growing season.

    In addition to providing an overview of the programs and services 
at CHC, I plan to focus on three specific initiatives that make a 
significant contribution to CHC's ability to effectively manage the 
care of our patients and deliver on our commitment to value: Integrated 
care Models, Quality and Population Health Management, and Laurens 
County Community Care center (LC4), a health center site located in a 
hospital contiguous to the Emergency Department.

    My comments are intended to support what is most critical to me as 
a health center leader, which is funding that is sustainable, 
predictable, and fully supported now and into the future. Support for 
long-term, sustainable, and predictable funding enables health center 
leaders like me to confidently lead our health centers into the future 
and empower our teams to continue the work of saving lives and saving 
money.
                                 ______
                                 
    The Chairman. Ms. Veer, thank you very much. Our final 
witness will be Jessica Farb. She is the Managing Director of 
the health care team at the U.S. Government Accountability 
Office, the GAO.

    Ms. Farb is responsible for leading the team that conducts 
audit work on the full spectrum of the health care sector. Ms. 
Farb, thanks so much for being with us.

STATEMENT OF JESSICA FARB, M.S., MANAGING DIRECTOR, GOVERNMENT 
             ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Ms. Farb. Thank you. Chairman Sanders, Ranking Member 
Cassidy, and Members of the Committee, thank you for the 
opportunity to be here today to discuss GAO's work on the 
health center program.

    For over 50 years, health centers have been helping low-
income individuals across the U.S. access care in medically 
underserved areas, as was previously noted, and primary and 
preventative health care is provided to over 30 million people 
by 1,400 health centers today, regardless of their ability to 
pay.

    In order to provide this care, health centers rely on 
revenue from a variety of public and private sources. There are 
four types of health centers under the health center program, 
which is administered by the Health Services--Health Resources 
and Services Administration, or HRSA.

    Over three-quarters of them are community health centers 
that serve the general population. The remainder health centers 
that serve specified populations, including health centers for 
the homeless, residents of public housing, and migrant workers.

    The scope of health care provided by health centers is 
broad, as my colleagues have said today, and must include 
primary care, such as internal medicine and pediatric care, 
preventative care such as immunizations and prenatal care, 
emergency care, which may be provided through arrangements with 
providers beyond the health center and enabling services to 
facilitate access to care such as translation and 
transportation services.

    Health centers are not required to provide behavioral 
health services, but according to HRSA, many do so to meet the 
needs of the populations they serve. In addition to the 
services they provide, health centers are also required to 
document the unmet health needs of residents in their service 
area and to periodically review their service area to determine 
whether the services provided are available and accessible to 
area residents promptly and as appropriate.

    Health centers also must have a sliding scale based on a 
patient's ability to pay and generally must be governed by a 
community board where at least 51 percent of the members are 
patients of the health center. HRSA determines whether health 
center grantees meet these and other health center program 
requirements when making award determinations.

    Over the past two decades, in response to program changes 
and funding increases, GAO has periodically been asked to 
examine various aspects of the Community Health Center Program.

    For example, in 2008, we looked at the number of health 
center sites in medically underserved areas, as well as the 
types of services the health centers provided. In 2011, we 
described strategies used by health centers to reduce 
unnecessary emergency department utilization.

    In 2012, we examined HRSA's oversight process and the 
extent to which the process identified and addressed 
noncompliance with key program requirements. Our most recent 
report on health centers published in 2019, described the 
amounts of health center revenue from 2010 through 2017.

    During this timeframe, health centers revenue more than 
doubled, from $12.7 billion in 2010 to $26.3 billion in 2017, 
as Senator Cassidy pointed out. This increase occurred at the 
same time that the number of centers grew going from 1,124 
centers to 1,373.

    The number of patients served also grew by 7.7 million 
individuals. Our 2019 report also described trends in the 
sources of health care revenue. According to our analysis, 
about 60 percent of health centers' 2017 revenue came from 
Medicaid, Medicare, and private insurance payments for the care 
that was provided.

    30 percent of health center revenue in 2017 came from 
Federal and state grants. Comparing those proportions to those 
in 2010, we found that revenue from public and private 
insurance had grown over time, and accordingly, the proportion 
from Federal and state grants had decreased.

    These Federal grants include those funded by the Community 
Health Center Fund, or CHCF. As we reported from Fiscal Year 
2011 through 2017, health centers received approximately $15.8 
billion from this fund. Of this amount, the vast majority, 
$12.6 billion, was awarded to maintain operations at existing 
health centers.

    We were told by HRSA officials in the course of our prior 
work that these grants to the CHCF were used to fill the gap 
between what it costs to operate a center and the amount of 
revenue a center received. As such, these grants help centers 
cover care that would otherwise have been uncompensated.

    The remaining portion of the $15.8 billion and CHCF grants 
from 2011 through 2017 were made to increase the amount of 
services provided in existing health centers, to increase the 
number of health centers, and to support special initiatives 
such as health information technology.

    While our most recent reporting predates the pandemic, 
health center revenue since 2020 has included funding made 
available through COVID-19 supplemental appropriations. 
According to HRSA, health centers have led efforts to ensure 
access to COVID-19 tests, vaccines and treatments, providing 
essential primary care and preventive health care to patients 
and their communities.

    As Senator Cassidy mentioned, in the coming months we will 
be starting an examination of trends in health center funding 
since our last review, including an assessment of how the 
supplemental funding provided in response to COVID-19 has been 
used. In addition, we anticipate analyzing the characteristics 
of the patients health centers served, among other issues.

    Chairman Sanders, Ranking Member Cassidy, and Members of 
the Committee, this completes my prepared statement. I will be 
happy to answer any questions you may have.

    [The prepared statement of Ms. Farb follows:]
                   prepared statement of jessica farb
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
    The Chairman. Thank you very much. Now, we will begin with 
questioning. I will start and Senator Cassidy will follow, and 
then we will go around the table.

    Panelists, let me read a quote which I think speaks to the 
bipartisan support the community centers have always had. This 
is what George W. Bush, President Bush said in 2004, and I 
quote, ``I think it is a wise use of taxpayer money to expand 
and increase the number of community health centers all across 
America.

    As a matter of fact, the goal I have set is every poor 
county in America has a community health center. It is much 
better if folks who need help get help at the community health 
center than in an emergency room or a local hospital. Not only 
do taxpayers save money, it is a more compassionate way to help 
people.''

    That is George W. Bush, 2004. Bush talked about expanding 
health centers to every low-income community in America. Today, 
we have medical deserts for almost 100 million Americans.

    Was Bush right in his desire to expand community health 
centers all across this country? Amanda, do you want to take a 
shot at that?

    Ms. Pears Kelly. Certainly. I appreciate you calling out 
the long history of bipartisan support for health centers. And 
I think he is right. I think health centers are poised to step 
up and do everything that they can to care for as many people 
as are in need.

    Our proposal focuses on reaching 40 million patients, but 
certainly I think health centers are up to the task. And I 
think to be honest, Senator and Members of the Committee, it 
really will come down to the investment that is made, enabling 
them to do so.

    If we are talking about caring for 100 million Americans, 
which I think health centers could certainly scale to do with 
the appropriate investment, we would need to scale our 
proposal. It would be considerably more over year to year.

    But there has never been a time where I have seen health 
centers not meet the task. And I think where we are today, it 
has everything to do with the investment that is made to enable 
them.

    The Chairman. Thanks very much. Let me ask Ms. Veer, in 
your testimony, you talked about keeping people out of the 
expensive emergency room care and getting them to a community 
health center. We are doing a little bit of that in Vermont as 
well. Is it your understanding that all across this country, 
people who do not have a medical home end up in emergency rooms 
and much more expensive care than would otherwise be provided 
through a community health center? Say a word about saving 
money in that regard.

    Ms. Veer. Absolutely, Senator. I believe the lack of a 
primary care medical home has that impact. And I think it is a 
multigenerational behavior that we see. Over generations, that 
is what people have done.

    As a result of that, not only are the hospitals saddled 
with incredible bad debt of the--I mentioned that one of our 
health center sites is located next to an emergency room, and 
we originally hoped that we would get direct referrals from 
that emergency department.

    What happened was really people got referred to us after 
the emergency room visit, but once they established care with 
us, 76 percent of them ceased using the emergency room within 
the next----

    The Chairman. At great savings to the system.

    Ms. Veer. At great savings to the system, because 43 
percent of them are uninsured.

    The Chairman. Okay. Mr. Harvey, you talked about diseases 
of despair, something that I have studied for quite a while. 
Tell us a little bit about what happens in rural America when 
people have no hope, no access to health care they need.

    Mr. Harvey. Yes, that is a great question. I mean, deaths 
of despair is kind of what it describes. You see the worse 
chronic diseases, substance use disorders creeping in, 
particularly in the county I grew up in as manufacturing jobs 
left.

    Without access to care, mental health care, substance use 
disorder treatment, those things get worse and they get worse 
quickly. I think you see that too with suicide, increased rates 
of depression, increased rates of hopelessness, and rural 
America is really in, and this is maybe too broad of a 
statement, but it is in dire straits.

    You see hospital closures--and health centers can be, in 
fact they are, they are that rate limiter. They have stepped 
into a lot of those areas and certainly in Indiana, and 
especially from substance use disorder, chronic disease 
treatment, provide that opportunity to even, one, hold back the 
tide, and two, reverse that.

    The Chairman. Let me ask anybody on the panel. We are the 
richest country in the history of the world. We now spend twice 
as much per capita on health care as any other people. In your 
judgment is it in fact too much to ask that every American at 
least have access to quality primary health care? And as 
Senator Cassidy mentioned, that includes dental care, mental 
health counseling, lower cost prescription drugs. Is that too 
much to ask in the United States?

    Ms. Veer. As I said in my testimony, that has been my 
life's commitment, is to ensure that we remove those barriers 
that prevent everyone from having access to that kind of care 
that also drives healthy behaviors that keep chronic disease 
controlled.

    The Chairman. Anybody else want to--is this utopian, out of 
the reach of the United States of America?

    Mr. Harvey. No. I don't think so. I think you are right. I 
mean, I think access to care, taking maybe the policy piece out 
of this, obviously has policy implications, but access to care 
is a core piece of the foundation to a healthy life. I have a 
son that has down syndrome.

    Without access to care life looks different for him. Life 
looks different for Hoosiers that don't have routine sources of 
primary care, that don't have routine sources of treatment. 
That really does matter.

    The Chairman. Okay. Thank you all very much.
    Senator Cassidy.

    Senator Cassidy. Thank you all. I, too, have devoted my 
professional life to making sure that those who do not have 
care have care, and I thank you for that commonality of 
interest. What our hearing here today is, how do we make sure 
that you have the adequate funding?

    Is it otherwise adequate or is more needed? Ms. Farb when I 
was speaking about 340B, looking--by the way, looking at this, 
it clearly is important 340B because both Ms. Pears Kelly and 
Ms. Veer both speak about the importance of it. I think as much 
as $18 million out of your total $44 million budget seems to 
come from 30--in terms of revenue, seems to come from 340B.

    Ms. Veer. It comes from our pharmacy services, a portion of 
which is 340B.

    Senator Cassidy. What portion of that would be 340B?

    Ms. Veer. I apologize, Senator, I didn't have time to 
actually----

    Senator Cassidy. That is Okay.

    Ms. Veer. [continuing]. Carve out those numbers.

    Senator Cassidy. But looking at your patient population, it 
is going to be a substantial portion.

    Ms. Veer. It is going to be at least 60 percent.

    Senator Cassidy. Ms. Farb, what--when I was mentioning and 
asking, is 340B revenue included here, and you were kind of 
nodding your head no, do you have any comment on that?

    Ms. Farb. Yes, Senator. So, the 340B program, given the way 
it works, so the entities are able to get discount of drugs and 
then they are able to submit claims for those drugs at the 
price that payer would pay.

    The funding shows up in Medicare, Medicaid, and private 
insurance. That is where those revenues will show up. And I 
looked to my colleagues to confirm that is where they would be 
reported. They would not be reported as part of other revenue, 
according to HRSA.

    Senator Cassidy. Let me ask you this, because it is my 
understanding that when it comes to Medicare and Medicaid, that 
the Federal--that community health centers get an extra rate 
relative to the guy who is just practicing next door.

    Ms. Farb. Right. They have an enhanced PBS.

    Senator Cassidy. What is the degree of that enhancement?

    Ms. Farb. Off the top of my head, I can't answer that 
question, but I will look to my colleagues because they might 
actually know. Yes, I think they would.

    Senator Cassidy. Ms. Pears Kelly.

    Ms. Pears Kelly. I wouldn't--I can't give you the specifics 
on what it looks like to be enhanced, but I can tell you that 
it is--it doesn't actually cover the total cost. And Sue may be 
able to speak to this.

    Senator Cassidy. I accept that. I am just trying to figure 
out, as we put together a business plan, if somebody had told 
me that it is the lesser of 80 percent of what you charge and 
you can kind of pick the charge or the PPS number, the lesser 
of those two. Mr. Harvey, you look at you are reading from----

    Mr. Harvey. Yes, I think it is a bit of a complicated 
picture, right. And PPS rates vary by state. So, Medicare has a 
set PPS rate with a geographic adjustment factor, but it varies 
by state Medicaid programs. And like Amanda mentioned, 
sometimes in certain places it will cover the total costs. But 
because of the global nature of what health centers provide, 
you are asked to do more----

    Senator Cassidy. I get that.

    Mr. Harvey [continuing]. Than a primary care.

    Senator Cassidy. Again, we are just talking about a 
business model. And how much subsidy is needed relative to that 
which you are receiving from other sources.

    Mr. Harvey. Yes.

    Senator Cassidy. Mr. Nocon, I noted that there is actually 
a bunch of lookalike community health centers. Lookalikes being 
they don't get the grant money that we are speaking of today, 
but nonetheless, they have grown. They have doubled since 2017. 
There is over 100 now.

    Dr. Nocon. Yes.

    Senator Cassidy. When you did your study, did you compare 
the lookalikes, those not getting grants, versus those 
receiving grants in terms of the array of services provided, 
the stability of the organization, the effectiveness of the 
organization, etcetera?

    Dr. Nocon. We have not done that. But the lookalikes are 
mixed into the sample for our studies.

    Senator Cassidy. Okay, Okay. And Ms. Farb, did you look at 
any of that, compare the difference between the two? Because 
clearly there is a business model out there that is working 
without the grant--without the grant dollars, and that is what 
I am interested in understanding this for. Ms. Farb.

    Ms. Farb. No, we did not look at that, Senator.

    Senator Cassidy. Mr. Harvey.

    Mr. Harvey. Yes, specifically Indiana has the second most 
lookalikes, I believe, of any state in the country, which is 
hard to believe in comparison to California, New York, other 
large states. But qualitatively, the lookalike leaders that I 
have, because again, of the unique nature of what health 
centers are required to provide, they don't receive that grant 
funding. They don't receive coverage under the FTCA.

    That is an economic strain. That is an economic pressure 
that they face because they don't have that sustained funding. 
Again, I could--we have a dozen lookalikes in the State of 
Indiana, and to an organization they would say that.

    Senator Cassidy. Well but that is not my question of 
whether or not there is a strain, is whether or not they have 
the ability to provide the services effectively.

