[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
INVESTING IN AMERICA'S HEALTHCARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
JUNE 4, 2019
__________
Serial No. 116-40
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
40-565 PDF WASHINGTON : 2021
COMMITTEE ON ENERGY AND COMMERCE
FRANK PALLONE, Jr., New Jersey
Chairman
BOBBY L. RUSH, Illinois GREG WALDEN, Oregon
ANNA G. ESHOO, California Ranking Member
ELIOT L. ENGEL, New York FRED UPTON, Michigan
DIANA DeGETTE, Colorado JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland PETE OLSON, Texas
JERRY McNERNEY, California DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice BILL JOHNSON, Ohio
Chair BILLY LONG, Missouri
DAVID LOEBSACK, Iowa LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon BILL FLORES, Texas
JOSEPH P. KENNEDY III, SUSAN W. BROOKS, Indiana
Massachusetts MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California RICHARD HUDSON, North Carolina
RAUL RUIZ, California TIM WALBERG, Michigan
SCOTT H. PETERS, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
------
Professional Staff
JEFFREY C. CARROLL, Staff Director
TIFFANY GUARASCIO, Deputy Staff Director
MIKE BLOOMQUIST, Minority Staff Director
Subcommittee on Health
ANNA G. ESHOO, California
Chairwoman
ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina, Ranking Member
Vice Chair FRED UPTON, Michigan
DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon BILLY LONG, Missouri
JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
Massachusetts SUSAN W. BROOKS, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont RICHARD HUDSON, North Carolina
RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex
officio)
CONTENTS
----------
Page
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 1
Prepared statement........................................... 3
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 4
Prepared statement........................................... 6
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 7
Prepared statement........................................... 8
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 10
Prepared statement........................................... 12
Witnesses
C. Dean Germano, Chief Executive Officer, Shasta Community Health
Center......................................................... 13
Prepared statement........................................... 16
Answers to submitted questions............................... 274
Diana Autin, Executive Codirector, SPAN Parent Advocacy Network.. 29
Prepared statement........................................... 31
Aaron J. Kowalski, Ph.D., President and Chief Executive Officer,
JDRF........................................................... 46
Prepared statement........................................... 48
Lisa Cooper, M.D., Bloomberg Distinguished Professor of Medicine,
Johns Hopkins Medicine......................................... 53
Prepared statement........................................... 55
Answers to submitted questions............................... 276
Thomas R. Barker, Partner, Cochair, Healthcare Practice, Foley
Hoag........................................................... 113
Prepared statement........................................... 115
Answers to submitted questions............................... 279
Mary-Catherine Bohan, Vice President, Outpatient Services,
Rutgers University Behavioral Health Care...................... 120
Prepared statement........................................... 122
Answers to submitted questions............................... 280
Michael Waldrum, M.D., Chief Executive Officer, Vidant Health.... 130
Prepared statement........................................... 132
Frederic Riccardi, President, Medicare Rights Center............. 134
Prepared statement........................................... 136
Answers to submitted questions............................... 282
Submitted Material
H.R. 1767, the Excellence in Mental Health and Addiction
Treatment Expansion Act........................................ 163
H.R. 1943, the Community Health Center and Primary Care Workforce
Expansion Act of 2019.......................................... 165
H.R. 2328, the Community Health Investment, Modernization, and
Excellence Act of 2019......................................... 169
H.R. 2668, the Special Diabetes Program Reauthorization Act of
2019........................................................... 172
H.R. 2680, the Special Diabetes Programs for Indians
Reauthorization Act of 2019.................................... 174
H.R. 2815, the Training the Next Generation of Primary Care
Doctors Act of 2019............................................ 176
H.R. 2822, the Family-to-Family Reauthorization Act of 2019...... 181
H.R. 3022, the Patient Access Protection Act..................... 183
H.R. 3029, the Improving Low Income Access to Prescription Drugs
Act of 2019.................................................... 185
H.R. 3030, the Patient-Centered Outcomes Research Extension Act
of 2019........................................................ 190
H.R. 3031, a Bill to amend title XVIII of the Social Security Act 192
H.R. 3039, a Bill to provide for a 5-year extension of funding
outreach and assistance for low-income programs................ 194
Statement of the American Osteopathic Association, et al., June
4, 2019, submitted by Ms. Eshoo................................ 198
Letter of June 3, 2019, from the American Federation of State,
County and Municipal Employees to Ms. Eshoo and Mr. Burgess,
submitted by Ms. Eshoo......................................... 200
Letter of June 3, 2019, from Stacy Chamberlin, Executive
Director, Oregon AFSCME Council 75, to Ms. Eshoo and Mr.
Burgess, submitted by Ms. Eshoo................................ 202
Letter of June 3, 2019, from Susan M. Cleary, President, AFSCME
District 1199J, and Joseph Masciandaro, President and Chief
Executive Officer, CarePlus NJ, to Ms. Eshoo and Mr. Burgess,
submitted by Ms. Eshoo......................................... 204
Letter of June 3, 2019, from Thomas P. Nickels, Executive Vice
President, American Hospital Association, to Mr. Engel,
submitted by Mr. Engel......................................... 206
Letter of May 6, 2019, from Thomas P. Nickels, Executive Vice
President, American Hospital Association, to Ms. Matsui,
submitted by Ms. Eshoo......................................... 207
Statement of the Endocrine Society, undated, submitted by Ms.
Eshoo.......................................................... 209
Letter of May 9, 2019, from Ms. DeGette and Hon. Tom Reed, a
Representative in Congress from the State of New York, et al.,
to Hon. Nancy Pelosi, Speaker of the House, and Hon. Kevin
McCarthy, Republican Leader, submitted by Ms. Eshoo \1\
Letter of May 31, 2019, from the Friends of NQF Steering
Committee to Hon. Judy Chu, a Representative in Congress from
the State of California, et al., submitted by Mr. Engel........ 212
Letter of June 4, 2019, from Mary R. Grealy, President,
Healthcare Leadership Council, to Mr. Pallone and Mr. Walden,
submitted by Ms. Eshoo......................................... 214
Statement of the American Academy of Family Physicians, June 4,
2019, submitted by Ms. Eshoo................................... 216
Letter of May 17, 2019, from Ceci Connolly, President and Chief
Executive Officer, Alliance of Community Health Plans, to Mr.
Pallone, et al., submitted by Ms. Eshoo........................ 220
Letter of May 28, 2019, from Kevin Longing, Chief Executive
Officer, and Holly Mattix-Kramer, President, National Kidney
Foundation, to Hon. Chuck Grassley, Chairman, and Hon. Ron
Wyden, Ranking Member, Senate Finance Committee, submitted by
Ms. Eshoo...................................................... 222
Letter of May 13, 2019, from Friends of PCORI Reauthorization to
Mr. Pallone, et al., submitted by Ms. Eshoo.................... 225
Statement of the PCORI Board of Governors by Grayson Norquist,
Chairperson, June 4, 2019, submitted by Ms. Eshoo.............. 232
Statement of the Council of Academic Family Medicine, June 4,
2019, submitted by Ms. Eshoo................................... 245
Letter of May 14, 2019, from Richard J. Fiesta, Chair, Leadership
Council of Aging Organizations, to Hon. Richard Neal, Chairman,
and Hon. Kevin Brady, Ranking Member, House Ways and Means
Committee, et al., submitted by Ms. Eshoo...................... 248
Statement of the Children's Hospital Association, June 4, 2019,
submitted by Ms. Eshoo......................................... 252
Letter of May 13, 2019, from Mr. Engel and Mr. Olson, to Hon.
Nancy Pelosi, Speaker of the House, and Hon. Kevin McCarthy,
Republican Leader, submitted by Ms. Eshoo...................... 253
Statement of America's Essential Hospitals, June 4, 2019,
submitted by Ms. Eshoo......................................... 269
----------
\1\ The letter has been retained in committee files and also is
available at https://docs.house.gov/meetings/IF/IF14/20190604/109583/
HHRG-116-IF14-20190604-SD022.pdf.
Letter of February 6, 2019, from Laura J. Warren, Executive
Director, Texas Parent to Parent, to Mr. Burgess, submitted by
Mr. Burgess.................................................... 271
Family-to-Family Health Information Center letters from Pip
Marks, Project Director, Family Voices of California, et al.,
to Representatives in Congress,bmitted by Ms. Eshoo \2\
Letter of June 4, 2019, from Sister Carol Keehan, President and
Chief Executive Officer, Catholic Health Association of the
United States, to Ms. Eshoo, submitted by Ms. Eshoo............ 273
----------
\2\ The letters have been retained in committee files and also are
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=109583.
INVESTING IN AMERICA'S HEALTHCARE
----------
TUESDAY, JUNE 4, 2019
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:01 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
Members present: Representatives Eshoo, Engel, Butterfield,
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas,
Welch, Ruiz, Dinged, Kuster, Kelly, Barragan, Blunt Rochester,
Rush, Pallone (ex officio), Burgess (subcommittee ranking
member), Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long,
Bucshon, Brooks, Carter, Gianforte, and Walden (ex officio).
Also present: Representatives Schakowsky, Soto, O'Halleran,
and Rodgers.
Staff present: Joe Banez, Professional Staff Member;
Jeffrey C. Carroll, Staff Director; Luis Dominguez, Health
Fellow; Waverly Gordon, Deputy Chief Counsel; Tiffany
Guarascio, Deputy Staff Director; Stephen Holland, Health
Counsel; Zach Kahan, Outreach and Member Service Coordinator;
Josh Krantz, Policy Analyst; Una Lee, Chief Health Counsel;
Aisling McDonough, Policy Coordinator; Meghan Mullon, Staff
Assistant; Samantha Satchell, Professional Staff Member;
Kimberlee Trzeciak, Chief Health Advisor; Rick Van Buren,
Health Counsel; C. J. Young, Press Secretary; S. K. Bowen,
Press Assistant; Jordan Davis, Minority Senior Advisor;
Margaret Tucker Fogarty, Minority Staff Assistant; Caleb Graff,
Minority Professional Staff Member, Health; Ryan Long, Minority
Deputy Staff Director; J. P. Paluskiewicz, Minority Chief
Counsel, Health; Brannon Rains, Minority Legislative Clerk; and
Kristen Shatynski, Minority Professional Staff Member, Health.
Ms. Eshoo. The Subcommittee on Health will now come to
order. The Chair now recognizes herself for 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Welcome to the witnesses. We are delighted to have you here
and look forward to hearing from you.
Today, the subcommittee will consider 12 bills to extend
critical public health programs and invest in Medicaid and
Medicare services.
These are programs that Congress has previously authorized,
but most will expire on September 30th. So Congress has to act
now to ensure their ongoing benefits.
We are going to hear testimony about the bipartisan bills
to extend and invest in the following programs, several that
were authored by members of this subcommittee. This is a long
list: Community Health Centers, National Health Service Corps,
Teaching Health Centers for Graduate Medical Education, the
Special Diabetes Program and the Special Diabetes Program for
Indians, Family-to-Family Health Information Centers, the
Patient-Centered Outcomes Research Institute, State Health
Insurance Programs, Area Agencies on Aging, Aging and
Disability Resource Centers, the National Center for Benefits
and Outreach Enrollment, the National Quality Forum, Certified
Community Behavioral Health Clinics, Disproportionate Share
Hospitals, and the Medicare Limited Income NET Program.
Many of these programs are stuck in a biennial cycle where
they may expire because of Congress' inaction. Can I just ask
that the committee be in order? There is a low undertone here.
I will finish as quickly as possible and then make sure that I
am not talking when you are.
So today we are consider reauthorizing these programs for a
longer time frame, giving them the certainty and the stability
to conduct long-term planning to better serve patients and the
American taxpayer.
I want to highlight a few of these important programs.
First, we are considering expanding several types of health
centers that serve our communities in very unique ways.
The Community Health Center Fund provides funding to nearly
12,000 health center locations across our country. That takes
my breath away--12,000 health center locations.
These health centers provide primary care to one in 13
Americans, regardless of their ability to pay. Building on the
Community Health Center model is the Excellence in Mental
Health and Addiction Treatment Expansion Act, authored by
Representatives Matsui and Mullin.
This important bill expands funding for certified community
behavioral health clinics to 11 more States, and that is very,
very important.
As we face a mental healthcare shortage, we have to do more
to expand access. In my State of California, Californians say
their community does not have enough mental health providers to
serve local needs.
Another center serving the community are the Family-to-
Family Health Information Centers, or the F2F grant program.
F2Fs assist families with children who have special health
needs to make informed choices about healthcare.
F2Fs are staffed by family members who have firsthand
experience in navigating special needs healthcare services.
Community Health Centers, Certified Community Behavioral Health
Clinics, and the F2F Health Information Centers provide unique
services for the specific populations.
We are also considering other programs to improve access to
vital primary care, including the Special Diabetes Program and
funding for Disproportionate Share Hospitals, which we all know
goes to hospitals that serve lower-income Americans.
Other programs conduct needed research to make sure we are
providing quality care. The Patient-Centered Outcomes Research
Institute and the National Quality Forum help our Nation's
clinicians deliver quality care to more people at a lower
price.
Finally, we are strengthening Medicare through stronger
enrollment support and help for low-income beneficiaries.
Today's hearing is critically important to make sure millions
of our fellow Americans receive quality healthcare.
I stand ready to work with every colleague to make sure
these programs are expanded and extended.
[The prepared statement of Ms. Eshoo follows:]
Prepared Statement of Hon. Anna G. Eshoo
Today, the subcommittee will consider 12 bills to extend
critical public health programs and invest in Medicare and
Medicaid services.
These are programs that Congress has previously authorized,
but most will expire on September 30th and Congress must act to
ensure their ongoing benefits.
We will hear testimony about the bipartisan bills to extend
and invest in the following programs, several that were
authored by members of this subcommittee:
Community Health Centers;
National Health Service Corps;
Teaching Health Centers for Graduate Medical
Education;
The Special Diabetes Program and the Special
Diabetes Program for Indians;
Family-to-Family Health Information Centers;
The Patient-Centered Outcomes Research Institute;
State Health Insurance Programs;
Area Agencies on Aging;
Aging and Disability Resource Centers;
The National Center for Benefits and Outreach
Enrollment;
The National Quality Forum;
Certified Community Behavioral Health Clinics;
Disproportionate Share Hospitals; and
The Medicare Limited Income NET Program.
Many of these programs are stuck in a biennial cycle where
they may expire because of Congress' inaction. Today, we will
consider reauthorizing some of these programs for a longer
timeframe, giving them the certainty and stability to conduct
long-term planning to better serve patients and the American
taxpayer.
I want to highlight a few of these important programs.
First, we're considering expanding several types of health
centers that serve our communities in unique ways.
The Community Health Center Fund provides funding to nearly
12,000 health center locations across our country. These health
centers provide primary healthcare to one in 13 Americans,
regardless of their ability to pay.
A Community Health Center in my district, the Asian
Americans for Community Involvement Health Center, provides
services through a multilingual team of doctors, nurses, and
patient navigators. This Health Center's team can speak up to
40 languages to make sure that vulnerable ethnic communities in
my District are well served.
Building on the Community Health Center model is the
Excellence in Mental Health and Addiction Treatment Expansion
Act, authored by Representatives Matsui and Mullin. This
important bill expands funding for Certified Community
Behavioral Health Centers to 11 more States.
As we face a mental healthcare shortage, we must do more to
expand access. In my State, half of all Californians say their
community does not have enough mental health providers to serve
local needs.
Another center serving the community are the Family-to-
Family Health Information Centers, or F2F grant program. F2Fs
assist families with children who have special health needs to
make informed choices about healthcare. F2Fs are staffed by
family members who have firsthand experience in navigating
special needs healthcare services.
Community Health Centers, Certified Community Behavioral
Health Centers, and the F2F Health Information Centers provide
unique services for the specific populations that benefit
greatly from these programs.
We're also considering other programs to improve access to
vital primary care, including the Special Diabetes Program and
funding for Disproportionate Share Hospitals which goes to
hospitals that serve lower-income Americans.
Other programs conduct needed research to make sure we're
providing quality care. The Patient-Centered Outcomes Research
Institute and the National Quality Forum help our Nation's
clinicians deliver quality care to more people at a lower cost.
Finally, we're strengthening Medicare through stronger
enrollment support and help for low-income beneficiaries.
Today's hearing is critically important to make sure
millions of Americans receive quality healthcare. I stand ready
to work with my colleagues to make sure these programs are
extended and expanded.
Ms. Eshoo. So the Chair now has the pleasure of recognizing
Dr. Burgess, the ranking member of the Subcommittee on Health,
for 5 minutes for his opening statement.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. I thank you for the recognition, and once
again today we are considering legislation to reauthorize vital
public health programs which expire in the coming months.
So this hearing is timely and, in fact, I am legitimately
getting worried because that time between now and September
30th always goes by so fast.
We are out the month of August, and there are always plenty
of other competing things that are going on in the House of
Representatives. So this is great that we are getting down to
this.
Community Health Centers, Teaching Health Centers, Special
Diabetes Programs, Family-to-Family Health Information Centers
are the bipartisan programs that make a real impact in
providing access to quality healthcare for Americans.
The Community Health Center in my district, Health Services
of North Texas, conducted more than 50,000 patient visits for
more than 14,000 patients in 2017.
Community Health Centers are the front lines for caring for
some of the most vulnerable individuals in our communities, and
there is bipartisan support for extending this and other public
health programs.
Reauthorizing these programs can take a substantial amount
of time, and I hope that we are able to accomplish these
reauthorizations prior to the end of the fiscal year.
I do remain concerned that these bills have funding
increases but no offsets. Additionally, the language in the
Community Health Center reauthorization bill does not include
Hyde protections, which have long been bipartisan and were
included in the Alexander-Murray Senate companion bill.
By not including these protections, the majority puts the
effort to reauthorize these critical programs at risk, and we
do have to worry about the ability to move them forward if that
position does not change.
Again, I hope we can work in a bipartisan manner to get
these reauthorizations across the finish line in a timely
manner. In an effort to do so, I introduced H.R. 2700, which
would use the $5 billion in offsets from the drug pricing bills
that passed through this subcommittee with unanimous support
and use that to pay for 1 year of public health extenders.
While 1 year is not a long enough extension, I thought it
was important to show our commitment to reauthorizing these
programs in a fiscally responsible way.
In fact, every Republican Member of the Energy and Commerce
Committee is a cosponsor of H.R. 2700.
The Patient-Centered Outcomes and Research Institute is
another program up for reauthorization, and I am interested in
learning today from our witnesses what the return on investment
has been and what we have learned from the comparative clinical
effectiveness research.
Additionally, there are a number of Medicaid deadlines
looming, the most significant of which is for the mandatory
cuts to the Disproportionate Share Hospitals.
The bill before us today, H.R. 3022, entirely eliminates
the DSH cuts. So OK, I am supportive of delaying DSH for 2
years or repealing them for 2 years, as Representative Olson
does in H.R. 3054.
However, eliminating the cuts entirely would prove a costly
task and preclude us from making any valuable changes, changes
that DSH payments desperately need if they are going to have a
meaningful relationship to the level of uncompensated care that
is actually being provided at the State level.
A 2-year delay would provide Congress with ample time to
revisit DSH and make any changes necessary to improve both the
efficiency and the effectiveness.
MACPAC recently recommended three policy changes to improve
the structure of these DSH allotment reductions, and we should
take the time to revisit this topic and engage with
stakeholders to pave a smooth path forward.
Another Medicaid topic that is absent from today's
discussion is reauthorizing Medicaid for Puerto Rico and our
other territories. We must remember that the individuals
reliant on Medicaid and the territories are American citizens,
and they are some of the most vulnerable.
Letting Medicaid funding for these individuals lapse would
be disappointing and unfair to those living in the territories.
And let us be clear, finding enough money to adequately fund
the territories will be much more difficult if we are paying
for a permanent elimination of the DSH cuts.
And I do have a letter from the Association of Hospitals of
Puerto Rico, who dealt with the Medicaid cliff. The coming
uncertainty it has created over the past decade--this was
before Hurricane Maria--over the past decade has been a major
contributing factor to the loss of doctors, specialists, and
health professionals in the island of Puerto Rico.
Reauthorizing these public health programs and delaying the
DSH cuts are important in maintaining access and quality for
healthcare for Americans.
I do hope we will be able to work in a way that will ensure
that we get the legislation to the President's desk prior to
the end of the fiscal year.
I remain concerned that the total cost of these bills could
exceed $50 billion, with no offsets identified to pay for the
policies.
So I thank you for having the hearing today, and I will
yield back the balance of my time.
[The prepared statement of Mr. Burgess follows:]
Prepared Statement of Hon. Michael C. Burgess
Today we are considering legislation to reauthorize vital
public health programs, which expire in the coming months.
Community Health Centers, Teaching Health Centers, the Special
Diabetes Programs, and Family-to-Family Health Information
Centers are bipartisan programs that make a real impact in
providing access to quality healthcare for Americans. The
Community Health Center in my district, Health Services of
North Texas, conducted more than 50,000 patient visits for more
than 14 thousand patients in 2017.
Community Health Centers are on the front lines of caring
for some of the most vulnerable individuals in our communities,
and there is bipartisan support for extending this and other
public health programs. Reauthorizing these programs can take a
substantial amount of time, and I certainly hope that we will
be able to accomplish these reauthorizations prior to the end
of the fiscal year. I do remain concerned, however, that these
bills have funding increases but include no offsets.
Additionally, the language in the Community Health Centers
reauthorization bill does not include Hyde protections, which
have long been bipartisan and were included in the Alexander-
Murray Senate companion bill. By not including these
protections, the Majority puts the effort to reauthorize these
critical programs at risk, and I worry about the ability to
move them all forward if that position does change.
Again, I do hope that we can work in a bipartisan manner to
get these reauthorizations across the finish line in a timely
manner. In an effort to do so, I introduced H.R. 2700, which
would use the $5 billion in offsets from the drug pricing bills
that passed through this committee with unanimous support to
pay for 1 year of public health extenders. While 1 year is not
a long extension, I thought it was important to show our
commitment to reauthorizing these programs in a fiscally
responsible way. In fact, every Republican Member of the Energy
and Commerce Committee is a cosponsor of H.R. 2700.
The Patient-Centered Outcomes Research Institute is another
program up for reauthorization. I am particularly interested in
learning from our witnesses what the return on investment has
been, and what we have learned from comparative clinical
effectiveness research.
Additionally, there are a number of Medicaid deadlines
looming, the most significant of which is for mandatory cuts to
Disproportionate Share Hospitals. The Majority bill before us
today, H.R. 3022, entirely eliminates the DSH cuts. I am
supportive of delaying DSH cuts for 2 years or repealing them
for 2 years as Rep. Olson does in H.R. 3054. However,
eliminating the cuts entirely would prove a costly task and
preclude us from making any valuable changes--changes DSH
payments desperately need if they are to have a meaningful
relationship to the level of uncompensated care actually being
provided at the State level.
A 2-year delay would provide Congress with ample time to
revisit DSH and make any changes necessary to improve upon both
efficiency and effectiveness. MACPAC recently recommended three
policy changes to improve the structure of these DSH allotment
reductions, and we should take the time to revisit this topic
and engage with stakeholders to pave a smooth path forward.
Another Medicaid topic that is absent from today's
conversation is reauthorizing Medicaid for Puerto Rico and our
other territories. We must remember that the individuals
reliant upon Medicaid in the territories are American citizens,
and that they are some of the most vulnerable. Letting Medicaid
funding for these individuals lapse would be disappointing and
unfair to those living in our territories. And let me be clear,
finding enough money to adequately fund the territories will be
much more difficult if we are paying for a permanent
elimination of the DSH Cuts, etc.
Reauthorizing the public health programs and delaying DSH
cuts are important in maintaining access to quality healthcare
for Americans. I hope that we will be able to work in a
bipartisan way to ensure that we get legislation to the
President's desk prior to the end of the fiscal year. I remain
concerned that the total cost of these bills could exceed $50
billion and that no offsets have been identified to pay for
these policies. Additionally, we have another $8-10 billion at
a minimum, we will have to spend on Medicaid funding for the
territories. I hope we can work together to resolve these
issues before the end of September so that we can keep our
promise to the Americans who rely upon these programs and
resources.
Ms. Eshoo. The gentleman yields back.
We do plan to have a hearing on the issue of Medicaid in
Puerto Rico, Dr. Burgess. And before I move on to Mr. Pallone,
I want to point out that we have some very special guests here
this morning with us, and you see them with the bright blue
ribbons on them.
They are representing foster children from across our
country. So welcome to each one of you. We are thrilled that
you are here.
[Applause.]
Ms. Eshoo. And as a former foster mom, an extra special
welcome.
Now, I have the privilege of recognizing the chairman of
the full committee, Mr. Pallone, for 5 minutes for his opening
statement.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Madam Chair.
Today we are examining 12 pieces of legislation that make
critical investments in programs supporting Medicare, Medicaid,
public health and our Nation's health workforce.
It is critical that we come to bipartisan agreement on
these bills because, without congressional action, many of
these programs will expire on September 30th.
On our first panel we will discuss several public health
initiatives, including three programs that play an essential
role in America's health workforce, and these are the Community
Health Center Fund, the National Health Service Corps, and the
Teaching Health Center Graduate Medical Education Program.
A strong health workforce is the foundation of a strong
health system. It is essential that we continue to invest in
these programs that are working to train providers and place
them in communities where they are needed the most.
And today, nearly 12,000 Community Health Centers provide
essential care to millions of patients across the country. I am
grateful to my colleagues, Representatives Clyburn and
O'Halleran, for their leadership in providing robust funding
for both Community Health Centers and the National Health
Service Corps, which offers loan forgiveness to health
professionals who commit to provide service in medically
underserved areas.
I would also like to thank Representative Ruiz for his
leadership on legislation to reauthorize the Teaching Health
Center Program, which trains primary care residents in
community-based settings such as Community Health Centers.
I am also proud to be a long-time advocate for the Family-
to-Family Health Information Center Program and strongly
support Representative Sherrill's legislation to reauthorize
it.
This program helps families of children with special
healthcare needs get the information and support needed to
provide the best care possible for their children.
On our second panel will examine proposals related to the
Medicare and Medicaid programs. We will discuss a proposal led
by Representative Engel that would permanently eliminate the
cuts to hospital funding that Congress has been forced to delay
over and over again every year.
Medicaid Disproportionate Share Hospital funds, or DSH
funds, provide critical financial support to hospitals that
care for some of the most vulnerable.
Without action by Congress, DSH funding will be cut by $4
billion in October of this year. These cuts will place an
incredible strain on hospitals that are already struggling to
provide care to children with complex medical needs, low-income
Americans, and rural communities, and I commend Representative
Engel for his efforts to permanently eliminate these harmful
cuts.
We will also get an update on a demonstration in Medicaid
to increase access to comprehensive mental health and substance
use disorder treatments through certified community behavioral
health clinics.
Every day, 130 people in the U.S. die from an opioid
overdose. As our country continues to struggle through this
terrible epidemic, clinics in the States participating in this
demonstration have had remarkable success at improving access
to care, including 24-hour crisis care, and I thank
Representatives Matsui and Mullin for their work to extend and
expand this important program.
So I just want you to know I am committed to working with
all of my colleagues to advance all these important programs
before the September 30th deadline.
It is also my hope that we can find a way to provide
longer-term extensions so that those who operate or receive
services from these programs have greater certainty.
[The prepared statement of Mr. Pallone follows:]
Prepared Statement of Hon. Frank Pallone, Jr.
Today we are examining 12 pieces of legislation that make
critical investments in programs supporting Medicare, Medicaid,
public health, and our Nation's health workforce. It's critical
that we come to bipartisan agreement on these bills because
without Congressional action many of these programs will expire
on September 30th.
On our first panel, we'll discuss several public health
initiatives including three programs that play an essential
role in America's health workforce; these are the Community
Health Center Fund, the National Health Service Corps, and the
Teaching Health Center Graduate Medical Education program.
A strong health workforce is the foundation of a strong
health system. It's essential that we continue to invest in
these programs that are working to train providers and place
them in communities where they're needed the most.
Today, nearly 12,000 Community Health Centers provide
essential care to millions of patients across the country. I'm
grateful to my colleagues Representatives Clyburn and
O'Halleran for their leadership in providing robust funding for
both Community Health Centers and the National Health Service
Corps, which offers loan forgiveness to health professionals
who commit to provide service in medically underserved areas.