    Mr. Harvey. Limited capacity compared to those that receive 
grant resources.

    Senator Cassidy. Gotcha. By the way, let me compliment Ms. 
Veer. It sounds like you are all using the 340B program the way 
the 340B program is supposed to be used. There are a lot of 
abuses of that program, but it does seem as if you are using it 
correctly.

    Tell me, if you want to elaborate on that, and are you open 
to reforms to the program to make sure that patients at your 
facility get them and they are not going to build a chandelier 
in a hospital, which, etcetera, etcetera, etcetera. And please 
be brief, because I don't have time.

    Ms. Veer. I will be as brief as I can. I think it is a 
complex problem, but and I do think there are abuses, but 
unfortunately the abuses get highlighted much more than the 
many, many thousands of organizations that do this right and 
that is patient centered. Certainly, we operate both a retail 
and 340B pharmacy.

    340B is used only for patients of this health center and 
only for prescriptions that emanate from our health center 
sites. That revenue is managed very carefully to ensure that it 
is allocated to our operating margin. And I use operating 
margin specifically because it is not a profit margin.

    It is a margin that allows us to operate much needed 
services. And that is--and it is a simple allocation of 
services that operate at a deficit are made whole by the 
contribution of our pharmacy margin. In terms of the----

    Senator Cassidy. Let me stop you there because I am already 
a minute over and I got to be gracious to my colleagues.

    Ms. Veer. Okay. Certainly.

    The Chairman. Thank you very much, Senator Cassidy.

    Senator Hassan.

    Senator Hassan. Well, thank you very much, Mr. Chairman and 
Ranking Member Cassidy for this hearing. And thanks to the 
witnesses not only for being here but for the work that you do. 
Mr. Harvey, I want to start with a question to you.

    Community health centers play a vital role in addressing 
the ongoing opioid crisis by serving as major providers of 
medication assisted treatment, which is widely accepted as the 
gold standard of care for individuals with opioid use disorder. 
However, many centers are facing difficulties in meeting the 
increased demand for treatment.

    To help address these challenges, I worked with Senator 
Murkowski to pass into law the Mainstreaming Addiction 
Treatment Act, which eliminated an unnecessary hurdle to 
providing treatment. Mr. Harvey, what else can Congress do to 
make sure that community health centers can provide care for 
those with substance use disorders?

    Mr. Harvey. Yes. Thank you for the question. I appreciate 
that very much, and maybe give kind of a Hoosier response to 
this. But yes, a couple of things around opioid use disorder. 
One is the dearth of the mental health workforce. Finding a 
psychiatrist in particular in rural Indiana is, I would say, 
nearly impossible, but it is very difficult.

    Senator Hassan. I just want to focus a little bit on 
medication assisted treatment, because the purpose of this is 
to allow primary care physicians to prescribe buprenorphine. We 
know that along with counseling, very successful.

    Mr. Harvey. Correct. Yes, and that is exactly it. So, 
extending the opportunity outside of the psychiatrist office. 
Extending the capacity of the mental health workforce, that is 
really a critical aspect of this.

    Workforce in general would be a big piece. Any 
administrative burdens as well. MAT over time, the 
administrative hurdles have gone down significantly, and that 
has really boosted access to treatment for----

    Senator Hassan. But you are also telling me, and I am sorry 
to cut you off, that more mental health workforce, more 
psychotherapy would be another critical thing we could do 
moving forward.

    Mr. Harvey. Yes, yes.

    Senator Hassan. Okay. Thank you. Let me follow-up, another 
question to you, Mr. Harvey, about our mental health crisis. In 
New Hampshire, patients seeking psychiatric care are being 
forced to wait in emergency rooms for days or weeks, hoping 
that an inpatient psychiatric bed will open up.

    According to the state's latest reports, 26 Granite 
Staters, including three children, are being boarded in 
emergency departments, and this boarding can last for weeks. 
Last week, a Federal court ordered the state to devise a plan 
to address this emergency room boarding crisis.

    How can community health centers help provide regular 
mental health care to patients and address mental health 
concerns before inpatient psychiatric care is needed?

    Mr. Harvey. Yes. That is a great question. I think you see 
that in Indiana. A number of the FQHCs will work with either 
the local court system or a number of local community providers 
to create a network of support for patients with mental 
illness, so you don't end up in that situation where someone 
ends up in the emergency room with nowhere else to go, right, 
and you just have a hold and it ends up in a spiral.

    Certainly, supporting them with funding, with resources, 
with workforce to provide that continuity of care would be a 
big piece for health centers to go to address that really 
unfortunate situation. And that is, like you said, occurring in 
your state, but also occurring nationwide. And so, from a 
capacity standpoint, we really have a ways to go to address 
that.

    Senator Hassan. Well, thank you. Ms. Veer, I want to turn 
to you for a moment. New Hampshire community health centers are 
grappling with an unprecedented workforce shortage, something I 
know we have already talked about this morning.

    To overcome this challenge, we have to prioritize the 
training and development of more doctors, nurses, and other 
community health care professionals. What role do community 
health centers play in training the health care workforce, and 
how can we support those efforts?

    Ms. Veer. Thank you very much, and it truly is a challenge. 
I think certainly we serve as rotation sites, often many of us 
serve as rotationsites for both medical professionals, as well 
as we train nursing staff. And one of the things that we have 
recently done is begun to provide stipends, living stipends and 
second year residency, with a commitment for a 4-year service 
agreement.

    In addition to loan repayment, that helps us. Now, that is 
an otherwise unfunded program, but it has enabled us to recruit 
and really get people into the health center model early. We 
are doing the same thing with our technical colleges.

    Senator Hassan. Well, and I know that in rural areas of the 
country, sometimes if we can get trainees into the rural areas 
too, they learn that they like not only the community health 
center model, but living in some really beautiful, wonderful 
rural areas in our Country, but we have to get them there so 
that they can experience it.

    Ms. Veer. Yes, until you experience it, it may not be where 
you think you want to go.

    Senator Hassan. I will yield the rest of my time, Mr. 
Chairman. Thank you very much. And thanks again to all the 
witnesses.

    The Chairman. Thank you, Senator Hassan.

    Senator Collins.

    Senator Collins. Thank you, Mr. Chairman. As Ms. Pears 
Kelly mentioned, having grown up in Maine, our community health 
centers in Maine play an absolutely indispensable role. Each 
year, the 20 community health centers provide critical health 
care services to nearly 210,000 patients.

    That is about 16 percent of the population of the State of 
Maine, and more than 60 percent of the patients are low income, 
and about 20 percent are over the age of 70. But what I am 
hearing now from our Maine health centers is that they fear 
that a perfect storm is brewing.

    They are experiencing unprecedented turnover and staff 
shortages. They feel they are facing threats to the critical 
340B drug pricing program. And they are having difficulty in 
recovering from the pandemic because patients are being slow to 
return.

    My question for Mr. Harvey and Ms. Pears is, given the 
current workforce crisis and the issues that I have mentioned, 
are our community health care services centers able to meet the 
workforce needs if we were to dramatically expand funding for 
them and scale that up rapidly? Are we going to end up with 
clinics that have more money but simply don't have the staff to 
serve? Mr. Harvey, we will start with you, and then Ms. Veer.

    Mr. Harvey. Yes, it is a fair question. I appreciate that 
question. Health centers, like you said, they are facing an 
array of difficulties coming up. Medicaid unwinding certainly 
in the states that have expanded Medicaid like Indiana.

    You are going to lose hundreds of thousands of patients 
from Medicaid, that coverage, trying to transfer them. Do 
health centers have the capacity? I would say I have spoken to 
all 39 of our health centers, and individually, each one of 
them has expressed the desire to go further, to do more, and to 
look for resources to do more, and that continued Federal 
funding.

    I think we have got a long history here of saying if 
Federal funding is increased, you will see concomitant 
increases in the work that health centers do, in the patients 
that they see, and the service sites that they have, and the 
services they offer.

    No, I don't think the funding would be lost. I think it is 
a really, like I said in my testimony, very wise investment on 
behalf of the Federal Government to continue to support and 
expand the support that health centers receive.

    Senator Collins. Ms. Veer.

    Ms. Veer. Yes, thank you very much for the question. And we 
definitely are facing those challenges. And I think two things 
come to mind. I hear of many health centers that are in fact in 
the process of reducing services because of the loss of 
contribution from the 340B program with the impact of the 
challenges that we have had there. And yes, you asked about 
being open to reform, Senator Cassidy.

    I think we are there. We really need to look at that. 
However, I agree that if we have the adequate funding to 
continue expanding the services that we provide, we have always 
stepped up to the plate, stood in the gap.

    We have always done it. I have a real commitment from the 
schools in the educational systems in my area. Now it is a 
pipeline, and so if people enter the pipeline now, it may be 
months, if not years, before we have them in place, but as we 
develop, we will get there.

    Senator Collins. I want to associate myself with the 
remarks of Senator Hassan about training opportunities at 
community health centers. I think that is absolutely essential, 
as we heard from the President of the University of New 
England.

    The more we can do those connections, the more likely the 
health care professional is to stay in a rural area and 
practice there. So, I think that is something we need to 
consider expanding and encouraging and incentivizing. Mr. 
Harvey, just a very quick final question for you.

    My largest community health center at the Penobscot 
Community Health Center has seen a real drop-off in patients 
coming back after the pandemic. Is that unique to my state, or 
have you experience that?

    Mr. Harvey. No, I don't think so. I think people's patterns 
of engagement with the health care system changed because of 
COVID.

    I think we have seen with health centers in Indiana some 
recovery from that, but it has to be really intentional 
intensive work and you have to develop new service lines, 
things like telemedicine, to reach patients from home to 
provide more--the right care in more convenient ways.

    No, I don't think it's unique, but I do think that there 
is--that is an additional burden on health centers now to try 
to continue to reach those patients who may have changed--just 
changed behaviors because of the impacts of the pandemic.

    Senator Collins. Thank you. Thank you, Mr. Chairman.

    The Chairman. Thank you, Senator Collins.

    Senator Smith.

    Senator Smith. Thank you, Mr. Chairman. And thanks to all 
of our panelists. I really appreciate this conversation. I want 
to just pick up on what Senator Collins and Senator Hassan were 
talking about. Creating opportunities for people to get 
training in rural communities is so important.

    I am reminded of the University of Minnesota Duluth 
Preceptor Program, which puts folks in medical school in 
communities with rural doctors so they can understand what that 
means and how to do that kind of practice, because it is 
different when you don't have a whole huge hospital around you 
or a whole big network around you.

    I think that is really something that I bet we could find 
good bipartisan agreement on. I am so blessed in Minnesota we 
have a strong network of community health centers. I have had 
an opportunity to visit many of them, and I have been so 
impressed by the work that they do, both in rural and--I mean 
in suburban and urban areas, but especially in rural 
communities where there is such a challenge getting access to 
health care.

    Here is one example in Cook, Minnesota, which is in the 
Northern part of Minnesota, up by Lake Vermillion, nearly 100 
miles away from the nearest big city, which is Duluth. The 
Scenic River's health service is the only primary care provider 
around for miles and hours.

    I want to just ask, and I think I am going to ask this 
question of Mr. Harvey and maybe Ms. Veer first. If we were 
going to think of one or two things that we have to do in order 
to support those rural community health centers, we have talked 
about training, and I fully appreciate that.

    What would be the one or two things that you want us to 
have foremost in our mind as we think about those rural 
centers?

    Mr. Harvey. Now you are speaking in my heart, rural health 
care. A couple different things. Rural health care is 
difficult. You talked about the workforce. Grow your own, that 
is a big piece of that.

    Sustained, predictable funding for health centers is really 
a critical piece of that. Workforce funding, we have talked 
about 340B. Those, doing those things will go a long way to 
supporting rural health centers, and in particular leaning into 
programs like you have mentioned, training programs that help 
rural health centers grow their own.

    Like you say, where you live, predicts where you are going 
to work. Oftentimes where you train, predicts where you are 
going to work. So that, doing all of those things will go a 
long way to supporting rural health care.

    Senator Smith. This question of sustained funding, I just 
want to follow-up on, because, Mr. Chairman, I remember so well 
visiting health clinics, some of these community centers in 
years past where they were faced with this fiscal cliff.

    They are trying to figure out how to plan, how to 
economically provide health care to their communities, and yet 
the funding streams are uncertain. And so, they are like, on 
the one hand, trying to figure out how to lay off people 
because they are not sure if that funding is going to be in 
place, at the same time that they are trying to figure out how 
to meet growing demand on the other hand.

    I think it just reminds me of what an important 
responsibility we have through the work that we are doing to 
reauthorize this legislation, to not put clinics in the 
position of wasting time and energy and resources trying to 
plan for a fiscal cliff that hopefully they won't have to face.

    I just, I appreciate you bringing that up. Let me also ask 
a question related to sort of the, I don't know, we use this 
term wraparound services, which I don't know if most people 
outside of Washington even know what that means. But what I am 
trying to get at is how in Minnesota you often have additional 
services, additional needs that people have when they come to 
community health centers.

    If you can't meet those needs, then the health care that 
you are trying to provide to them is not going to work. A great 
example of that is an FQHC center in Minnesota, which has been 
around for 50 years. And many of the folks that they are 
serving are folks that don't speak English.

    They are immigrant workers, they are migrant workers that 
make our farm economy work, and it is our--to me, it is 
essential that they have access to health care. So that means 
we need interpretive services.

    But interpretive services aren't paid for. They have got to 
figure out how to raise the money for that. Would anybody like 
to comment on the value, the importance of having those kinds 
of additional services in order to make the whole thing work?

    Ms. Veer. I would say that they are absolutely essential. 
Our Spanish speaking population in three of our centers has 
increased probably tenfold over the last 5 years. And without 
translation services, we can't deliver appropriate care.

    We really can't use the family member that is standing 
there that doesn't have the medical training. So, there is a 
real investment that needs to be made in that. And keeping in 
mind, I love the fact that you used the word sustainable and 
predictable, because flat funding in these days is not flat 
funding because of inflationary pressures that have really 
increased our costs.

    Senator Smith. Yes, I think--I appreciate that. And I 
suspect that almost everybody on this Committee would agree 
that while we may--we certainly have, I think, a moral 
obligation to make sure that people can get the health care 
that they need, if we are not able to provide health care to 
those folks, then they are going to--that doesn't mean that 
they are not going to get sick.

    It just means that they are not going to get the health 
care that they need at the time that they need it, and that is 
why this is so important. Mr. Chairman, I have another question 
which I will submit for the record around the importance of 
integrated care, mental health care and behavioral health care 
and dental care, which we do a good job of providing in 
community health centers, and we need to do a better job of. 
Thank you.

    The Chairman. Thank you, Senator Smith.

    Senator Braun.

    Senator Braun. Thank you, Mr. Chairman. I am going to start 
off with this simple statement. No one should go broke in this 
country because they get sick or have a bad accident.

    Everyone in a country like ours should have access to 
health care on the entire spectrum. Here is where it gets 
complicated. How do you do it? When I mentioned going broke, 
what is really broke in a different way is our health care 
system in general.

    I think you are a manifestation of when it is not working 
where it should be, I don't even like to call it the private 
sector, it is not a market delivery, something is going to 
happen and you are the manifestation of it.

    Eventually I will get to a question and see how you are 
doing such a good job of being the cost leader in it. We are in 
a place here where we borrow about 30 percent of what we spend. 
It would be a tricky long term business partner hooking up with 
the Federal Government as we now operate it. The other side is 
even worse.

    You have got a system that has evolved over time, wrestling 
with it like I did as a small business owner. You can't imagine 
how frustrating it was to hear how lucky I was to only have my 
health insurance going up 5 to 10 percent each year. It didn't 
feel very lucky. 15 years ago, took it on at the grassroots 
level.

    It would be for another time and conversation. You may want 
to come work for my company when you hear this, that I no 
longer run. We made it consumer driven, gave every tool to 
avoid the broken system by putting every wellness tool out 
there. Created a health care consumer. Cut costs by 50 percent 
then.

    Have not had a premium increase in 15 years. Somehow, we 
ought to be talking about the entrepreneurialism that needs to 
go along with the entrepreneurialism you are doing being 
financed by the Federal Government. Your long-term business 
partner, I don't think is healthy. The system is broken.

    We need to find out how working together we deliver a 
better product to the American public. What intrigued me is 
that you are doing primary health care. First of all, insurance 
was never probably intended for that, but then it would beg the 
question how do people that can't afford any health care, let 
alone insurance, how do they get proper health care?

    Here you go. You are there. I think primary health care 
needs to be where it starts. If it is not through what you are 
doing, and maybe you are going to have individuals dealing on a 
direct pay basis with providers that can afford it, something 
other than we got.

    Until that system gets fully transparent, competitive, and 
is run like a real market, we shouldn't be defending it here 
because it is broken. Let's start with you, Mr. Harvey, out of 
deference to being a Hoosier, and then we will go to Ms. Kelly.

    What are you doing that takes the entry point in health 
care and where you are doing it at a better value than the 
other way that you get primary health care? What is the secret 
sauce?

    Mr. Harvey. Yes, it is a great question. I appreciate the 
question. I think there are three things that I was thinking of 
as you were making that--health centers provide integrated 
whole person care, that is community based, and we can't 
overlook that.

    The community really runs and owns these organizations on 
the board. They are patient driven health centers, and they 
also provide those enabling services They have the ability to 
provide those comprehensive services to support, I think that 
was brought up earlier, things like translational services, 
things like transportation services.

    They are really systems of primary care that are good, that 
are going deeper with individuals to produce those cost 
savings. So again, yes, I would agree with you. I think too 
what you mentioned, Senator Braun, and a long part of this is 
the administrative burden that health centers face.

    We are not outside of that. Health centers aren't outside 
of that. We do that in the face of that, when you are dealing 
with very complex billing arrangements, you are dealing with 
all of the prior authorization pieces, all of the credentialing 
pieces that you have to deal with from an insurance 
perspective. There is this huge beast of administrative costs 
that goes into all of this.

    Senator Braun. Are you transparent and do you post the 
prices of things you do?

    Mr. Harvey. Yes, that is right.

    Senator Braun. Hallelujah.

    Mr. Harvey. Yes, health centers are required----

    Senator Braun. The other side--the other side of provision 
doesn't do it. And now even practitioners, doctors and nurses, 
are getting tired of now having to be employed by huge 
corporations where it is not like it was before and they don't 
embrace transparency at all. So, before we run out of time, Ms. 
Kelly.

    Ms. Pears Kelly. Thank you. It is a great question, and I 
think Ben hit on several of the things that I would call out. 
But you mentioned a couple of things, the consumer component. 
The beauty of health centers has been said is that it is a 51 
percent consumer majority board.

    The services are actually driven by the people living in 
the community. They see what is needed. They are able to 
address that immediately. The other thing is that it is 
competitive.

    All of the health centers have to go through a competitive 
grant process to make sure that they are actually in a position 
to address those needs and the community concerns. So, the 
savings is there.

    The model has proven itself, the integration of care, all 
of it. I think you know the stats. I am happy to repeat them, 
but we have the stats around the savings for sure.

    Senator Braun. Alert to the people that provide our health 
care, from hospitals now that I think control a bigger share of 
it than anyone. Used to be more evenly balanced with 
practitioners.

    Health insurance, we got to get to where people accept 
their own responsibility for their own well-being and give them 
the tools to do it. They need to take a note from what you are 
doing because they ask for so many benefits from Government.

    The way you pay for health care, whether it is the 
Government or on the private side, the delivery of it has got 
to get more competitive, more transparent, and more operate 
like markets and do what you are doing. Kudos. Keep doing it. 
Thank you.

    The Chairman. Senator Hickenlooper.

    Senator Hickenlooper. Thank you, Mr. Chairman and Ranking 
Member. I am proud to have a long history of supporting 
community health centers. I don't want to date myself, but 50 
years ago I helped a very agitated, very focused young man 
named Mark Masselli start a Community Health Center, Inc. in 
Middletown, Connecticut back when I was a college student.

    Community Health Center, Inc. is one of the Nation's 
largest and most innovative, I would argue, most innovative 
primary care centers for the poor, the underserved, just as you 
have all been saying, making sure that we help provide--they 
have been making sure that we help provide safety net providers 
in all 50 states with workforce training, research, and 
education.

    They branched out even beyond Connecticut. But I do have 
that experience where, and I first saw telemedicine back and he 
was starting it in 1998, 1999 with certain applications, and 
clearly it blossomed during COVID in a way that we didn't 
really understand.

    Dr. Nocon, you probably have some more data on how possible 
deleterious effects, negative effects of too much telemedicine, 
although I haven't seen any, but certainly the cost savings 
that I have seen have been dramatic.

    Dr. Nocon. Yes, thank you for that question. We have not 
specifically looked at that question in terms of telemedicine 
use in the context of FQHCs, but certainly we have seen it, 
Kaiser Permanente, significant increases in use of telemedicine 
and certainly the fundamental sort of underlying costs of that 
you would expect to be a more efficient model of patient 
interaction.

    Senator Hickenlooper. I will look forward to some 
measurements. I think that is the next step. As an industry, to 
begin to look at telemedicine and make sure that we are being 
careful to maintain quality but look at those things.

    I mentioned that the community health center in Connecticut 
now has over 200 locations. And I thought, Ms. Kelly, I would 
ask you, since you are a parallel in a parallel universe, what 
are some of the ways you look to mobilize getting health care 
into every community?

    Ms. Pears Kelly. I think a couple of things. And I hate to 
bring this back to it, but it has to do with investment and 
funding. That is one of the most key factors that enables that 
expansion and that growth.

    But I think because all of these health centers are 
community governed, they look at where there is increasing 
need, they do market assessments. They look at where do they 
need to go to meet people where they are.

    There are health centers that are extremely creative in 
trying to find ways, and leverage funding, and pull together 
what they can. But at the end of the day, that expansion does 
in a lot of ways depend on the Federal investment in order to 
have that stability.

    That has come up earlier today that it is very difficult to 
stand something up without the continuity, without the 
guarantee of continuity. Though I think CHC, Inc. is a 
fantastic example of what can happen and what can be when there 
is an investment in health centers appropriately.

    Senator Hickenlooper. Okay. Well, there--it is interesting 
if you go back and he has a book that has come out now on the 
first 50 years, as he humorously refers to his health center 
career. And it recounts in that first decade how many forces 
were aligned against them getting that funding and the 
continuity of funding.

    All kinds of competitive health services saw this as an 
imminent threat to their future growth and well-being. And even 
I remember vividly back in the late 70's, some of the 
transportation funding they thought was getting waylaid by the 
community health center movement, which was just beginning to 
take up speed.

    I agree with you completely that being able to move and 
expand so that we get into the smaller towns, the smaller 
communities, get that health service provided closer to where 
people live, depends on getting the funding there to get to get 
started. We have a wonderful community health center in 
Colorado called Tepeyac, all bilingual, and I know--watched you 
guys discussing that before.

    But I do think the language barriers writ large are still a 
challenge. And there is software now that we can get that 
actually really helps us dramatically deal with the divisions 
caused by different languages. Have any of you guys used that 
as a solution?

    Ms. Veer. Yes, we use technology across all 12 of our 
centers around translation. So, it is not always the perfect 
solution. Oftentimes, particularly in rural areas where we may 
have connectivity problems. So that can be difficult.

    Senator Hickenlooper. Another problem we are going to 
address. A different committee.

    Ms. Veer. Yes, different committee. But yes, it is very 
useful when you can't find the translation staff to be doing it 
in person.

    Senator Hickenlooper. Great. Thank you very much. And I do 
have another question on workforce, but I won't ask about--I 
will submit it, but I know that you guys are all involved in 
how do we get more workforce training into the process. I know 
we discussed it a little bit as I watched in my office.

    The Chairman. Thank you, Senator Hickenlooper.

    Senator Marshall.

    Senator Marshall. Well, thank you, Mr. Chairman. I am a 
huge fan of community health centers. I volunteered in them 
before. Practicing in rural Kansas as an obstetrician, I had 
significant interaction with our community health centers. I 
have tried to visit most of the 32 community health centers 
that we have across our great state. Another program I think 
has been successful is the 340B program.

    They are certainly profit centers for rural hospitals, any 
hospital that is using them as well as community health 
centers. My first question will be for Ms. Veer, and I am 
asking you to explain how the pharmacy benefit managers steal 
money from the 340B program from the community health centers.

    As I understand it, and this is based upon community health 
centers and pharmacists, community pharmacists tell me that the 
PBMs have found a way to make money off the 340B program by 
requiring contract pharmacies to disclose which 340B drugs they 
dispense.

    By requiring this disclosure, pharmacy benefit managers 
shave off a portion of those savings, savings which Congress 
intended to go to the safety net providers who support 
vulnerable patient populations.

    Ms. Veer. That is very true. And I can give you some 
specific examples without naming specific PBMs.

    Senator Marshall. Please do.

    Ms. Veer. There are two major assaults on the 340B program. 
The first is manufacturers refusing to submit to a contract--or 
340B pricing at contract pharmacies without submitting data.

    When we submit data that becomes transparent to the PBMs, 
who then in turn, in order to recoup the rebates, they have 
lost, reimburse for less than what they would for a retail 
pharmacy. I will use one example. Because we operate both 
retail and 340B, it gives me a lens into both.

    For the retail pharmacy that the reimbursement rate might 
be AWP -4 percent. You turn it over to 340B and it is AWP -32.5 
percent. It is a dramatic reduction in reimbursement that 
oftentimes when you add IR fees on top of that, it is below 
cost.

    Senator Marshall. Yes. Mr. Chairman, I just hope staff is 
taking note of this conversation. And this is an issue for a 
separate hearing. And Ranking Member, I certainly think we need 
to dive deeper into that one.

    Next question for Ms. Farb. I am trying to put my numbers 
together here. As far as the payer mix, we saw the dollars and 
cents, but from a patient volume, most these clinics probably 
60 percent Medicaid, 20, 25 percent Medicare. Does that sound 
about right to you?

    Ms. Farb. I think that is correct, Senator, based on our 
analysis and based on currently what we see in terms of the 
patients who are covered, even going up to current numbers, I 
think. It is probably a little bit less, closer to 50 percent 
Medicaid and about 11 percent Medicare.

    Senator Marshall. Okay. And then there is a certain number 
that would have private insurance.

    Ms. Farb. Right. About 20 percent.

    Senator Marshall. How many are just literally self-pay? 
Don't have insurance, don't have Medicaid, don't have Medicare.

    Ms. Farb. Sure. Uninsured is about 20 percent or--and self-
paid is included in that, too.

    Senator Marshall. I know. So, you got to break those apart 
for us if you can.

    Ms. Farb. I do not have those numbers broken out by 
uninsured versus self-payers, so.

    Senator Marshall. Okay. Anybody have a quick guess who runs 
the clinics. Of that 20 percent that are self-pay, how many of 
those actually have private insurance? Half of them?

    Mr. Harvey. How many have private insurance? Are you 
talking about commercial insurance so that----

    Senator Marshall. Of the number of patients that you see in 
your clinics, what percentage of them might have private 
insurance as opposed to Medicaid or Medicaid?

    Mr. Harvey. Generally, it is less than 10 percent in the 
State of Indiana.

    Senator Marshall. Of all the patients you are seeing, it 
sounds like maybe 5 percent don't have either Medicare or 
Medicaid or insurance. I wanted to make that point to you as 
well. Ms. Veer, do you deny any access to your clinic because 
of a patient's inability to pay?

    Ms. Veer. We do not.

    Senator Marshall. Mr. Harvey, do you?

    Mr. Harvey. No.

    Senator Marshall. Dr. O'Connor, are you aware of any 
clinics that don't allow access because of their ability to 
pay?

    Dr. Nocon. No. That part is built into the statute around 
health centers.

    Senator Marshall. This is what I am trying to communicate 
with the Chairman is that financial is not the problem with 
access to care. If their ability to pay is not the access to 
care, who is this group of people that aren't getting care 
then? So, you mentioned the desert. We have 32 clinics in 
Kansas.

    I would guess that 95 percent of the patients that don't 
get health care live within 30 minutes of them. So, it is--why 
do patients not get health care that they need and they show up 
in my emergency room instead. Ms. Veer, why? What are we 
missing here? It is more than just throwing money at it.

    Ms. Veer. It is more than throwing money at it, but the 
investment is really important. For example, I have one family 
medicine practice that is very in high demand and it is a 3-
month wait to see a provider there.

    Another thing that we are seeing, I think largely as a 
result of the pandemic that we are coming out of is more need 
for walk-ins, same day services, particularly for community 
members who may not already be established with us.

    But as we see COVID continue to be part of our lives, they 
need testing, they need vaccines, they need treatment. And so, 
they are looking to us to provide that, but many of us can't--
don't have the resources to do a same day walk-in clinic.

    Senator Marshall. Great. I would love to have more answers, 
but I am past time. Thank you so much, Chairman.

    The Chairman. Thank you, Senator Marshall.

    Senator Markey.

    Senator Markey. Thank you, Mr. Chairman, very much. 
Massachusetts is the birthplace of the community health center 
movement in the United States. From North Adams to 
Provincetown, our community health centers proudly bring health 
care to every corner of the state.

    Our community health centers are leading the way in 
providing health care to trans people, treating substance use 
disorder, and battling health impacts of food insecurity. They 
are at the forefront and frontlines of responding to 
intensifying storms and stronger heat waves.

    They care for people before they need to go to overcrowded 
emergency rooms and provide a welcoming environment to 
communities too often ignored or maltreated by our health care 
system. Health justice is not just about affording health care. 
Health justice means people can get the health care when and 
where they need it.

    Community health centers provide the accessible, holistic, 
and compassionate care that empower the people who they serve. 
There is no question, we need community health centers that 
serve every single city and town in our Country.

    Community health centers proved how vital they were in the 
early stages of the COVID pandemic. They provided gold standard 
care when treating people and getting people vaccinated. But 
COVID isn't the only crisis that we are facing. Climate change 
is bringing intensifying floods, fires, and pandemics.

    With it, people are experiencing worsening health impacts. 
Ms. Pears Kelly, what would deep investments in community 
health centers mean for the ability for our health care system 
to adequately respond to the ever-increasing threat from 
climate change to our Country?