I would also like to thank Representative Ruiz for his
leadership on legislation to reauthorize the Teaching Health
Center program, which trains primary care residents in
community-based settings such as Community Health Centers.
I'm also proud to be a longtime advocate for the Family-to-
Family Health Information Center program and strongly support
Representative Sherrill's legislation to reauthorize it. This
program helps families of children with special healthcare
needs get the information and support needed to provide the
best care possible for their children.
On our second panel, we'll examine proposals related to the
Medicare and Medicaid programs. We'll discuss a proposal led by
Representative Engel that would permanently eliminate the cuts
to hospital funding that Congress has been forced to delay year
after year. Medicaid Disproportionate Share Hospital funds, or
DSH (DISH) funds, provide critical financial support to
hospitals that care for some of our most vulnerable.
Without action by Congress, DSH funding will be cut by $4
billion in October of this year. These cuts will place an
incredible strain on hospitals that are already struggling to
provide care to children with complex medical needs, low-income
Americans, and rural communities. I commend Representative
Engel for his efforts to permanently eliminate these harmful
cuts.
We'll also get an update on a demonstration in Medicaid to
increase access to comprehensive mental health and substance
use disorder treatment through certified community behavioral
health clinics. Every day, 130 people in the United States die
from an opioid overdose. As our country continues to struggle
through this terrible epidemic, clinics in the States
participating in the demonstration have had remarkable success
at improving access to care, including 24-hour crisis care. I
thank Representatives Matsui and Mullin for their work to
extend and expand this important program.
I'm committed to working with all of my colleagues to
advance all of these important programs before the September
30th deadline. It is also my hope that we can find a way to
provide longer-term extensions so that those who operate or
receive services from these programs have greater certainty.
Thank you to all of the witnesses for being here today.
Mr. Pallone. And now I would like to yield the remainder of
my time to Congressman O'Halleran. Oh, down there.
Mr. O'Halleran. Thank you, Chairman Pallone, Ranking Member
Walden, Congresswoman Eshoo, and Ranking Member Burgess for
allowing me to join the subcommittee hearing this morning on
two very important pieces of legislation I am proud to have
introduced.
First, the Community Health Investment Modernization and
Excellence Act would reauthorize and provide moderate increases
in funding for Community Health Centers, the National Health
Service Corps, over a period of 5 years.
These services are vital for rural and medically
underserved areas including the 1st District of Arizona where
18 federally funded health community organizations provide care
for nearly 200,000 patients.
Second, the Special Diabetes Program for Indians is an
incredibly important program and has been successful in
lowering rates of diabetes across Indian country.
I have seen firsthand how these communities have long been
disproportionately impacted by diabetes. Prior to the inception
of this program, the prevalence of this disease was increasing
among the American Indian and Alaska Native communities.
A lot of it is because of food also, not just exercise, but
the fact that these are food deserts, for the most part, and
50, 100 miles round trip to get to food at all.
Unfortunately, rates of diabetes in these populations
remain higher than any other group. We have more work to do. It
is my hope that as we move forward that we realize that these
programs are vital to Native Americans across our country.
And I yield back.
Ms. Eshoo. The gentleman yields back.
I would like to recognize a former Member of Congress
that's here with us today and was a member of the Energy and
Commerce Committee, Phil Gingrey--I am sorry. I wanted to
pronounce it right. Dr. Phil, that's right. Another Dr. Phil.
Welcome. It is great to see you.
[Applause.]
Ms. Eshoo. OK. Now I would like to introduce the first
panel of witnesses for today's hearing.
Mr. Walden. Madam Chair?
Ms. Eshoo. Yes. Oh, I am sorry. The gentleman from Oregon,
the ranking member of the full committee. I am sorry. I
apologize.
Mr. Walden. Thank you. We will move on. Not a problem at
all.
Ms. Eshoo. I apologize. You have 5 minutes.
Mr. Walden. Not 6?
Ms. Eshoo. Five wonderful minutes.
Mr. Walden. I have one----
Ms. Eshoo. Five and a half. How is that?
Mr. Walden. OK. I will try----
Ms. Eshoo. For my blunder.
Mr. Walden [continuing]. To knock this out faster than
that.
Ms. Eshoo. Yes.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Good morning. Good morning to our panelists and
everybody here.
This is a really important day and marks an important step
for the committee's work to examine legislation that really
strengthens our healthcare safety net by extending these
critical programs.
These programs, which have long enjoyed, and I think you
have heard this this morning, strong bipartisan support,
include Community Health Centers, Teaching Health Centers, the
National Health Service Corps, Special Diabetes Programs, and
more.
Each program plays a very significant role in our Nation's
safety net for millions of Americans, especially the medically
underserved who face barriers to accessing care.
In my own district in Oregon, we have 12 Community Health
Centers. They serve 240,000 people through 63 different
locations. So we need to work together to both strengthen this
program and the others that we are examining today.
In the last Congress, I helped lead the effort to provide
record funding for our Community Health Centers and reauthorize
and fund these other programs.
We did it in a bipartisan way, and we got it into law. We
are also reviewing legislation that extends the Patient-
Centered Outcomes Research Institute, the Excellence in Mental
Health Demonstration Program, and legislation repeals part of
the Affordable Care Act's requirement that DSH hospitals suffer
these payment cuts.
I want to raise a couple of concerns at the beginning for
my colleagues as we begin this reauthorization process. I am
concerned that the language in the Teaching Health Center
reauthorization bill may have some unintended consequences for
the program and the legislation reauthorizing the Community
Health Centers does not include the Hyde language, as we have
discussed previously, which Congress has consistently supported
and renewed annually on a bipartisan basis multiple times and
for decades.
In addition, I am concerned most of the bills we are
reviewing significantly increase the authorization levels but
don't identify pay-fors to keep the promise of higher funding
levels.
And while we are the authorizing committee--I understand
that--we also know it is a bit of a false promise to set a high
reauthorization level without also doing the heavy lift to
figure out how to pay the bill, because we are going to get
called upon to do that.
A significant concern is H.R. 3022, the bill to eliminate
DSH cuts, giving hospitals relief from the cuts that were
called for under the Affordable Care Act.
Let me be clear. Republicans have never supported the DSH
cuts and worked successfully to prevent them. But we should not
surrender completely our ability to reform and modernize the
program to ensure that funding is actually directed to those
that it was intended to be used for.
In fact, in March of this year, MACPAC's own report states,
and I quote, ``The commission has long held that DSH payments
should be better targeted to hospitals that serve a high share
of Medicaid-enrolled and low-income uninsured patients and have
higher levels of uncompensated care consistent with the
original statutory intent of the law establishing DSH
payments,'' closed quote.
In other words, we should make sure the law is working as
intended.
I am pleased to see the bipartisan commitment to continuing
to fund the Excellence in Mental Health Demonstration. As one
of the eight States to be awarded funding, Oregon has seen
significant and positive results that truly helped my State's
residents.
In fact, recently I met with providers at a certified
community behavioral health clinic in southern Oregon that's
involved in this demonstration. The initial findings show they
are achieving great results in the community. So count me as a
fan.
The demonstrations are created to determine if new programs
actually work, and we need to get the results of this
demonstration before we dramatically expand it, as the
legislation we are viewing today would do by adding 11 States
to the program.
My legislation, H.R. 3074, the Continuing Access to Mental
and Behavioral Health Care Act, would extend funding for the
original eight States for an additional 2 years so we can
complete the demonstration project and get the data that
taxpayers really deserve.
I am disappointed, Madam Chair, that the committee did not
include in this hearing H.R. 2700, the Lowering Prescription
Drug Costs and Extending Community Health Centers and Other
Public Health Priorities Act.
Republicans are serious about our commitment to responsibly
extend these critical public health programs with bipartisan
offsets, and I am not sure why our legislation was excluded
from the discussions today.
We, obviously, will work together as we have to avoid
unnecessary shutdown of these programs in September when their
authorizations expire.
So we look forward to working with you and others on the
committee. I look forward to hearing from our witnesses today.
And thank you, Madam Chair, and I yield back. I would say
as a footnote I know several of us have the other hearing
upstairs we have to get back and forth to.
But thank you for being here, and thanks for the great work
you and the people represented in this room do for our citizens
back home.
I yield back.
[The prepared statement of Mr. Walden follows:]
Prepared Statement of Hon. Greg Walden
Today marks an important step forward in this committee's
work to examine legislation that strengthens our healthcare
safety net by extending critical public health programs.
These programs, which have long enjoyed strong bipartisan
support, include Community Health Centers, Teaching Health
Centers, the National Health Service Corps, and the Special
Diabetes Programs. Each program plays a significant role in our
Nation's safety net for millions of Americans, especially the
medically underserved who face barriers to care. In my rural
district in Oregon, we have 12 Community Health Centers that
serve more than 240,000 Oregonians across 63 delivery sites, so
we need to work together to strengthen this program and the
others we are examining today. I led the effort in the last
Congress to provide record funding for America's Community
Health Centers--and we did it in a bipartisan effort.
We are also reviewing legislation that extends the Patient-
Centered Outcomes Research Institute, the Excellence in Mental
Health Demonstration Program, and legislation that repeals the
part of Obamacare that requires cuts to Disproportionate Share
Hospital (DSH) payments.
I want to raise a couple of concerns for my colleagues as
we begin this reauthorization process. I am concerned that
language in the Teaching Health Center reauthorization bill may
have some unintended consequences for the program, and the
legislation reauthorizing the Community Health Centers does not
include Hyde language, which Congress has consistently
supported and renewed annually on a bipartisan basis, multiple
times, for decades.
In addition, I'm concerned that most of the bills we are
reviewing significantly increased the authorized funding
levels, but don't identify pay-fors to keep the promise of
higher funding levels. And while we are the authorizing
committee, we all know it's a false promise to set a high
reauthorization level without doing the heavy lift of figuring
out how to pay the bill.
Of significant concern is H.R. 3022, the Democratic bill to
eliminate the DSH cuts--giving hospitals relief from cuts
established under Obamacare. Let me be clear, Republicans have
never supported the DSH cuts and worked successfully to prevent
them, but we should not surrender our ability to reform and
modernize the program to ensure that funding is directed to
those that need it.
In March of this year, MACPAC report's own report points
out, and I quote: ``The Commission has long held that DSH
payments should be better targeted to hospitals that serve a
high share of Medicaid-enrolled and low-income uninsured
patients and have higher levels of uncompensated care,
consistent with the original statutory intent of the law
establishing DSH payments.'' We should make sure the law is
working as intended.
I am pleased to see the bipartisan commitment to continue
funding for the Excellence in Mental Health Demonstration. As
one of the eight States to be awarded funding, Oregon has seen
significant, positive results that have truly helped
Oregonians. I recently met providers at a certified community
behavioral health clinic in southern Oregon that is involved in
this demonstration. The initial findings show they're achieving
good results in the community.
So, count me as a fan. But demonstrations are created to
determine if new programs actually work. We need to get the
results of this demonstration before we dramatically expand it,
as the legislation we're reviewing today would do by adding 11
States to the program.
My legislation, H.R. 3074, the Continuing Access to Mental
and Behavioral Health Care Act, would extend funding for the
original eight States for an additional 2 years so we can
complete the demonstration project and get the data taxpayers
deserve, rather than prejudge the outcome.
I'm disappointed that the committee did not include in this
hearing H.R. 2700, the Lowering Prescription Drug Costs and
Extending Community Health Centers and Other Public Health
Priorities Act. Republicans are serious about our commitment to
responsibly extend these critical public health programs with
bipartisan offsets. I'm not sure why our legislation was
excluded from the discussion today. We need to work together to
avoid an unnecessary shutdown of these programs in September
when their authorizations expire.
Ms. Eshoo. The gentleman yields back.
Now I would like to introduce the first panel of witnesses
for today's hearing. Mr. Dean Germano, chief executive officer
of the Shasta Community Health Center. Welcome and thank you.
Ms. Diana--is it Autin? Autin. She's the executive codirector
of SPAN, S-P-A-N, Parent Advocacy Network. Welcome, and thank
you to you.
Dr. Aaron Kowalski, president and chief executive officer
of JDRF--marvelous organization that has chapters all over the
country, and they come on a regular basis to my Palo Alto
district offices. I am sure they do to every Member's office
here. Dr. Lisa Cooper, professor of medicine, Johns Hopkins
University School of Medicine--welcome to you, and thank you.
Just a quick word about the lights. First it is green. When
it turns yellow, you have 1 minute, and red you stop. So it is
only as complicated as that, and I know that you will adhere to
it.
So now I would like to recognize Mr. Germano for 5 minutes
for your testimony. If you would like to summarize what you
have written and submit it to us and do something other than
what you submitted to us, you are all welcome to do that.
You are recognized, Mr. Germano. Thank you again.
STATEMENTS OF C. DEAN GERMANO, CHIEF EXECUTIVE OFFICER, SHASTA
COMMUNITY HEALTH CENTER; DIANA AUTIN, EXECUTIVE CODIRECTOR,
SPAN PARENT ADVOCACY NETWORK; AARON J. KOWALSKI, Ph.D.,
PRESIDENT AND CHIEF EXECUTIVE OFFICER, JDRF; AND LISA COOPER,
M.D., BLOOMBERG DISTINGUISHED PROFESSOR OF MEDICINE, JOHNS
HOPKINS MEDICINE
STATEMENT OF C. DEAN GERMANO
Mr. Germano. Chairwoman Eshoo, Ranking Member Burgess,
distinguished members of the subcommittee, thank you for
inviting me to testify about the Teaching Health Center
Graduate Medical Education, Community Health Centers, and the
National Health Service Corps Programs.
I strongly encourage you to provide increased and stable
funding for all three programs before they expire on September
30th. The success of these critical programs is at risk when
funding for any one of them is jeopardized.
Shasta Community Health Center is based in Redding,
California, in a predominantly rural and medically underserved
region. Federally qualified health center since 1996, we care
for over 40,000 patients annually.
Since 2014, we have been one of 56 teaching health centers,
graduating eight residents, and we have employed 25 National
Health Service Corps loan repayment recipients since 2000.
Our eight THCGME graduates--of the eight, five work
primarily in underserved populations in Redding and similar
communities. Even using these programs my health center is four
to five primary care physicians short and it can take up to 12
to 18 months to recruit a physician.
So growing our own through the THCGME program is a survival
imperative. In 2018, Congress reauthorized the THC program
through this September at a more sustainable level of $150,000
per resident.
Responding to the primary care physician shortage is
incredibly timely because by 2030 we will need more than
120,000 physicians to meet this country's demands.
I am very grateful that Representatives Ruiz and McMorris
Rodgers have introduced bipartisan legislation, H.R. 2815, to
extend the THC program for 5 years.
We know that hospital-based training produces physicians
whose skills and experiences don't always match the primary
care needs of the community and who rarely choose to practice
in rural or underserved areas.
By contrast, the THC model uses ambulatory health centers
in underserved communities for training and the data proves
that these graduates are three times more likely to practice in
such settings after their residencies.
H.R. 2815 will help THCs restore some resident slots that
were authorized by HRSA but not filled during the years of
uncertainty and it would fund a very modest increase in
resident allocation to help offset inflation.
Lastly, H.R. 2815 expands the program to meet pent-up
demand. HRSA last approved a new THC in 2014 and many potential
sponsors of such centers have expressed interest in becoming a
teaching health center.
Our health center depends on the Section 330 grants which
allow health centers to expand their facilities, open new
sites, and to meet unmet needs in areas with limited access to
care.
Section 330 grants leverage other funders because they
confer status of high-quality healthcare provider. Broad
bipartisan support for health centers has sustained 1,400
community health center organizations, caring for over 28
million patients and more than 11,000 rural, urban, and
frontier communities nationally.
The September 30th expiration date threatens the very
existence of the health center program. Over the last several
years, Shasta and CHCs across this Nation have experienced
serious uncertainty due to funding disruptions.
Our doors are open to everyone regardless of ability to
pay. Services are offered on a sliding fee scale basis and we
locate sites in medically underserved communities.
However, recent funding lapses threaten the notion of
continuous access. We are grateful that Representatives
O'Halleran and Stefanik introduced H.R. 2328 to provide 5 years
of stable funding for the CHC fund including $200 million in
annual growth and $15 million in annual growth for the National
Service Corps.
Likewise, H.R. 1943, introduced by Representative Clyburn,
provides 5 years of funding with 10 percent annual growth, an
addition of $4.6 billion for health center capital funding,
which would further--and would further expand the Corps.
Shasta has benefitted greatly by the Corps. Over 50 years
the Corps has effectively placed more than 50,000 people in the
highest areas of need in our country so they can provide
primary medical, dental, and/or mental and behavioral health
services in underserved communities with more than 10,000
placements last year alone.
Our clinicians have come to Shasta with staggering student
debt, enter the National Health Service Corps loan repayment
program, and through their service many are debt free in just a
matter of years.
Thankfully, Congress has extended the Corps through
September and we are very concerned that another expiration of
funding would cause great damage to the program.
Additionally, currently funding only allows for awards of
40 percent of loan repayment applicants and a mere 10 percent
of scholarships.
H.R. 2328 and 1943 would fund even more applicants for
loans and awards and thus substantially increase access. As CEO
of the community health center, a teaching health center, on
behalf of all National Health Service Corps recipients, I urge
Congress to provide increased and stable funding for these
programs before they expire on September 30th.
Thank you.
[The prepared statement of Mr. Germano follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Castor [presiding]. Thank you.
Ms. Autin, you are recognized for 5 minutes.
STATEMENT OF DIANA AUTIN
Ms. Autin. Good morning, Chairman Eshoo, Mr. Ranking
Member, members of the subcommittee. I am Diana Autin,
executive codirector of the SPAN Parent Advocacy Network, home
of New Jersey's Family-to-Family Health Information Center, or
F2F.
Today, I represent both SPAN and Family Voices, a national
organization of and for families whose children and youth have
special healthcare needs, which also provides support to the
Nation's F2Fs.
I am here today to support H.R. 2822, the Family-to-Family
Reauthorization Act, which will extend funding for F2Fs for an
additional 5 years at the current funding level of $6 million a
year.
F2Fs help families with special healthcare needs navigate
healthcare and other systems advocate effectively for their
children and work as partners with providers.
Children and youth with special healthcare needs include
those with autism, epilepsy, traumatic brain injury, cancer,
schizophrenia, asthma, diabetes, or any other condition that
requires healthcare services beyond that required by children
generally.
Throughout the U.S. there are about 14 million children
with special healthcare needs, 19 percent of all children under
18 and more than one in five families with children.
Families struggle to find the right primary and specialty
care providers to treat their children and to pay for their
care. Even with insurance, out-of-pocket costs can be very high
with copayments and other costs that insurance may not cover at
all.
It is difficult to navigate through the worlds of public
and private insurance and other sources of care and financing
that all have different eligibility criteria.
Children may miss getting needed services because their
families are unaware of or don't know how to access or afford
them. That's where F2Fs come in.
We are staffed by parents of children with special
healthcare needs. Beyond their training, our staff have
expertise and empathy, learn through personal experience.
We reach out to underserved communities and provide our
services in a culturally and linguistically appropriate manner.
We provide one-to-one assistance like helping a family appeal
denial of coverage for needed services, get insurance coverage
or find appropriate pediatric specialty care.
For example, in New Jersey, a father called our F2F about
his 13-year-old son with Downs Syndrome, autism, major
behavioral challenges. He was struggling to afford prescribed
medications which were making his son's behavior worse and
making him gain weight.
Our F2F staff connected him to a nearby federally qualified
health center and helped him develop a behavior support plan
for school and access additional services.
Within 6 months, his son was weaned off the medications and
had lost 30 pounds, and his overall health and behavior had
improved.
Some families face more than the usual challenges. Military
families must relocate often, needing to find new providers,
reapply for Medicaid, and negotiate for services in a new
district.
In New Jersey, we help these families by embedding staff at
and working closely with Joint Base McGuire-Dix-Lakehurst.
Special challenges also arise for families who aren't
proficient in English or who come from diverse cultural
backgrounds or urban low-income families who may need to take
multiple busses to get to services, and for rural families who
must travel long distances to get specialized care. Sometimes
one parent may even have to relocate.
Families in the territories and Native American and Alaska
Native families face linguistic and cultural barriers and the
complications of remote locations, often compounded by extreme
poverty.
That's why we were so pleased when last year Congress
expanded the F2F program to serve these families. There is now
one F2F in each State, five territories, and three Tribal
organizations as well as DC.
Each receives $96,750 a year. Despite our modest budgets,
we provided information, training, and/or assistance to nearly
1 million families in 2018.
F2Fs provide a great value for taxpayers. We help families
get the care and services their children need to survive and
thrive and to avoid medical bankruptcy and we assist providers
and policy makers to better serve children and youth with
special healthcare needs.
Our efforts result in higher quality, more cost effective
care and better outcomes.
The bill before you today would extend the F2F program for
an additional 5 years, longer than ever before. Although
modest, the F2F grant provides a foundation upon which other
funding and activities can build.
Status as a Federal grantee provides credibility that makes
it easier to secure additional funds and partners. However,
those other funding sources--government agencies, foundations
and individual donors, and community partner organizations
don't want to invest time or money in an entity that might not
survive for more than a year.
Greater stability of F2F funding would be extremely
valuable to our effectiveness. Since its creation over a decade
ago by Senator Charles Grassley and the late Senator Ted
Kennedy, the F2F program has enjoyed strong bipartisan support.
We thank Representatives Sherrill and Upton for continuing
this bipartisan commitment to F2Fs so we can help families
secure timely, high quality, and family-centered care for their
children and youth.
On behalf of Family Voices and SPAN and as a parent myself,
I thank the subcommittee for the opportunity to testify about
the value of Family-to-Family Health Information Centers, and I
am happy to answer any questions.
Thank you.
[The prepared statement of Ms. Autin follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Castor. Thank you very much.
Dr. Kowalski, you are recognized for 5 minutes.
STATEMENT OF AARON J. KOWALSKI, Ph.D.
Dr. Kowalski. Ranking Member Burgess and members of the
subcommittee, thank you for giving me the opportunity to
testify before you today.
In 1977, my brother--my younger brother, Steven, was
diagnosed with type 1 diabetes, or T1D, at the age of 3. In
1984, I too was diagnosed with T1D when I was 13 years old.
Because of that, I went on to get my doctorate in
microbiology and molecular genetics, and then focused my career
on the fight to cure this terrible disease and to help other
people with diabetes stay healthy until then.
I've worked at JDRF, the world's largest charitable funder
of type 1 diabetes research for 15 years, and just 8 weeks ago
I became its president and CEO.
I am here today with a simple message from our community.
The Special Diabetes Program is making a tremendous difference
in our lives and our hopes for the future.
We need you to continue to give it robust support. There is
so much momentum that we can't afford to lose. We are grateful
for the leadership of this committee on both sides of the aisle
over the years and the broad bipartisan support in Congress for
this Special Diabetes Program, or SDP.
By supporting the SDP, you have been the catalyst that has
fundamentally changed diabetes management, diabetes care, and
have brought us even closer to cures for diabetes.
In addition, lives are being transformed by the Special
Diabetes Program for Indians, or SDPI, which funds prevention
and treatment programs for those in American Indian and Alaska
Native communities that are particularly affected by type 2
diabetes.
Approximately 30 million Americans have type 1 or type 2
diabetes and about a third of the Medicare budget is spent on
people with diabetes.
Thanks to the funding provided by Congress, we have seen
major progress in type 1 diabetes research that has led
directly to improvements in the health and quality of life for
people with diabetes and significantly reduced the risk for the
terrible and costly complications of the disease.
This includes the first FDA-approved artificial pancreas,
or AP system, which came on the market several years earlier
than expected, thanks to research supported by SDP.
AP systems drive significantly better glucose levels, which
reduce the risk for these terrible complications. For those who
do have complications, we've seen incredible advances in drugs
that preserve and even improve vision who have diabetic eye
disease, and other drugs that are being tested as we speak for
those who are at risk for diabetic kidney disease.
And this is just the start. The SDP is currently funding
multidisciplinary and path-breaking research to understand the
causes of type 1 diabetes and how it can be cured.
While the SDP research funding moves us closer to cures and
improves the quality of care for those with type 1 diabetes,
the SDP eye program that is run by the Indian Health Service
has played a critical role in tackling type 2 diabetes among
American Indians and Alaska Natives, a population that is
disproportionately suffering from the disease.
These communities have a diabetes prevalence rate
approximately 2 times the national average and the death rate
1.8 times higher than the general U.S. population due to
diabetes.
Thanks to the SDPI, which funds evidence-based diabetes
treatment and prevention programs that help over 700,000 people
in 35 States, there have been marked improvements in average
blood sugar levels and reductions in the incidence of
cardiovascular eye and kidney disease.
As you can see, SDP and SDPI programs are making a real
difference in the lives of people with type 1 and type 2
diabetes. That's why JDRF strongly supports House Bills 2668
and 2680, introduced by Representatives DeGette, Reed,
O'Halleran, and Mullin that will raise the amount of funding to
$200 million a year for SDP and SDPI and fund them for 5 years.
All of us at JDRF are grateful that 378 representatives,
including nearly all of the members on this subcommittee and
the full committee signed a letter to leadership, led by
Representatives DeGette and Reed, that recognizes the important
contributions of this program--these programs, and calls for
the program's renewal.
We look forward to working with this broad group to get
these bills passed and continue diabetes research advances and
care.
Thank you, and I would be happy to take any questions.
[The prepared statement of Dr. Kowalski follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo [presiding]. Dr. Cooper, you are recognized for 5
minutes for your testimony.
Put your microphone on.
STATEMENT OF LISA COOPER, M.D.
Dr. Cooper. Good morning, Chairwoman Eshoo.
Ms. Eshoo. We want to hear every word. We want to hear
every word of your testimony.
Dr. Cooper. Thank you. Ranking Member Burgess and
distinguished members of the subcommittee, thank you for
inviting me to participate in today's hearing.
I am Dr. Lisa Cooper, a professor at the Johns Hopkins
Schools of Medicine, Nursing, and Public Health, where I have
served as faculty for 25 years.
As a board-certified general internist, I treat adult
patients with a range of illnesses and unique healthcare needs.
As a health services researcher, I have devoted my career to
improving quality and addressing disparities in the U.S.
healthcare system.
Over the past 9 years, my colleagues and I at the Johns
Hopkins Center for Health Equity, along with our health system
and community partners, have completed three NIH-funded
clinical trials improving hypertension control in African-
American communities.
And now, with the support of PCORI, I am leading a new
trial called Rich Life, launched in 2016 with 30 primary care
practices in Maryland and Pennsylvania.
Rich Life investigates whether system improvements and
team-based care models can reduce disparities and
cardiovascular risk factors, including hypertension, diabetes,
and depression.
This study will help clinic directors and primary care
doctors choose how to care for people who have high blood
pressure and could be extremely impactful in communities that
have high rates of this condition and limited access to care.
Throughout my experience as a practicing clinician and
researcher, one theme is clear. Too often, patients do not have
enough accessible or relevant information to make informed
decisions about their care and too often we, as clinicians,
must make decisions about our patients without knowing which
option would best fit their unique needs and circumstances.
For all the advances we have made with new innovative
clinical research, we sometimes still lack the information we
need to help our patients make the best choices for themselves.
That is why the Patient-Centered Outcomes Research Institute,
or PCORI, is so important.
PCORI is the leading funder of comparative effectiveness
research, which is research that compares how well different
treatments and care approaches work so patients and doctors
have the information they need to make decisions that are right
for them.
PCORI's research is unique and complementary to research
funded or conducted by the NIH, which focuses on discovery, the
AHRQ, which focuses on health services research, and FDA, which
focuses on reviewing drugs, devices, and other products for
safety and efficacy.
Patient-centered outcomes research is comparative
effectiveness research that focuses not only on clinical
outcomes but also on the needs, preferences, and outcomes most
important to patients and those who care for them.
This research is helping patients choose the treatments
best for them and focuses on many of the most pressing health
concerns our country faces today such as heart disease, cancer,
diabetes, and opioid dependence.
PCORI is the only research funder that ensures that
everyone has a seat at the table who has a stake in healthcare
improvement.
As a researcher who has received funding from both the NIH
and PCORI, I have seen firsthand the values and differences of
both institutions and what they both bring to the table.
To date, PCORI has funded more than 600 studies that
address high-priority conditions, new and emerging approaches
to care, as well as ways to improve doctor-patient
communication and, importantly, PCORI funds the dissemination
of research findings as well as implementation of actionable
results.
For example, PCORI funded a study that found that a simple
decision aid can help people who go to the ER with chest pain
better understand their risk of having a heart attack and
therefore decrease unnecessary hospitalizations for testing.
Over 5 years this could benefit 9.4 million Americans and
save $4.8 billion nationwide. Another example is a study in
Washington State clinics that implemented an initiative focused
on more cautious prescribing of opioid drugs, which led to
reductions in high dose opioid prescribing while preserving
patient pain control.
In both these examples, using a patient-centered approach
not only improved health outcomes and patient quality of life,
it also reduced utilization.
Simply put, results from PCORI-funded research are
actionable, impactful, and have the potential to improve health
outcomes for patients across the country and that is why it has
strong support from more than 170 healthcare organizations.
But there is still much more to be done. Ensuring that
PCORI has long-term and consistent funding is vital to their
research funding mission. It also provides the stability that
researchers need to conduct this work in training and support
for the next generation of researchers.
In closing, our healthcare system requires solutions that
are both evidence based and patient centered to improve are and
reduce healthcare spending. PCORI is uniquely set up to meet
this challenge.
Therefore, I urge Congress to renew its investment in
patient-centered outcomes research and enact a 10-year
reauthorization of PCORI's charge and funding before it
expires.
Thank you for your time and I look forward to our
discussion.
[The prepared statement of Dr. Cooper follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Dr. Cooper.
We have now concluded the opening statements of our
witnesses. Our thanks to each one of you. We will now move to
Members' questions. Each will have 5 minutes to question the
witnesses, and I will start by recognize myself for 5 minutes.
Mr. Germano, in your testimony you mentioned a grow your
own--grow your own strategy of training healthcare providers to
address the primary care shortage, and we have that shortage in
the country, and primary care physicians are the gateway to the
entire healthcare system.
Can you tell us briefly how that strategy has actually
worked? How has it benefited the community?
Mr. Germano. Well, our data through HRSA--the teaching
health center information--really shows that we have three
times the success rate of training and keeping our residents in
our communities compared to other models of training.
So the data is pretty clear. It is----
Ms. Eshoo. But what makes it so?
Mr. Germano. Well, I think a big part of it is----
Ms. Eshoo. They love your community? I mean, what is it
that keeps them glued there?
Mr. Germano. Well, I think part of it is that they see the
mission. They're connected to the mission. Many of them come
from those communities or communities like it.
They have a heart for what we do and we really support them
in their training and they have become confident in working
with underserved populations, and they get connected rooted
into our communities.
Ms. Eshoo. In California, thanks to the ACA, we've reduced
our uninsured rate down to 6.8 percent, which is incredible
when you think of the most populous State with the most diverse
population, which is not the easiest to insure. That's down
from 16 percent before the ACA was passed.
These are--these are large increases in healthcare
coverage. So if someone really doesn't know that much about
Community Health Centers and what they do, how would you
respond to them and say this is why we are needed?
Mr. Germano. Well, we had that success in California. Our
rates up in Shasta are higher than that. They were almost 25
percent before and now they're down to almost 6 and now have
climbed back to 10 percent again.
We also have the situation of people with major medical and
other costly front-end plans that make it difficult to afford
primary care.
Our goal is primary prevention. We need a solid system. Any
system in the world that has success in terms of caring for
their populations and keeping a lid on costs really have strong
primary care systems and that's what the Community Health
Centers represent is a very strong primary care preventive
health system.
That is the--I think that is the key for every community
across America and we have 84 million Americans that don't have
the benefit of a community health center to do that for them.
Ms. Eshoo. Even though we have how many, 12,000 in the
country?
Mr. Germano. Fourteen thousand.
Ms. Eshoo. Fourteen thousand. My staff wasn't right. Oh, my
goodness. Mortal sin.
Dr. Cooper, in the studies that are done, can you just
briefly describe how those studies develop legs and walk into a
patient's life?
Studies are always important for what they reveal. But then
how do they become real in people's lives?
Dr. Cooper. So I think what I would say is the way they
become real in people's lives is that actually their patients
involved in the design of these studies so they're actually
involved from the very inception. Patients contribute----
Ms. Eshoo. But the larger population, though.
Dr. Cooper. So you mean afterwards? After the research is
done? I think this is a critical piece is that once we have
results of the work, for example, if we know that there is a
tool that helps patients to make decisions about whether or not
to stay in the hospital for chest pain is actually getting that
information out to doctors and patients so that when they're at
the point of making that decision they are aware of the
existence of that tool.
Ms. Eshoo. So have you measured this? I mean, just does
that--that as an example, patients with--that go to the
emergency room, they think they are having a heart attack--your
study says you should do A, F, and Z, what is the outcome?
Dr. Cooper. So that is not--that is not my study. That is
another study that was funded by PCORI where, basically once
people used the tool they were able to determine whether or not
they felt comfortable going home.
Ms. Eshoo. Well, how do you do that? Do you go through
insurers?
Dr. Cooper. So what we do----
Ms. Eshoo. Do people line up at a clinic----
Dr. Cooper. Right.
Ms. Eshoo [continuing]. To get the piece of paper that
explains it?
Dr. Cooper. Right.
Ms. Eshoo. Tell us how it works.
Dr. Cooper. Yes. So the--I think the process varies
depending on where you are, right. So one of the reasons we
have a lot of people involved in PCORI research is that we talk
to insurers, we talk to front line providers, we talk to staff,
and we talk to patients and families, and we find out what
works in a particular system.
And so one size doesn't fit all. So we may learn from a
particular health system that they have community health
workers who are the ones who work with patients and who show
them how to use the tool, and----
Ms. Eshoo. I think I know how it works. I want everyone
else to hear it.
Dr. Cooper. Right. But, you know, in another health
system----
Ms. Eshoo. Always know the answer to your own question,
right?
Dr. Cooper. Right. In another system it might be something
different where they have pharmacists who are the ones who
actually help people to work through their questions and
their----
Ms. Eshoo. Well, my time is expired, and I thank the
witnesses. The Chair now recognizes Dr. Burgess for his 5
minutes to question.
Mr. Burgess. Thank you for the recognition, and I want to
first start off by answering Mr. Germano's question that you
asked of him--how, when you grow your own, how does that work
and for at least in the physician space--I can't speak to other
healthcare providers, but from a physician space we tend to
settle where we train, and this is something we have--I have
studied this question for years and the Texas Medical
Association has done an extensive research on this. Not so much
where someone goes to medical school but where they do their
training.
You typically marry during those years and, as a
consequence, your spouse has a big say in where you spend your
practice life. You become familiar and comfortable with the
doctors to whom you refer or you know who to watch out for in
the community.
So that information is very helpful to the young physician
just starting out, trying to build a practice.
So when you gave that answer, I was reminded of all the
work the AMA has done on this and it is--it is a significant
body of work.
It became really apparent to me after Hurricane Katrina and
visiting with doctors down in the Louisiana-Mississippi gulf
coast and the Dallas-Ft. Worth area where I am from was guilty
of stealing a lot of physicians from that area at that time and
quite successfully.
But one of the best predictors as to whether or not someone
was going to stay in the--in the area around New Orleans was if
their spouse was from there--not if they were from there but if
their spouse was from there. That is a very--that can be a very
powerful anchor. And, again, we do tend to marry during our
training years and that is, I think, part of the answer there.
Now, of course, Dr. Gingrey being in the audience, and I am
reminded of the night we heard--we marked up the--well, it
wasn't really the Affordable Care Act.
It was what went over to the Senate. But it came back and
it was entirely different. I remember his insightful questions
on the comparative effectiveness research that night.
Dr. Cooper, just so everyone understands, you get a direct
appropriation under the Affordable Care Act of $150 million a
year. Is that correct?
Dr. Cooper. So my understanding is that the funding is set
through a separate funding stream for PCORI--that there is a
PCORI fund that is funded through a variety of different
sources.
Mr. Burgess. Right. There is a trust fund. There is a
charge for every insurance policy that is sold as well as there
is a transfer from the Medicare trust fund, which makes up an
aggregate of dollars that you have to spend.
Do we have anything that would give us sort of a return on
investment guide for the Patient-Centered Outcomes and Research
Initiative?
Dr. Cooper. So we have a number of different studies that
have shown that different approaches, when incorporating
patients' preferences into decision making, that actually we do
reduce utilization and could really save significant amounts of
money.
So the example I gave you----
Mr. Burgess. But let me interrupt you for a second. Who
would save significant amounts of money? Do we know? Do we have
a good sense of--we have spent, I think last year, $630 million
on PCORI. What's the return on investment for that?
Dr. Cooper. So I would get back to you with the help of the
PCORI staff on that because PCORI actually doesn't fund cost
effectiveness research. It wasn't--that wasn't part of----
Mr. Burgess. Comparative effective, just not cost
effective.
Dr. Cooper. Yes.
Mr. Burgess. And I get that. And, you know, your specialty
through the American Board of Internal Medicine several years
ago came up with the Choosing Wisely program. Is that something
you have looked at through PCORI, sort of look at those studies
that we know we all do as physicians but the return on
investment is not that great?
And I think it was the--again, your specialty society which
said maybe we ought to think about what we are ordering.
Dr. Cooper. Absolutely. I know of one study that was funded
by PCORI that specifically looked at monitoring of glucose
levels in patients who are on oral treatment for diabetes and
showed that actually doing glucose monitoring at home really
didn't contribute anything important to the patient's health.
And so the study actually suggested that people on oral
hypoglycemics do not need to engage in glucose monitoring. And
so that kind of an outcome really shows that you can save money
by eliminating all of those----
Mr. Burgess. I am just going to interrupt you for a second.
My time is running out. Of course, it might affect your
decision as to whether nor not to have that piece of coconut
cream pie that's in the refrigerator.
But on the chest pain study that you did with the chest
pain tool, is there any way that you can assess--look, I am an
OB/GYN doctor. I practice defensive medicine.
So I will tell you from my days in the ER, chest pain--I
mean, it is a problematic situation for the doc on the front
line and you're always worried you're going to send someone out
who then ends up having the big one in the parking lot and
dies.
So is there a way you have dealt with the liability
question?
Dr. Cooper. What I would say is that there is a clinical
algorithm that was used with that tool, which included some
risk prediction, and that people who answered questions in a
certain way on that tool were able to be sent home safely.
And, in fact, those people who went home had lower uses of
utilization and didn't have any worse complications. And so an
estimation is that that would save considerable amounts of
money if people were able to feel comfortable, both doctors and
patients, based on a thorough assessment of the patient's
profile that it was safe for them to go home.
Mr. Burgess. I will follow up with you about that in
writing because it is--it is an important concept. I will yield
back.
Ms. Eshoo. The gentleman yields back.
The Chair now recognizes the chairman of the full
committee, Mr. Pallone, for 5 minutes for questions.
Mr. Pallone. Thank you, Madam Chair.
I first wanted to ask the question of Mr. Germano. When the
Community Health Center Fund was created in 2010 under the ACA,
it was originally authorized to boost funding to Community
Health Centers for 5 years and we have reauthorized it twice in
the 4 years since for periods of 2 years each time.
Since we first passed the Community Health Center Fund,
we've seen growth based on a record of success. Health centers
have grown from serving 19.5 million patients and providing
almost 77 million patient visits in 2010 to serving 27.2
million patients and 110 million patient visits in 2017.
For today's hearing, Chairwoman Eshoo has noticed two bills
that both reauthorize Community Health Centers and the National
Health Service Corps for 5 years as well as the 5-year
extension of the Teaching Health Center Graduate Medical
Education Program.
And I strongly believe that all these programs are very
worthy of a long-term extension to bring stability to centers
like your own that are providing community-based residency
training and essential services to those who need it.
So, Mr. Germano, if I could ask you, can you tell us about
the impact a long-term extension of funding would have on your
health centers' ability to provide care to patients, manage a
budget, recruit and retain members of the healthcare work force
and can you compare that to the challenges that your health
center would face with a short-term extension?
Mr. Germano. Thank you for that question, Congressman.
The running of a Community Health Center tied to your
community is a complex venture. Most of the things we do to
impact our community are long-term orientation.
Think about building a new site, for example. I say it
takes 4 to 5 years from thought to finish if you have all the
means. When you--when you're working on short term
appropriations it has a paralysing effect on your ability to
plan ahead and make those kinds of investments. It really does.
2018, when we went through the 2-year--the fiscal cliff
piece--I know of health centers that created layoffs. They did
freezes of staff. They withdrew contracts for clinicians that
they needed because they couldn't--they didn't know they
could--they didn't have the confidence they could commit to
meeting those obligations.
It really has a paralysing effect on the ability to think
forward and plan. It has that same effect on your board of
directors and it also sends a message to your community about
how stable are you really if the rug can be pulled out from
under you so easily, from their perspective.
So the long-term is really about planning and doing things
efficiently and correctly. Short term is--it makes it very
difficult to think ahead and make those kinds of commitments.
Mr. Pallone. Thank you. I appreciate that. And I would add
too--I have to go to the next question---but, you know, a lot
of these are very small, too, and I think when you talk about
small Community Health Centers, which many are including in my
district--it is even worse, I think.
But anyway, let me--I have to go to Ms. Autin, and my
question is about New Jersey's experience with Family-to-
Family. I want to acknowledge that New Jersey has for a long
time been a leader in the Family-to-Family program, which
connects families of children and youth with special needs to
the healthcare resources they need and I am glad my colleague
from New Jersey, Representative Mikie Sherrill, has taken a
leadership role introducing the bill to reauthorize this vital
program.
So let me just ask you, can you talk about your
organization's long history in New Jersey and how that helps
you provide technical assistance to other States, the
territories, and Tribes that have sought to implement and
improve their own programs, if you will.
Ms. Autin. So SPAN actually has been around for over 30
years and we were one of the very first F2Fs that was selected
out of the legislation that was--came from Senator Grassley and
Senator Kennedy.
So that's been--you know, being one of the first F2Fs that
got started that gave us the opportunity to really learn on the
ground and then be able to share that information with other
F2Fs.
We also had the opportunity to do that because along with
the two people from National Family Voices including Norah
Wells, the executive director of Family Voices, I am one of the
codirectors of the national center that provides technical
assistance to the F2Fs, and one of the ways in which we do that
is by providing peer-to-peer support.
And so we connect F2Fs that have knowledge and expertise in
one area to other F2Fs. Because we are in such a diverse State,
because we've been around so long, because we have many other
programs that can supplement and support our F2F and because of
our really very positive relationship with our State Department
of Health Title 5 program, I think we have a lot of lessons
learned that we've been able to share with other F2Fs around
the country and hosted them when they came to visit us for
different issues around cultural responsiveness, et cetera.
So----
Mr. Pallone. All right. Thanks so much. Thank you.
Thank you, Madam Chair.
Ms. Eshoo. The gentleman yield back.
I now would--let us see, who is--who is next?
Oh, Mr. Upton. A pleasure to recognize former chairman of
the full committee Mr. Upton of Michigan.
Mr. Upton. Well, thank you, Madam Chair, and I appreciate
the hearing. I know that we all do. And before I get to my
questions I wanted to take this opportunity just for a moment
to draw my colleagues' attention to a bill that I am
cosponsoring, which I think is an excellent complement to the
programs being discussed today.
H.R. 2075, which is the School-Based Health Centers
Reauthorization Act of 2019, this is a bill that I strongly
believe in. I have talked to many of my schools back home in
Michigan. I look forward to working with the chair and the
ranking member to advance this bill in the coming months.
It is bipartisan and it really does make a difference in a
meaningful way. I guess I will start off with Dr. Kowalski. In
your testimony you told us about the critical diabetes
management--how critical that diabetes management is and the
role that SDP has played in bringing innovative new
technologies to the market.
I have been involved with this issue for a long time and
have seen wonderful advancements as I watch folks who started
early with JDRF 20 some years ago and are still--I mean,
technology changes are amazing and really lifesaving.
How do these technologies prevent the complications from
diabetes in terms of lowering health costs as we look to
reauthorize this money?
Dr. Kowalski. Sure, and thank you for your leadership. I
was just up at UM talking about a center that we are working on
with the team there.
And both type 1 and type 2 diabetes complications are
caused by high blood sugar, and high blood sugar has a
nefarious effect of driving changes in your body that affect
your eyes, your kidneys, your heart, and your limbs.
The incredible advances that have happened in terms of the
ability to monitor blood sugar, for example, SDP helped support
the advancement of continuous glucose monitors.
I use a continuous glucose monitor. I have not poked my
finger in over 5 months. It is absolutely incredible, and we
are seeing those advances be applied in type 1 and type 2
people to lower A1C measures, which is the measure of blood
glucose levels.
Mr. Upton. Let me just interrupt you for a second. I
don't--so one of the manufacturers is, what, Dextrom, right? So
if they moved Dextrom----
Dr. Kowalski. Dexcom.
Mr. Upton [continuing]. Monitor that so that they've got a
new system now without having to poke and test that, literally,
every day?
Dr. Kowalski. Yes. They do, as does another company, Abbott
Diabetes, and from a JDRF perspective, we think competition is
good. We want more options out there, and what we are seeing is
competition driving more access, better glucose levels, less
risk for complications.
Mr. Upton. Thank you.
Ms. Autin, H.R. 2822--it is a bill that I have cosponsored
along with Ms. Sherrill, reauthorizes the F2F program for 5
more years. You talked a little about it--remarks about why
this is so important and I know more than just New Jersey--my
colleague is not--can you elaborate why it is--why this is an
important issue for us to move forward?
Ms. Autin. Thank you for that wonderful question, and it is
important for all of the F2Fs. For one thing, it is very
difficult to do planning, you know, as an organization when you
don't know whether or not you're going to be around for more
than another year.
I talked about partners and other funders. I mean, in our
organization that F2F funding, you know, brings in lots more
money to do that work and many other F2Fs the same thing is
true. They want to know that there is going to be stability in
that organization before they put their money there.
I think one of the most important things, though, is that
we all are staffed by families of children with special
healthcare needs.
Mr. Upton. And that is important.
Ms. Autin. That is so important. It is important because we
are the people who know what the systems are like and how to
really navigate them on the ground. But, of course, we also
have children that have special healthcare needs.
And so we--it is even more important that we have stability
of employment, stability of health insurance, being able to
know and project that we are going to be able to have a job and
keep our children covered under that same health insurance plan
where we have already found the 10 specialists that are all
covered by our, you know, health maintenance organization.
And, you know, I have had to have this experience multiple
years where I have had to tell staff, I can't promise you that
there is going to be a job here in the next six--you know,
after 6 months from now, and then those families have to make
that very difficult decision to possibly leave a job that they
love and that they are really great at and go someplace else
where they have more stability, and that means we have more
turnover.
That means we lose great staff and then that means there
are more costs that are associated with trying to reach out to,
you know, somebody else to come and fill that position.
So the--you know, having the 5 years of funding is going to
be one of the most important improvements in the F2F
reauthorization that we have ever had.
Mr. Upton. I look forward to working with everybody to get
that done. Yield back. Thank you.
Ms. Eshoo. The gentleman yields back.
The Chair now recognizes Ms. Matsui of California, who is
the sponsor of H.R. 1767, for 5 minutes of questioning.
Ms. Matsui. Thank you very much, Madam Chair, and I really
appreciate all of you being here today and I would like to
extend a special welcome to Mr. Germano from my home State of
California.
Now, I appreciate your sharing with the committee how long-
term sustainable healthcare funding is essential to supporting
primary care and preventive services in Shasta and across
California.
And as you may know, in 2014 I helped author the Excellence
in Mental Health law that established certified community
behavior health centers--CCBHCs--in eight States across the
country.
Earlier this year I introduced H.R. 1767, a bill to expand
Excellence's CCBHC's Medicaid demonstration with my colleague,
Representative Markwayne Mullin from Oklahoma.
Now, in the Medicaid demonstration program we also know how
important it is to have mental and physical health a holistic
way of doing things. So we encourage partnerships in
coordination with certified community behavior health centers
and Community Health Centers.
And I would like to get a better sense of how CHCs address
serious mental and addiction disorders, specifically, the level
of access that patients with schizophrenia and opioid use
disorders have to intensive community-based services in Shasta
and the surrounding counties.
I know in my district in Sacramento are seven federally
funded health center organizations and 36 clinical delivery
sites create a safety net infrastructure that provides primary
and behavior healthcare needs in Sacramento.
Mr. Germano, what kind of partnerships has the Shasta
Community Health Center forged with community mental health
providers in your service area?
Mr. Germano. Thank you for that question, and certainly, in
rural areas of California and across this country the mental
health gap is huge, and that is true also in our community.
Our health center has two--played two major parts in this.
One, we have created an integrated behavioral health component
which really integrates the behavioralist, typically LCSWs--
licensed clinical social workers--as well as marriage and
family therapists within our primary care practice as team
members with our primary care doctors and nurse practitioners
and PAs so those warm hand-offs can happen.
That's important, and some screening can be done more
effectively. We also employ psychiatrists on our staff--because
our county and our systems in California are mostly county-
based for the seriously mentally ill, have really struggled in
trying to keep that--those services going.
So we have in fact gone off and hired psychiatrists and we
work with the county as well because of in-patient services,
and then there are advocacy groups, NAMI and others, that we
work very closely with. We cannot do what we do effectively in
underserved communities without an effective mental health
delivery system.
Ms. Matsui. Right.
Mr. Germano. And it takes all those pieces, and it does
take a village to provide those kinds of services. And I am
happy to say we've been working hard at it on the addiction
side. We have moved very heavily into medically assisted
therapies now.
We have--we have redirected our resources into creating
what we call MAT services. We are--right now we have 200
patients on medically assisted therapies and we are growing
that program to try to meet that need--the opioid abuse issues
in our communities, and we are really pleased with the results
so far.
Ms. Matsui. Well, that is wonderful. With the Excellence
Act with the certified community behavioral health centers we
have a Federal definition. So it is just like we had to
federally qualify health centers.
So, in a sense, they, working together, can really have an
effect on the community. I will have to say that my cosponsor,
Markwayne Mullin, is not here today because of floods in his
district.
But he has worked with many public safety groups in order
to provide that type of service so that they feel very good
because they don't have to waste hours and hours taking these
people to ERs or trying to figure this out.
So anything that we can do, particularly in rural areas, I
know will help the people there who don't have ready access to
behavior health needs.
So anyway, I thank you very much and I yield back.
Ms. Eshoo. I thank the gentlewoman. She yields back.
I now would like to recognize the gentleman from Virginia,
Mr. Griffith, for 5 minutes for his questions.
Mr. Griffith. Thank you very much, Madam Chair. I do
appreciate it. I appreciate our witnesses being here.
What I like about having hearings like this is we learn a
lot. This is not my field of expertise, although I have about
30 or 31 Community Health Centers in my district.
It is a fairly large district. Probably have needs for a
few more, in all fairness, but I do appreciate what you all do.
And I am now going to yield to Dr. Burgess.
Mr. Burgess. I thank my friend from Virginia for yield.
Mr. Germano, let me--let me ask you. In your testimony you
talked about the--expanding or you mentioned that expanding the
types of providers that would be eligible to participate in the
National Health Service Corps is a zero-sum game. Can you--can
you further elaborate why this is?
Mr. Germano. Yes. As I stated in my testimony, only about
40 percent of current applicants actually get a loan repayment
acknowledged. You know, they participate. They can go forward,
and only 10 percent of scholars.
So if the fund isn't significantly increased--significant--
adding more players to that field will just water down that
benefit and I don't think it serves any of our purposes.
I happen to support the allied health professions who are
looking to take advantage of this. But we need to greatly
increase the scope of the National Service Corps--their
dollars--in order to do that. It really is a zero-sum game
right now.
Mr. Burgess. And Dr. Kowalski, if I could just ask you--
obviously, your organization of which you are now president--so
congratulations on the ascendency to that lofty position, or my
condolences, one of the two--so can you tell us how JDRF
collaborates with the National Institute of Health on research
priorities and particularly as it relates to the Special
Diabetes Program?
Dr. Kowalski. Yes, that is a great question. Thank you.
We work very, very closely with the NIH including with Dr.
Griffin, who heads up NIDDK, and the program staffs who--staff
members who focus on various areas. We break up our research
into curing type 1 diabetes, preventing type 1 diabetes, and
better treating it, and each of those areas have embedded
scientists who are experts at JDRF working hand in hand with
the team at NIH.
For example, last week, NIH held a meeting where they were
setting their program priorities and our team participated. So
there is very close coordination on the research efforts of
both organizations.
Mr. Burgess. So tell me this. I spoke to someone yesterday
on the issue of islet cell transplant. What is the--you talk
about a cure for type 1 diabetes--what is out there on the
horizon as far as a cure is concerned?
Dr. Kowalski. So islet cell transplantation, for those who
are not familiar, is the harvesting of the cells that make
insulin from somebody who has passed away prematurely--just
like an organ transplant but just the cells.
And what we have seen in that procedure is you can cure
people with diabetes. I was with one of the founders of that
procedure and he has people 17 years post-transplant off
insulin.
The barriers are the cell source and the immunosuppression
that is required. So both JDRF and NIH and SDP has really laid
the foundation here of creating renewable cell sources so that
we would not require transplant donors, and protecting the
cells, and we have a variety of amazing programs going on both
through materials or now with the gene editing CRISPR-Cas
technology.
So I am incredibly optimistic. While we are making great
progress on better treatments, those are band-aids. What we
need is what we call disease-modifying therapies and I think
cell therapy is incredibly promising.
Mr. Griffith. And, Dr. Burgess, if I might jump in real
quick and reclaim my time----
Mr. Burgess. Yes, please.
Mr. Griffith [continuing]. We have some folks working on
genetically modified pigs who are able to grow some of these
cells. I think they're doing experiments with it, but they have
eliminated the alpha-gal syndrome or the alpha-gal protein in
these pigs and some other things to try to reduce the amount of
suppression.
Yield back. Yield back to my friend.
Mr. Burgess. So there you have it. I knew I was asking that
question for a reason.
Mr. Germano, you heard my earlier discussion about the
liability issues and in Community Health Centers you are under,
if I recall correctly, a national----
Mr. Germano. Federal Tort Claims Act?
Mr. Burgess. Federal Tort Claims Act. So your costs for
liability insurance are reduced so you're able to expand the
amount that you're able to offer because you're not spending so
much on that part of the overhead.
Is that true in the teaching health centers as well?
Mr. Germano. Unfortunately, there are gaps. Because of the
way the FTCA has been interpreted for us, it essentially says
that as long as the patients are our patients and the services
are within our scope, it is covered.
But as you know, as a resident you go in the hospital,
you're never sure who you're going to run into in the emergency
room or surgery. So we have to buy alternative insurances to
cover our residents because of that gap.
Mr. Burgess. I would like to help you with that.
Mr. Germano. I would love to have the help.
Mr. Burgess. All right. We will follow up after committee.
Thank you.
Mr. Griffith. And I yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize the gentleman from New York,
Mr. Engel, for 5 minutes.
Mr. Engel. Thank you, Madam Chair. I appreciate your
calling on me.
Let me say that there are six Community Health Center
networks in my district. I want to mention them, as they do a
good job: Bronx Community Health Network, Hudson River Health
Care, Morris Heights Health Center, Mount Vernon Neighborhood
Health Center, New York City Health and Hospital Corporation,
Open Door Family Medical Center, Incorporated.
Together, they deliver high-quality care to nearly half a
million of my constituents. Now, I have heard from some of
these clinics that 2-year reauthorizations can hinder their
ability to implement innovative care programs and retain
experienced staff, and to that end I am pleased to cosponsor
the CHIME Act, a bipartisan measure which would provide 5-year
reauthorization to increase funding.
Let me ask Mr. Germano, could you please describe some of
the consequences of short-term funding measures on a Community
Health Center's ability to implement care coordination
programs?
Mr. Germano. Thank you for that question.
As was mentioned before, the biggest effect is the
paralysing effect of not knowing what your future has in store.