    Ms. Pears Kelly. Thank you very much. It is a very 
important question. So, this is a matter of public health, and 
further investment would enable health centers to be able to 
develop plan and operations to be responsive to natural 
disaster emergency, you name it.

    But climate change is very much a high priority in this 
space, and we have had many health centers, whether it was in 
areas where there have been severe flooding, wildfires, 
hurricanes, and health centers are on the front line of that.

    This continued investment enables them to be responsive to 
those needs, and frankly, to continue to play the role that 
they often do, which is to coordinate the response in these 
communities that are already underserved, which frankly can't 
afford to be battered any further.

    Senator Markey. Yes, thank you. Mr. Harvey, thank you for 
your attention to substance use disorder and the opioid 
epidemic. As my colleague, Senator Hassan, mentioned, 
medication treatment is a key resource for people with opioid 
use disorder.

    That includes methadone medication, which is locked behind 
outdated restrictions and regulations. Treatment barriers can 
have deadly consequences. How are community health centers 
helping patients overcome these structural barriers in our 
Country?

    Mr. Harvey. Yes, it is a great question. I appreciate you 
bringing that back up. A big piece of this is enabling the 
patients to get the treatment that they need by being 
accessible, by supporting their payment methodology, which we 
just talked about. And then as well, trying to navigate the 
system.

    We spend a lot of time navigating the system. And also, to, 
I would say health centers are really good about integrating 
services, right, recognizing when someone has a substance use 
disorder, and trying to get them into available treatment, and 
as well building their treatment options around the existing 
constraints.

    But it has been a long--there has been a long evolution of 
policy around mental health. Mental health is looked at now 
differently than it was when it was being legislated 15, 20 
years ago, and that is a really good thing.

    Health centers have been engaged in that evolution and are 
certainly seeing more and more patients coming to them with 
mental health needs and then seeking to address those.

    Senator Markey. Okay. In follow-up----

    Mr. Harvey. Yes----

    Senator Markey [continuing]. Talk about what can be done to 
ensure that there is better coordination between community 
health centers and hospitals, so that there is some form of 
continuum care for these people. Too many of them, as we know, 
are Black, Brown, immigrant, poor. So, their understanding of 
the system is very low. What can be done?

    Mr. Harvey. Sure. Yes, I mean, I think at the local level, 
the relationships matter a lot. Sometimes those can be one 
sided, but oftentimes they are a two-way street. I think the 
requirements that health centers have certainly assist them in 
the way they oriented the system in trying to develop those 
relationships.

    Oftentimes, hospitals are very good at the dynamics of the 
hospital system right now. The players that are in the hospital 
system sometimes can be limiting factors for community health 
centers.

    Like you said, payment mechanisms really can be limiting 
factors for patients getting in there. But by requiring that 
integration, requiring those two sides talk to each other, that 
goes a long way into creating services.

    Senator Markey. Thank you.

    The Chairman. Thank you, Senator Markey.

    Senator Budd.

    Senator Budd. I thank the Chairman, I thank the Ranking 
Member, and the panelists for being here today. Just a few 
moments ago, I was in an agricultural meeting just one floor 
below in a couple of offices away, and while we were talking 
agricultural policy, the No. 1 question came up was about rural 
access to health care and not even related to this Committee.

    Again, I appreciate you being here, but I hear all over 
North Carolina, I was last year or so in all 100 counties and I 
constantly hear about the access concerns for patients in rural 
North Carolina, and that community health centers really help 
close that gap serving over in our state.

    It is a half million people, so I appreciate what you do. 
And it is an important safety net, and it is important that 
providers have the flexibility and tools that they need to 
treat patients, including in rural and underserved areas.

    Community health centers also provide critical resources to 
expectant mothers in at risk families while making sure that 
taxpayer dollars don't fund abortions. The Community Health 
Center Fund is one of several funding sources for these 
centers, of course, as you know. But before considering its 
reauthorization, we need to understand how program funds have 
been used to make sure that we are staying accountable to the 
taxpayers.

    Ms. Veer, again, thank you for being here. The funding for 
community health centers comes with--it is a mix of Federal, 
state, and private sources, as you know. But in your role as 
CEO of Carolina Health Centers, can you provide specific 
examples within the Federal funding programs where Congress 
could give health centers more flexibility to innovate and meet 
the needs of their patients?

    Ms. Veer. That is an excellent question. And the first 
thing I think about when you say more flexibility to innovate 
is, it goes to workforce, and the ability to use resources to 
create those incentives for people to come on board with us. 
Innovation, certainly, I feel like we were really innovative 
with our early childhood services program.

    We are something of a unique model within the community 
health centers, but I applaud HRSA because just recently they 
released a notice of funding opportunity for health centers to 
compete for funding to place an integrated early childhood 
services program in pediatric medical homes.

    That is critical. I mean, we have saved lives. We have sent 
people back to college. So, looking beyond the walls of a 
traditional medical practice and what can we invest in that 
affects people's lives as it relates to their health.

    One of the first grants--in fact, the first grant through 
the Office of Economic Opportunity back in 1965, had a quote 
that said, the need is not for passive recipients, but for the 
active involvement of the community in ways that will change 
their knowledge, their attitude, and their behavior as it 
relates to their health care.

    We need to be able to be flexible in using our resources to 
go out into the community and affect people where they live.

    Senator Budd. Thank you for that. Further, can you go into 
more detail on how managed care and value-based arrangements 
improve health care outcomes for underserved areas while also 
generating savings for the health care system?

    Ms. Veer. Absolutely. That I did put in my written 
testimony, some examples of this. Our health center is part 
of--we, 14 health centers in South Carolina are partners in 
what is called an independent practice association, IPA for 
short, and our IPA is financially and clinically integrated to 
enable us to develop shared protocols about how we manage care, 
and to then work with our managed care, our Medicaid managed 
care organizations to develop value-based arrangements.

    I can tell you that to date, those value-based arrangements 
have resulted in millions of dollars over the last 10 years for 
the 14 partnering health centers. We are provided are those 
incentives based on our collective performance, but then the 
IPA distributes them based on individual performance.

    For example, my health center for the last few years has 
been in the top three performing of those partnering health 
centers.

    Senator Budd. Great. Thank you. And in the time, I have 
remaining, I can't leave out a fellow graduate of Appalachian 
state. So, Ms. Farb, thanks again for being here. As this 
Committee considers reauthorizing the Community Health Center 
Fund, are you aware if the GAO studied duplication or overlap 
in the funding sources to CHC?

    Ms. Farb. We have not studied duplication or overlap, but 
as many of you know, we have a pretty robust process for 
looking for duplication and overlap throughout Federal 
programs.

    The only area that we have looked at in the past that is 
related to overlap is whether or not the community-based health 
clinics that provide care through the Medicaid program, if 
there is duplication paid through Medicaid, and looked at how 
CMS oversees that. But we have not looked at the CHC Fund in 
particular.

    Senator Budd. Thank you again. And again, thank the 
panelists. I yield back.

    The Chairman. Thank you, Senator Budd.

    Senator Kaine.

    Senator Kaine. Thank you, Mr. Chairman, Ranking Member. 
What a great panel. I have really learned a lot from sitting 
and listening to you. There are 30 community health centers 
that serve Virginia.

    Two are in West Virginia, right on the border with Virginia 
and serve Appalachia, Virginia. 28 are based in Virginia, 26 
are FQHCs, 1 is a rural health clinic, 1 is a lookalike. They 
serve about 370,000 Virginians. The FTEs in our Virginia health 
centers is about 2,800 FTEs. The work that they do, and I see 
it every day, is truly tremendous.

    I want to ask Mr. Harvey, I am going to start with you on a 
workforce question, because I was intrigued in your testimony 
you talked about Indiana FQHCs that are doing their own grow 
your own programs to train medical assistants.

    Medical assistants work in a variety of health care 
settings, performing both clinical and administrative tasks. 
They are critical members of the medical team. They support the 
delivery of high-quality care. From 2011 to 2021, the number of 
medical assistants employed in the U.S. grew from nearly 
540,000 to over 725,000, reflecting the growth of this 
occupation as part of primary care teams.

    Like other frontline workers, medical assistants reported a 
lot of burnout and stress during COVID. About 29 percent of 
them intend to leave their jobs within the next 2 years, by 
their own reporting. And when a provider leaves, an 
organization usually incurs a turnover cost of about 40 percent 
of that individual's salary to sort of figure out how to 
backfill and make it up, as well as intangible costs, lower 
levels of productivity, staff morale, patient satisfaction.

    It is clear that medical assistants are very vital to 
primary care clinics. One way we can bring more medical 
assistants in is by reducing training costs, giving people more 
incentives. I recently reintroduced with Senator Braun of 
Indiana the JOBS Act, with my fellow--with many of my fellow 
HELP colleagues.

    The bill would make high-quality, short-term education and 
workforce training programs eligible for Pell Grants. We don't 
allow Pell Grants to be used for high quality career and 
technical education. But we need to do more.

    I would just like to ask Mr. Harvey, how would something 
like the JOBS Act, which would allow Pell Grants to be used for 
high quality CTE, help us bring people into entry level health 
care professions? And what other strategies do you all have to 
suggest to us around retention?

    Mr. Harvey. Yes, I think it would be a big catalyst, quite 
honestly. We have a program in Indiana that is similar that a 
number of health centers have used, that is funded by the 
Indiana Department of Workforce Development. Though it has its 
own limitations in terms of funding, it is next level jobs, the 
Governor's next level jobs program, and it provides 
opportunities for credits toward training in those high 
priority positions.

    High demand occupations and medical assistants are part of 
that. A number of the health centers have relied on that 
because it is a critical source of funding to both support the 
cost of the training. Growing your own is a really great model, 
but it requires resources.

    Then also for MAs, people that are in the community that 
are interested in being medical assistants oftentimes they are 
not good--oftentimes don't have college educations. They will 
need to support themselves, to be able to bear the cost of 
whatever that educational opportunity is.

    But it is a huge catalyst because when you are growing your 
own in the community, and if you have resources to enable 
people who otherwise couldn't get that training, you get 
someone that is brought in more to the health center, bought in 
more, retained more. And then health centers oftentimes will 
double down by creating career ladders for MAs.

    It's not unusual, and I think the Ranking Member made this 
point in the last hearing about a nurse that he knows, where 
you can go up from MA, LPN, RN, BSN, and really scale up in 
your career, and you can do that in a health center with some 
other supports around that.

    I think that is a really, really important idea to support 
people in those areas.

    Senator Kaine. I hope it is an idea whose time has come. It 
is interesting, the Pell Grant program is known for its 
flexibility, so we have Pell for full time college students. We 
have Pell for part time college students.

    We recently restored something that had been part of Pell 
originally, which is Pell can be used by incarcerated folks to 
get skills so that when they finish their time, they are going 
to be able to get productive jobs. But we have never allowed 
Pell to be used for high quality, current technical education.

    A family that is income qualified for Pell, if they got one 
child wants to go to college, Okay, great, we want you to go to 
college. You have got another child that wants to get CTE, it 
is like we don't really care about that. And in an economy 
where there are so many credential programs, you want to make 
sure that they are high quality that can be offered for entry 
level medical positions or other.

    We are doing an infrastructure bill, who is going to build 
everything? I just hope we can take our tradition of using Pell 
and flexible--and finally, say, high quality career and 
technical education is every bit as good as going to college.

    This is something I look forward to working on with my 
colleagues. And I think it would have particular benefit in the 
health care professions. Thank you, Mr. Chairman.

    The Chairman. Thank you, Senator Kaine.

    Senator Murkowski.

    Senator Murkowski. Thank you, Mr. Chairman. Thank you, to 
the Ranking Member. Thank you to the witnesses here, and for 
all that you are doing. We had our--the community health 
centers had their annual fly in to Juneau last week.

    I was with many of them as they were there talking about 
many of the issues that you have presented here today. The 
concern over 340B, some mentioned 330. Certainly, the workforce 
issue all over the place.

    But again, I was reminded of the value that comes from our 
community health centers and the fact that it really is patient 
driven care, but understanding what the real issues are in the 
community and then being able to respond.

    The folks at the Sunshine Clinic up in Talkeetna, their 
real challenge is a lot of the people in their service area, if 
you will, don't have running water. And so, when you are 
thinking about health concerns and considerations, and you 
don't have good water that you can count on, that adds a whole 
additional layer of complication and complexity to what you are 
dealing with.

    Those people know what to do with it, and they are 
advocates in other areas. So, I am a huge fan for community 
health centers. I wanted to follow on just a little bit with 
Senator Kaine when we were talking about workforce. Where we 
are going to get these great people from.

    One of the programs that has been helpful for us in Alaska 
is through the National Health Service Corps. I haven't heard 
any of you mentioned that this morning. I would be curious to 
know if you feel that we can be doing more with National Health 
Service Corps to help bolster our workforce, Ms. Pears Kelly.

    Ms. Pears Kelly. Thank you so much for your understanding 
and your long history of support. And the National Health 
Service Corps could not be more important to health center 
workforce. So, I think as we are talking about investing in the 
community health center program, we also have to think about 
programs like the National Health Service Corps, which enables 
them to staff up.

    If you are making the investment in health centers, you 
have to think about part of the access equation is that 
workforce. The National Health Service Corps has a decades long 
record of success, both in terms of diversity, but also in 
retention in the areas where they are doing the training.

    There is a request for significant funding to at least keep 
intact what has been invested over the last couple of years to 
the rescue plan, which has been a huge enabling factor to 
making sure health centers have been able to bring in and 
retain the staff that they have. And so, I cannot echo and 
emphasize enough the importance of the National Health Service 
Corps specifically.

    I would also say the Teaching Health Center Graduate 
Medical Education Program as well. That is really what enables 
health centers to train up. And just getting at what you also 
mentioned, Senator, around where are these people coming from.

    There are so many individuals in the community who are 
poised and want to pursue a pathway within the health center, 
and it doesn't need to be just clinical. There is operations, 
there is technical, there is, you name it, and health centers 
need it, every bit of it.

    I think the National Health Service Corps, the Teaching 
Health Center program, but also, frankly, giving health centers 
added investment to be able to innovate, to create these 
programs, to create homegrown opportunities for developing 
workforces, not just needed, but absolutely critical.

    Senator Murkowski. We are going to be working on that 
reauthorization. One of the other issues that folks were 
talking about back home, one of the larger facilities that had 
been open to Medicare eligible individuals had just closed. We 
have a real challenge in Alaska with access, for those who are 
Medicare eligible.

    Our reimbursement rates are so out of whack in Alaska that 
it is a real challenge for us. And those Medicare eligible 
folks are just not able to find care. So, we are seeing more 
shifting over to our community health centers.

    Then we also have this situation coming up at the beginning 
of April with Medicaid and the disenrollment or the 
redetermination of the Medicaid populations that is going to be 
required when the emergency, the public health emergency is 
taken down.

    We are concerned or we are hearing that there's going to be 
concerns where you are going to have individuals who are not 
really able to navigate how they then gain access to new 
insurance plans, or they may be looking at plans that have 
potentially higher deductibles and co-pays.

    The question is, do you have--is anybody doing anything to 
kind of anticipate this? Are there navigation assistance that 
might be made available? What are we doing to deal with this 
population that we may see coming to your doorstep?

    Ms. Veer. That is an incredibly important question. The 
unwinding is going to have just a ripple effect. And it is--we 
are trying to invest right now in working with that population 
to make sure that correct addresses are in the system, 
etcetera, etcetera. One of the problems we are facing in South 
Carolina is the re-enrollment process is paper only. There is 
no electronic re-enrollment allowed.

    Senator Murkowski. In your state, or----

    Ms. Veer. Just in our state. But looking at it across the 
Nation in terms of if there were a way to if there were some 
central way for these people to be re-enrolled or go through 
the re-enrollment process, it would be helpful. We expect to 
lose thousands, tens of thousands of beneficiaries from the 
Medicare rolls--Medicaid rolls.

    Senator Murkowski. Any handle on what it is, it is coming 
in just a matter of----

    Ms. Pears Kelly. May I, just to follow-up on that. So, it 
is a massive issue. And I think South Carolina is not alone in 
terms of some of the barriers. It really varies from state to 
state.

    Health centers have been very active in coordinating with 
their states, but also taking the initiative independently to 
make sure that there is as much outreach and navigation as 
possible. But there is an enormous administrative burden.

    The issue also is churning, which is something that has 
been an issue with Medicaid for years. But what happens is 
that, to your point about eligibility, you do have folks who 
will continue to meet eligibility requirements but getting them 
into the system is both costly to the state and to the health 
center.

    Senator Murkowski. Thank you, Mr. Chairman. Little over my 
time.

    The Chairman. Thank you, Senator Murkowski.

    Senator Baldwin.

    Senator Baldwin. Thank you, Mr. Chairman. I have been 
really amazed with the community health centers in my home 
state where they really led the way when it comes to expanding 
services to meet the needs of their patients.

    It is especially true when it comes to behavioral health, 
substance use disorder treatment, as well as dental services. 
There has, however, been some frustration or challenge with the 
lack of funding for service line expansions, those grants.

    I support additional funding for brand new community health 
centers, but I also want to make sure that we also explore ways 
to make funding go farther by investing in our existing health 
centers and allowing them to expand their service array to meet 
local need.

    Mr. Harvey, can you talk about the importance for health 
centers to have the resources to expand service lines?

    Mr. Harvey. Yes, it is a great question. Thank you for 
pointing that out. Yes, particularly services like dental 
services, for example, historically very expensive and 
historically quite needed in areas that are served by health 
centers.

    But that sustained investment is really going to be 
important for existing health centers to be able to expand 
their service lines in areas like oral health and dental 
services, areas like mental health. We have talked about 
substance use disorder.

    That is really critical to enabling them to support both 
the operational, additional operational expense, the additional 
personnel expense, and just the general expense that comes into 
operating the community health center model and going deep and 
comprehensive with individuals to treat the issues that they 
face.

    Senator Baldwin. Well, thank you. Several of our witnesses 
today have noted that health centers are also supported by the 
Medicaid program. I will say that again, Medicaid, which helps 
support those with disabilities, families that need nursing 
home care, and new moms and babies, also supports health 
centers.

    Cuts to Medicaid would be devastating to Wisconsin. It 
would put the more than 1 million vulnerable Wisconsinites who 
rely on Medicaid for their health care at risk and also would 
hurt our community health centers.

    Ms. Pearce Kelly, can you describe what you expect to 
happen if there are significant cuts to Medicaid? Would this 
force community health centers to cut staff, reduce hours, see 
less vulnerable patients, or possibly force some clinics to 
shutter altogether?

    Ms. Pears Kelly. Unfortunately, yes. Health centers will be 
very challenged with the reduction in basically reimbursement 
that comes through Medicaid. They are required to treat 
everyone who walks through their doors and they will continue 
to do that. And I am proud of my colleagues that we can say 
that with full commitment.

    But the reality is, is that loss in revenue, that loss in 
funding will mean additional strains to the workforce, which is 
already extremely burdened and burnt out. It will mean making 
difficult decisions around services, to your point, how can you 
continue to fully operate when you are facing a multimillion-
dollar loss in revenue? It will absolutely have an impact on 
future predictions--or future ability to care for all of the 
real needs in the community.

    Again, the needs are not going to go away just because they 
happen to fall off Medicaid. These are patients that are going 
to need someplace to go, and unfortunately, the alternative is 
they end up in an emergency room.

    The health centers will do everything that they can to 
ensure that doesn't happen, but the loss of revenue is going to 
have a sharp impact on that. And I think it does go across 
services, across sites, across workforce, and possibly other 
areas as well.

    Senator Baldwin. Thank you. Well, let's stay with you, Ms. 
Pearce Kelly. We talked a lot today about how health care 
centers distinguish themselves from other providers because of 
the populations they serve and the value they add to the entire 
system. With that in mind, I wanted to get back to the 340B 
program.

    I have been a long supporter of 340B and have serious 
concerns about how the actions of drug companies and PBMs have 
jeopardized this program, which helps low income and other 
vulnerable patients access more affordable medications. What is 
unique about the community health centers' participation in the 
340B program?

    Ms. Pears Kelly. Well, for starters, they invest every 
single dollar back into patient access and community, and we 
can verify that. That is over and over again with every single 
data point of report that you are going to get with health 
centers.

    It is also used to address a lot of the issues that we have 
been talking about today, whether it is workforce, expanded 
services, longer hours, transportation, enabling services, you 
name it. But all of these things can be documented, and every 
single dollar that comes from the 340B program is verifiable to 
be used in that way.

    I can't speak to other entities, but I can say that the 
data exists and that there have been many hearings over years 
and years to verify that. And so, I think it does distinguish 
health centers that the intention of the 340B program, as it 
was designed, is being used and executed by health centers 
extremely accurately and properly.

    Ms. Veer. If you don't mind my interrupting, but I have to 
also add one other distinguishing characteristic, is that we 
are, as a 340B covered eligible entity, we are required under 
330 to provide all services regardless of ability to pay, which 
means we are required to provide affordable medication at a 
discount. So that is one of the distinguishing factors as well.

    Senator Baldwin. Thank you. Mr. Chairman, I yield back.

    The Chairman. Thank you, Senator Baldwin. Senator Casey, do 
you want--Cassidy, do you want to ask some additional 
questions?

    Senator Cassidy. Yes, thank you. Great panel. Thank you 
very much. My goal coming in here is attempt to understand the 
business model. How do we in Congress ensure that we have a 
viable path forward for the good work you do?

    Dr. Nocon, I looked up an article you had, factors 
associated with federally qualified health center financial 
performance, and it kind of goes with this growth in Medicaid 
funding. In your study, you did a multivariate analysis and you 
found that a higher percent of patient mix of Medicaid covered 
patients was associated with better margins, and that was socio 
of many other better things.

    Dr. Nocon. Yes.

    Senator Cassidy. Now, Ms. Veer has talked about the 
struggles in South Carolina in which she probably has a higher 
percent of patients who are uninsured, I am guessing, because 
you are not a Medicaid expansion state.

    Ms. Veer. Exactly.

    Senator Cassidy. Yes, that is my point. So, and it is my 
understanding that the grant funding is given irrespective of 
whether or not a state has done the Medicaid expansion or not.

    As we look at that, did you find that--is there a 
difference between--intuitive--kind of inherent in your paper 
is that if you separate it out between those states that have 
done Medicaid expansion and those not, that the federally 
qualified health center is probably doing a little bit better 
financially and therefore in the other means as well in those 
states that do the expansion versus those that did not. Is that 
a fair statement?

    Dr. Nocon. Yes.

    Senator Cassidy. In the dollar spent per patient, we did 
the math, and based on your work, Ms. Farb, it was about $650 
bucks in 2011 and $970 bucks in 2017. With inflation, that is 
probably about flat funding.

    But I am guessing that in those states which did the 
Medicaid expansion, that their funding per patient probably 
grew more significantly and has pulled down a little bit, if 
you will, when you average across those states that did not do 
the expansion. Is that, again, a fair statement?

    Dr. Nocon. Likely, yes.

    Senator Cassidy. Likely. And so, as I look at the business 
model, and again, we want to make--we want to make sure that 
you have an adequate business model. In those states that did 
the expansion, I am thinking I am hearing, because even in 
South Carolina without, congratulations to you, you all are 
managing to keep it together.

    In states that did do it, they are just going to be better 
off financially with all that entails in terms of the ability, 
as you point out in your paper, better margins means better 
services. Again, is that a fair characterization of your paper?

    Dr. Nocon. Could you repeat that, Senator Cassidy?

    Senator Cassidy. I am just trying to understand if in the 
business model, those states in which there is a Medicaid 
expansion, which also have federally qualified health centers, 
if they--if you are able to see that those federally qualified 
health centers had better margins than those states that did 
not do the Medicaid----

    Dr. Nocon. Those appear to be doing better financially.

    Senator Cassidy. Therefore, they had the other positive 
things associated with those better margins?

    Dr. Nocon. Presumably, yes.

    Senator Cassidy. Okay. Thank you.

    The Chairman. Let me just ask----

    Senator Cassidy. Can I ask one more thing?

    The Chairman. Sure.

    Senator Cassidy. I guess my other overall point, it does 
seem like a diversified income stream is also associated with 
clinics doing better. You are not dependent upon one thing. 
Rather, you have multiple things feeding into the overall 
financial health.

    Dr. Nocon. I think that would be a reasonable statement in 
particular, because we also find that community health center 
funding is associated with more stable and stronger financial 
performance.

    Senator Cassidy. Yes. Okay, thank you.

    The Chairman. Great. Thank you, Senator Cassidy. Let me 
just ask a few more questions and then we will wrap it up. We 
spend over 18 percent of our GDP on health care. That is almost 
double what any other country spends.

    As broken as our general health care system is, it seems to 
me that our primary health care system is even more broken, 
with tens of millions of people not able to get to a doctor 
when they get sick.

    I have talked to physicians in Vermont and around the 
country who tell me that people walk into their offices very, 
very sick and sometimes with incurable illnesses that could 
have been dealt with if they walked in the door on time. And 
they didn't because they didn't have insurance.

    They were embarrassed, or not have any money to pay. In 
your judgment, No. 1, would at a time when we spend so much 
more than other countries on health care, if we provided at 
least primary health care to every man, woman, and child, we 
have had primary health care accessible to everybody, in the 
long run, would it save our health care system substantial sums 
of money? Ms. Veer, you are jumping to answer that.

    Ms. Veer. I am, Senator. Thank you so much for the 
question. And I would say yes, maybe. But then because the 
maybe is you also need to make sure that they not only have 
access, but the work is being done to connect them to the 
appropriate services. Because just having the access, it 
doesn't connect people to the appropriate services. Quality and 
population health management----

    The Chairman. But that runs us into another issue, again, 
having to do with the fact that we are the only major country 
not to have a national health care program. So, somebody walks 
in and you make a diagnosis and say, we are sorry, you have 
breast cancer. Oh, but I can't afford the other treatment that 
I need or I am going to go medically bankrupt as a result of 
it.

    Who else wants to jump into the issue of the morality of 
providing health care for all people at a time when we lose--we 
don't talk about it very much, but studies that I have seen 
suggest that we lose over 60,000 people a year who don't get to 
a doctor on time, and that if we don't treat people, you said 
it, an ounce of prevention is better than a pound of cure.

    Are we spending on the cure, the tertiary health care, the 
hundred-thousand-dollar surgeries, rather than making sure 
people have the medicine and the primary health care they need?

    Amanda.

    Ms. Pears Kelly. I appreciate you putting it in that 
context, and I will just call out some of the comments that 
Senator Cassidy made earlier that this is the wise investment, 
and to your point, it is about keeping people healthy.

    If you keep them healthy on the front end, if you keep them 
out of the emergency room, if you keep their chronic diseases 
managed, if you keep them from getting severely ill, which you 
can do in health centers, yes, it is going to serve and it is 
meaningful for the 100 million people that we have called out 
today, but really for everyone. Primary care is the path to 
success in health care, period.

    The Chairman. Yes.

    Dr. Nocon.

    Dr. Nocon. I would just add that a long history of research 
on primary care generally, specifically looking at comparative 
performance of health systems across countries, has reinforced 
that a strong, high functioning primary care system is 
associated with a broad range of health system outcomes that we 
look for.

    The Chairman. Is it fair to say that specifically in terms 
of primary care, we invest far less than other major countries?

    Dr. Nocon. Absolutely.

    The Chairman. That is perhaps one of the contributing 
factors why we end up spending so much per person on health 
care. Is that a fair?

    Dr. Nocon. That would be fair.

    The Chairman. Yes, Okay. All right, listen, let me thank 
the panel all for being here. You were great. We are talking 
about a major issue of concern to the American people, and it 
is my determination to do everything we can to come up with 
legislation that will improve and expand community health 
centers in this country and move us toward the goal of making 
sure that every person no matter where they may be, have access 
to primary health care.

    That is the end of our hearing today. I want to thank all 
of our witnesses for their participation. For any Senators who 
wish to ask additional questions, questions for the record will 
be due in 10 business days. That is March 17th at 5.00 p.m.

    Finally, I ask unanimous consent to enter into the record a 
statement from Senator Casey and statements from stakeholder 
groups outlining their priorities for community health centers.

    [The information referred to can be found on page 105]
    The Chairman. The Committee stands adjourned.
                                ------                                


                          ADDITIONAL MATERIAL

               statement of senator robert p. casey, jr.
    I regret that I was unable to attend the Committee on Health, 
Education, Labor, and Pensions (HELP) hearing on Thursday, March 2, 
2023 due to medical leave. This hearing examined the critical ways in 
which community health centers (CHCs) provide care to patients across 
the Nation. This is an important priority of Chairman Sanders, and I am 
eager to work with him to strengthen our CHCs.

    The Community Health Center Fund was created by the Affordable Care 
Act to fill gaps in primary care access. CHCs are required to provide a 
host of medical services related to family medicine, internal medicine, 
pediatrics, obstetrics, and gynecology, in addition to diagnostic 
testing, preventative health services, emergency medical services, and, 
in some cases, pharmaceutical services.

    In 2021, over 30 million patients--or 1 in 11 Americans--visited 
their local CHC for their health needs. CHCs serve 1 in 5 uninsured 
Americans, 1 in 3 Americans living in poverty, and 1 in 5 rural 
Americans. In many rural areas, CHCs may be the only primary care 
providers. CHCs offer high quality services regardless of a patient's 
ability to pay, actualizing a commitment to health equity.

    CHCs continue to serve as critical junctions in our Nation's COVID-
19 response. As of August 2022, CHCs administered 22.2 million vaccines 
and 20 million diagnostic tests. In order to mitigate disease spread in 
health care settings, most CHCs proactively pivoted to telehealth 
appointments so as not to disrupt patient care plans.

    CHCs employ 270,000 professionals from dentists to behavioral 
health specialists to nurse practitioners, serving as key employers in 
their communities. In order to combat workforce shortages, CHCs 
participate in programs like the National Health Service Corps, the 
Teaching Health Center Graduate Medical Education program, and the 
Nurse Corps Scholarship Program. By placing eligible providers in CHCs, 
a reliable workforce takes shape in underserved communities.

    Supporting whole person health is an essential component to 
comprehensive health care, which is why many CHCs provide mental and 
behavioral health services. There is evidence to show that co-locating 
and integrating primary care with mental health care yields stronger 
patient outcomes. CHCs lower the already high barriers to access mental 
and behavioral health services.