We are making long-term commitments to really change the face
of delivery in our communities, whether that be the hiring of
clinicians, whether that be creating of points of access.
All those things take planning and investment, and when the
dollars are--can only go out so far, most boards--most
communities are going to say, we have to put--we have to slow
down or stop and in some cases we have health centers who ended
up taking loans to meet payroll. We had others that rescinded
contracts to providers who were coming because they couldn't
guarantee they could afford them. It is a very--it really has a
very destabilizing effect having such a short window like that.
Mr. Engel. Thank you. I appreciate your testimony.
Let me also say that when we look at diabetes in my home
State of New York, there are 2 million New Yorkers who have it.
It costs the State an estimated $15 billion annually in direct
medical expenses and, unfortunately, these figures are expected
to rise as the diabetes epidemic worsens.
To help turn the tide in this epidemic, Congress created
the Special Diabetes Program. The program funds cutting-edge
research into diabetes treatments and technologies, and New
York research institutions have been awarded $86 million in SDP
grants.
Let me ask you, Mr. Kowalski, what are some innovative
diabetes technologies that have been developed with SDP funds
and how are they improving diabetes care?
Dr. Kowalski. Thank you for the question, and first and
foremost, I think what we've seen, as mentioned earlier,
continuous glucose monitoring technology has played a pivotal
role in driving better glucose control.
More recently, artificial pancreas technologies are coming
to the market and the SDP program played a pivotal role in
driving those into the American system much earlier than
expected and I can tell you that my brother and I use those
systems very successfully with much better results.
Ultimately, both in type 1 and type 2 people with diabetes
these advances forestall the need for--the development of
diabetes complications and those costly expenses, both SDP and
SDPI both playing a critical role in slowing and reducing those
costs.
Mr. Engel. Thank you very much.
And Mr. Germano, let me--let me ask you this. The United
States has a growing shortage of primary care physicians, which
is estimated to reach 50,000 by the year 2030.
The shortage disproportionately affects underserved
communities and the Teaching Health Center program plays a
vital role in addressing this gap.
So, Mr. Germano, can you please describe how a 5-year
reauthorization will help Teaching Health Centers prepare the
next generation of primary care physicians?
Mr. Germano. Thank you for that question. The 5-year
authorization goes to that issue of stability. When we take a
class in, we are committing to 3 years.
So when we have 1 or 2 years' worth of funding, it is a
real leap to guarantee to these young people that we are going
to continue to support them.
The health centers that are in underserved communities--
Congressman, sorry--Burgess--Dr. Burgess mentioned that 70
percent--the data shows 70 percent of those trained in--well,
in locations where they're trained land within a hundred miles
of where they are trained.
So when we are training them in underserved communities we
greatly increase the opportunity to keep them in our
communities. Our data shows three times more success than other
kinds of models.
So yes, we need teaching health centers in underserved
communities. We need to keep them there to take care of our
communities.
Mr. Engel. Thank you.
Madam Chair, thank you so much for this. This is really
important stuff that I know we have both worked on.
Thank you.
Ms. Eshoo. I thank the gentleman and he yields back.
I now would like to recognize the gentleman from Missouri
who is long on humour and friendship, Congressman Billy Long.
Mr. Long. Thank you. Appreciate being recognized.
Mr. Germano, the Teaching Health Center Graduate Medical
Education Program plays an important role in bringing more
primary care physicians to rural and underserved areas.
Shasta Community Health Center participates in this program
so I am interested in your perspective on this. What are the
training differences in a teaching health center residency
versus a traditional hospital residency?
Mr. Germano. Thank you for that question.
There is quite a bit of overlap because we have accrediting
requirements that we have to meet. It doesn't matter where you
are trained--you have to meet those requirements.
The difference is that we are looking for medical students,
fourth year, wanting to get into our residency, for people who
have a heart and understanding of our community and our
mission--serving our community.
We are looking for people with experiences that would
demonstrate that they will be successful in our environment. We
then surround them with support and faculty and all the other
resources we have to make sure they are successful in working
in our communities.
We help them root in our communities to the best extent,
and if they are not staying, we--I have gone out and looked for
similar communities where their spouse wants to move to and we
connect them to a health center there.
So we span the gamut, and I would just finish by saying
that what we are doing now is we are going now downstream to
our high schools and saying to our own underserved communities,
listen, have you thought about a career as a primary care
doctor.
And this is how you get in and this is how we are going to
help you get there, and we are going to get you into medical
school and we are going to get you into our residency and
you're going to serve your mother, your dad, your neighbors
when you're done.
To me, that is the long term. That is what 5 years of
commitment does. It gives us that kind of support.
Mr. Long. How can teaching health centers help alleviate
the primary care workforce shortages that we are facing?
Mr. Germano. Well, in H.R. 2815 there is a--in fact, a
number of the bills--the important thing is we have to grow the
program. The program is sort of stuck on 56 across the Nation
with the funding that we have.
So we need to grow it. In 2815 there is a provision to add
eight new programs in 2021 and an additional eight in 2023, I
believe, and it instructs HRSA and then there are other
expansions of existing programs.
We have to greatly expand the number of people--of
residents that we train and that bill allows for, I believe,
250 more spots of training in our country.
Mr. Long. And how likely are residents to stay serving in
the underserved areas after completing their residency at a
teaching health center?
Mr. Germano. The data from HRSA shows that it is running
about--around 60 percent in the communities where they are
trained. It doesn't mean--and it is something like 82 percent
stay in primary care.
And as I mentioned before, if they're not staying in your
community, they are moving to another underserved community
where they benefit.
One of my residents moved to rural Arkansas because that's
where her hometown was and that is where they needed her, and
she is helping to deliver babies down there right now. So----
Mr. Long. Let me--let me ask you another question, kind of
following up on what my friend, Mr. Engel, was asking.
You note that over the next decade the United States will
require nearly 50,000 primary care physicians but the number of
graduates is now greater than the number of residency slots,
which I know a lot of Americans would be shocked to find out
that you can go completely through medical school and not be
able to get a residency.
Mr. Germano. It is true.
Mr. Long. Not be able to become a doctor. What else can we
do to ensure that graduates can get residency slots and be able
to practice particularly in rural and underserved areas, which
will face the deepest impact from these physician shortages?
Mr. Germano. Well, first and foremost, I think we need to
create more teaching health centers in underserved communities.
There are health centers around this country willing to be a
sponsoring entity and I think we should make a deep investment
in those health centers.
And I believe there are other community-based and other
rural communities that could support a residency teaching
program. But, for me, if you really want to target underserved
communities, the Community Health Center environment is where
the investment should happen.
I think it can and it should.
Mr. Long. OK. The National Health Service Corps will play a
vital role in bringing more primary care physicians to rural
and underserved areas.
There are four programs within the NHSC--the scholarship
program, the loan repayment program, the State loan repayment
program, and the students to service program.
However, four of the five programs' placements are within
the loan repayment program. Could you talk about the role of
the other three programs that are within NHSC and what we can
do to enhance the placements within these programs?
Mr. Germano. Specifically, the scholarship program and the
State loan repayment program? I want to be clear--is that what
you're referring to?
Mr. Long. The--all but the loan--yes, the repayment--the
State loan repayment program, student to service program, and
the scholarship program.
Mr. Germano. Well, I would almost need to get back to you
with more detail of what we can do.
Mr. Long. We are out of time anyway so that is a good plan.
Let us do that. I yield back.
Ms. Eshoo. The gentleman yields back.
I now would like to recognize the gentlewoman from Florida
and thank her for chairing while I ran off to another
subcommittee upstairs. The gentlewoman from Florida, Ms.
Castor.
Ms. Castor. Well, thank you very much, Madam Chair, and
thank you for organizing this hearing because it is very
important that the committee examine health initiatives that
are effectively helping families back home.
That certainly includes the Special Diabetes Program,
everything the Family-to-Family Initiative does to ensure
families with kids with special needs get the care they need.
Patient-Centered Research is vitally important.
Thank you for your summary on Teaching Health Centers. I
hope we can expand them and I want to salute Ms. Matsui for
working for many years to expand our community behavioral
health clinics. I think that has a lot of promise for families.
Probably the most impactful in my Tampa area district will
be Community Health Centers, and since the adoption of the
Affordable Care Act with the Community Health Center funding
that provides grants, I have seen significant expansion.
It is so important to families in my community. Tampa
family health centers currently leverages over $9 million in
Federal investments and serve well over 100,000 of my neighbors
back home.
Now, Community Health Centers, they rely on a number of
funding streams--Medicare and Medicaid reimbursements, some
private pay. But the grants that come from the Community Health
Centers fund are critical to expansion.
Mr. Germano, tell us how health centers across the country
are using the grants that come from specifically the Community
Health Center Fund.
Mr. Germano. Well, our main purpose of the Federal grants
is really, I think, twofold. One is to make sure that we
provide effective primary preventive care to our uninsured.
So every State, depending on how they dealt with the ACA,
have a different number there.
Ms. Castor. And isn't that important in States that did not
expand Medicaid, which, unfortunately, includes the State of
Florida.
Mr. Germano. The 330 grant is truly a lifesaver for those
States because the uninsured rates are much higher. The other
places that it helps to support the infrastructure delivery of
those services, not all those other funding sources cover a
part of what's--of what it costs but it is not the whole thing.
So we need all those funding sources, including the Federal
grant. The Federal grant also provides for Federal tort claims.
People--you know, that's the malpractice coverage that we lean
on to help make it more affordable for us to deliver services.
It also allows us to work with our States on prospective
payment under Medicaid. So Medicaid pays its fair share of what
it costs to deliver services.
So the Federal grant is fundamental as a foundational
building block for what we do.
Ms. Castor. And a couple of years ago, we were entirely
frustrated because the Community Health Centers Fund was in
need of reauthorization. I think you answered Chairman
Pallone's question about the importance of continuity and on
the longer term extension.
I know in my community the 6-month delay in funding for
Community Health Centers, the National Health Service Corps,
the Teaching Health Centers, among others, was particularly
damaging.
We heard from folks back home that said this funding cliff
is untenable. They said they had to freeze hiring, including
physicians, and support personnel. They had to stop all
construction expansion plans. That is not smart or financially
wise.
They had--even reducing the number of patients they saw and
considered closing existing facilities. So you talked about the
importance of continuity. But, boy, if--give me a good example
of how a funding lapse and additional delays affects patients'
access to care and the workforce that we need to train.
Mr. Germano. Well, many of our health centers have been--
are at the maximum of their capacity. So the only way to take
care of more people is to look at expansion. But to expand you
have to plan. It just doesn't--you just don't pitch a tent and
start delivering services in many cases.
So the continuity and being able to plan ahead to do that,
I mentioned earlier, takes three to 5 years to plan a new site,
you know, from thought to finish, and you have to have some
certainty of your funding is going to be there.
The Teaching Health Centers, as I mentioned, every class is
a 3-year commitment. You have 1 or 2 years' worth of funding
and a 3-year commitment, it doesn't serve anybody very well.
It creates a lot of anxiety, and particularly in part of
the residents, I might add, wondering if they're going to
actually finish in the training program they started.
We did lose one health center during that period. Twenty-
four residents lost their training program. We had to scramble
and absorb them across the country. Not a good situation.
Ms. Castor. Well, I agree with you and I--Madam Chair, I
look forward to the committee marking up these bills with
robust funding and extension and reauthorization.
Thank you, and yield back.
Ms. Eshoo. The gentlewoman yields back.
A pleasure to recognize the gentleman from Kentucky, Mr.
Guthrie, for 5 minutes of questions.
Mr. Guthrie. Thank you, Madam Chair.
My first question is for Mr. Germano. I am a big supporter
in Community Health Centers. I think they do a fantastic job.
We just need to ensure that they are on a successful track
and they are funded responsibly. One of the things that I have
been driven by, being on this committee, is all the fantastic
innovation coming in healthcare.
Now we can cure--Dr. Francis Collins said we can use the
``cure'' word for sickle cell anemia. Just all this stuff
that's coming forward.
So I just kind of--what innovation do you see Community
Health Centers doing to be part of the great revolution or
innovation revolution in healthcare and how they are innovating
to better serve their communities?
Mr. Germano. Well, I think a lot of these technologies,
these advancements, are moving into the ambulatory space. We've
done--we are doing less and less in the hospitals or at least
less time, and now it is moving into the outpatient
environment.
We have to make sure that the health centers have the
resources to take advantage of those technologies and those
therapies. I know that we look at best practices all the time
in our practice--what can we do, how can we influence, for
example, our State Medicaid authority to make sure that these
technologies are somehow added to our scope--are paid for under
our scope of services.
We have to make sure that our uninsured aren't left out of
those advancements, and that's what the 330 program does is
help us do that.
We have to stay on top of it. We have patient-centered
medical homes now. We wrap services around our patients. The
mental health piece is very important in terms of behavioral
health. It is not just the technologies; it is actually helping
people maybe change behaviors to take advantage of these
things.
Mr. Guthrie. OK. Thanks. I just have a couple questions.
So, Dr. Kowalski, thanks for being here today as well. I am
the ranking member on Oversight and we have been looking at
insulin pricing and barriers to diabetes care.
Can you please describe how the diabetes--Special Diabetes
Program helps--decreases these barriers and is innovating for
individuals with diabetes?
Dr. Kowalski. Well, I testified a couple weeks ago on
insulin pricing and we have an issue in the United States.
Nobody should die or suffer for lack of insulin. I think what
we talk about here is we have innovation happening through SDP
that----
Mr. Guthrie. The artificial pancreas is something that is
now available----
Dr. Kowalski. The artificial pancreas and a variety of more
coming down the pike when you talk about cures--potential
cures--and we need to ensure they're accessible.
So we have been working with Members of Congress and across
NIH and, of course, with our team to look at policies that
ensure that the advances that we are seeing that are faster
than I have ever seen in all my time in science are accessible
to anybody who will benefit.
Mr. Guthrie. It is happening at such a rapid, rapid pace,
isn't it?
Dr. Kowalski. Absolutely.
Mr. Guthrie. It is amazing how--and I have two nieces with
diabetes and so that--I keep a pretty close eye on that as
well.
So, Dr. Cooper, can you please just speak to how PCORI-
funded research is taken up in practices and are there any
long-term measuring tools that PCORI uses to track impact of
PCORI research?
Dr. Cooper. Certainly I can do some of that. So I can tell
you that in the work that I am currently doing the practices
that we work with are--many of them are Community Health
Centers and they are eager to test different evidence-based
approaches in their own settings and to try different ways of
actually implementing the things that we know from NIH
discoveries should be used in practice but aren't because often
those studies aren't done in the real world practices with the
people who actually have to deliver those services and
treatments.
So I think there is a lot of enthusiasm to be engaged in
PCORI type research and to problem solve with researchers
around how to get these new discoveries actually implemented
with the realities of the resources and the staffing that
exists in the settings.
Mr. Guthrie. Can you measure the implementation of your
research? Do you have measures to see how that is moving
forward?
Dr. Cooper. So some of the measures we have have to do
with, first of all, the levels of engagement with different
stakeholders and what contributions they each make to the
overall process and how that actually changes the work from its
inception to when it is complete and then later on looking at
to what extent the intervention or the program is taken up.
So we look to see, for example, how many people are
actually using the intervention that's being tested, how many
people are being exposed to it, whether it is being used with
fidelity, so is it being used like--as it was intended or is it
being adapted and used in a different way.
And then we look to see to what extent that uptake actually
leads to the outcomes that we look at.
Mr. Guthrie. OK. Well, thank you, and my time has expired
and I will yield back.
Ms. Eshoo. The gentleman yields back.
Now I would like to recognize the gentleman from New
Mexico, Mr. Lujan, for 5 minutes of his questioning.
Mr. Lujan. Thank you, Madam Chair, and thank you all for
being here today.
I want to address a disturbing health trend among Native
American populations in the United States. Native Americans
have the highest rates of type 2 diabetes in the United States.
Native American adults are also 2.4 times as likely as white
adults to have diabetes, and in 2013 Native American women were
twice as likely to die from diabetes as white women.
The reality is that Native Americans are unnecessarily
dying from diabetes. As we have heard today, the Special
Diabetes Program and the Special Diabetes Program for Native
Americans are both extremely successful and have meaningfully
improved patients' lives.
For example, since the establishment of SDPI, the
prevalence of diabetic eye disease and end-stage renal disease
have been cut in half.
I believe it is our responsibility to ensure that these
vital programs have the funding necessary to continue but also
to expand.
Mr. Kowalski, in your testimony you highlighted the
groundbreaking research SDP and SDPI have funded since their
creation. For Native American communities disproportionately
affected by type 2 diabetes, how do these programs ensure that
they receive the access and quality of care that they deserve?
Dr. Kowalski. Thank you for that question, and I think this
is a tremendous example of how evidence-based medicine--we have
had a number of questions about evidence-based medicine, and
the implementation--can it be cost savings and deliver true
impact.
And I think you point out quite rightly that SDPI is
serving an underserved community who is suffering from a
disease that is often stigmatized but is highly genetic and
inherited--type 2 diabetes--and requires significantly more
resources deployed against it.
We know that these interventions can make a difference and
you point out statistics such as the higher than average
diabetes rates and death rates.
The prevalence of type 2 diabetes has plateaued since SDPI
has been implemented. We know that the rates of diabetes
complications are being reined in and I think this investment
has been shown to be cost saving.
The reduction in diabetic kidney disease, which is
completely covered by CMS, is estimated to be saving over $500
million since the implementation of this program.
So I think there is much more to do and I think the
reauthorization of this program is a hugely important next
step.
Mr. Lujan. Well, and that's my follow up is what happens if
this program is not reauthorized?
Dr. Kowalski. Well, we know that diabetes is growing, of
course, in the Native population. But this is across our entire
country. And if we don't intervene we are going to see
increasing costs driven by diabetes complications and
management.
These interventions work. There is no doubt. This program
is not just research for research sake. This is implementation
that is driving better outcomes and saving cost.
So I think that time is of the essence and we need to get
this reauthorized as soon as possible.
Mr. Lujan. Well, I appreciate the emphasis not just on the
fact that this investment is cost saving, but the second part
of my question is not just the importance of this
reauthorization but to expand the service.
What more can be done to get services in areas where they
are still needed that they're not getting out there?
Dr. Kowalski. There is no doubt that here in the United
States we have a problem on kind of both ends of the spectrum,
meaning that even people with the best tools still struggle.
Diabetes is a very hard disease to manage. So when you're
in an underservedved environment it is tremendously difficult
and the investment in these communities pay huge dividends.
One-third of the Medicare budget is driven by diabetes
complications. More investment will reduce cost and, of course,
this is a human disease. We are talking about costs but these
are families who are suffering and we need to do better.
Mr. Lujan. I appreciate your response very much and
highlighting the importance of reauthorizing this important
program.
And with that, Madam Chair, I yield back.
Ms. Eshoo. The gentleman yields back.
That is a stunning figure that you just gave, Dr. Kowalski.
Say it again.
Dr. Kowalski. One-third of the Medicare budget, and that is
because Medicare is paying for all end-stage renal disease, and
when we look at the advances in diabetes care and new kidney
disease drugs we expect, we could significantly reduce those
costs.
Ms. Eshoo. Thank you.
I now would like to recognize the gentleman from Indiana,
Dr. Bucshon, 5 minutes for questions.
Mr. Bucshon. Thank you very much, and thank you all for
testifying.
The programs we are discussing today are all very
important. I think that is pretty clear. And I think we all
agree they should be funded, the more years the better, for the
reasons that people have outlined.
But that said, I have strong concerns about some of the
bills before us for consideration which do not include the Hyde
Amendment protections--prolife protections that have been in
funding bills, preventing government funding for abortions, and
that has been in place since 1976 and has been supported by
both parties for decades until about 2016 when many Democrats
began supporting government funding of abortions.
It is just an unnecessary partisan discussion injected into
what is a discussion over critical programs that we need to
authorize and it makes it difficult for Republicans to be
supportive of the legislation in their current form.
I mean, Dr. Burgess introduced H.R. 2700 to reauthorize the
Community Health Centers and National Health Service Corps, the
Teaching Health Centers GME, Special Diabetes Program, Family-
to-Family Health Information, centers in sexual risk,
avoidance, education, and personal responsibility education for
1 year, and his bill would have used the savings gained from
the recently passed--at least committee-passed bipartisan drug
pricing bills to fund that extension, even though it is short,
it had a pay-for.
Instead, unfortunately, last week we used the money to fund
partisan Affordable Care Act provisions, which Republicans
can't support.
So I think if we are really serious about preventing these
program authorizations from expiring, I think we need
bipartisan legislation--that we need to come to a bipartisan
agreement on how to pay for these priorities, which we have in
the past, and I look forward to working with my colleagues on
both sides of the aisle to advance these critical policies in a
fiscally responsible way.
Mr. Germano, in your testimony you talk about the important
ability to provide dental, mental health, and overall health
services to the homeless, which is a growing problem in all of
our districts.
Additionally, you mention that you use telemedicine
extensively, and I have a very rural district and am a big
supporter of telemedicine. It is important.
Can you talk more about how the Federal funding helps
support these and other important services that Shasta
Community Health Centers provide?
Mr. Germano. Thank you for that question, Congressman.
Oral health, historically, has been one of the forgotten
services that are needed in communities of need. Oral health
disease is the number-one pediatric disease, period, in
America.
We made a commitment through Federal 330 dollars a number
of years ago to build an oral health infrastructure and we have
actually helped get a school of hygiene open because of our
association with the junior college and expanding that access
throughout our community. So a lot of leveraging that went on
there.
Telemedicine is a great advancement in a rural community.
We are--we have consults with--a thousand miles away with
specialists in major teaching facilities, access that our
patients would never ever get, really, truthfully, otherwise.
However, it is expensive. Not so much the technology but
you're working with major teaching hospitals and what have you.
So the 330 grant helps to subsidize a lot of that cost to allow
us to do that and to have our patients be seen effectively.
Mr. Bucshon. Yes. I mean, I think a lot of things that--I
was a cardiovascular surgeon before I was in Congress and we do
overlook dental and oral health and, obviously, we are
struggling to make sure we have parity in mental health
services, which I support, obviously.
And things like telemedicine and other things that I think
Community Health Centers in rural areas can provide is really
critically important, and I am hopeful that we can come to an
agreement on how to make sure that we get all of these programs
that I mentioned reauthorized hopefully for more than just a
year or 2 years, but longer, because as I think you outlined,
this certainty involved in that is really a critical piece to
this puzzle.
With that, Madam Chairwoman, I yield back.
Ms. Eshoo. I thank the good doctor and he yields back.
Now I would like to recognize the gentleman from Maryland,
Mr. Sarbanes.
Mr. Sarbanes. Thanks very much, Madam Chair. Thank you to
our panel over here.
So, first of all, I want to thank the chairwoman for
bringing all these bills before us and having us discuss the
importance of the reauthorization. These are all critical
programs and there is a lot of bipartisan support, as you
gathered, from just the comments of my colleagues today.
Mr. Germano, I wanted to talk to you a little bit about the
Community Health Centers. You have given very powerful
testimony today to why continuing to fund those at robust
levels and provide those resources is so critical, going
forward.
Those health centers, as you know--and maybe you could
speak to this--serve children and young people significantly.
So you have a sense of the degree to which that's the case? The
kind of numbers we are looking at, percentages or anything like
that?
Mr. Germano. Across--I can't give you across the country
but it is substantial. I would say at least 40 percent or more
in the most----
Mr. Sarbanes. Yes. I think it is at least 30 and in some
places it exceeds that in terms of patients that are served by
health centers who are children under the age of 18.
And I certainly want to thank my colleagues who have
introduced H.R. 2328 and H.R. 1943 for maintaining our strong
commitment to Community Health Centers which support the needs
of children.
But it is children's stake in these programs and services
that has led me to kind of carve out a niche commitment or
perspective here on the committee and in Congress with respect
to strengthening school-based health centers because I really
feel like you have a captive audience.
You, obviously, have the young people there, and if you can
deliver services right there on site and do it in a consistent
way and a comprehensive way, it can make a dramatic difference,
not just for those individuals--for those students, for their
families, for the community, for the health of the school, et
cetera. You can spot issues that may be arising.
I think having mental health services as a key component--
integral component--of what is delivered by school-based health
centers is something that we need to examine more deeply.
Can you speak to--and I know that I think about 50 percent
of the school-based health centers in the country have some
linkage to community-based health centers and maybe you could
talk a little bit to that relationship because through that
lens you would know of or have a perspective on how important
it is to deliver those services at the school level because I
really--I have introduced some legislation that would
strengthen the support of school-based health centers but I
have always viewed the Community Health Centers and their
health as fundamental, kind of foundational to building off of
that the school-based health response. So if you could speak to
that, it'd be terrific.
Mr. Germano. Thank you for that question.
I think the advantage of school-based health centers--you
have mentioned it--is they are there. They are there with the
kids. They are there with the families.
But in my judgment, they are an island unto themselves
unless they are connected to a system and that is what the
health centers are--a system.
So you are a nurse practitioner in a school, you come
across kids who may have onset--new onset diabetes or other
indicators, you need a referral in to the services we provide,
which would include maybe seeing the pediatrician at my health
center.
Maybe needing the diabetic counselor. Maybe helping mom and
dad with how to plan for their--you know, buying food and those
kinds of things. Getting them signed up for Medicaid if they're
eligible.
So the connection to the network, to the system, is really
important, I think, in terms of maximizing the value on the
ground for those services in the schools.
Mr. Sarbanes. I appreciate that, and, again, I come back to
this concept that it is a huge lost opportunity if you don't
site some of these health services in the place where you have
hundreds, thousands, potentially, of individuals that can take
advantage of them.
So resourcing them is important. Examining best practices
of these school-based health centers--what it means to design a
comprehensive school-based health center sort of covers the
waterfront in terms of what you would want to see.
And then to your point, making sure that the linkages are
there so that you can, you know, make the right kind of
referrals, you can step back, get a more holistic view of what
that individual and their family needs, et cetera, and then
provide other services as a result.
So we are going to continue to really lean on this effort
around school-based health centers but make sure as we do it
that we are connecting it to the community-based health
centers, and so keeping them strong, which is what you are here
to testify about today is, obviously, key.
And with that, I yield back my time.
Ms. Eshoo. The gentleman yields back.
Pleasure to recognize the gentleman from Illinois, Mr.
Shimkus, for 5 minutes of his questions.
Mr. Shimkus. Thank you, Madam Chairman.
I would like to yield my time to Congressman Guthrie of
Kentucky.
Mr. Guthrie. OK. Thank you for yielding.
Dr. Cooper, the PCORI-funded study you are leading is
comparing two ways to treat high blood pressure. Who will this
research benefit and how do you envision the outcomes of this
research changing the way care is delivered?
Dr. Cooper. Thank you. I think the research will benefit
several different groups of people.
So, first of all, it will benefit patients who have high
blood pressure and who often have other chronic conditions as
well--because we are studying people who have more than one
chronic condition--and we are helping them to figure out
whether working with a team that includes a nurse and a
community health worker and also access virtually to
specialists works better than simply going to a clinic where
they get information in a brochure.
And so I think if we can show that that works, patients
will be able to request to work with a nurse community health
worker team to help them address their issues more
comprehensively.
It'll also help clinics and health centers that are trying
to decide how to staff to take care of patients with certain
needs--hypertension and other chronic conditions as well as
social determinants of health, because we are working with
underserved communities, and it'll help them figure out what
resources they need, what staffing they need, and also provide
them with ways to train and monitor that--those programs.
So that is--I am hoping that that will benefit patients as
well as health systems and then also help providers to figure
out what kinds of programs they can refer their patients to
when they need extra support.
Mr. Guthrie. OK. Thank you.
And, Mr. Germano, Community Health Centers program's annual
funding has more than tripled between fiscal year 2002 and 2018
due to increases in community health center funds.
The grants have been used for broad purposes and types of
grant-supported program activities have expanded and changed
over time. So since the establishment of the Community Health
Center Fund in 2011, in general, how have these grant funds
been used and how have the new investments changed over time?
Mr. Germano. I think--thank you for that question.
The biggest increase is in new sites and new services. We
have seen a tremendous expansion of the Community Health Center
model across the United States.