    The Community Health Center Fund was most recently reauthorized in 
the Consolidated Appropriations Act, 2021 with approximately $4 billion 
in mandatory and $1.8 billion in discretionary funding through Fiscal 
Year 2023. Every year, I join Senator Stabenow in support of sustained 
funding for this essential program.

    I have heard from CHCs across the Commonwealth of Pennsylvania 
devising innovative ways to spread resources. Congressionally directed 
spending requests, when available, offer one avenue for CHCs to make 
needed investments. The American Rescue Plan (ARP) offered a lifeline 
for CHCs in their response to the COVID-19 pandemic. The ARP Health 
Center Construction and Capital Improvements program offered a one-off, 
scaled funding opportunity for CHCs to update their infrastructure to 
better serve their communities. We need more opportunities like this to 
build the sustainability of CHCs moving forward.

    With an upcoming opportunity to reauthorize the Community Health 
Center Fund, I look forward to working with my colleagues on both sides 
of the aisle to develop new ways to support CHCs as they continue to 
provide a breadth of services.
                                 ______
                                 
           statement of the american academy of opthalmology
    Chairman Sanders and Ranking Member Cassidy:

    The American Academy of Ophthalmology appreciates the opportunity 
to share our perspective on the role community health centers can play 
in increasing access to eye disease screening ahead of the Committee's 
hearing, Community Health Centers: Saving Lives, Saving Money. The 
Academy is the largest national member's association of 
ophthalmologists--medical and osteopathic doctors who provide 
comprehensive eye care including medical, surgical, and optical care. 
The Academy seeks to protect sight and empower lives by setting the 
standards for ophthalmic education and advocating for our patients and 
the public.

    For decades, community health centers have played a critical role 
in providing Americans with access to primary care. In many 
communities, they serve as the central or only healthcare access point. 
Their important role in protecting the public health of American 
communities was underscored by the COVID-19 pandemic, where community 
health centers served as a critical resource for patient care and 
access to life-saving vaccines. Because of their important role in 
community health, as well as reducing health disparities, the Academy 
is focused on identifying ways for our members to partner with 
community health centers to expand access to badly needed eye care 
services, increase eye disease screening rates, and promote better 
patient outcomes.

    While community health centers have expanded their portfolio of 
healthcare services beyond primary care, including dental and mental 
health services, access to vision services remains limited. In 2020, 
only 26 percent of health centers had onsite vision services. Access 
currently varies dramatically state-to-state, with health centers in 
California, New York, and Massachusetts having strong vision services 
across site locations but other states facing significant limitations 
or a total lack of vision services, including in Vermont and Louisiana. 
\1\ The financial costs of incorporating vision services into community 
health centers remains a significant barrier. Because of population 
growth and patients with a diverse set of clinical needs, health 
centers must make tough decisions on how best to allocate their 
resources. This can make significant investments in vision services 
unlikely, especially hiring full-time eye care providers, as well as 
allocating office space and providing administrative support. Yet, 
their patient populations are comprised of those at elevated risk of 
severe eye diseases like diabetic retinopathy and glaucoma, as well as 
uncorrected refractive error. The Academy believes that there are 
pathways for community health centers to provide patients with vision 
services that require less financial investment, while still providing 
tremendous benefits by detecting eye disease that pose significant 
threats to their patient's quality of life. The increased utilization 
of telemedicine, including by community health centers, provides one 
avenue for expanding access.

    \1\  2020 HRSA Uniform Data System. Bureau of Primary Health Care, 
Department of Health and Human Services.
---------------------------------------------------------------------------
Utilizing Telemedicine & Artificial Intelligence Technologies to Expand 
                Access to Diabetic Retinopathy Screening
    Diabetic retinopathy can cause vision loss or blindness in patients 
with diabetes and is the leading cause of blindness among working-age 
adults. In early stages, patients are often asymptomatic which can 
reduce the likelihood of detection and diagnosis without proactive 
efforts to screen patients with diabetes. Unfortunately, too many 
patients with diabetes do not get timely eye or retinal examinations. 
For patients with advanced diabetic retinopathy, the cost of treatment 
with anti-VEGF drugs can be substantial due to both the cost of the 
drugs and the need for frequent injections.

    The Academy has championed the use of telemedicine to expand access 
to diabetic retinopathy screening, which has demonstrated value by 
increasing rates of significant disease detection and thereby promoting 
faster and often more effective treatment. Early identification of the 
diabetic retinopathy is important not only to patient outcomes but can 
dramatically lower the cost to the U.S. healthcare system.

    Recent FDA-approvals of AI based technology for early detection of 
diabetic retinopathy provide another pathway for technology to provide 
a cost-effective way to expand access to screening in community health 
centers. Because the AI device can identify diabetic retinopathy severe 
enough to threaten vision, it can speed up and increase referral 
appointments for patients who have a need but would not otherwise seek 
out an eye or retinal examination. It can also be used as a tool by 
primary care providers or others that manage the treatment of patients 
with diabetes. While the use of AI for diabetic retinopathy screening 
in community health centers is currently limited to a few states, it is 
increasingly being incorporated as a tool in diabetic treatment models.

 CDC-Funded Glaucoma Screening Programs-Expanding Access in FQHCs and 
                           Community Clinics

    Expanding access to glaucoma detection and treatment is another 
area where the Academy believes community health centers can play an 
integral role. The Vision Health Initiative (VHI) at the Centers for 
Disease Control and Prevention (CDC) funded 5-year research programs to 
study the use of telemedicine to expand access to glaucoma detection 
and treatment for vulnerable populations. Two of the funded programs 
are working in collaboration with federally Qualified Health Centers 
(FQHCs), including one in Flint, Michigan and others in rural Alabama. 
While the research focus is glaucoma, these programs are providing 
screening for diabetic retinopathy, cataracts and uncorrected 
refractive error. As of January 2023, the CDC funded programs had 
screened nearly 4,000 patients, referred over 1,500 for follow-up eye 
care, and identified over 800 cases of glaucoma or suspected glaucoma. 
These rates of detection are significantly higher than national 
averages and underscore the risk of advanced eye disease faced by these 
patient populations. The Academy supports increased investment in the 
Vision Health Initiative at CDC. The research programs and existing 
models they have funded that work in collaboration with FQHCs have the 
capability to be scaled and offered in other communities.

                            Closing Remarks

    The Academy appreciates the focus of you and your colleagues on the 
Committee on the important role that community health centers play in 
protecting public health and providing access to care for millions of 
Americans. The Academy knows that many health centers face financial 
constraints and that limits their ability to provide vision services, 
but we do believe that investments in health centers can pay 
significant dividends and promote increased attention on expanding 
pathways to addressing the visual health needs of their patient 
populations.

    As you examine the important role of community health care centers, 
the Academy looks forward to the opportunity to partner with you and 
your colleagues on the HELP Committee to address the eye health needs 
of Americans.

               Disclosure of Federal Grants or Contracts

    Between 2013 and 2015, the American Academy of Ophthalmology (AAO) 
received funding from the Agency for Healthcare Research and Quality 
(AHRQ) under the Developing Evidence to Inform Decisions about 
Effectiveness (DECIDE) Program, to disseminate the Registry for 
Glaucoma Outcomes Research (RiGOR) study findings through the use of 
social media tools.

    AAO is a 501c (6) educational membership association.
                                 ______
                                 
         statement of the american physical therapy association
    Chairman Sanders, Ranking Member Cassidy, and Members of the Senate 
Health, Education, Labor, and Pensions Committee:

    The American Physical Therapy Association represents more than 
100,000 physical therapists, physical therapist assistants, and 
students of physical therapy nationwide. On behalf of our members and 
the patients we serve, we thank you for this opportunity to provide 
APTA's perspective on the critical role community health centers, or 
CHCs, play in delivery care to rural and underserved areas, and 
suggestions for improving access for the patients they serve.
                               Background
    CHCs provide primary health services to more than 30 million people 
at over 14,000 delivery sites nationwide, including nearly 3 million 
Medicare beneficiaries and 1 in 5 Medicaid beneficiaries. These 
facilities provide a lifeline to communities in need of essential 
health services whose barriers to health care include cost, lack of 
insurance, and distance. Presently, CHCs offer a range of health 
services, including access to physicians, advanced practice nurses, 
dentists, clinical laboratory, emergency medical, and behavioral 
health.

    Community health centers depend upon a network of over 255,000 
clinicians, providers, and staff to deliver on the promise of 
affordable and accessible health care. The currently limited list of 
reimbursable health care providers is a particular barrier for health 
centers, including access to physical therapist services. Recognizing 
these additional billable provider types, such as physical therapists, 
will help facilitate care coordination with health care providers, 
connect patients with community-based services, and support community 
health center efforts as they address multiple health care challenges, 
including the current opioid crisis and the impact of patients with 
long COVID. In addition, reimbursement must recognize activities such 
as interdisciplinary team training and other support services patients 
need to navigate complex and siloed care as well as connect with other 
community resources.
   Adding Physical Therapists as Billable Providers in CHCs to Help 
                Address the Opioid Crisis and Long COVID
    Between 2015 and 2018, 73 percent of community health centers 
reported an increase in opioid use disorder, and 69 percent reported an 
increased number of patients addicted to prescription opioids. This 
public health emergency is widespread in rural and medically 
underserved areas where CHCs are often the only option for medical 
care. COVID-19 has caused health, social, and economic stress that has 
exacerbated the opioid epidemic.

    Data collected by the Overdose Detection Mapping Application 
Program demonstrated that drug overdoses generally were 18 percent 
higher in March, 29 percent higher in April, and 42 percent higher in 
May 2020 than in their respective months in 2019. There is a growing 
realization that current strategies for managing pain have to change--
that opioid-centric solutions for dealing with pain, at best, mask 
patients' physical problems and delay or impede recovery and, at worst, 
may prove to be dangerous or even fatal. Physical therapists evaluate 
individuals for risk factors for pain to help prevent future pain 
issues. These services often can reduce, if not eliminate, a patient's 
pain, and help a patient avoid surgery, hospitalizations, and opioid 
use.

    Physical therapists also treat patients with long COVID for 
musculoskeletal conditions such as fatigue, weakness, and muscle or 
joint pain. Physical therapy is essential to long COVID recovery, and 
can improve strength, stamina, and quality of life for patients with 
long COVID symptoms.

    Physical therapist services play an essential role in addressing 
the challenges caused by the opioid epidemic and long COVID, especially 
in rural and underserved areas. However, CHCs are restricted in how 
physical therapist services are delivered and reimbursed. Currently, 
PTs working in a CHC are not authorized to independently bill for the 
therapy services they provide. In many cases, a CHC will need to refer 
a patient out to receive physical therapy at another location, 
preventing them from getting treatment in a timely and cost-effective 
way.

    To address this problem, APTA urges Congress to pass legislation 
that would allow CHCs the option to permit PTs to independently bill 
for the services they provide to patients in CHCs who are covered by 
Medicare and/or Medicaid. In the 117th Congress, H.R. 5365, the Primary 
Health Services Enhancement Act, was introduced in the U.S. House of 
Representatives by Reps. Jackie Walorski, R-Ind., Ron Kind, D-Wis., 
Diana DeGette, D-Colo., and Don Bacon, R-Neb., to achieve this purpose. 
This bipartisan legislation, endorsed by the National Association of 
Community Health Centers, would expand patient access to essential 
physical therapist services to children and adults who receive care at 
CHCs. H.R. 5365 would not mandate that CHCs furnish physical therapist 
services, but rather provide CHCs with the necessary flexibility in the 
delivery of physical therapy to patients who may require such services. 
APTA anticipates reintroduction of this important legislation in the 
118th Congress in the near future.

    Adding physical therapists to the list of providers who can bill 
for their services in CHCs increases patient access and provides 
flexibility to CHCs. It should be noted that adding physical therapists 
to the list of billable providers does not create a new benefit; it 
simply enables CHCs flexibilities in how patients access physical 
therapy, a benefit that is already provided for under Medicare and 
Medicaid. Doing so also would provide options for CHCs to create 
innovative service delivery models. Patients would be accessing vital 
therapy services in the same clinic they are receiving other services, 
eliminating the need to travel to another location to receive physical 
therapy.

                               Conclusion

    APTA thanks the Committee for focusing attention on the importance 
of community health centers and the critical health care services they 
deliver to millions of Americans. Enacting legislation to add physical 
therapists to the list of providers who can independently bill in CHCs 
would be an important step toward improving consumer access to more 
health care services and improving health outcomes. APTA stands ready 
to work with Congress on this issue and others affecting our Nation's 
health care system. Should you have any questions regarding our 
comments, please contact Steve Kline with APTA congressional Affairs.
                                 ______
                                 
                              United States Senate,
        Committee on Health, Education, Labor, and 
                                          Pensions.
                                            Washington, DC.
                                                      March 1, 2023
The Honorable Gene Dodaro
Comptroller General of the United States
U.S. Government Accountability Office
441 G. Street, N.W.
Washington, DC.

    Dear Mr. Dodaro:

    As we consider the reauthorization of the Community Health Center 
Fund we must study the effectiveness of the overall program in 
achieving its statutorily defined goals. We will also need to examine 
all funding streams that community health centers receive to understand 
the health of the program and ensure proper stewardship of American 
taxpayer dollars.

    I request that you update your report, ``Health Centers: Trends in 
Revenue and Grants Supported by the Community Health Center Fund,'' 
with up-to-date data. The current report covers community health center 
revenue from fiscal years 2011-2017 and the purposes for which grants 
were awarded during that time period. Specifically, I request that your 
updated review also include funding for health centers provided by 
COVID-19 related legislation, and the American Rescue Plan Act.

    I hope that you can prioritize this project as we will look to it 
as we reauthorize the program by the end of this fiscal year. I 
appreciate your attention to this matter.

            Sincerely,
                                Senator Bill Cassidy, M.D.,
                                            Ranking Member,
       Committee on Health, Education, Labor, and Pensions.
                                 ______
                                 

                        QUESTIONS FOR THE RECORD

 Response by Amanda Pears Kelly to Questions of Senator Casey, Senator 
 Smith, Senator Hickenlooper, Senator Murkowski, and Senator Tuberville
                             senator casey
    Question 1. Community Heath Centers are intended to meet the needs 
of medically underserved populations (MUPs), including racial and 
ethnic minorities. One in four Black Americans have a disability. One 
in six Hispanic Americans have a disability. The CDC has reported that 
3 in 10 American Indians and Alaskan Natives have a disability. The 
Department of Agriculture reports that 9 percent of migrant farmworkers 
have a disability. The Department of Housing and Urban Development 
reports that 40 percent of unhoused individuals have a disability. 
MACPAC reports that 10 million of those eligible for Medicaid have a 
disability. All of these populations are designated as underserved. 
What is necessary to ensure that members of these MUPs who have 
disabilities are able to be served by Community Health Centers in an 
accessible manner to reduce racial, ethnic, and income disparities?

    Answer 1. Senator Casey, thank you so much for this question and 
for your deeply held commitment to Americans living with disabilities.

    Health centers that receive funding under Section 330 of the Public 
Health Service Act are required to provide accessible health care to 
all patients. Each one of our members provides comprehensive, 
culturally competent primary health care services to a wide range of 
vulnerable populations such as (but not limited to) school children, 
the elderly, pregnant women and infants, immigrants, minority 
populations, the LGBT community, people with disabilities, and military 
veterans. These communities' needs evolve over time, and in many cases, 
become more complex and expensive. We are proud of our tireless 
commitment to meet these needs, but we cannot do it without support.

    With the right investment, community health centers can fulfill 
their mission as hyper-local health care hubs--treating the full range 
of patients' needs, supporting community transformation, and achieving 
true health equity. ACH's vision for community health center funding--
$30 billion by 2030--isn't rooted in dollars and cents. It's rooted in 
a vision of what can be achieved for our patients, our communities, and 
all those in need.

    Question 2. Community Health Centers are intended to meet the needs 
of medically underserved populations, including rural populations with 
few health care resources. In many rural areas, CHCs may be the only 
primary care providers. The Centers for Disease Control reports that 
over 30 percent of people living in rural regions have a disability, 
the highest rate of disability of any Census urban-rural 
classification. What steps should be taken to ensure rural residents 
with disabilities can be accessibility served by Community Health 
Centers?

    Answer 2. We really appreciate this question and would love to work 
with you more closely on this issue. Americans in our rural communities 
are facing a health care crisis--one that is only compounded when 
families are also living with disabilities. Between 2010 and 2021, 136 
rural hospitals closed. Nineteen of these closures occurred in 2020, 
the year the COVID pandemic hit the United States. Community health 
centers have responded to the growing health care access crisis in 
rural areas. Based on the most recent data, community health centers 
serve one in five rural residents, and those numbers are rising. 
Research has shown that in areas previously served by a rural hospital, 
there is a higher probability of new community health center service 
delivery sites post-closure. Over time, most rural areas are seeing an 
increase in access to community health centers. We would welcome the 
opportunity for additional funding to open new sites and centers in 
rural areas that focus on inclusive, accessible care.

                             senator smith

    Question 1. Community health centers across Minnesota are working 
to integrate physical, behavioral, and dental care to improve health 
outcomes. I have led legislation with Senator Moran to improve access 
to integrated care--our Improving Access to Behavioral Health 
Integration Act, which was signed into law as part of last year's 
omnibus spending package, will enable community health centers (CHCs) 
to apply for grants to implement integrated care models and will make 
it easier for CHC patients to get the behavioral health care they need.

    1 (a) How can grant programs like this one help CHCs improve health 
outcomes in their communities?

    Answer 1 (a). Senator Smith, thank you for your leadership on 
integrated health care, which is a priority that we share at ACH.

    In a recent survey of our members, we found that the majority of 
patient visits now include some element of behavioral health care. 
Centers are constantly looking to expand and strengthen their 
behavioral health capacity, integrating services wherever they can and 
referring patients for more specialized services. Grant programs like 
the one you and Senator Moran championed support community health 
centers--the largest source of primary care in the country--as they 
make integrated behavioral health care a more routine way to deliver 
care.

    1 (b). What are the specific health and economic benefits of 
integrating physical and behavioral health care in CHCs, and how do 
these benefits impact rural communities in particular?

    Answer 1 (b). Studies of integrated behavioral health care at CHCs 
have shown increases in both provider and patient satisfaction. \1\ 
Integrated behavioral health care has been associated with increased 
utilization of medical services and decreased hospitalizations for 
individuals with severe mental illness and has also been shown to 
promote access to mental health services particularly in the 
underserved populations that FQHCs typically serve, including rural 
communities. \2\, \3\
---------------------------------------------------------------------------
    \1\  Petts, R.A., Lewis, R.K., Brooks, K. et al. Examining Patient 
and Provider Experiences with Integrated Care at a Community Health 
Clinic. J Behav Health Serv Res 49, 32-49 (2022). https://doi.org/
10.1007/s11414-021-09764-92.
    \2\  Krupski A, West II, Scharf DM, et al. Integrating primary care 
into community health centers: impact on utilization and costs of 
health care. Psychiatric Services. 2016;67(11):1233-1239.
    \3\  Bridges AJ, Villalobos BT, Anastasia EA, et al. Need, access, 
and reach of integrated care: a typology of patients. Family, Systems, 
and Health. 2017;35(2):193-206.

    1 (c). What resources do community health centers need to implement 
---------------------------------------------------------------------------
integrated care models?

    Answer 1 (c). Currently, while CHCs prioritize integrated care and 
other behavioral health services in order to provide the most 
comprehensive care, it is not a required service under Section 330. We 
strongly support the President's fiscal year 2024 Budget request to 
require that all health centers provide behavioral health services. The 
Budget also proposes $7.1 billion for Health Centers, which includes 
$5.2 billion in proposed mandatory resources, an increase of $1.3 
billion above fiscal year 2023 enacted, in part to help support the new 
behavioral health requirement.

    1 (d). What more can we do at the Federal level to expand 
integrated care models, especially in rural communities?

    Answer 1 (d). Two of the barriers preventing more widespread use of 
integrated health models are workforce shortages and Medicaid billing 
limits. At ACH, we propose addressing both of these barriers with one 
comprehensive solution--supporting more health centers in the journey 
to value based health care.

    Within the Prospective Payment System under Medicaid for FQHCs, 
certain staff are not able to trigger an encounter payment. If more 
FQHCs received value-based payment arrangements that included a broader 
interdisciplinary care team, they could more effectively integrate 
critical staff and deliver more efficient, effective care. Currently, 
some clinicians are currently having to work on issues outside of their 
scope of work, including billing and payment issues. If a therapist, 
psychiatrist, or addiction medicine physician does not have to perform 
roles that typically a case manager, behavioral health specialist or 
community health worker could do more effectively, their time is freed 
up to serve more patients and they experience less burnout.

    Similarly, many states prohibit same day billing of Medicaid 
encounters--meaning, behavioral health and primary care cannot be 
billed on the same day, effectively ending the integrated care 
approach. If FQHCs are able to receive capitated payment for patients 
and leverage resources for a more efficient, patient-centered approach, 
we believe more FQHCs could more readily deploy integrated health care.

    For both of these issues, Federal legislation could either require 
or incentivize states to work on value based care for Medicaid safety 
net providers, including FQHCs. We would be glad to work with your 
office on this issue.

                          senator hickenlooper

    Question 1. How are community health centers particularly well 
equipped to recruit and retain providers that reflect the communities 
they serve? How can we further support health care workforce training, 
particularly in supporting diversity?

    Answer 1. To recruit, train and retain workers, community health 
centers leverage HRSA's health care workforce scholarships and 
education loan programs which help train a diverse workforce, including 
dentists, dental hygienists, mental health professionals, community 
health workers, nurses, midwives, primary care professionals, and 
faculty. These programs provide care in community-based settings to the 
most vulnerable patients, and help retain a workforce who are most 
likely to serve those communities after training.

    These vital programs include:

          National Health Service Corps (NHSC)

          Health Careers Opportunity Program (HCOP)

          Scholarships for Disadvantaged Students (SDS)

          Teaching Health Center Graduate Medical Education 
        Program. (THCGME)

    In total, in 2021-2022, there were over half a million participants 
nationwide and over 368,000 graduates from these programs. Among these, 
over 42,000 participants reported being from an underrepresented 
minority, disadvantaged, or rural background. Over 25,000 participants 
focused on the Department of Health and Human Services (HHS) priority 
of health equity and addressing social determinants of health. 69 
percent of recent graduates now practice in a medically underserved 
community, primary care setting, or rural area.

    Further, NHSC providers represent a diverse group of clinicians. 
Thirty 3 percent of the Nation's total population identifies as Black 
or Hispanic/Latino. This same population only represents 11 percent of 
physicians in the U.S. However, roughly 25 percent of physicians 
serving through the NHSC identify as Black or Hispanic/Latino, a key 
indication that the NHSC is successfully driving clinician diversity.

    As I testified to before the HELP Committee, we are requesting 
investments in health centers that total $30 billion in funding by the 
year 2030. In addition to expanding and improving the care centers 
deliver, we believe that this investment would allow health centers to 
train an additional 25,000 providers.

                           senator murkowski
    Question 1. All Witnesses: As you all know, the National Health 
Service Corps (NHSC) program plays a critical role in training and 
recruiting providers to Health Professional Shortage Areas (HPSAs) in 
Alaska and throughout the country. Could you speak to how CHC's utilize 
NHSC to bolster the rural primary care workforce? What updates are 
needed to the existing programs to address the shortage we are seeing 
in Alaska and across the country in primary care providers and mental 
health professionals?

    Answer 1. Senator Murkowski, thank you for your longstanding 
commitment to the NHSC and your support for Alaskan patients and 
clinicians. Today, the NHSC receives $310 million in mandatory funding 
via a dedicated trust fund (which will expire at the end of fiscal year 
2023) and received $121.6 million in annual discretionary 
appropriations in fiscal year 2023. The 2021 American Rescue Plan (ARP) 
COVID-19 relief package provided an historic one-time investment of 
$800 million for the NHSC, with a further $100 million directed toward 
the Corps in 2022.

    However, if current funding levels are continued in the years to 
come, only a portion of Loan Repayment and Scholarship applicants will 
be granted awards, particularly once ARP funds run out. Collectively, 
more than 158 million individuals reside in HPSAs, including nearly 
300,000 in Alaska (source). Yet, thousands of NHSC applications could 
go unfunded due to lack of resources.

    Furthermore, the COVID-19 pandemic had dire effects in communities 
already suffering challenges with provider shortages. Without long-
term, sustainable funding to accommodate the existing and growing need, 
underserved areas across the country which can least afford to deal 
with additional strains and shortages on their clinical workforce may 
reach a breaking point.

    Now more than ever, it is crucial to continue to fund and grow the 
NHSC to ensure access to care for millions of people living in shortage 
areas. The estimated cost to eliminate all existing HPSAs through the 
NHSC is approximately $1.5 billion annually. We ask that Congress 
support legislation that ensures adequate and sustainable funding for 
the National Health Service Corps program and expands the program to 
address the urgent need for primary care in underserved communities 
across the country now and in the future.
                           senator tuberville
    Question 1. In preparing for this hearing, I reached out to CHCs in 
Alabama to get their perspective on how telehealth has impacted their 
practice abilities and the rural and underserved areas where they 
operate.

    These stakeholders have let me know that, in fact, telemedicine is 
a major part of the solution, but there are some important caveats. It 
is important to see what steps need to be taken first, to stretch 
Federal dollars as far as possible. We need to realize that money spent 
on telehealth infrastructure could potentially be wasted if not 
invested carefully--and how there could even be adverse consequences to 
different patient populations.

    There are many ways that people define ``telehealth'' and 
``telemedicine,'' and what that looks like in practice can depend on 
many different factors. The entire system can get overwhelming if we 
try to build it from scratch--so some CHCs in Alabama have voiced 
support for enhancing our current infrastructure and helping existing 
systems and providers reach patients through a myriad of ``telehealth'' 
options.

    These stakeholders are recommending a version of telehealth that 
integrates and supports the existing healthcare system. However thin 
and fragmented it is currently, telemedicine designed correctly can de-
fragment and re-integrate healthcare for the 21st century.

    Providers at multiple CHCs in Alabama have recommended the 
following principles to help telehealth services support rural and 
underserved communities:

        (a). Patients should be able to access their local MDs via 
        telephones.

        (b). Local MDs should be able to bill for these visits.

        (c). There should be transparency and appropriate regulation.

        (d). Safeguards should be put into place regarding far-out-of-
        network telehealth.

        (e). Local MDs should have robust access to sub-specialists--
        perhaps the specialist gets a consult fee, and the local doctor 
        gets an administrative origination fee.

    In outlining these proposed principles, providers have emphasized 
the funding of programs like THCGME and maintaining pandemic-era 
innovation. They also recommend that the overwhelming majority of any 
Federal telehealth funding should go to two places: proven, major 
subspecialty units, and high-speed internet in rural and underserved 
urban areas.

    Please provide comments, concerns, and recommendations on how to 
achieve the principles laid out above for rural and underserved 
communities.

    Answer 1. Senator Tuberville, thank you for your strong 
relationship with your CHCs in your state and your thoughtful approach 
to this important policy issue. We absolutely share the five principles 
that the Alabama CHCs suggested to guide telehealth expansion and, we 
hope, permanency in rural and underserved communities.

    All ACH members successfully increased access to care for clients 
with the implementation of telephonic/telehealth services during the 
pandemic, and we believe these access improvements should continue. In 
particular, behavioral health clients are experiencing increased 
intensity of symptoms and behaviors and need more frequent and 
intensive interactions and services. FQHCs are also seeing increased 
high-risk behaviors (suicide attempts, relapses, substance use 
disorders) as well as an increase in requests for services from 
prospective clients seeking behavioral health care.

    We would especially like to underscore your centers' principle (a). 
With the availability of telephonic services during the pandemic, our 
FQHCs have seen a dramatic increase of clients keeping their 
appointments, even among those with serious and persistent mental 
illness. In one center, the no-show rate pre-COVID was generally above 
30 percent; during COVID it has dropped below 5 percent. This level of 
access to care helps patients with moderate illness to get treated 
early, stay out of the hospital, and return to the workforce.

    Behavioral health providers report that they have also seen an 
increase in client engagement, including increased comfort in sharing 
interpersonal challenges and traumas. Telemedicine has allowed millions 
of people who have been struggling for a long time but did not have 
access to care or had many barriers, to come out and seek care. The 
ability to talk to clients where they are, and avoid many anxieties 
associated with going to and from face-to-face visits has increased our 
ability to serve our clients with limited barriers. Maintaining 
telephonic services to this population post-COVID would strengthen our 
communities and allow for continuity of behavioral care in a time where 
we are experiencing a provider shortage.
                                 ______
                                 
     Response by Ben Harvey to Questions of Senator Casey, Senator 
        Hickenlooper, Senator Murkowski, and Senator Tuberville
                             senator casey
    Question 1. People with disabilities are part of all medically 
underserved populations and medically underserved areas. People with 
disabilities also often face significant barriers to accessing basic 
preventive medical and health services. What resources are necessary to 
ensure Community Health Centers are able to provide reliable, 
consistent, and low-cost access to primary and preventive care for 
people with disabilities?

    Answer 1. This is a fantastic question, and one I very much 
appreciate as a father of a son with a disability/special needs.

    Community Health Centers are access points for Americans across 
populations, geographies and needs. Community Health Centers benefit 
from many of the same resources as other care providers who provide 
services to individuals with disabilities. In addition, Community 
Health Centers coordinate care with other care providers and services, 
which is particularly important for individuals with disabilities as 
they often have multiple care providers and services due to their 
medical complexities. Ongoing, predictable Federal funding is a core 
resource for Community Health Centers to continue to provide care to 
their communities in this way.

    Community Health Centers would benefit from resources dedicated 
directly to training their workforce to provide more robust care for 
individuals with disabilities. A good example is the provision of 
dental services for individuals with disabilities, which is often a 
difficult and intensive experience for the individual and the dentist. 
Dentists and dental hygienists can benefit directly from training on 
best practices for providing dental care to individuals with 
disabilities, and would also benefit from additional resources to 
support the additional time and treatment costs related to providing 
those services. Training programs supported by HHS would be of 
significant benefit.