More and more underserved communities have created these
Community Health Centers. Existing health centers have expanded
into new communities. Services mentioned earlier--oral health,
mental health, telemedicine, healthcare for the homeless, HIV
care--Ryan White.
So we have really reached out with those dollars and have
more and more impact. We are now at 28 million Americans who
are cared for by Community Health Centers. I would like to see
that doubled. We have 84 million people in America right now
without a good primary care home and that is what we can
represent is a good primary care home for them.
Mr. Guthrie. OK. Thank you.
That is my questions. If anybody wants my time I will yield
back.
Mr. Butterfield [presiding]. The gentleman yields back.
The gentleman from Oregon, Mr. Schrader, is recognized for
5 minutes.
Mr. Schrader. Thank you very much, Mr. Chairman. I
appreciate it.
Dr. Cooper, thanks for being here. As one of the original
sponsors of the bipartisan bill that put PCORI into effect, the
Comparative Effectiveness Research bill in 2009. So very
interested in the work that you're doing and trying to bring it
to fruition and implementation.
The main goal was to make the healthcare system work a
little better, centered around the patient, best outcomes. Did
some initial investment. You have indicated it has been paying
off. You gave several different examples of, you know, cases
where you came up with some pretty interesting things that
you're trying to disseminate out there to the marketplace, to
different clinics, hospitals, et cetera.
Things have changed a little bit in the intervening 10 or
15 years and particularly in the drug space. Things are
becoming very expensive. Some lifesaving medications--there has
been the discussion on this panel about value-based
reimbursement for some of these, you know, medications and what
have you and the cost of treatment, the copays, et cetera, are
getting a little more attention for that upper middle class in
the Affordable Care Act.
So would you agree that cost of treatment is part of a
patient's consideration when deciding what--where to go and
what type of therapy to have?
Dr. Cooper. I certainly think that cost is part of the
patient's consideration and people do need to often factor that
into their decision making around what care or approaches they
want to take and will be accessible and affordable to them.
Mr. Schrader. So given that and the problem we have that
PCORI is expressly prohibited from considering cost
effectiveness in its mission, should we be thinking about
tinkering with that a little bit and include the cost of
treatment as part of an impact so that the patient has the full
understanding of what they're coming up against, given the fact
there are so many great treatments out there?
Dr. Cooper. So I think it is up to you as the lawmakers to
make that decision. I think that information is important and
it should be studied somewhere and whether it comes through the
way that PCORI is funded or authorized or through some other
mechanism, I am sort of agnostic to that.
But I think we would all agree that it is important work
that needs to be done and coordinated with the work that's
happening at PCORI, either coordinated or done there.
Mr. Schrader. All right. Thank you. Thank you.
A little concerned that CMS is not particularly implemented
or at least from my understanding chosen to really adopt some
of the great recommendations that are coming out of PCORI.
Is there a way we should be talking with them or trying to
get them to perhaps use some of your recommendations a little
bit more recent or a little more ongoing basis? The outcomes
are good.
Dr. Cooper. Right. I definitely would encourage that. I
think one of the things that PCORI does encourage is
conversations among researchers and payers and insurers so that
they are all at the table and they're involved in the design of
the work and we are answering the questions that are relevant
to them so that they can use that information in decisions
about resource use and follow-ups.
But any other support that we can get in that realm I think
would be very helpful.
Mr. Schrader. How about incentivizing CMS? You know, there
are some great practices--get a chance to use that again. We
are talking about value-based reimbursement, getting good
outcomes.
Dr. Cooper. I think incentivizing patient-centered outcomes
is important and oftentimes we have been incentivizing,
typically, clinically and biomedically based outcomes and I
think it is important to also incentivize health systems that
pay attention to things that matter to patients and their
families.
Mr. Schrader. I think particularly given CMS's clout and
the influence they have it would be nice to get them behind
some of these and help disseminate that information.
Mr. Germano, popular guy here today. We all love CHCs--you
know, critical to bringing healthcare to a lot of folks that
can't afford--that have no other access, actually.
But I am a little concerned that the alignment between some
of the outcomes that HRSA uses to judge, you know, how the CHCs
are doing don't align necessarily with the Medicaid outcomes.
For instance, if you're a health center, child
immunizations have to be completed by age three. If you're a
managed care organization, it is age two. You know, would it be
smart to maybe try and sort of align both the CHC outcomes with
the Medicaid outcomes too?
Mr. Germano. Please, can you make that happen?
[Laughter.]
Mr. Germano. It does drive my clinicians up the wall
because we have all these multiple standards and what are we
held to and what are they held to.
So to the extent--I mean, I think we are working on it with
our Medicaid managed care plan or State, not so sure about HRSA
but trying to get them all aligned to agree as to frequency and
what the goals are so that we can work towards them.
It is maddening, in many respects, that we have to do--deal
with it.
Mr. Schrader. Thank you. Oregon, I know, is working on
that, and I yield back, Mr. Chairman.
Mr. Butterfield. The gentleman yields back.
The gentlelady from Indiana, Mrs. Brooks, is recognized for
5 minutes.
Mrs. Brooks. Thank you, Mr. Chairman.
I am going to start with you, Mr. Germano, but I have
several questions for the panel, and thank you all so very much
for being here.
Can you further discuss the kind of treatments that
Community Health Centers are using combatting the opioid
epidemic?
Mr. Germano. Thank you for that question.
Our primary mechanism is to use buprenorphine Suboxone--
medically assisted therapies. We have created clinic systems
around that. We have about 200 patients now in therapies right
now. Behavioral health is a big component of that; not just the
drug, but the behavioral health and the follow-up.
So we are--we have doubled that program in a year. We are
probably going to double it again and we are going to add it to
our maternity services as well.
Mrs. Brooks. And do you know is that a trend that you are
seeing with other Community Health Centers?
Mr. Germano. Very much so. I think we are gaining
confidence as a system that it works, it is helpful, and if
done correctly with behavioral health it can be very effective
for our communities, yes.
Mrs. Brooks. One of the concerns that I have is the
workforce shortage, and while we have talked about physician
shortages, and I appreciate you talking about the issues with
graduate medical education, I have introduced an Opioid
Workforce Act because, as I understand, one of our biggest
concerns in the treatment of opioids is the lack of a trained
workforce.
In the teaching Community Health Center model, are there
any addiction medicine programs for residents that you're aware
of and is that--Representative Schneider and I from Illinois
have introduced this Opioid Workforce Act to try to increase
Medicare-funded residency slots for addiction medicine
specifically. Are you familiar with any of those types of
programs?
Mr. Germano. I am not. But I will say this much. In our own
residency program, we have made the MAT program a core part of
their training. So when they are done, they are X waivered and
they are ready to go when they finish training.
Mrs. Brooks. That is excellent. Do you know if that is
something that other Community Health Centers are doing as
well?
Mr. Germano. I believe that many of them are doing that. I
can't say all of them, but I am familiar with several that are.
Mrs. Brooks. Would additional funded residency programs
make that more possible or do you think there is a need for any
specific addiction medicine residencies?
Mr. Germano. I really can't answer that question. All I can
say is in the teaching health center world, because our
communities are suffering from the scourge of opioid abuse,
they should be training their residents in this field. They
should give them comfort.
Mrs. Brooks. And so you'd like to see all--would you like
to see all the primary care residency programs include your
medication-assisted treatment training?
Mr. Germano. I think every community has to decide what is
a priority. But from what I have seen across this country, I
would say yes.
Mrs. Brooks. Dr. Cooper, I would like to ask you about the
PCORI program relative to opioid and pain management. You
talked about it a little bit in your written testimony, and I
am sorry, I had to go to another hearing and missed your
testimony here. Can you talk a little bit about PCORI-funded
programs relative to addressing the opioid epidemic?
Dr. Cooper. Sure. So I did mention the one where there was
an initiative targeting providers and getting them to decrease
prescribing of opioids.
There are other programs looking at team-based models of
care for opioid addiction, different programs focusing on how
to monitor medication used for patients, also looking at
different approaches that combine medication such as Suboxone
with cognitive and behavioral therapy included.
So a number of different programs comparing different
strategies for addressing opioid addiction.
Mrs. Brooks. Thank you.
Shifting just for a moment, Dr. Kowalski, congratulations
on your new role and I have been involved in the Special
Diabetes Program reauthorization in the past and I know we have
spent a fair amount of time asking about the funding and so
forth.
What are the greatest challenges that are remaining as you
have taken on this new role and the obstacles? What are kind of
the biggest obstacles in the disease that concern you the most
and the greatest challenges that you face, and how can the
Special Diabetes Program help overcome those?
Dr. Kowalski. I will echo what we have heard today. The
lack of clarity on sustained funding is a big obstacle for us
in diabetes as well. In your home State, we have IU doing some
of the most innovative work in the immunobiology of type 1
diabetes, an autoimmune form of the disease.
TrialNet has played a pivotal role in our understanding of
potential interventions to slow, prevent, and ultimately, we
believe, cure the disease.
The NIH and the SDP play a pivotal role in driving that
research forward. So a sustainability of funding at a moment
where we are seeing science exploding, not only in type 1
diabetes; there is a lot of overlap in other autoimmunity that
we are working--MS, celiac, rheumatoid arthritis.
That progress needs to be sustained and we need to keep
that momentum going.
Mrs. Brooks. Thank you. Thank you for your work, everyone.
I yield back.
Mr. Butterfield. I thank the gentlelady.
The gentleman from California, Dr. Ruiz, is recognized for
5 minutes.
Mr. Ruiz. Thank you, Mr. Chairman.
First, I would like to thank Congresswoman McMorris Rodgers
for cointroducing the Training of the Next Generation of
Primary Care Doctors Act with me.
This bill will reauthorize the Teacher Health Centers
Graduate Medical Education Program, which will soon end in
September 2019 and it will add more primary care doctors in the
communities that need them the most.
I know a little bit about this because I grew up in the
very underserved community of Coachella--farm worker family--
and when I came back after leaving home and coming back as a
doctor I set to mission to really address the healthcare crisis
that we have in the area.
And I did research with some of my students that I was
mentoring--premed students--and we came up with the Coachella
Valley Health Care Initiative and Health Care Access Report,
and we counted that there was one full time equivalent doctor
per 9,000 residents in large segments of the Coachella Valley.
And you usually think of Coachella Valley as lush country
clubs, right. But there are a large portion that still struggle
to get the care that they need. It is one of the reasons why I
ran for Congress as well and it is the primary reason why I set
off to be a doctor.
The medically appropriate number--recommended number is 1
to 2,000. So we are 1 to 9,000. To be determined as medically
underserved it is 1 to 3,500. So we have a lot of work to do
and the Teaching Health Center Graduate Medical Education
Program was created under the ACA in the effort to get more
doctors in medically underserved areas.
You see, we have a drastic physician shortage crisis
everywhere in America in terms of absolute numbers. But the
secondary crisis is that they are maldistributed, leaving large
portions of our country very medically underserved without
doctors.
And as we know, those of us who practice and study this
that the two largest predictors of where a physician will
eventually lay roots and practice are where they are from and
where they last train.
So I built pipeline programs from the underserved
communities through my physician--Future Physician Leaders
Program, getting them from high school, putting them through
undergrad medical school with the USR School of Medicine and
then training them in underserved areas, and that is the best
way that you're going to address the physician shortage crisis
in the underserved and rural areas.
So this program works. The Teaching Health Center Graduate
Medical Education Programs work. In 2017, statistics show that
82 percent of Teaching Health Center graduates remain in
primary care compared to 23 percent of traditional GME
graduates.
Fifty-five percent of Teaching Health Centers' graduates
practice in underserved communities, compared to only 26
percent of traditional GME graduates, and 20 percent of
Teaching Health Center graduates practice in rural settings
compared to only 8 percent of traditional GME graduates.
And I am working in my districts with Borrego Health and
Neighborhood Health and Clinicas de Salud del Pueblo to really
address this and bring in more residents into the underserved
areas.
So Teaching Health Centers truly take a different approach
to graduate medical education by placing residents directly in
the communities most in need of care.
Dr. Germano, in your testimony you referred to it as ``grow
your own'' strategy. Could you further explain how Teaching
Health Centers training experience and outcome is different
from traditional GMEs?
Mr. Germano. Thank you both for you commitment to the
Teaching Health Center Program. And I am not a physician so----
Mr. Ruiz. I've got 1 minute, so I got too many questions.
Mr. Germano. But, really, it is about seeding programs in
underserved communities and rural areas, in particular, have a
tough time just as----
Mr. Ruiz. And is different from traditional GMEs how?
Mr. Germano. In that we identify young people with a
commitment to serve in our community that come from our
community and we train them, and that is how we do it.
Mr. Ruiz. Right. The other problem is that for these
programs most of them have residencies that require 3 years,
right. That's one of the minimum years for a family medicine
residency program. But we have been reauthorizing them for 2
years. Why is that a problem?
Mr. Germano. Well, every class you take is a 3-year
commitment. When you have 2 years' worth of funding, it creates
a lot of insecurity.
Mr. Ruiz. Exactly. So this is going to add funding for 5
years and, hopefully, will start to change that problem.
The other issue we have is the not only disparities in the
diversity or lack of diversity in physician workforce but we
also know that if you train more Latinos and African Americans,
et cetera, they will go to--more likely to go to Latino and
African-American communities and they tend to be underserved as
well.
So how does this help that?
Mr. Germano. Well, again, it is that pipeline from our own
communities, from the faces of our community into the medical--
just like what you are doing down your way.
We are trying to do that across the country in teaching
health centers, drawing from our community--our own underserved
populations, moving them through, looking like the patients
that, you know, they are going to take care of.
Mr. Ruiz. And that is not just important in the overall
idea of diversity is good, but when a patient understands the
instructions and when the doctor understands the community in
which they live in, they are better able to tailor the
therapeutic recommendations and advice so that the patients can
actually implement them.
And studies have shown that patients are more compliant,
especially if they understand through the cultural nuances and
language--they are more compliant and they have better
outcomes.
So it is actually--when you want to measure value of public
health, having physicians who are similar and can understand
the life experience of their patients will lead to better
health.
Mr. Germano. I agree.
Mr. Ruiz. I yield my time.
Mr. Butterfield. The gentleman's time has expired. The
gentleman yields back.
The gentleman from Florida, Mr. Bilirakis, is recognized
for 5 minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
Mr. Germano, give Florida's traditionally higher senior and
veteran populations, maintaining a skilled healthcare workforce
is critical. It becomes even more of a challenge when student
debt drives where residents choose to practice.
Often, it is our rural and traditionally underserved areas
who suffer, unfortunately. According to HRSA, a family medicine
resident physicians who train in health center settings are
nearly three times as likely to practice in underserved
settings after graduation, when compared to residents who did
not, underscoring the value of the Teaching Health Center
Graduate Medical Education Program.
That is why I recently joined my E&C colleagues introducing
a fully paid for measure to extend this program--H.R. 2700, the
Lowering Prescription Drug Costs and Extending Community Health
Centers and Other Public Health Priorities Act.
How often--the question is, again, to Mr. Germano--how
often do medical professionals choose to stay in a medically
underserved area once Federal funding is no longer available?
Mr. Germano. Well, that--gosh, it makes it hard, because
they are making a commitment of their life, right. It is their
practice and then their family, and they need to have some
sense of security.
Mr. Bilirakis. Sure.
Mr. Germano. When they don't have that, they have choices.
The marketplace--there are so many opportunities that going to
an underserved community isn't going to be high on their list
if they don't feel security.
So we have to create a secure environment in order to
attract and keep them.
Mr. Bilirakis. Yes. How do you propose we do that?
Mr. Germano. Well, I think stable funding is huge. The
messaging that comes from that, that you're going to be here
for the long run, that this is a commitment. We are stable as
an organization and, obviously, we need them in our
communities.
So they are wanted and needed and we can help support them
in their lives.
Mr. Bilirakis. OK. Next question. Can you describe how
Community Health Centers--I am a huge proponent of Community
Health Centers, as cochair of the caucus--how are they--and
then also the community clinics--how are they sustained?
Mr. Germano. We have multiple funding sources. The 330 is
the building block which we all work from. We have--Medicaid is
another big piece of it. Medicare is another large piece of it.
I mentioned the 330 program. We have State resources,
private--we put it all together. We are not dependent on just
one but you pull one of those cards out, particularly the 330
program, and sort of the whole thing falls apart.
So we pool our resources together to serve the greatest
broadest scope of services to the biggest number of patients
that we can reach. So all those--it is a piece of everything,
including 340(b) and others--other income.
Mr. Bilirakis. What is your position on veterans having
access to Community Health Centers and actually the Community
Health Center would be reimbursed by the VA? And, you know,
there aren't a lot of--in some rural areas, you know, you don't
have a lot of access. We don't have VA clinics in some areas,
VA hospitals.
What is your position on that and can the Community Health
Center actually provide for those veterans? Is there room for
that?
Mr. Germano. I think--it think that is already happening in
many places where the--there the Veterans Administration has
reached out to the Community Health Centers, and I think they
are limited by capacity issues--going back to workforce again.
But I think there isn't--other than technical barriers in
terms of, you know, how payment is made and those kinds of
things--contracts--I think health centers would readily embrace
doing more for their veterans.
Mr. Bilirakis. Yes. And, you know, we would like the
veteran to have the choice to go.
Mr. Germano. Absolutely.
Mr. Bilirakis. Instead of the VA saying, you know, you can
go into the community, the veteran should have the choice to go
to the Community Health Center because, again, the care is very
good.
Mr. Germano. So we have a healthcare for the homeless
program and probably a quarter of our homeless are veterans.
And so we pull them into the system and help them.
Mr. Bilirakis. Well, thank you very much. Thanks for what
you do.
I yield back, Mr. Chairman.
Mr. Butterfield. The gentleman yields back.
At this time the Chair recognizes Mr. Gianforte from
Montana.
Mr. Gianforte. Thank you, Mr. Chairman. I appreciate you
having this important hearing. It is imperative that we find
common ground on these very bipartisan programs so that there
are no lapses in funding.
Community Health Centers, National Health Service Corps,
Teaching Health Centers, and Special Diabetes Program for
Indians, and the mental health are all incredibly important to
the State of Montana.
I fully support these programs and the work they do in our
State. We need to ensure that they are funded. Robust public
health programs lead to future savings and better health
outcomes for all.
I am concerned, however, by our lack of ability to pay for
increased funding levels for these programs. We need to ensure
that we strike a balance between fiscal responsibility and
guaranteeing that all have access to high-quality primary and
mental healthcare.
So I thank the panel for being here today and I want to
start with a question here for Dr. Kowalski, if I could. In
your testimony, you mentioned the differences between type 1
and type 2 diabetes, and that the American Indian and Native
Alaskan population have a disproportionately higher and are
affected by type 2 diabetes, in particular.
Can you elaborate a little bit on the differences between
type 1 and type 2 and also why the Native American population
has such a high incidence?
Dr. Kowalski. Sure. So type 1 diabetes is a form of
diabetes that is caused by an autoimmune response to the cells
that make insulin, thus rendering people unable to make insulin
and requiring replacement.
Type 2 diabetes is a metabolic disease where the body makes
insulin but it doesn't work as well. And so why are some
populations more susceptible?
That is a huge area of research but we do know it is very
genetic. Again, earlier I said this is a disease that is
stigmatized and I think tremendously unfairly because these are
problems that are inherited and we see in Native populations
across the globe a higher propensity.
So this investment in helping people who are underserved
with type 2 diabetes, namely, in this case, our Native
populations, pays huge dividends in terms of the quality of
their lives, their reduction in risk for all of the types of
damage that high blood sugar causes--eye, kidney, and heart
disease.
And we have seen the proof is in the pudding. The return on
investment on this program has been very, very high.
Mr. Gianforte. So you would advocate for increased focus on
type 2 diabetes in Native populations?
Dr. Kowalski. Both forms of diabetes are under funded by
Congress. So we believe that both SDP and SDPI are really a tip
of the iceberg--that there is an unmet need here that is
significant.
Mr. Gianforte. OK. Thank you.
Mr. Germano, unfortunately, Montana has the highest
incident of suicide in the country. We also have a
methamphetamine abuse epidemic.
What role do Community Health Centers play in serving--
ensuring that patients have access to mental health?
Mr. Germano. Thank you for that question. Community Health
Centers of today have really embraced what we call integrated
behavioral health. There is a stigma tied to going to a mental
health system for some people, and unfortunately so. But
they'll go to their family doctor--their Community Health
Center.
We have embedded behavioral mental health folks in our
primary care practices. We introduce them to them. We connect
them to those. We screen for those behaviors--depression,
anxiety. We connect them to resources. We work together with
their family doctor, nurse practitioner, PA.
So it is a huge access point for people who could be, you
know, subject to, you know, taking their lives, which
unfortunately is also the case in my region, and that's why we
have done a lot in this space.
The addiction piece is another growing element of the
health centers. We have gotten into the medically assisted
therapies in a big way and in combination with also our
behavioral health services because it takes not just the
therapies but also the mental health support as well.
Mr. Gianforte. Yes. I recently held a round table on mental
health and substance abuse, and I was surprised at how
intertwined these two things are and very hard to diagnose
between.
Can you talk about what the Community Health Centers are
doing, given how closely related mental health and substance
abuse are?
Mr. Germano. Well, the first thing is we had to get over
our own biases and understand, and I think we have, very
quickly--that there is definitely a behavioral health component
to a lot of these situations and needs of our patients and
working collaboratively, like I said, between our primary care
clinicians and our behavioral health specialists and our
psychiatrists, in some cases, who think about what's best for
the patient and their families and their significant others. So
that's it.
Mr. Gianforte. OK. I want to thank the panel, and these are
important programs. We need to make sure they continue.
With that, I yield back.
Mr. Butterfield. The gentleman yields back.
The gentleman from Illinois, Mr. Rush, is recognized for 5
minutes.
Mr. Rush. --that are vital to my constituents and,
importantly, it is absolutely critical, Mr. Chairman, that we
do not allow the DSH payments to be cut now or in the future.
The funding--this funding is critical to my county--Cook
County's level one trauma centers and burn centers and
emergency preparedness plans for my county, and if these cuts
were to go into effect, not only these services but all
healthcare services that serve those folks in need would be
severely at risk and it would be--this is totally unacceptable
and I am glad to see this subcommittee taking an aggressive and
upstanding posture as it relates to coming up with some
solutions for this pending problem, and I am proud to be a part
of this subcommittee under the leadership of the chairman.
I want to take a moment to discuss Community Health
Centers. You know, Community Health Centers assure that
healthcare is affordable and accessible for patients in my
district and around the country. There are eight federally
funded health centers in my district that serves almost 341,000
patients each and every year, and in my State 2 out of 10
patients are unserved, and 6 out of 10 are Medicaid
beneficiaries. Without Community Health Centers, we would be
far worse off than we are right now.
And so I have a question I want to ask Mr. Germano. Mr.
Germano, I am concerned about pharmaceutical deserts--
pharmaceutical deserts. Does your health center dispense
prescriptions?
Mr. Germano. We have--yes, we do. We do quite a bit,
actually.
Mr. Rush. All right. There are many drug stores--Walgreen's
and CVS, CVS particularly--that are closing down in underserved
communities and putting at risk particularly the elderly who
depend on these drug stores for their filling of their
medication--refilling of their medication.
With these closures, seniors, the poor, those who are risk,
those who are ill, have to travel many miles in order to get
their medication, and that is why we--there have been some
published articles around pharmaceutical--what they call
pharmaceutical deserts.
So my question, if given the authority do you believe that
there is a role that Community Health Centers can play in
running free-standing pharmacies and would it be helpful if
there were public-private partnerships between private
pharmacies and Community Health Centers?
Mr. Germano. Thank you for that question, Congressman.
Around me are a number of frontier health centers. They're
out in communities where the local private pharmacist has
retired or left, and you're right, there is no pharmacy in
their community and they have to travel an hour or two, in many
cases, to the small cities that they can get to.
It really is a problem with compliance. My health centers
have worked really hard--my colleagues out there in terms of
things like mail order pharmacies to try to connect people that
way.
There is telepharmacy that is being, you know, developed
out there that can help as well. We keep stocks of medicines--
certain kinds of medicine--to get people started until we can
find a more stable source.
Health centers have pharmacies. Many of them do. Many of
them run their own. In my case, it is a public-private
partnership. We have a local pharmacy that actually is embedded
in my health center. So we work together to deliver that
service to our patients.
It really is about compliance and what's in the best
interest of the patient.
Mr. Rush. Thank you, Mr. Chairman. I yield back.
Mr. Butterfield. I thank the gentleman.
The Chair now recognizes himself for 5 minutes--5 absolute
minutes.
Mr. Germano, again, thank you. As the other colleagues have
said, thank you for being here today.
Last week, I visited Lincoln Community Health Center in
Durham, North Carolina, which is formerly Lincoln Hospital,
which was named for the 16th President of the United States.
Lincoln is Durham County's main provider and primary
healthcare for low-income, under insured, and uninsured
patients.
The chief medical officer there and his team do remarkable
work under very difficult circumstances. Seventy percent of the
patients treated at Lincoln are uninsured or under insured.
Over 70 percent are living at or below the poverty rate.
They epitomize the vital work being done in Community Health
Centers like yours and many others all across the country and I
underscore why today's hearing is so important.
Sir, let me ask you. I wanted to talk with you about the
National Health Service Corps. You mentioned that you have a
number of them at your health center today.
I have long championed this program. Last Congress I
introduced 3862, which is the National Health Service Corps
Strengthening Act, and this year I led the NHSC Member Funding
letter to the Appropriations Committee because I know it is a
critical recruitment and retention program for health centers.
Like the Rural Group in my district, they have successfully
used it recruit a number of providers over the years but ran
into trouble last Congress when we let funding expire, at least
for a time.
We were eventually able to get the funding extended but the
Rural Health Group lost out on an OB/GYN that they were
recruiting at the time. We must extend this valuable program
before it expires once again in September.
You mentioned a bill that I am cosponsoring, H.R. 1943--
that's not the year I was born but it is pretty close--
introduced by my colleague and good friend, Congressman
Clyburn, that would expand the NHSC.
Can you tell me what it would mean to the program if we
were to enact the funding level proposed in that bill, if you
are familiar with that bill?
Mr. Germano. Yes, thank you for that question. That bill
would actually fund every applicant to the program. It would be
successful--almost every applicant obtaining a contract to
serve in an underserved community.
Right now, only about 40 percent do. So that bill--that
funding bill would allow 100 percent of all applicants to be
able to be contracted under the National Service Corps and
serve their communities.
Mr. Butterfield. Do you support the bill without
reservation?
Mr. Germano. Absolutely. Sure.
Mr. Butterfield. Thank you. I yield back.
The gentlelady from Illinois, Ms. Schakowsky, is recognized
for 5 minutes.
Ms. Schakowsky. Thank you so much, and I am always so
grateful to be able to waive onto this subcommittee as these
issues are so important to me.
By 2032, the United States may face shortages of over
100,000 physicians. But I actually would argue that we already
have significant physician shortages today because of the fact
that healthcare access is not equitable across race,
socioeconomic status, and geographic location.
This status quo is unacceptable for our growing aging
population, for our children, and for all vulnerable
communities in our country.
In order to address the shortage and improve healthcare
access, I am fully supportive of all of the bills that are in
front of us in this subcommittee today, especially those that
address inequalities.
It is clear that we have to reauthorize the National Health
Service Corps and the Teaching Health Center Graduate Medical
Education Program for at least 5 years, if not longer, and
increase funding levels to strengthen our workforce and
increase access to care.
On May 17th, Ranking Member Burgess and I introduced H.R.
2783, the EMPOWER for Health Act--a long acronym--Education
Medical Professional and Optimizing Workforce Education and
Readiness Act--that spells EMPOWER.
And the EMPOWER for Health Act is designed to increase
access to healthcare in underserved areas and ensure that a
more diverse healthcare workforce is able to meet the needs of
our entire population.
When we pass this bill, we will finally reauthorize
critical Title 7 funding for--that would ensure people around
the country have access to skilled physician and medical
professionals regardless of who they are or where they live.
Mr. Germano and Dr. Cooper, I wonder if each of you could
discuss why it is so important that we not only support our
physicians through the National Health Service Corps and the
Teaching Health Center Graduate Medical Education Program but
also ensure that we are building a diverse healthcare workforce
as the aim of this legislation, the EMPOWER for Health Act. We
can start with you, please.