                          senator hickenlooper

    Question 1. How are community health centers particularly well 
equipped to recruit and retain providers that reflect the communities 
they serve? How can we further support health care workforce training, 
particularly in supporting diversity?

    Answer 1. Community Health Centers are particularly well equipped 
due to their foundational requirement to have a majority patient Board 
of Directors. Additionally, Community Health Centers are bounded by the 
service areas and populations for whom they receive Federal funding to 
provide services to. This unique positioning of being patient-driven 
and locally based provides a unique opportunity to recruit and train 
the community being served.

    Diversity in the healthcare workforce is a long-standing aim of 
programs from HRSA which support Community Health Centers, such as the 
National Health Service Corps. Continued, robust funding for the 
National Health Service Corps, the Teaching Health Center Graduate 
Medical Education, and the Nurse Corps Program, is crucial to enable 
Community Health Centers to continue to recruit and train a robust 
workforce.

    Additionally, one initiative here in Indiana which has proven to be 
massively successful, and could be enhanced at the Federal level, is 
providing resources to Community Health Centers to recruit and train 
positions such as medical and dental assistants, which are typically 
left out of Federal loan repayment programs. Creating a Health Care 
Workforce Innovation Fund within HRSA, and providing incentives to 
Community Health Centers to further enhance and establish additional 
formal agreements with training programs and educational institutions 
would significantly support the Community Health Center workforce.

                           senator murkowski

    Question 1. All Witnesses: As you all know, the National Health 
Service Corps (NHSC) program plays a critical role in training and 
recruiting providers to Health Professional Shortage Areas (HPSAs) in 
Alaska and throughout the country. Could you speak to how CHC's utilize 
NHSC to bolster the rural primary care workforce? What updates are 
needed to the existing programs to address the shortage we are seeing 
in Alaska and across the country in primary care providers and mental 
health professionals?

    Answer 1. The NHSC is a vital lifeline for Community Health Centers 
(CHCs), particularly CHCs in rural areas. Without NHSC loan repayment 
and scholarship opportunities, CHCs would struggle to recruit providers 
due to disparities in ability to pay, driven mostly by reimbursement 
rates due to lower rates of commercial insurance in rural areas. Rural 
CHCs in Indiana leverage the program to recruit and retain providers 
who otherwise may not be willing to live or work in a rural setting.

    There are a number of updates to the NHSC program which would help 
improve workforce shortages in rural areas. First, the vast majority of 
health workforce training programs are not located in rural areas. In 
particular, less than 10 percent of physician residency slots are 
located in rural communities, and most are based within or adjacent to 
major metropolitan areas. Targeting NHSC funds to providers who have 
been trained in rural communities, and leveraging NHSC dollars to 
support rural training programs, would provide critical support to the 
rural workforce. Additionally, providing more flexibility in who can 
receive NHSC loan repayment and scholarship funds would help expand the 
health workforce. CHCs and rural providers are struggling to fill their 
workforce needs at all levels, not just at the advanced level of 
providers (e.g. physicians, dentists). This includes medical 
assistants, dental assistants, and laboratory staff.

    Question 2. Community Health Centers can play a vital role in 
training physicians in underserved communities. Unfortunately, as you 
are well aware, many CHCs--both in Alaska and across the United 
States--are experiencing a shortage of primary care providers. The 
issue is especially acute in Alaska. We struggle to recruit and retain 
providers even in our largest cities. Our state does not have its own 
medical school, and many Alaskans live in rural areas and are off of 
the road system. Can you share some of the biggest challenges you face 
with workforce recruitment and retention, both currently and as you 
look into the next decade? As Congress considers additional efforts to 
increase the health care workforce pipeline, how can we incentivize 
more physicians to serve in rural and underserved communities, and 
especially in areas far removed from where physicians are typically 
trained?

    Answer 2. This is a fantastic question, and one I have wrestled 
with for a long-time. The biggest challenges we see as CHCs are a 
continually shrinking primary care physician workforce as physicians 
select to enter other specialties at a higher rate, chronic and 
exacerbated shortages of providers, increased burn-out rates, and non-
traditional workforce shortages (e.g. medical assistants). Certainly, 
the effects of the COVID-19 pandemic are still lingering and causing 
disruption to the workforce, and will for at least the rest of this 
decade.

    A long-standing truism in labor-related studies is that people tend 
to reside where they train, or in an area similar to where they were 
raised. The physician workforce in particular adheres to this truism, 
as most physicians are not raised in rural areas nor do they train in 
rural areas, which creates little surprise that they do not then 
practice in rural areas. Congress, through Medicare GME funding, has 
the most substantial lever to address how and where physicians are 
trained. Directing this funding in a more substantial way toward rural 
training, would create a positive retention effect, while minimizing 
the difficulties in creating new incentives and the long-term retention 
of physicians after the incentives end.

    It is critical to identify, educate, and train physicians in rural 
areas, in addition to incentivizing practice in rural areas after 
training through programs like the NHSC, or enhanced geographic 
reimbursement rates through Medicare. CHCs through programs like the 
Teaching Health Center Program, demonstrate the efficacy of training 
providers in rural and underserved areas, which are the areas where you 
want the providers to be located.

    Question 3. A large fraction of CHC revenues comes from Medicare 
and Medicaid reimbursements. As we look toward the end of the public 
health emergency and Medicaid continuous enrollment provisions end, can 
you share how you may be impacted by the disenrollment that will 
follow? Assuming that many disenrolled patients are eligible for 
Marketplace plans and subsidies, what capacities do CHCs have to help 
patients apply for and navigate new insurance plans? Are there specific 
policy changes Congress can make to support a smooth transition for 
patients and CHCs, with limited gaps in coverage? For patients 
navigating new plans with potentially higher deductibles and copays, 
what financial resources are available? Can community health centers 
apply sliding fee scales for these individuals?

    Answer 3. CHCs will be impacted directly by a reduced amount of 
individuals covered by the Medicaid program, and most likely those 
individuals previously covered will now become uninsured. In Indiana, 
the state Medicaid program estimates that 400,000 individuals will lose 
coverage, and some CHCs estimate they will have upwards of a $3 million 
loss due to this (roughly 5-10 percent of their annual budget).

    CHCs do have a good level of capacity, through Navigators and 
Community Health Workers, to help transition those individuals who lose 
coverage. However, the disenrollment period we are now in, is of 
historic levels, and Congress should seek to provide additional 
resources to CHCs to assist in this period.

                           senator tuberville

    Question 1. In preparing for this hearing, I reached out to CHCs in 
Alabama to get their perspective on how telehealth has impacted their 
practice abilities and the rural and underserved areas where they 
operate.

    These stakeholders have let me know that, in fact, telemedicine is 
a major part of the solution, but there are some important caveats. It 
is important to see what steps need to be taken first, to stretch 
Federal dollars as far as possible. We need to realize that money spent 
on telehealth infrastructure could potentially be wasted if not 
invested carefully--and how there could even be adverse consequences to 
different patient populations.

    There are many ways that people definite ``telehealth'' and 
``telemedicine,'' and what that looks like in practice can depend on 
many different factors. The entire system can get overwhelming if we 
try to build it from scratch--so some CHCs in Alabama have voiced 
support for enhancing our current infrastructure and helping existing 
systems and providers reach patients through a myriad of ``telehealth'' 
options.

    These stakeholders are recommending a version of telehealth that 
integrates and supports the existing healthcare system. However thin 
and fragmented it is currently, telemedicine designed correctly can de-
fragment and re-integrate healthcare for the 21st century.

    Providers at multiple CHCs in Alabama have recommended the 
following principles to help telehealth services support rural and 
underserved communities:

        (a) Patients should be able to access their local MDs via 
        telephones.

        (b) Local MDs should be able to bill for these visits.

        (c) There should be transparency and appropriate regulation.

        (d) Safeguards should be put into place regarding far-out-of-
        network telehealth.

        (e) Local MDs should have robust access to sub-specialists--
        perhaps the specialist gets a consult fee, and the local doctor 
        gets an administrative origination fee.

    In outlining these proposed principles, providers have emphasized 
the funding of programs like THCGME and maintaining pandemic-era 
innovation. They also recommend that the overwhelming majority of any 
Federal telehealth funding should go to two places: proven, major 
subspecialty units, and high-speed internet in rural and underserved 
urban areas.

    Please provide comments, concerns, and recommendations on how to 
achieve the principles laid out above for rural and underserved 
communities.

    Answer 1. Telehealth services have exploded in utilization since 
before the pandemic, and have become an essential tool for health care 
providers. Pre-pandemic, less than 1 percent of CHC services were 
provided via telehealth, but utilization has never gone below 10 
percent since the pandemic started. Providers across the care spectrum 
utilize telehealth as both a primary means of connecting with patients, 
and also as a way to provide follow-up or ancillary care.

    Audio-only telehealth is an important ``extender'' of telehealth 
services, particularly for individuals who have limited access to 
broadband in both rural and urban areas. A number of studies have shown 
the primary utilizers of audio-only telehealth services are 
economically disadvantaged, which makes audio-only services an 
important tool for providers to improve access for these populations.

    Care coordination is key with telehealth, and Medicare has a 
developed a good framework for originating site fees and specialist 
consulting fees/codes within their most recent physician-fee schedule 
regulations. One area of continued important is telehealth payment 
parity, which means telehealth services are reimbursement at the same 
rate as an in-person visit. While the facility costs of seeing a 
patient in-person are not present when utilizing telehealth services, 
many other costs remain, including the cost of technology and 
personnel. Providers should not be penalized for providing access to 
their patients in the most effective way for the patient.

    Additional Federal telehealth funding should continue to support 
the development of broadband infrastructure across the country. In 
Indiana there are still significant portions of the population who do 
not have access to broadband services.
                                 ______
                                 

 Response by Sue Veer to Questions From Senator Casey, Senator Smith, 
    Senator Hickenlooper, Senator Murkowski, and Senator Tuberville
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

Response by Jessica Farb to Questions of Senator Murkowski and Senator 
                               Tuberville
                           senator murkowski
    Question 1. All Witnesses: As you all know, the National Health 
Service Corps (NHSC) program plays a critical role in training and 
recruiting providers to Health Professional Shortage Areas (HPSAs) in 
Alaska and throughout the country. Could you speak to how CHC's utilize 
NHSC to bolster the rural primary care workforce? What updates are 
needed to the existing programs to address the shortage we are seeing 
in Alaska and across the country in primary care providers and mental 
health professionals?

    Answer 1. We have not conducted the work necessary to directly 
answer this question. However, in 2021 GAO examined the National Health 
Service Corps (NHSC) program, including how many providers served and 
where. For example, in fiscal year 2020, the majority of NHSC providers 
(60 percent) served at federally qualified health centers. At these 
health centers, primary care providers represented the most common type 
of NHSC providers. We also found that NHSC providers practiced in every 
state, the District of Columbia, and five territories. Nationwide, 44 
percent of participating sites were in areas classified as rural. 
Through our review of the literature, we identified studies that found 
that NHSC programs have been effective in increasing capacity in 
community health centers and underserved areas. For example, two 
studies found that NHSC providers helped alleviate shortages in mental 
health professional shortage areas by attracting other staff and 
increasing capacity for mental health care, particularly in rural 
areas. Further, one study noted that these rural NHSC providers 
increased mental health care capacity at these sites by roughly twice 
as much as non-NHSC providers in rural areas or NHSC providers in urban 
areas. The authors attribute this difference to a higher need for NHSC 
providers in rural areas to address staffing gaps than in urban areas, 
and they also attribute this to requirements that NHSC providers spend 
80 percent of their time in clinical tasks and direct patient care.
                           senator tuberville
    Question 1. In preparing for this hearing, I reached out to CHCs in 
Alabama to get their perspective on how telehealth has impacted their 
practice abilities and the rural and underserved areas where they 
operate.

    These stakeholders have let me know that, in fact, telemedicine is 
a major part of the solution, but there are some important caveats. It 
is important to see what steps need to be taken first, to stretch 
Federal dollars as far as possible. We need to realize that money spent 
on telehealth infrastructure could potentially be wasted if not 
invested carefully--and how there could even be adverse consequences to 
different patient populations.

    There are many ways that people definite ``telehealth'' and 
``telemedicine,'' and what that looks like in practice can depend on 
many different factors. The entire system can get overwhelming if we 
try to build it from scratch--so some CHCs in Alabama have voiced 
support for enhancing our current infrastructure and helping existing 
systems and providers reach patients through a myriad of ``telehealth'' 
options.

    These stakeholders are recommending a version of telehealth that 
integrates and supports the existing healthcare system. However thin 
and fragmented it is currently, telemedicine designed correctly can de-
fragment and re-integrate healthcare for the 21st century.

    Providers at multiple CHCs in Alabama have recommended the 
following principles to help telehealth services support rural and 
underserved communities:

        (a) Patients should be able to access their local MDs via 
        telephones.

        (b) Local MDs should be able to bill for these visits.

        (c) There should be transparency and appropriate regulation.

        (d) Safeguards should be put into place regarding far-out-of-
        network telehealth.

        (e) Local MDs should have robust access to sub-specialists--
        perhaps the specialist gets a consult fee, and the local doctor 
        gets an administrative origination fee.

    In outlining these proposed principles, providers have emphasized 
the funding of programs like THCGME and maintaining pandemic-era 
innovation. They also recommend that the overwhelming majority of any 
Federal telehealth funding should go to two places: proven, major 
subspecialty units, and high-speed internet in rural and underserved 
urban areas.

    Please provide comments, concerns, and recommendations on how to 
achieve the principles laid out above for rural and underserved 
communities.

    Answer 1. We have not conducted the work necessary to answer this 
question.

    Question 2. Some believe that Congress should increase mandatory 
authorized spending through the Community Health Center Fund. You have 
discussed other revenue sources available to the CHCs, including 
Medicare and Medicaid reimbursement and Federal grants. I don't 
necessarily agree that the answer to every problem is more Federal 
spending. I think in order to get results, it's helpful to have 
government and private industry work together toward a shared goal. In 
Alabama, we have a lot of fantastic industry growth across a lot of 
sectors. Our companies and businesses and their leadership have shown a 
desire to really become a part of the community and give back in many 
ways.

        (a) What other sources of revenue to CHCs have, outside of the 
        Community Health Center fund?

        (b) Are CHCs allowed to accept donations from private 
        businesses or donors? Could that possibly be a way to 
        supplement boost the success of these centers and expand their 
        effectiveness, without the Federal Government footing all the 
        bill?

    Answer 1(a)-1(b). Health centers' revenue comes from a variety of 
sources. In addition to the Community Health Center Fund, these revenue 
sources may include:

          Medicaid,

          Medicare,

          other public insurance,

          private health insurance,

          Federal and state grants,

          private grants and individual monetary donations, and

          other non-patient related revenues, such as rent from 
        tenants and medical record fees.

    Based on our reviews of HRSA's Health Center Program Uniform Data 
System, community health centers may receive private grants or 
individual monetary donations, which they are to report as revenues. 
However, we have not reviewed the extent to which community health 
centers receive such donations.
                                 ______
                                 
    [Whereupon, at 12:03 p.m., the hearing was adjourned.]

                             [all]