Mr. Germano. Sure. Thank you for that question.
Debt is a huge issue for medical students. The average debt
is $240,000 coming out of medical school, and much higher. I
have had doctors, $300,000, $400,000. My son is a resident.
He's going to have $400,000 worth of debt by the time he is
done. It is untenable, and that is a factor in them choosing
primary care practice as an option in residency because,
unfortunately, there is a gap between what certain specialties
make and what primary care clinicians make. So that's a
problem.
You can even that gap out with things like the National
Service Corps. You can take some of that pressure off and help
them to--make it easier for them to choose what they want to
do, which is to work in primary care if they could.
So I think that is a huge issue. And in terms of the
Teaching Health Centers, we are in the communities that are
underserved. As was mentioned earlier, we look at pipeline. We
look at residents--medical students--who have a heart and have
a connection to our communities--reflect our communities.
They are the ones who are going to be most effective and
successful, and that is why we are such big supporters of it.
Ms. Schakowsky. Thank you.
Dr. Gordon? Cooper. Dr. Cooper. I am sorry.
Dr. Cooper. So----
Ms. Schakowsky. And if you could talk to about how
diversity then is affected.
Dr. Cooper. So, you know, one of the areas in which I have
spent most of my career is better understanding and addressing
disparities in healthcare, and although there are a lot of
different factors that contribute to those disparities, one
significant one is the lack of diversity among health
professionals. So some of the earlier work that I did actually
did document that when there was ethnic and racial concordance
and language concordance between patients and providers that
patients had better experiences and in some instances actually
better quality of care as well.
So we know that it is important, not necessarily that every
patient has an ethnic or racially concordant provider, but we
know that ethnic concordance and we know that diversity within
the health professions actually contributes to better cultural
competence among all physicians, right, because it changes the
culture of the profession and it broadens cultural sensitivity
and knowledge of different social determinants and those
factors within the profession. So it is critically important.
And I also think that funding for agencies like PCORI that
does address the needs of underserved populations and addresses
disparities and care and health outcomes is an encouragement to
people from diverse backgrounds who want to pursue careers that
are focussed on research. But if they feel that the research
that they're interested in or that will benefit their
communities is not being supported, that's also a
discouragement.
So I think that, you know, all of these programs--the
funding for training in clinical care as well as in research--
are factors that will help to enhance the diversity of our
profession.
Ms. Schakowsky. Thank you so much. I am way over time. I
yield back. Thank you.
Ms. Eshoo. The gentlewoman yields back.
I now would like to recognize the gentleman from Oregon,
Mr. Walden, for 5 minutes of his questions.
Mr. Walden. Thank you, Madam Chair, and again, thanks to
all of you for being here and your testimony and answers to our
questions.
Mr. Germano, health centers are oftentimes the only
provider in our rural areas, and my district is just north of
you. You're in Redding. I am across the border in Oregon.
So in addition to isolation and distance, what other
challenges should we be aware of that you face? I kind of have
an idea because I spend a lot of time with my health center
folks.
But what do you run into? What do you hear from your
colleagues?
Mr. Germano. Well, I think that transportation is a big
problem and particularly sometimes it is tough even getting
people into our little town of Redding, let alone if they need
to go to a big teaching center like down in Sacramento or San
Francisco.
So we run into that issue quite a lot, and there is also
smaller groups of, like, for example, for Laotians and others.
Language can be an issue if it is not common. But there are
groups that need care, and you have to try to wrap services
around them that are effective, so interpretation----
Mr. Walden. What about broadband and telehealth? What do
you run into there? Do you run into cross-state issues on
medical licensure?
Mr. Germano. Yes.
Mr. Walden. You mentioned it takes 18 months or whatever to
fill----
Mr. Germano. Recruit a physician, yes.
Mr. Walden. I mean, it seems to me--I mean, I run into this
and you're going across state lines. My district border is
Washington, California, and Nevada----
Mr. Germano. Yes.
Mr. Walden [continuing]. And the rest Oregon, and some of
this doesn't make sense anymore in today's telehealth world to
have these----
Mr. Germano. Artificial barriers.
Mr. Walden. Thank you.
Mr. Germano. Yes.
Mr. Walden. Do you run into that?
Mr. Germano. Yes, we do. We have to pretty much stay to
California when it comes to telemedicine for those various
reasons. Whether it be liability, licensure, our state
requirements, our Medicaid plan, it really limits us to our own
region and it is problematic on the borders.
Mr. Walden. Right.
Mr. Germano. That is where you--you know, you could have a
great facility 10 miles north of you and you can't access it
because you're in another state.
Mr. Walden. Mm-hmm. Yes, we face that a bit on the east
side, going up against Boise or you might be--now, the
veterans--I think Veterans Administration can go nationwide.
Mr. Germano. Yes, they figured it out. Yes.
Mr. Walden. And there should be a way we could--it is
something we ought to--I don't know how we deal with this, your
state's rights versus whatever. But, you know, come on. You
might have the expert 10 miles away----
Mr. Germano. Exactly.
Mr. Walden [continuing]. And you literally can't access
them. So and then can you help me and the committee--explain
the differences between the Teaching Health Center GME program
and other GME programs.
Mr. Germano. Very briefly, the graduate medical education
Medicare CMS program is an entitlement program. They go by a
whole separate set of rules. They have to follow the same
accreditation requirements we do under the American Council of
Graduate Medical Education. But their funding stream is
hospital based, typically. That is where their funding comes
from.
The Teaching Health Center Program is really about--the
funding runs through the Community Health Centers or the
consortia of partners, and then we are able to, within the
scope of those accreditation requirements, tweak their training
to reflect our reality.
Mr. Walden. Got it.
Mr. Germano. For example, we do a lot more in homeless
healthcare with our residents. Our medically assisted therapies
is another, you know, core element of what we do, which is
different than hospital-based training.
Mr. Walden. Yes, it is really important and I think we've
got to figure out how to make sure we are staffing up--that you
are able to staff up. I run into that as well, just the
recruitment and the retention. What I have also found is if
they come through one of these programs and practice in that
area there is a higher likelihood they stay. Is that what you
run into as well?
Mr. Germano. Well, the data shows that, you know, and we
are a living example. I mean, I would like to keep more. I
would like to keep more of our residents in our community.
But all of them stay in primary--nearly all of them stay in
primary care, key one, and two, almost all of them stay in
working in underserved communities. So that's the other
benefit. If not ours then their neighbors. So yes, the model
does work.
Mr. Walden. Mm-hmm. OK. That's, I think, all I have, Madam
Chair, at this point. So I yield back.
Ms. Eshoo. I would like to work with you on this--on the--
you know, on the licensure and all of the complications of not
being able to go over state lines. It is not defensible anymore
and there are so many communities that would benefit from our
fixing that. So let us put that on the to-do list.
I know that Mrs. McMorris Rodgers is waiting. But we need
to take the Members and then you will waive on. So I will now
recognize Mr.--the gentleman from California, Mr. Cardenas, for
5 minutes of his questions.
Mr. Cardenas. Thank you very much, Madam Chairwoman, and
also Ranking Member Burgess for having this important hearing.
It is great that we are talking about these programs and we
need to keep focused on the Americans who are all trying to
make sure that they get better service.
According to the nonpartisan Kaiser Family Foundation,
those who visit health centers are far more likely to be low
income and working poor, by the way, with more than half
falling below the poverty line and are far more likely to come
from a community of color.
Health centers are also far more likely to serve patients
that speak only--other than English, for example, when compared
to other primary care settings. These are the primary care
providers that these communities have come to rely on and where
many families have received life-saving care we need to make
sure that these centers actually are able to continue to serve.
Again, I just want to point out that far too often when
people think of people getting care where there is little to no
fee to the actual end user that it is somebody who is not
working for a living.
I want to make it very clear that I know that in my
district I have many, many working poor individuals who fit the
results that the Kaiser Family Foundation research has exposed.
Mr. Germano--in my district we would call you Germano--I am
sorry if I am saying it wrong--so can you talk about some of
the outreach activities that Community Health Centers are able
to do to reach these communities?
Mr. Germano. Our health centers in our region and across
our State and our Nation really is about outreach. We have a
number of our staff who that is their job is to reach
populations, people who won't normally connect with us whatever
the situation.
So we work with churches. We work with social services
agencies. We work with our police departments, law enforcement.
They come in contact with folks or families or situations--
social services agencies.
So our goal is to make sure that we are connected to all
these other resources and that we welcome everybody into our
medical home.
Mr. Cardenas. OK. Where would these communities go if they
no longer had access to services provided by Community Health
Centers?
Mr. Germano. You know, I shudder to think. The default is
the emergency room, right, and----
Mr. Cardenas. Or no care at all?
Mr. Germano. Pardon me?
Mr. Cardenas. Or no care at all.
Mr. Germano. Or they--right. They defer until it becomes a
critical issue, and that would be horrible for everybody.
Mr. Cardenas. I just had an unfortunate reality conveyed to
me by a young woman who was explaining to me the horrors of her
family's experience in this country when it came to healthcare.
She had two parents that were working poor. They had to
rely on facilities like this to get their care. Her little
brother was born with congenital conditions that they never
could figure out exactly what it was, and he passed away.
And later on, her father became very, very ill--the father
of this little boy--and he, apparently passed away as well. So
two tragedies in one family.
And the actual tragedy to her little brother was actually a
factor in why her father passed away way, way too young,
because his exact words to her that she conveyed to me when she
said, ``Dad, you're really sick. You need to go to the
doctor,'' and this is pre-Affordable Care Act, because I asked
the question--I said, but the Affordable Care Act.
She said my father passed away a month before the
Affordable Care Act kicked in. He said, ``I am sick and tired
of seeing all these bills. I can't afford it.''
So your--the facilities that we are talking about today are
the facilities that will actually help individuals get access
to healthcare and, secondly, not be afraid--not be afraid of
the financial burdens at least--at least to see a doctor. At
least to find out am I going to die or am I going to be OK.
Mr. Germano. You know, even today we see some of our
uninsured patients come in with late onset diseases and you ask
them, we've been here--we've been--why--they have reasons, and
we don't fully understand it.
But it is up to us to get the message out that this--you
can come here and you will see a doctor or a nurse practitioner
or PA. We will help you to get medications. Anything we can do
within our four walls we will try to do for you. It gets
tougher once you get outside of our four walls. But we can do a
lot within our four walls.
Mr. Cardenas. And what area of California do you serve?
Mr. Germano. Up in Redding, California.
Mr. Cardenas. Do you know a Dr. Lupercio? Have you ever met
him? He works in a hospital. I was curious if you have come
across each other.
Mr. Germano. I don't think so.
Mr. Cardenas. Pulmonary specialist, born in Mexico, got
educated here. Serving the community. Amazing human being.
Mr. Germano. I will have to meet him.
Mr. Cardenas. Thank you, Madam Chair. I am sorry. I went
over my time. Thank you so much.
Ms. Eshoo. I am a nice chair. I let people go over and
finish their thoughts.
But we are winding down. Now, I would like to recognize the
gentlewoman from New Hampshire, Ms. Annie Kuster of the famous
Kuster family in her home state.
Ms. Kuster. Thank you, Chairman Eshoo, and thank you for
this hearing and for all you for your patience today.
Many of the programs that we are talking about today are
critical in my home state of New Hampshire where we are in the
midst of a major opioid epidemic. 2017 we had 424 drug overdose
deaths involving opioids and many of the programs that we are
discussing are critical to combatting this epidemic.
I want to give a particular shout out to our Community
Health Centers serving some of the most vulnerable populations
in our rural state. They have been instrumental in providing
comprehensive care to those who need it, particularly, after
Medicaid expansion under the Affordable Care Act.
And programs like PCORI have funded incredible research at
Dartmouth Medical School in my district, studying treatment for
pregnant women with opioid use disorder.
So I also appreciate that this collection of bills address
the workforce issues that we have been seeing. We are trying to
encourage young people getting into career in technical
education in our high schools, to get an LNA coming out of high
school and then go to our community colleges and then go to our
4-year colleges and working their way up in the healthcare
credentials.
I want to start, Mr. Germano--you spoke of the difficulties
in recruiting and retaining primary care physicians to
underserved areas, and I am hoping that you could speak
particularly with the Community Health Center model and the
workforce that stands up the Community Health Centers are
especially equipped to handle many of the public health
challenges we face, and if you could elaborate on how these
programs will make a difference for these workforce issues.
We have an unemployment rate of 2.4 percent, which is the
envy of many of my colleagues. But it creates tremendous
challenges in rural communities.
Mr. Germano. Definitely. The health centers more and more
across this country have become, in my judgement, the de factor
public health department now. They are the ones touching the
lives of great swaths of our community.
No disrespect to public health. They have gone into more
the monitoring and surveillance and those kinds of very
necessary things. So the primary care networks--the Community
Health Centers have been the face of immunizations and sort of
other surveillance and interventions.
So yes, we play a critical role as a safety net. That is
our job. That is what we should--one of our jobs--that should
be one of the things we do. Workforce with the lower--I mean,
it is a great thing we are seeing our unemployment rates drop
but it creates some real challenges in terms of recruitment and
retention.
Can we stay competitive, and not just about the doctors and
the nurse practitioners but all our front line staff and what
have you. So we are constantly chasing our tail, making sure
that we are remaining competitive to keep our employees and
sustain them.
So, again, ongoing sustainable funding is really critical
in us to predict what we can afford.
Ms. Kuster. Great. Thank you, and thank you for appearing
on behalf of the Community Health Centers, a great asset to our
community.
Dr. Cooper, I am going to turn to you about the PCORI
funding--that we have researchers at Dartmouth College
examining the outcomes of prenatal care for women receiving
medication-assisted treatment and the research is integral to
understanding how to--prenatal, postpartum, how to support moms
to have healthy babies. Could you discuss how a gap in
appropriations will impact projects like these and the need for
predictable and consistent funding?
And just while you are at it, in your opinion are there any
other entity sources--NIH or the Agency for Health Care
Research and Quality--that would be able to fill the gap or is
this research that wouldn't continue?
Dr. Cooper. I think a gap in funding from PCORI would
significantly threaten a project such as the one you described
for a number of reasons.
One of them is that oftentimes when we do have results from
such a project and they are positive results the promise that
they hold is that we could then spread them to other settings
or disseminate them more widely.
But without ongoing support from an institute like PCORI
the ability to package the materials that have been developed
and to use the learnings from that research to spread to other
settings or to disseminate it would be limited significantly.
Additionally, you would have researchers who are conducting
patient-centered outcomes research who may leave the field
because of that uncertainty and either go back into clinical
practice or do administrative work or something else.
They might also pursue research that is not patient-
centered outcomes research and I don't think NIH and AHRQ would
fill that gap completely. I think that there are some
institutes at NIH that support similar work.
For the most part, they don't support the level of
stakeholder engagement that PCORI does. It takes a long time to
build partnerships with patient advocacy groups, family
members, health insurers, health system leaders to conduct the
research that ends up being very practical and sustainable over
time, and we don't get that kind of funding.
Ms. Kuster. My time is up. I apologize. I would like to
yield back. But thank you. Thank you.
Ms. Eshoo. The gentlewoman yields back.
I now would like to recognize the gentlewoman from
Illinois, Ms. Kelly, for 5 minutes of questioning.
Ms. Kelly. Thank you, Madam Chair and Ranking Member, and
thank you for your testimonies this morning.
I have heard from patients and providers that PCORI's
approach to incorporating patients into research process makes
the results more meaningful to people who will actually use it.
Dr. Cooper, you mentioned PCORI's unique governance
structure with the emphasis on patient input and engagement.
For the last couple of years I have been very involved with
legislation dealing with maternal mortality, and while no one
knows exactly what happens and why there are the healthcare
disparities--I mean, some things we can guess--do you see PCORI
being helpful or instrumental in dealing with that healthcare
disparity? Because there is a great one in this country.
Dr. Cooper. Most certainly I do see a strong potential for
PCORI to contribute to research in the area of disparities in
maternal mortality, one reason being that often women who come
from underserved communities and African-American women in
particular and American-Indian women who have higher rates of
either maternal mortality or infant mortality are not
represented in a lot of studies. So their perspective isn't
given.
And so at PCORI they would have the opportunity to
contribute to the research questions that would be answered and
to contribute to the way that research should be conducted and
the way the results should be shared with other patients and
family members who would need the information in their decision
making around their care.
Ms. Kelly. I know in these we had OB/GYNs in and I know in
the State of Washington, Native American women died 8 times the
rate of white women, and in my State of Illinois black women
die 6 to 1 times rate, which is bigger than the national
average.
And then you have been here a long time, so is there
anything we haven't asked you that you want us to know about
PCORI?
Dr. Cooper. I think the only thing I would say is that I
was so excited when PCORI was funded because it is the kind of
work that I thought was needed for a long time--that we have a
lot of wonderful discoveries and therapies and drugs but they
just weren't getting out to the people who need them, and
people weren't able to make sense of a lot of the information
that was coming at them.
And what PCORI allows us to do is actually to compare a lot
of these different developments and discoveries and actually
learn more about how each one of them works and applies to
different people because they don't all work the same for
everyone and it is really important to get everyone's
perspective and to tailor those treatments and the appropriate
concerns that people have and to the appropriate needs and
resources within the context where they get healthcare.
Ms. Kelly. Thank you very much, and I will yield back.
Ms. Eshoo. The gentlewoman yields back.
Now I will recognize the gentlewoman from California, Ms.
Barragan, for 5 minutes of questioning.
Ms. Barragan. Thank you. I wanted to first thank the panel
for being here. There is so much to cover in so little time.
But before I do that, I wanted just to quickly talk about
something that's going to happen on the second panel. I want to
just spend a moment to discuss the Medicare limited income
newly eligible transition program.
This demonstration program which began in 2010 provides
temporary Part D prescription drug coverage for low-income
Medicare beneficiaries not already in the Medicare drug plan.
This program has been incredibly successful in the past 10
years, saving $300 million and making sure beneficiaries get
access to medication.
I was proud to introduce the Improving Low-Income Access to
Prescription Drugs with my colleagues, Congressmen Olson,
Marchant, and Lewis, that would make the LI NET program
permanent.
Far too many individuals across America already struggle to
afford their prescription drugs. By making the LI NET program
permanent, we can continue to provide transitional prescription
drug coverage for those with low incomes.
I look forward to advancing our work to help all Americans
get the medications they need.
Now, talking a little bit about Community Health Centers,
this past week in my district I held a round table with
Community Health Centers and other healthcare providers in my
district, and in my district we work very closely with the
Harbor Community Clinic in San Pedro.
And I know there is already been a lot of discussion about
what Community Health Centers do and I also know some of this
has been covered earlier.
But I think it is really critically important. Mr. Germano,
if you could just tell us what the impact would be on
communities of color if the fund is not reauthorized.
Mr. Germano. Health centers are very centered in
communities of color around the country. They really are. They
have a huge presence, and not enough, in my judgment.
And if funding becomes destabilized then I think you start
losing those investments that have already been made and it
prevents further investments in those communities because you
can't plan ahead. It is that certainty again.
Ms. Barragan. So we've recently seen an outbreak of the
measles----
Mr. Germano. Yes.
Ms. Barragan [continuing]. And Community Health Centers
provides, as you mentioned, immunizations. Would that be at
risk if this was not funded?
Mr. Germano. It goes back to that public health safety net
role again. We had that situation in my own community where we
became ground zero for detection as we had a couple cases in
our community, and public health rallied around us to be that
face of prevention in our community.
Yes, it would be--it would be a loss across this country
and a danger.
Ms. Barragan. Thank you. My district is California's 44th.
It is south L.A., it is Compton, it is Watts, it is the Port of
L.A. It is a majority minority district. It is about almost 90
percent Latino/African American, and we have the highest
diabetes rate than any other congressional district in the
State of California.
It is also very personal. My mother has diabetes. Family
members have type 1. And so Mr. Kowalski, what would be the
impact on communities of color if this program were no longer
funded--the Special Diabetes Program?
Dr. Kowalski. So the Special Diabetes Program has delivered
on a number of advances that will help anybody with diabetes.
But, of course, in underserved communities you have a much
higher incidence and prevalence rates.
We have tremendous momentum on many fronts via treatment,
preventative therapies, and ultimately cures for diabetes, and
it would be a tremendous shame to see us lose that momentum and
what we would be doing is costing individuals time in their
lives, literally, and ultimately our system millions and
millions of dollars.
So I urge the Members, as you know, that this program is
paying dividends and it will help all communities who are
impacted by diabetes.
Ms. Barragan. All right. Thank you.
Dr. Cooper, I want to thank you for your work on the issue
of racial health disparities. It was in 1999 when I was working
at the NAACP that this issue became one near and dear to me.
Can you tell me how the Patient-Centered Outcomes Research
Extension Act of 2019 plays a role in helping address racial
health disparities?
Dr. Cooper. Yes, I would be happy to do that. One of
PCORI's main focus areas is addressing disparities. So they
also focus on several special populations which include racial
and ethnic minorities, persons with low socioeconomic status as
well as people who have many disabilities.
So I think because they have a special portfolio focused on
addressing disparities a lot of that work actually does address
issues that are critical to those communities and those
populations.
For example, you might have a new drug or therapy for
diabetes. But what we might not understand is how acceptable is
that treatment to people who will have low income or people who
live in an ethnic minority community. Are there stigmas around
certain kinds of therapies? What about the costs associated
with getting those things or any other barriers to managing
their condition that might get in the way of them benefiting
from those therapies, and PCORI has the ability to address a
lot of those with their research portfolio.
Ms. Eshoo. Does the gentlewoman yield? The gentlewoman
yields.
I now would like to recognize the gentlewoman from
Delaware, Ms. Blunt Rochester, for 5 minutes of questions.
Ms. Blunt Rochester. Thank you, Madam Chair, for the
recognition and for turning the committee's attention to the
critical public health programs that must be reauthorized this
fall.
Just yesterday I introduced legislation to reauthorize
another program set to expire in September--the Personal
Responsibility Education Program, or PREP--and I look forward
to working with my colleagues on the committee to ensure that
this and other public health programs are reauthorized before
the September deadline.
Delaware has three federally qualified Community Health
Centers, serve approximately 50,000 patients across the State
each year. So in Delaware that's one in 19 Delawareans.
And I support both H.R. 1943--the Community Health Center
and Primary Care Workforce Expansion Act--and H.R. 2328--the
Community Health Investment Modernization and Excellence--CHIME
Act, because Community Health Centers need long-term sustained
funding. I think that is a message that we have heard loud and
clear here today.
Delaware has seen the impacts of this firsthand because
Westside Family Health Center became the first Community Health
Center in the country to lose a location because of unstable
Federal funding, a closure that impacted about 2,800 patients
who were disproportionately low income.
So I want to just kind of turn to the issue of planning--
short-term planning but, specifically, on the impact of
recruiting and retaining particularly primary care physicians.
And I know, Mr. Germano, you talked about this. In
Delaware, it has a huge impact. It is estimated that we have
just 815 primary care physicians in Delaware, down 5.4 percent
since 2013.
And so I just wanted to ask you, you talked a little bit
about the impact but and you said--you talked about the fact
that wherever a person is trained they might tend to stay.
So if you could just reiterate that, and also just briefly
talk about suggestions that you would have to incentivize
people to continue to stay and work in those underserved
communities.
Mr. Germano. Thank you for those questions. The data shows
overall, I had mentioned, that 70 percent of residents stay
within 100 miles of where they have trained, and the Teaching
Health Centers go even further. We had more success because we
have looked or providers who meet our mission, who are
interested in our mission, and are many times tied to our
communities in other ways, so have roots or will develop roots
there.
So I think absolutely critical. That is the pipeline
bringing them into our system and then getting them through and
then helping them stay.
So I think those are--those are the big ones. Those are the
issues.
Ms. Blunt Rochester. No, that's helpful. That's helpful.
I am going to shift very quickly to Dr. Cooper. You talked
about PCORI and, you know, one of the reasons why what you
shared is so vital is because of the issue of health
disparities and I was hoping that you could spend a little bit
of time on that, the impact of addressing health disparities.
In Delaware, we have the Nemours child health system and
health corps that are key stakeholders in receiving these funds
and doing exciting work. But particularly as it relates to
trust in clinical trials and how you get people to actually
participate for their own--the connection to the healthcare
system.
Dr. Cooper. Thank you. Yes, so I will just mention briefly,
I actually had a project that was funded that engaged with the
Westside Health Center in Delaware many years ago.
It was not funded by PCORI. It was funded by AHRQ, and we
were able to successfully engage health centers and African-
American patients in a project that compared two different
approaches to treating depression.
The difference between that project and my PCORI-funded
work is that I did not have the benefit of the full year of
planning to engage all the appropriate stakeholders and to get
their input into the program.
And so when that project ended, even though we showed
successful results, it wasn't actually sustained. But now, with
the kind of funding that PCORI offers, there is actually a full
year devoted to planning and to stakeholder engagement so that
everyone sort of on board with the plan gives input to it and a
lot of discussion takes place about how this program will be
sustained if it is shown to be successful.
Ms. Blunt Rochester. Excellent. Thank you for sharing that.
Just one last point. Delaware had the sixth highest rate of
overdose deaths in 2017, and so we know that the opioid crisis
is having a huge impact, and one of our health centers, La Red,
actually has focused on this.
So I will submit some questions for the record surrounding
the opioid addiction crisis as well. So thank you and I yield
back.
Ms. Eshoo. The gentlewoman yields back.
Now it is a pleasure to recognize the gentleman from
Georgia, Mr. Carter, and followed by the patient gentlewoman
from Washington State, Ms. McMorris Rodgers.
So first, the gentleman from Georgia.
Mr. Carter. Thank you, Madam Chair. I thank all of you for
being here. I know it is been a long day and you're almost
there, so hang in there, OK?
Certainly important things we are talking about. There is
no question about that. Mr. Germano, I wanted to ask you, do
you happen to know how many health profession shortage areas
there are in this country? Any idea?
Mr. Germano. I don't, but there are a lot.
Mr. Carter. There is a lot. Most of them in rural areas, I
would assume, as opposed to urban. But I suspect we'd be
surprised to find them in urban areas as well.
Mr. Germano. I think there are quite a few in urban areas
as well.
Mr. Carter. Right. Right. Earlier, we--earlier one of my
colleagues asked you about dental health and that is certainly
important.
First of all, again, I am from Georgia, and remember there
are two Georgias. There is Atlanta, and there is everywhere
else, and it is true. And I represent south Georgia. We got a
lot of rural areas in south Georgia, a lot of healthcare needs.
Accessibility to healthcare is a big concern of ours and a
big challenge and particularly oral healthcare as well, and I
was just wondering if you could reiterate what you said earlier
about oral healthcare and how important it is, particularly in
our most needy areas like that.
Mr. Germano. Well, know that oral health disease is not
just a cosmetic thing. It has the underlayment of causes other
problems. Women who are pregnant with oral health disease could
have bad outcomes with their babies, for example.
We know that we can prevent a lot of this. It is not just
having a dental office. We have embedded dental hygienists in
our pediatric practices now where they are going in after the--
after the visit, in many cases, and they are doing a little
education and they are painting the teeth of children so to try
to prevent, you know, cavities and other problems and educating
as well.
Oral health disease--number-one pediatric disease in
America is oral health disease.
Mr. Carter. Right.
Mr. Germano. And it is preventable. That's the thing. A lot
of oral health disease is preventable.
Mr. Carter. You know, we talk a lot about making sure we
have--with good reason making sure we have doctors in
underserved areas. But there are other healthcare professionals
that we need to concentrate on also such as dentists.
Mr. Germano. Yes.
Mr. Carter. Any others that you can think of that really
propose a glaring void there--healthcare professionals that we
just----
Mr. Germano. Well, I would love to see the role of the
pharmacists be more----
Mr. Carter. Thank you very much. Oh, did I mention that I
am currently the only pharmacist serving in Congress?
Ms. Eshoo. That was a good answer.
Mr. Carter. It was a good answer.
[Laughter.]
Mr. Germano. I do think there is a role for--the problem is
in the FQHC world, pharmacists are not recognized as billable
providers; hence, it makes it difficult to put it together.
But it makes total sense. My clinicians clamour for that--
you know, that kind of direct clinical pharmacy involvement,
not just on the retail side but on the clinical side. It would
make a world of difference.
Mr. Carter. Right. Thank you for that.
Let me switch now to a problem that, unfortunately, we are
a leader of in the State of Georgia and that is maternal
mortality. And, you know, it is--it is embarrassing for me to
say that and whereas I do question sometimes how we arrive at
some of these figures because I want to make sure we are
comparing apples to apples when we talk about maternal
mortality. But we cannot deny the fact that it is a problem and
particularly in the State of Georgia.
And I am just wondering, you know, one of the challenges
that we face, as I mentioned before, is just a lack of
providers, and what--you mentioned earlier, and you are spot on
because, when I served in the Georgia State Legislature, one of
the things that we discovered was that most of the physicians--
as Dr. Burgess pointed out as well--most of the physicians stay
where they practice--where they do their residency--and we
learned that in Georgia.
That is why we increased the number of residencies in our
State in order to try to attract physicians and try to get them
to stay.
But any ideas on what we can do aside from that to increase
the number of providers, particularly in the--in the rural
areas and particularly in the way of OB/GYNs where we need this
for--to address the situation of maternal mortality?
Mr. Germano. Well, most OB/GYN training programs are in big
cities, so that you are running against it right away in terms
of attracting OB/GYNs to rural communities. So that is tough.
But what we can do is to work with, like, our nurse
practitioners.
Mr. Carter. There you go.
Mr. Germano. Early prenatal care, getting women in the
first trimester, really critical. Getting them tucked into
prenatal care and then we can help monitor and support them
through their pregnancy. I think that can make a world of
difference.
Mr. Carter. And, you know, scope of practice is pretty much
a State issue. But at the same time, if we--if we empower some
of these other healthcare professionals to give them the
opportunity to serve, I think they can help us to achieve what
we are trying to achieve here.
Mr. Germano. I agree.
Mr. Carter. Very good. Again, thank all of you. This is
extremely important and we certainly support what we are trying
to do here. The question is how we are going to pay for all
this. But nevertheless, this is very important.
And thank you, Madam Chair, and I yield back.
Ms. Eshoo. The gentleman yields back.
And now the ever-patient gentlewoman from the State of
Washington, Mrs. McMorris Rodgers, also the sponsor of H.R.
2818, which we thank you for. It is an important bill. You are
recognized for 5 minutes.
Mrs. Rodgers. Thank you, Madam Chair, and just thank you
everyone who has been a part of this, the witnesses, and your
testimony today.
I am pleased that you are bringing this legislation forward
today. Earlier, Representative Ruiz was talking about the
Teaching Health Centers and how important they are.
I am proud in Spokane to represent one of the Teaching
Health Centers that is making a big difference in our region.
We are excited that Washington State University has built a
medical school. The University of Washington and Gonzaga are
partnering on a rural training track.
I represent an area that has a lot of rural communities and
these--this effort in Spokane is definitely part of the
solution.
When you--when I look at the partnership between the
Teaching Health Center, the universities, the local hospitals,
and then our local VA, we need more doctors. We need more
doctors throughout eastern Washington.
And I am also reminded that where the doctor does their
residency they are more likely to practice. I met a guy, a
doctor, not too long ago who had come from California to
Spokane 30 years ago to do his residence and he is still there.
And it underscores how important it is, these residency
programs. So I am a strong supporter of the Teaching Health
Center Graduate Medical Education Program, that legislation
that is before the committee today.
You know, it is estimated that nationwide we will have more
than 23,000 shortage--we will be short 23,000 doctors by 2025,
and it is really unacceptable. And you see it further in the
rural communities where the physician-to-patient ratio is
especially stark.
Only 10 percent of physicians practice in these areas, even
though a quarter of the population lives there. Compared to
doctors who trained in the traditional Medicare program, those
trained at Teaching Health Centers are 60 percent more likely
to practice primary care and 30 percent more likely to work in
a rural or underserved community.
I was proud to help lead this legislation in the last
Congress where we doubled the funding, and I am excited and
encouraged that we are continued that effort in this Congress.
Representative Ruiz, Torres Small, Representative Roe and I
have joined in introducing H.R. 2815. What it does is continue
the support for this program by extending it for another 5
years and increasing the funding and providing more certainty,
which we need across the country.
This legislation and this program is important--meeting the
needs of rural and underserved communities for a new generation
of primary care medical professionals.
The Teaching Health Center has programs that are meeting
important needs in psychiatry, OB/GYN, primary care, internal
medicine--you know, the very fields that we need more of our
doctors to be pursuing.
So I have a few questions to Mr. Germano. I wanted to--in
your testimony you talked about the Shasta Community Health
Center electing to become a Teaching Health Center as a means
of addressing the ongoing physician shortage.
And I just wanted you to elaborate on that decision and
just comment on how positively that may have impacted your
effort to meet the needs in your community.
Mr. Germano. It is a big decision for a health center to be
a sponsoring entity. You have to meet all the accrediting
requirements. There are resources that go into it.
In the beginning it is tough because your best clinicians
become your teachers, which means you take them out of the
direct services and now you're teaching.
So the investment is more medium to long-term when you make
that decision. But my job and my board's job is to look ahead
and look at what's coming at us, and the shortage was very real
then. It is even more so now.
So the Teaching Health Center Program is a huge investment
in our future--in our current and into our future, and we are
seeing the paybacks now.
Mrs. Rodgers. Would you just address how your facility
compares to other Teaching Health Centers across the country,
and then also--I am afraid I am going to run out of time--the
importance of the 5-year reauthorization?
Mr. Germano. Well, each health center has their own sort of
reality that they are--the resources they have available to
them. So we are all a little different in that respect. Some
are urban. Some are rural. Some are frontier.
So, you know, we are very rural and, hence, I think we have
a few more challenges we are starting to get our hands around.
We are not having the same exact retention rates as some of the
city programs but we are getting there. So I am really excited
about that.
And, I am sorry--the second question was?
Mrs. Rodgers. Well, the importance of a 5-year
reauthorization.
Mr. Germano. We have to--we commit 3 years to every class.
They have to know when we are recruiting. I can't have a
medical student say to me, are you going to be around in 2
years if this program is going away? That is not a great
recruitment tool into our program. We need to know--we have to
have certainty.
Mrs. Rodgers. All right. A 2-year reauthorization for a 3-
year program just----
Mr. Germano. Doesn't make sense. Thank you.
Mrs. Rodgers. Doesn't make--OK. I appreciate the chairwoman
for allowing me to waive on today. Thank you.
Ms. Eshoo. Thank you for your patience and thank you for
your important work on the--on the legislation. I think that we
have really very strong bipartisan support on this and which is
really pleasing.
Now I am going to recognize the gentleman from Arizona, Mr.
O'Halleran, who is one of the sponsors--key sponsors--of H.R.
2328, 2822, and 2680, 5 minutes of questioning.
And then I think after Mr. O'Halleran we'll be--we'll ask
the staff to ready the table for the next panel. But I want to
recognize the gentleman now and thank him for his patience,
too.
Mr. O'Halleran. Thank you, Madam Chair.
A little perspective--my district is larger than the State
of Arizona--I mean, Illinois--60 percent of Arizona. It goes
from a few small urban areas to frontier--a Navajo reservation,
a Hopi reservation, 12 Native American Tribes.
Economic conditions on the Tribal lands anywhere from--most
of them 50 to 85 percent unemployment rate, getting worse. You
can imagine the problems associated with that and the quality
of life that people coming in to those areas have to address
their lives to and the change.
You know, Mr. Germano, the National Health Service Corps
provides vital scholarship and loan repayment programs that
reduce workforce shortages in medically underserved areas and
it has a successful retention program.
For instance, a 2012 study found that an amazing--more than
half of the participants in the National Health Service Corps
stayed in a health shortage area 10 years after their
participation in the program ended.
My anecdotal information in my district, that is not true.
Not that it is not true nationwide, but the realities of this
district are different, and thank God for Community Health
Centers.
What effects could we expect to see in rural and medically
underserved areas if we--in the longer authorized and increased
funding for this program?
Mr. Germano. Well, I think if it is tough now, I can only
imagine how tough it would be without that loan repayment. The
cost of medical education has gone out of sight and these young
people are making decisions about where they're going to
practice and what they're going to practice.
And if they don't see the opportunity of loan repayment as
an option, it is going to be very difficult for us as Community
Health Centers or any real provider in rural communities to be
able to recruit them to our communities.
Mr. O'Halleran. Thank you.
Mr. Kowalski, thank you for your testimony here today. And
as you are well aware, the Special Diabetes Program for Indians
is tremendously important.
According to the Centers for Disease Control and
Prevention, the American Indian and Alaska Native communities
suffer from disproportionately high rates of diabetes.
This high prevalence, coupled with food deserts and limited
access to healthcare facilities, can lead to more negative
outcomes for these communities.
In addition, the high level of unemployment, Tribes with
the inability to find jobs even if there was the ability to
find the economic conditions under which those were to survive,
will you please highlight how this program effectively
supplements the Indian Health Care Services work in preventing
diabetes and related complications among Native American
populations?
Dr. Kowalski. Thank you, Representative, for that question
and thank you for your leadership in introducing H.R. 2680,
which would increase funding and extend funding for this
incredibly important program.
As you point out, in your State we have Tribes that have
diabetes incidence rates of over 50 percent, some Tribes
upwards of 80 percent, and they are very underserved.
It is this program that has made significant differences.
We talk about the importance of culturally tailored
interventions and we have seen that in this program.
And I said earlier the proof is in the pudding. We have
data-driven metrics in terms of the impact, in terms of glucose
control levels being better, reducing the risk of
complications.
For those complications, significant decreases, for
example, in kidney disease and eye disease, which will save
money. This is a critical program for underserved community--
the Tribal communities in your State and across the country
that deserves renewal and re-upping and I, again, thank you for
your leadership.
Mr. O'Halleran. Well, thank you. And another question for
you is this program has remained flat since fiscal year 2004.
It is amazing. At the same time, the population served by
Indian Health Care Services increased.
Will you please explain what the effects would be if
Congress simply reauthorized the program but did not increase
its annual appropriations?
Dr. Kowalski. So since 2004, if you did just the simple
math of inflation, we are talking about $150 million versus
what would now be $230 million for a problem that has only
grown.
So we are, again, under resourced for a problem that is
hurting these communities and costing our economy. We need to
do better and we are seeing results from the program, I think.
The up side is huge here.
Mr. O'Halleran. Thank you, Madam Chair. Sorry for taking so
much time, and I yield.
Ms. Eshoo. The gentleman yields back.
And that concludes our first panel. I want to thank each
one of the witnesses. You have done a superb job. I know that
this has been a long hearing. You haven't had a break.
But we are taking up 12 bills and these are all important
to the American people. So you have given marvellous testimony.
You have underscored the need for stability and confidence
in the program so that we--in our reauthorizations that they
have a longer pathway before reexamination by the Congress, and
I think that that's a very prudent way to go.
But I just--I couldn't help but think during the hearing
what would we ever do without what each one of you testified
about. All the people in our country that are being cared for
as a result of your work and your leadership.
So every blessing on each one of you in your work. We thank
you for being here, and we will ask the staff to prepare the
table for the next panel of witnesses.
Thank you, everyone.
[Pause.]
Ms. Eshoo. We now will hear from the second panel of
witnesses and we want to thank you for--I think you were all
waiting patiently. I think you have been here for the better
part of the day and we thank you for that and what you are
about to do.
Mr. Thomas Barker, partner and cochair of Healthcare
Practice at Foley Hoag; Ms. Mary-Catherine Bohan, vice
president of outpatient services at Rutgers University
Behavioral Health Care; Mr. Fred Riccardi, who is president of
the Medicare Rights Center, and I want to call on our--the vice
chair of our committee to introduce his constituent, Dr.
Michael Waldrum.
Mr. Butterfield. Thank you very much, Madam Chair, and I
realize the hour is late. It looks like we are going to have
votes in just a few minutes.
But I would like to recognize and to join the subcommittee
in receiving the chief executive officer of--and distinguished
professor of internal medicine and pulmonary and critical care
at the Brody School of Medicine at East Carolina University.
Very briefly, my district consists of 14 counties and one
of those counties is called Pitt County, and this university is
a major economic engine in Pitt County.
And so I want to welcome Dr. Michael Waldrum to the
subcommittee and look forward to his testimony. Thank you.
Ms. Eshoo. Thank you.
So we will--at this time the Chair recognizes Dr. Green for
5 minutes for your opening statement.
Mr. Barker. I am sorry.
STATEMENTS OF THOMAS R. BARKER, PARTNER, COCHAIR, HEALTHCARE
PRACTICE, FOLEY HOAG; MARY-CATHERINE BOHAN, VICE PRESIDENT,
OUTPATIENT SERVICES, RUTGERS UNIVERSITY BEHAVIORAL HEALTH CARE;
MICHAEL WALDRUM, M.D., CHIEF EXECUTIVE OFFICER, VIDANT HEALTH;
AND FREDERIC RICCARDI, PRESIDENT, MEDICARE RIGHTS CENTER
STATEMENT OF THOMAS R. BARKER
Mr. Barker. Thank you, Madam Chair--Chairwoman Eshoo, Dr.
Burgess. Thank you very much for the opportunity to appear
before the subcommittee today.
Thirty-eight years ago this week, I started my first job on
Capitol Hill as an intern in this building, and when I walked
through the Rayburn Horseshoe from the Capitol South Metro I
never in a million years would have imagined that I would have
had the honor of appearing before this subcommittee. So thank
you very much for this opportunity.
I want to clarify at the outset, Madam Chair--you mentioned
my affiliation with my law firm. I want to clarify at the
outset that although I was recently appointed the MACPAC, I am
not appearing today on behalf of the Commission.
Rather, I am speaking to you as a healthcare lawyer with
many years' experience representing both the Government as the
chief legal officer of CMS and HHS. I also represent healthcare
providers and payers in private practice and as a former
professor of healthcare law and policy at George Washington
University and Suffolk University School of Law.
My remarks today focus on the bill that was introduced by
Mr. Engel that deals with the pending cuts in Medicaid DSH
payments that were enacted as part of the Affordable Care Act
and that had been deferred several times since then under
current law.
As the members of the subcommittee know, the first round of
DSH cuts will occur in fiscal year 2020. So my testimony, which
I am not going to, obviously, repeat but my testimony focuses
on those pending cuts and it gives a little bit of history of
the DSH payment system, which I hope will be helpful to the
subcommittee as it begins its deliberations on an extenders
package.
I think it is important to understand that the DSH cuts of
the ACA did not happen in isolation but, rather, as a part of a
nearly 40-year history of Congress recognizing the special
needs of Disproportionate Share Hospitals.
In my testimony I went through the history of DSH, which
actually started in 1981, probably in this room, when the House
was beginning deliberations over the Omnibus Budget
Reconciliation Act of '81, which was the first time that
Congress told the States to focus on the needs of DSH
hospitals, and that statute was amended again in 1987, 1991,
1993, the BBA in 1997 and then again in 2010 when the ACA was
enacted into law.
And my testimony concludes by referring the subcommittee to
recommendations that MACPAC made to structure the DSH cuts
differently by phasing them in over a longer period of time to
allocate the cuts first to States that have unspent DSH
allocations and then really--and most importantly, in my view,
to restructure the DSH allotments or the DSH caps to better
align the State-specific DSH caps to the percentage of low-
income nonelderly individuals in a State.
After all, that was the real original intent of DSH when it
was enacted in 1981, which was an agreement by the Reagan
administration, by the Governors, and by the Congress over how
Medicaid rates should be set by States.
So let me conclude by thank you for the opportunity to
testify before the subcommittee this afternoon. I would be
pleased to answer any questions that you have and I am happy to
make myself available to the members of your staff if you have
any questions about DSH.
Thank you.
[The prepared statement of Mr. Barker follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. We thank you for that, Mr. Barker, and I love
the history. We never know what paths in life--where they are
going to lead us and take us.
Mr. Barker. Well, Mr. Waxman was here then. Mr. Dingell was
here then. I certainly remember working for them. Thank you.
Ms. Eshoo. Yes. It is a wonderful story. We stand on great
shoulders.
Now I would like to recognize Ms. Bohan. You are recognized
for your 5 minutes of testimony, and thank you.
STATEMENT OF MARY-CATHERINE BOHAN
Ms. Bohan. Thank you for the opportunity to testify in
support of the Excellence in Mental Health and Addiction
Treatment Expansion Act, and to share with you how becoming a
certified community behavioral health clinic--CCBHC--has
impacted my organization and community.
I am honored to be there today on behalf of the National
Council for Behavioral Health, a national association that
represents 3,100 member organizations who, collectively, serve
more than 10 million adults and children living with mental
illness and addiction.
I am further honored to represent Rutgers University
Behavioral Health Care, one of the seven CCBHCs participating
in the 2-year demonstration project in New Jersey.
Established in 1972, UBHC is one of the largest academic
behavioral healthcare delivery systems in the Nation and is the
largest behavioral health provider in the State of New Jersey,
serving over 18,000 individuals per year.
I have been vice president of outpatient services at UBHC
since 2016. I am a clinical social worker by training and I
have been a direct provider and administrator of mental health,
addiction treatment, and community-based services for over 35
years in three different States.
I know only too well how siloed mental health and addiction
services can be. Historically, neither system assessed the
physical well-being of their clients, often missing vital
information that should be part of their care.
At Rutgers, CCBHCs have been the vehicle that has allowed
us to finally offer integrated services and provide holistic
care to those we serve.
I would like to take a moment to share what behavioral
health services at Rutgers UBHC look like now as compared to
before the CCBHC implementation.
The three outpatient clinics that were transitioned to
CCBHC served about 3,300 individuals. In the first year of the
program, we increased the number of people served to 5,000. In
year 2, we have treated 6,000 individuals and families.
We currently maintain 300 clients on medication-assisted
treatment, or MAT, versus the 30 individuals that we treated
the year prior to CCBHC.
Before the demonstration, the average wait time for first
appointment was 21 days with a no-show rate of 50 percent.
Individuals with behavioral health issues need immediate access
to care and we were losing the opportunity to help people at
the time that they identified their need.
Now we proudly offer same-day/next-day access. Our no-show
rate is down to about 24 percent and continues to drop. When
individuals were disengaged in treatment, outreach was limited
to phone calls or letters. We now engage clients face to face
in the community, person to person.
In one instance, a clinician was concerned about an
adolescent who had missed an appointment and could not be
reached by phone. The case manager did a wellness visit at her
home and intervened with the client, who was in the middle of a
self-harm episode.
The case manager contacted EMS, the family, and facilitated
getting this client to the appropriate level of care. This type
of intervention simply would not have been available to us
prior to the CCBHC.
Two years into this program, Rutgers UBHC is just hitting
its stride. We are positioned to go further and do more for our
community. But with the continued funding at risk, we have been
unable to hire additional staff or pursue initiatives that
would drive further innovation.
If the CCBHC demonstration project is not extended past
June 30th, the impact on Rutgers UBHC is enormous. Case
management and peer support services will be discontinued,
which means our ability to engage individuals in the community
will end.
Without case management and peer support, our same-day/
next-day access model, which relies on a team approach to
function, will be greatly impacted and I fear that wait times
will again grow to be weeks long.
Health screens and subsequent linkage to primary care will
be greatly reduced. The ambulatory withdrawal management
program that treats individuals with opiate use disorder will
likely close.
To be frank, if the program expires all of the success I
shared with you today is at risk. We cannot go back to business
as usual. Not Rutgers, not the other UBHCs, and most
importantly, not our clients, because those are the ones who
will lose out the most if this program ends.
So today I am asking for the committee's support in passing
the Excellence in Mental Health and Addiction Treatment
Expansion Act so that the eight States who are currently
operating CCBHC can continue this work and additional States
can be afforded the opportunity to transform their behavioral
health delivery systems.
On behalf of the individuals and families we serve, I would
like to thank this committee for your focused attention on this
issue and I would especially like to thank Congresswoman Doris
Matsui and Congressman Markwayne Mullin for their leadership in
sponsoring the Excellence Act expansion bill.
Thank you, and I look forward to your questions.
[The prepared statement of Ms. Bohan follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you for your outstanding work. It is very
hopeful, what you described to us. Thank you for your
testimony. Powerful testimony.
Now I'd like to recognize Dr. Waldrum. You have 5 minutes
for your testimony, sir. Thank you.
STATEMENT OF MICHAEL WALDRUM, M.D.
Dr. Waldrum. Thank you, and good afternoon.
And thank you, Chairwoman Eshoo, Ranking Member Burgess,
and distinguished members of this subcommittee for inviting
Vidant Health to testify at today's hearing.
I am Michael Waldrum, chief executive officer of Vidant
Health, a health system guided by its mission: to improve the
health and well-being of the people of eastern North Carolina,
a geographic region the size of Maryland that 1.5 million
people call home, including the subcommittee's vice chair,
Congressman Butterfield.
I am honored to speak to you today about the vital
importance of Medicaid Disproportionate Share Hospital, known
as DSH, funding is for my health system and the people and
communities we serve.
Vidant Health is a nine-hospital system and includes one of
four academic medical centers in North Carolina, the Vidant
Medical Center, which is a tertiary referral center and the
only level one trauma center on the Eastern Seaboard between
Norfolk, Virginia, and eastern--and Charleston, South Carolina.
We employ more than 14,000 North Carolinians and contribute
$3.5 billion to North Carolina's gross State product.
Vidant Health and the hundreds of essential hospitals like
it across the country reach well beyond our walls to meet
people where they live and help communities cope with social,
economic, and environmental factors that affect their health.
We have ample experience with this. The majority of the
counties we serve are among the most economically distressed
areas in our State.
In the Vidant Medical Center primary service area, Pitt
County, 60 percent of the public school students are enrolled
in free or reduced lunch programs and the poverty rate is 24
percent.
Our providers work hard every day to combat obesity,
chronic conditions, the infant and maternal mortality crisis,
the opioid epidemic, and to support our communities where they
live who are disproportionately burdened by these illnesses.
So we fund programs that empower community partners to
overcome social economic factors that contribute to poor
health, from chronic conditions support to food banks for
school health programs and many other initiatives we are making
a difference.
In fact, last year Vidant Health partnered with more than
159 different programs across eastern North Carolina,
contributing almost $2 million in grant contributions to other
social service organizations which serve more than half a
million of our neighbors.
Today's hearing is about investment in healthcare and these
programs represent our investment in the health and
productivity of our community.
We can do these things because Medicaid DSH helps us ease
the financial pressure that comes with our commitment to
meeting the healthcare needs of all of our people, including
those faced with severe financial hardships.
That commitment to mission translates to more than $200
million in uncompensated care costs annually for Vidant Health.
Medicaid DSH helps close that gap.
Our situation is not unique. The 300 hospitals in our
national association, America's Essential Hospitals, alone
provide nearly a quarter of all charity care nationally and
more than nine times the amount of uncompensated care on
average than other U.S. hospitals.
Vidant Health and the Nation's other essential hospitals
depend on Medicaid DSH to offset the financial losses we
sustain caring for our Nation's most vulnerable people who are
often are the most complex and costliest patients.
This leaves essential hospitals with no financial cushion
to absorb a cut the magnitude of this year's DSH reduction, $4
billion, or a total of a third of the DSH funding.
A cut this size would deeply change our ability to meet the
needs of the individuals and families who depend on Vidant
Health. These cuts will be felt even more so by the patients in
States that have not expanded Medicaid, such as North Carolina.
DSH cuts would devastate the Nation's safety net and
jeopardize healthcare access and jobs in eastern North Carolina
and the communities in the country with a particularly acute
impact of rural America and including the rural environment
that we serve.
Congress has wisely chosen to delay these cuts four times
previously, each time with strong bipartisan votes. We greatly
encourage--we are greatly encouraged to see the same
bipartisanship on this issue this year.
We thank Congressman Engel and Olson for organizing a
letter to the House leaders calling for a further delay and we
thank the 300 bipartisan House colleagues including the members
of this subcommittee who signed that letter.
Thank you for allowing me to share Vidant's story.
[The prepared statement of Dr. Waldrum follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Dr. Waldrum, very much.
Mr. Riccardi, you are recognized for 5 minutes for your
testimony.
STATEMENT OF FREDERIC RICCARDI
Mr. Riccardi. Good afternoon, and thank you.
Chairwoman Eshoo, Dr. Burgess, and members of the
subcommittee, I am Fred Riccardi, president of the Medicare
Rights Center.
Medicare Rights is a national nonprofit organization that
works to ensure access to affordable healthcare for older
adults and individuals with disabilities through counselling
and advocacy, educational programs, and public policy
initiatives.
Thank you for the opportunity to speak with you today about
several bipartisan Medicare-related programs that we urge you
to address in extenders legislation this year.
Specifically, there are three points I would like to share.
I request that for permanent authorization for the low-income
program outreach assistance, the Part D safety net program
known as LI NET, and continue funding for the National Quality
Forum.
Doing so will ensure that these initiatives continue to
help improve the health and financial stability for people with
Medicare.
Every day on our national consumer help line we hear from
people who are struggling to cover healthcare and prescription
drug costs. For many, particularly those with low or fixed
incomes, the program's premiums and cost-sharing amounts are
just out of reach.
Already half of Medicare beneficiaries--nearly 30 million
people--live on approximately $26,000 or less a year and a
quarter of them live on approximately $15,000 or less a year,
and healthcare costs are taking up larger and more
disproportionate share of beneficiaries' very limited budgets.
Thankfully, assistance is available. The Medicare Part D
extra help benefit helps beneficiaries access the prescription
drug program by paying their premiums and lowering the cost of
their copayments.
Additionally, the Medicare savings program pays for
Medicare Part B premiums. But people don't always know how to
access these programs or how to apply for them and, as a
result, they may not be getting the help or the care that they
need, which can lead to worse health outcomes and higher costs.
The extra help in the Medicare savings program benefits
increase affordability and access to care can truly be
lifesaving, helping beneficiaries manage chronic conditions and
better meet the needs of daily living.
At Medicare Rights, we have seen people access extra health
benefit in the Medicare savings program and acquire transplants
and heart surgery and treatment for Parkinson's disease.
One such program encompasses outreach and enrollment
efforts aimed at enrolling more people into the extra help and
Medicare savings program benefit, authorized by the Medicare
Improvements for Patients and Providers Act--known as MIPPA--of
2008.
This funding allows community-based organizations to
connect beneficiaries with limited incomes to these programs,
and since 2009 the program has helped nearly 3 million Medicare
beneficiaries.
Additionally, the Limited Income Newly Eligible Transition
program--LI NET--is a safety net program for people who are not
currently enrolled in a prescription drug plan but are eligible
for extra help or have Medicaid or supplemental security
income.
We are pleased to endorse H.R. 3029, which would
permanently authorize this critical program and we are grateful
to Representatives Olson, Barragan, Marchant, and Lewis for
championing this effort.
We also support continued funding for the National Quality
Forum introduced by Representatives Chu, Engel, and Carter.
H.R. 3031 would allow the National Quality Forum to build upon
quality measurement, advancements already underway to create
high-quality, high-impact, and more cost-efficient healthcare
system.
Finally, as you develop an extender's package or otherwise
look for opportunities to improve the Medicare program, we
respectfully ask that you prioritize the bipartisan bicameral
BENES Act, championed in the House of Representatives by
Representatives Ruiz, Walorski, Schneider, and Bilirakis.
The BENES Act would, in part, simplify the Part B
enrollment process and better inform those approaching Medicare
eligibility about the responsibilities.
Thank you for your time and consideration. Again,
healthcare and prescription drug affordability are ongoing
challenges.
Adequately funding and making permanent these programs I've
discussed today will help ensure that older adults and people
with disabilities can access and afford high-quality care.
[The prepared statement of Mr. Riccardi follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much, Mr. Riccardi, and to each
one of the witnesses.
We have now concluded your statements for this panel. But
there are votes on the floor. So what we are going to do is
recess for about 25 minutes to a half hour. Depends on how long
the votes are. I think there are three of them.
Let us just say we'll resume in 30 minutes, and to ask our
questions of you. So you have a little bit of a break, and we
are going to run over to the Capitol and we will see you in a
bit, OK?
Thank you. The committee is in recess.
[Recess.]
Mr. Butterfield [presiding]. All right. I guess we need to
proceed, if we can. We will now move to Member questions and I
will recognize myself for 5 minutes.
Dr. Waldrum, thank you again for your testimony today and
for the work that you do in eastern North Carolina,
particularly for vulnerable populations. It has been very
helpful to understand the potentially devastating impact onto
Vidant Health if Medicaid DSH reductions were to take place
this year.
The Affordable Care Act included DSH reductions with the
expectation--the expectation that Medicaid expansion would lead
to a decrease in hospital uncompensated care costs.
However, only 33 States and the District of Columbia have
expanded Medicaid.
Dr. Waldrum, North Carolina has yet to expand Medicaid. Is
that correct?
Dr. Waldrum. Yes.
Mr. Butterfield. The majority of the counties that you
serve are among the most economically distressed areas in our
State. I can certainly say that for a fact.
Can you discuss the difficulties of being a safety net
provider in a nonexpansion State?
Dr. Waldrum. Thank you for the question.
Yes. So Medicaid expansion, clearly, is important to us and
our region, and providing care in a distressed safety net
organization and region is always a challenge.
As you know, we serve primarily a rural environment and
North Carolina has the second largest rural population in the
country and eastern North Carolina has 1.3 million citizens in
rural environments.
And so we are always looking at how we provide care to
those environments, and hospitals and providers in rural
environments are challenged. You have had a lot of the
discussion about that today as I listened to the deliberations
this morning and we all know some of the issues.
There is a higher burden of disease in the citizens that
live in rural environments with obesity, cancer, cardiovascular
disease, and diabetes, as you have heard this morning, and the
aging population in rural environments with a shrinking
population.
And but people still live there, and in some services with
some of the dialogue this morning, OB services, for instance,
in a number of our hospitals we only have on average one baby a
day. And so you have to have the infrastructure to provide
services to those patients. But we do not get enough revenue to
cover the cost for those services.
So that puts a burden on us. But if we didn't have those
services, the mothers and babies would have to travel in some
areas over an hour to have their baby.
Mr. Butterfield. So this is affecting your bottom line, to
be sure.
Dr. Waldrum. For sure.
Mr. Butterfield. And when your bottom line is impacted,
other things are impacted as well?
Dr. Waldrum. Well, it just compromises our mission to
support our communities.
Mr. Butterfield. And you have a concentration in critical
care. Can you discuss the impact that Medicaid expansion could
have on access to critical healthcare services for your
patients?
Dr. Waldrum. Yes. I appreciate that.
So it would--it would give coverage for many types of
services and critical care services. With uncovered care, which
is a very high-cost service, which is my specialty--critical
care--having coverage for those services would really help our
institution provide and cover those costs, obviously.
But there are other important services such as behavioral
health and we know that having covered lives with Medicaid
expansion helps us cover things like behavioral health, which
helps with the opioid epidemic.
And so it really goes from ambulatory services like
behavioral health all the way to critical care.
Mr. Butterfield. Now, the Census Bureau has identified 386
counties in the United States as persistent poverty counties,
which means that a county has been in poverty 20 percent or
better for the last 30 years.
That's a persistent poverty county--486 in the U.S. and 12
are North Carolina. Six are in the area covered by your
hospital.
Can you speak to the impact that poverty and hunger and
nutrition and safe housing have on a person's health?
Dr. Waldrum. I can speak to it because I've frequently
visited our communities and one of the communities I think
you're referring to is Bertie County, which we have a hospital
in, and travel, food insecurity, access to care or coverage,
but just to drive to get access the distance--so access to
social services, I mean, you name it, it affects the people we
serve.
Mr. Butterfield. Has your hospital or your association
taken a position on Medicaid expansion in North Carolina?
Dr. Waldrum. Yes. We support it fully.
Mr. Butterfield. OK. Thank you. I have some more, but I
think I am going to yield back and pass it on to one of the
other Members.
All right. To the ranking member, Mr. Burgess.
Mr. Burgess. Thank you, Mr. Butterfield.
Mr. Barker, let me be a little bit provocative. Do we still
need DSH?
Mr. Barker. I am sorry. Could you repeat?
Mr. Burgess. Do we still need the disproportionate share
funding?
Mr. Barker. Oh, I think so.
Mr. Burgess. And given that context, what about just the
proposed removal of the proposed cuts, just DSH funding goes
forward with no structural reforms? Good idea? Bad idea?
Neutral idea?
Mr. Barker. Well, I guess I would say, again, not speaking
for MACPAC because I am not--technically, I am not yet on
MACPAC. I will be tomorrow. But I do think that MACPAC had a
very thoughtful approach toward the--ending DSH cuts.
I think that MACPAC was trying to be sensitive to the
budgetary impact and that they were concerned that just flat
out repeal of the DSH cuts would have a budgetary impact and so
they proposed a more gradual implementation of the cuts
combined with what I think is equally important and that is
rebalancing the State DSH allocations with low income
nonelderly population in a particular State.
The DSH caps were set at a time that--were set over 20
years ago and they weren't based at the time on poverty levels
in a State, and I think maybe it is time to revisit how they're
allocated.
Mr. Burgess. So if the DSH cuts were wiped out in their
entirety, the problems with the formula would still exist?
Mr. Barker. Yes.
Mr. Burgess. So--and I think you make this point in your
testimony, in your written testimony, certainly--but maybe you
can elaborate a little bit on the fact that historic spending
in the disproportionate share funding may bear little or no
relationship to the low income nonelderly population in a given
State today?
Mr. Barker. Yes, I think that is true because the way that
the DSH caps were first established happened at a time when
Congress and I think the--it was the George H. W. Bush
administration were very concerned about the explosion in DSH
spending.
I pointed out in my testimony that DSH spending went from a
little over a billion dollars in 1990 to $17 billion in 1992,
and something was going on and they wanted to get a handle on
it.
And so they imposed a cap, but the cap was just based on
what States were spending in DSH at that particular time. It
really didn't bear any relationship to the low income or the--
the low income rate or the poverty level in a State.
Mr. Burgess. So I am going to ask you something because
I've always been a little sensitive about this as a physician.
I mean, you look at hospitals who get disproportionate share
funding but, of course, the physician workforce in that area
may also be taking care of a very low income population or
uninsured or under insured population.
There has never really been anything that balances what it
costs providers to be in that area versus what it costs
hospitals. As we heard, one delivery a day doesn't fund the
entire labor and delivery unit.
But it can also be very difficult for a provider to run a
practice with that type of through put.
Mr. Barker. Yes, absolutely.
Mr. Burgess. And has there ever been anything looked at
that would balance the equation for docs as well as hospitals?
Mr. Barker. I think that is why you are seeing a lot of
hospital acquisition of physician practices just because--that
is one of the reasons that there has been a growth in hospital
acquisition of physician practices because physicians can't
manage it on their own.
Mr. Burgess. Which brings us then to what I consider the
great conundrum. It is OK for hospitals to own physicians but
physicians can't own hospitals, right?
Mr. Barker. That's--I think that is correct.
Mr. Burgess. And we need to fix that. I wait for the
judges' input and we will do that.
Do you think that a full repeal of the DSH cuts makes
critical reforms of the program more or less likely?
Mr. Barker. I think it would make it less likely just
because the--there wouldn't be the political impetus.
Mr. Burgess. And, ultimately, then that is to the detriment
of those populations that DSH was set up to serve in the first
place.
Mr. Barker. Yes.
Mr. Burgess. Is that--is that a fair assumption?
Mr. Barker. Yes. Yes.
Mr. Burgess. Thank you, Mr. Chairman. Oh, that struck----
Mr. Butterfield. Thank you, Dr. Burgess. Thank you so very
much.
Mr. Burgess. I had a hard time getting that out.
I will yield back.
Mr. Butterfield. Thank you.
At this time I will recognize the gentleman from New York,
Mr. Engel.
Mr. Engel. Thank you, Mr. Chairman.
Medicaid DSH payments--I want to talk about those--they
help hospitals and health systems, serve some of our Nation's
most vulnerable communities.
In fiscal year 2017, Medicaid DSH payments amounted to
$18.1 billion, allowing safety net providers to deliver free or
subsidized care to millions of Americans.
In October, these vital payments will be cut by $4 billion
for the upcoming fiscal year and $8 billion for the following
year. That is not a good thing to do.
Safety net hospitals regularly operate on thin or negative
margins. In fact, New York hospitals have some of the narrowest
margins in the country. If Congress fails to delay Medicaid DSH
cuts, some of our Nation's safety net providers will be forced
to close, leaving our constituents in communities without
access to an important source of care.
Fortunately, there is broad bipartisan support for
addressing these cuts. On May 13th, 300 Members of the House
joined Congressman Olson and me in pushing for a delay. I urge
my colleagues to join me in helping preserve access to care for
the most vulnerable among us.
Mr. Chairman, I also want to thank you and the committee
for including legislation which would reauthorize funding for
the National Quality Forum. I am pleased to sponsor this
bipartisan legislation with Congresswoman Chu and Congressman
Carter.
The National Quality Forum is one of the Nation's leaders
when it comes to developing tools for improving healthcare
quality and outcomes.
Before asking questions of our witnesses, I ask unanimous
consent to submit two letters of support into the record, the
first from the American Hospitals Association in support of the
Patient Access Protection Act, and the second from the Friends
of NQF, supporting H.R. 3031.
Mr. Butterfield. Without objection on both of those
requests.
[The information appears at the conclusion of the hearing.]
Mr. Engel. Thank you, Mr. Chairman.
Let me ask Mr. Riccardi--in recent years Medicare has made
numerous efforts to move away from fee for service, instead
toward a system that rewards value over volume. It is critical
that we continue to find ways to measure and incentivize the
highest quality of care.
So let me ask you, Mr. Riccardi, as we continue to pursue a
healthcare system that pays for value instead of volume, what
role do you see for the National Quality Forum's work?
Mr. Riccardi. An increasingly important one. NQF--we need
to ensure that they remain funded and sustainable for the
direction of value-based care.
NQF has a membership of 450 organizations and the Medicare
Rights Center is an active member of NQF. NQF facilitates
dialogue across the private and the public sector, creating
measures that operate throughout the Medicare program. In fact,
hospital readmission rates have fallen by 8 percent and as
States pursue value-based care arrangements and also focus on a
variety of initiatives, these measures are key.
Increasingly, we are hearing beneficiaries calling our help
line with questions about quality, and as CMS has improved
tools for--to evaluate and determine the quality of a variety
of different facilities and settings, these measure are also
key in that in helping beneficiaries access valuable efficient
care. Thank you.
Mr. Engel. Thank you. Hospitals use Medicaid DSH payments
to support vital community health programs including
initiatives to address opioid prescription abuse and improve
maternal health.
Mr. Waldrum, could you please describe how your hospitals
use Medicaid DSH payments to better care for your local
community?
Dr. Waldrum. I would say I don't have time and we partner
with our communities. But I will tell you to deal with all of
those issues.
But we support a number of local initiatives and I will
tell you one that happens in Conetoe, North Carolina, with
Reverend Richard Joyner.
And so we have funded an initiative because the burden of
the disease in those folks was very high, and so we helped him
engage with the community to build a sustainable model where
they educate children about healthy lifestyles and give them
employment on a farm, and that has brought the parents in and
they have a sustainable model to sell their product in our
hospitals, and that has created a college fund and those kids
are going to college and are breaking the cycle of poverty and
ill health that they have been burdened with for decades.
And Ms. Bush, who is a 72-year-old woman in that community,
actually fought against it happening, and today, this morning,
she was on that farm working and she's been working there for
the last year and she is off 22 of her medicines because she
has adopted the lifestyle and the habits that are being taught
by that farm. So she is one example, and then these kids are
the future of eastern North Carolina.
Mr. Engel. Well, thank you both. I think what you have said
is very important and we all should heed it. Thank you.
Thank you, Mr. Chairman.
Mr. Butterfield. Thank you, Mr. Engel.
Richard Joyner is a dear friend of mine and I will let him
know that you have acknowledged him today.
The Chair now recognizes the gentlelady from California,
Ms. Matsui.
Ms. Matsui. Thank you, Mr. Chairman.
Ms. Bohan, thank you for sharing with us how becoming a
certified community behavioral health clinic has benefited your
organization and community.
And we are hearing similar successes from clinics across
the country where the demonstration has expanded treatment
capacity and transformed their ability to meet the growing
demands for community-based services.
Ninety-four percent of all CCBHCs have increased the number
of patients they treat for addiction and nearly two-thirds have
been able to decrease wait times.
With the June 30th funding expiration looming, our CCBHC
demonstration States are now stressing the extreme financial
threat they face to sustain operations and provide vital
continuous care.
I was glad to hear Ranking Member Walden express his
support for extending the Excellence in Mental Health
demonstration for additional 2 years.
Just this morning, I heard from a CCBHC in Oregon how a
sustained investment in the program would allow its providers
to reach into the community to further extend access to
behavioral health services for individuals with serious mental
illnesses.
In the midst of an opioid epidemic, we should be supporting
innovative approaches like CCBHCs to provide integrative
primary and behavioral healthcare. That is why expanding the
Excellence in Mental Health demonstration as the support of
interdepartmental serious mental illness coordinating committee
of SAMHSA has been endorsed by Dr. Sally Satel of the American
Enterprise Institute and has the support of 14 of my Republican
colleagues.
People struggling with mental illness and substance use
disorder across the country should be able to benefit the same
as patients in the eight States participating in the demo.
That is why I am fiercely advocating to extend this
demonstration for the participating States and expand it to 11
more States in my bill with Representative Mullin, H.R. 1767.
In a new report entitled ``Bridging the Treatment Gap,''
the National Council for Behavioral Health surveyed the CCBHCs
and the results offer hope in our Nation's battle against the
opioid crisis.
The report showed, among other things, nearly universal
adoption of medication-assisted treatment--MAT--and decreased
patient wait times for these lifesaving interventions.
There is strong evidence that the program is leading to
reduced overdose deaths in upstate New York, and I am also
encouraged that CCBHCs in Oklahoma are reporting huge
reductions in hospital emergency room utilization.
With that as background, Ms. Bohan, I would like to ask you
a few questions. First, I understand that in New Jersey CCBHCs
have opened new service lines like the 24-hour emergency
psychiatric care and medication-assisted treatment while
serving patients who have never received care before.
With the sustained funding including in my bill, how can
your CCBHC further integrate and expand services for vulnerable
patient populations?
Ms. Bohan. Thank you very much for your question and your
support. Can you hear me? Yes. OK.
So you are absolutely right. We have expanded service lines
across the State of New Jersey. Twenty-four-hour mobile crisis
services that did not exist previously in counties like
Monmouth County are now really an integral part of the delivery
there and they have quickly become the--community resources
have quickly become dependent on these services and being able
to reach out directly to CCBHCs.
We are linked in with the Health Information Exchange so
that community partners can really identify that someone
belongs to a CCBHC and we are able to see if someone lands in
an emergency room, and we can quickly get case management out
and so forth to perhaps avoid a hospitalization and reengage
them quickly.
Ms. Matsui. That is wonderful.
Ms. Bohan. And in terms of the opioid epidemic, many of
the--including Rutgers, the programs are looking at bridge
programs from local emergency departments directly to CCBHCs so
that individuals can be started on medication-assisted
treatment and bridged directly over to the CCBHC where they
could be maintained on this really lifesaving intervention.
Ms. Matsui. That's great. What risk would a lapse in
demonstration funding have on your ability to provide holistic
services that address the ongoing opioid epidemic?
Ms. Bohan. It'll have a huge impact. As I said in my
testimony, there are--all of us have expanded our services,
which also means expanding our workforce.
So we have individuals in place. We've expanded our ability
to prescribe MAT. We have all established ambulatory withdrawal
management programs so the individuals can come in and be
inducted on MAT safely, and we are also able to deal with other
medications as well in that setting.
So that is a program that is at great risk across the
State.
Ms. Matsui. Well, thank you so much and I really appreciate
your participation. Thank you so much, and I yield back.
Mr. Butterfield. The gentlelady yields back.
At this time, I will recognize the gentleman from Florida,
my friend, Mr. Bilirakis.
Mr. Bilirakis. Thank you, my friend. Thank you, Mr.
Chairman. I appreciate it.
Mr. Barker, the DSH program--and I know that this has been
covered but it is so very important to my State and other
States as well, taking care of the indigent--but the DSH
program provides payments to hospitals, as you know, serving a
disproportionate number of Medicaid patients and the uninsured.
ACA reduces this payment--the payments by $14 billion from
2014 to 2019. Additionally, due to an arbitrary cap on DSH
payments frozen since the early 1990s, Florida has been
inequitably funded, and I know we are not the only State--
funded for DSH payments compared to other States with much
lower uninsured populations, and this is a bipartisan issue.
So while I am supportive of delaying the cuts, certainly, I
am concerned that simply repealing the cuts would not address
the underlying issue.
The antiquated formula created in the early '90s that
continues to negatively impact Florida and other good States,
Florida's Medicaid patients and uninsured they are impacted by
this and it is a real problem.
Should Congress update the DSH formula? Why or why not,
sir?
Mr. Barker. Mr. Bilirakis, were you directing that question
at----
Mr. Bilirakis. The question is for Mr. Barker.
Mr. Barker. Yes.
Mr. Bilirakis. Thank you.
Mr. Barker. So Dr. Burgess raised this issue----
Mr. Bilirakis. Yes.
Mr. Barker [continuing]. When he was here before, and I do
think that repealing the DSH cuts in their entirety would
remove the impetus to reform the DSH formula. Yes, I agree with
that statement.
Mr. Bilirakis. OK. All right. Very good. Thanks for--you
know, and, again, this is a time to get it done. So how might
Congress consider reforming the DSH formula to better reflect
the current patient population in States like Florida and South
Carolina, North Carolina, but all over the country--New Jersey?
Mr. Barker. So the DSH caps that are in the statute right
now were based on how much States were spending on DSH in 1991
or 1992.
Mr. Bilirakis. Right.
Mr. Barker. It doesn't bear any relationship to the number
of low income or uninsured patients in the State whereas the
whole purpose of DSH is to account for the situation of
hospitals that treat a disproportionate number of low income
individuals.
And so one idea would be that the DSH allocations be set
based on a measure of low income nonelderly individuals in a
State.
Mr. Bilirakis. Yes. I mean, again, it has affected so many
States because things have changed since '91. So it is
antiquated, and I appreciate--thank you for the input and
hopefully we can get something done about it.
Thank you, and I yield back, Mr. Chairman.
Mr. Butterfield. The gentleman yields back.
At this time I will recognize the gentleman from
California, Dr. Ruiz.
Mr. Ruiz. Thank you, Mr. Chairman. There are many issues
surrounding the outreach and enrollment for Medicare. So I
would first like to thank my colleague and friend,
Congresswoman Dingell, for her work on H.R. 3039, which
provides the 5-year extension of funding for Medicare outreach,
enrollment in education for low income beneficiaries.
This funding will help connect those most in need with
critical assistant programs. But we know that difficulties with
Medicaid enrollment extend beyond this much-needed targeted
specific funding which this funding will help. There are still
many who fall through the cracks through the Medicare
enrollment and suffer because of that.
In fact, most people that are newly eligible for Medicare
are automatically enrolled in Part B because they are
collecting Social Security retirement at the age of 65 and
there is that communication so they automatically enroll.
But a growing number are not, as they are working later in
life and deferring their Social Security benefits. Many of them
are in under insured or uninsured or very little benefits to
cover health insurance in those type of employments.
So unlike those who are auto enrolled in Part B, these
individuals make an active Medicare enrollment choice. So
taking into consideration specific time lines and existing
coverage.
Far too many seniors make honest mistakes when trying to
understand and navigate this confusing enrollment system. The
consequences of Part B enrollment mistakes are significant.
So if you are working, you are not automatically enrolled,
you haven't enrolled, you don't have health insurance, you find
out later that you don't have--you're not enrolled in Medicare,
you missed the deadline and that includes--the penalties are
late enrollment penalties, higher out-of-pocket healthcare
costs, gas and coverage, and barriers to accessing needed
services.
In 2018, an estimated 760,000 people--760,000 people with
Medicare were paying a Part B late enrollment penalty with the
average penalty amounting to a 28 percent increase in the
monthly premium.
So I introduced a bill that will hopefully close this gap
for seniors who are falling through and it is called the BENES
Act, which will direct HHS to send enrollment notices to
individuals approaching eligibility to educate them on how and
when to enroll in Medicare Part B and close a coverage gap that
currently exists for individuals that do not enroll at a
specific time.
In other words, it gives these working seniors who deferred
their Social Security a heads up proactively and giving them
the opportunity to learn how and when to enroll so they don't
miss that gap or fall through the cracks and miss the
enrollment.
So, Mr. Riccardi, can you explain this underlying issue as
well as the extent of the problem and what you are hearing from
folks calling in to the Medicare Rights national help line?
Mr. Riccardi. Yes. And thank you, and thank you for
championing the BENES Act and also Representative Bilirakis for
sponsoring the bill also.
This trend emerged on our help line as confusion abounds.
Medicare rules are complicated and, as you mentioned, a
majority of individuals are automatically enrolled into
Medicare if they're collecting Social Security.
But 20,000 people are turning 65 every day, people are
working longer, and they are waiting to also collect their
Social Security retirement benefits since the full retirement
age for Social Security benefits is now age 66 and it is
continuing to increase.
And so confusion is found from people of all backgrounds,
of all incomes, and all educational backgrounds, and in
particular we are seeing problems with individuals who may have
some other type of coverage since our healthcare system and
health insurance is confusing, and HR specialists and employers
are also confused about how to guide people through Medicare
enrollment.
One barrier that could be easily addressed legislatively is
to require that notice be sent to people before they're turning
65 to inform them about their eligibility for Medicare Part B
and for Medicare.
And just remember, these individuals are entitled to the
Medicare program but they are going without. This trend had
emerged a few years ago on Medicare rights help line and to
this day I still recall speaking to a client who had worked for
a large company, and he had retiree coverage and he had worked
for many years and contributed to Social Security and the
Medicare program, but he was without Medicare Part B.
And for years, he had this retiree coverage. But it wasn't
until he had stage four cancer that they no longer would pay
for his cancer bills.
And so he was caught within this very catastrophic gap in
coverage when you are waiting to enroll into Part B but you
can't. And so he had to go, you know, close to 12 months, 14
months, without coverage and in his case, him and his wife had
to take out a reverse mortgage.
And this was one of the first calls that we received on
this issue, and every day we are hearing more and more from
people who are missing their enrollment period through no fault
of their own.
And so the BENES Act would do, as you had mentioned, three
really important things. First, it would inform people about
their Medicare eligibility as they are turning 65.
It would simplify the enrollment periods. Generally, people
are very confused about when to enroll into Part B and
prescription drug coverage. It would simplify these enrollment
periods.
And lastly, it would do away with this catastrophic gap in
coverage that is in place. So thank you for your support.
Mr. Ruiz. Well, thank you for that information and I too
want to thank my good friend, Representative Bilirakis. We join
efforts on a multitude of bipartisan bills together and this is
one, I think, that we are going to pass through the House and
get signed by the President.
Thank you.
Ms. Eshoo [presiding]. Thank you.
I was on the floor to handle a bill. So excuse me for not
being here for a good part of your testimony and thank you
again for really essentially being here all day with us.
Let me just circle back, Mr. Riccardi. I got the tail end
of this. At one time, Social Security would notify an
individual that they--that they would become--becoming eligible
by whatever date and have an explanation, and I've always
thought out of all the government agencies that Social Security
materials are really understandable. They are written so
clearly. It is not written in federalese and all of that.
So people are not notified anymore by Social Security that
they are--that they are about to become eligible for their
benefits?
Mr. Riccardi. For individuals who are not collecting Social
Security benefits there is no information or separate notice
that is provided to individuals to inform them that they are
turning 65 and that they're within the window of time to enroll
into Medicare.
So, currently, that is not happening.
Ms. Eshoo. Maybe I am confusing Social Security with AARP
because when you are 55 they start telling you that you are
going to turn 65 in 10 years.
Thank you for that. And your legislation addresses this; it
closes the gap. So they will get a notice?
I am sorry. You need to--he can't hear you.
Mr. Ruiz. So yes, correct. So for those who aren't drawing
Social Security and retiring, they either continue to work and
don't have health coverage or enough health coverage, then they
don't get a notice.
So my bill will send--be proactive and let them know about
their enrolling.
Ms. Eshoo. Let me ask this. Is there still going to be
anyone left out, without a notice?
Mr. Riccardi. The notice--the notice will improve
people's--the information that they can access around
enrolling, and with that information people should be able to
make a more informed decision.
Going back to my earlier point, there are a number of
beneficiaries who are living on very limited incomes. As I had
mentioned, a quarter of people are living under, you know,
$15,000 a year. So the cost of Medicare and the Part B premiums
can still be prohibitive to some.
So that's why we encourage enrollment into the Medicare
savings program because there are some reasons why somebody may
not be enrolled in Medicare because they can't afford it.
Ms. Eshoo. We had--Mr. Barker, you have--I heard your
testimony on disproportionate share of hospitals.
Mr. Barker. Yes.
Ms. Eshoo. Yes. I would like to know if you know the
following. And I don't recall exactly how many States decided
not to participate in the expansion of Medicaid with the ACA.
Were there 22 or something like that?
Mr. Barker. I think 33 States have expanded Medicaid so----
Ms. Eshoo. Thirty-three States. Thirty-three States left--
the expansion, right? And they left a great deal of money on
the table. But, to me, the worst of it all was that the people
that they represented in their States didn't have the
opportunity to enroll.
Having said that, do you know of--in those States how those
Disproportionate Share Hospitals have fared? Has their
population--the people that they serve gone up and, if so,
exponentially? Do you have any information on that?
I can't help but think that there is a nexus between the
two. Do you know?
Mr. Barker. I don't know. I actually think that Dr.
Waldrum----
Ms. Eshoo. Does anyone on the panel know?
Mr. Barker [continuing]. Might know more than I do
because----
Ms. Eshoo. Dr. Waldrum?
Mr. Barker [continuing]. His hospital is in a State that
has not expanded Medicaid.
Dr. Waldrum. Yes, I very much appreciate the question, and
I think it is a very valid point. The States that did not
expand Medicaid, the facts are pretty clear that we have had
more rural hospital closures in those States than we have in
States that expanded.
And so the burden that it has placed because of the issues,
primarily rural nonexpansion States, that is where the
hospitals are closing and there is literature to support that
it has to do with the lack of----
Ms. Eshoo. Do you think that you could get that information
to us?
Dr. Waldrum. Yes, we would be happy to.
Ms. Eshoo. You know, around here rural is a big issue on--
no matter what we do, whether it is telecommunications,
technology, the digital divide, the homework divide,
healthcare, transportation, you name it, rural areas in our
country are affected and I that this is another one.
And when you say that a hospital has closed, that is a very
big deal in Anyplace, USA, much less in a rural area. So I
would really appreciate getting that information and my own
sense is, understanding pretty well--very well--how DSH works
that without another appropriation of those funds, what will
happen to these places?
Dr. Waldrum. I am certain that more----
Ms. Eshoo. What will happen to the people in these places?
Dr. Waldrum. More hospitals will close. There will be
reduction in services and we know that what happens is that
services are curtailed initially. One that we mentioned
earlier, OB services--so in a lot of rural hospitals they have
gotten out of OB services because of the low volume and that
limits access and that is contributing to the maternal and
fetal--I mean, infant mortality crisis in rural America, and
actually there is data that shows that when that happens the
next thing is that the hospital closes and then the town, the
community, suffers and in some cases actually goes away.
Ms. Eshoo. Wow. What a description. That doesn't belong in
America. Thank you very, very much.
I now would like to recognize the gentleman from Oregon,
Mr. Schrader, for his 5 minutes of questions.
Oh, I am sorry. Should I go to Mr. Guthrie then?
OK. Mr. Guthrie?
Mr. Guthrie. Thanks. Thank you very much. Appreciate it.
Ms. Eshoo. The gentleman from Kentucky. We need to
introduce you appropriately. The gentleman from Kentucky, Mr.
Guthrie.
Mr. Guthrie. Well, thank you. I appreciate that very much.
Thank you very much.
So, Mr. Barker, the--I know in one of the opening
statements about the responsibility to stop the DSH cuts--the
DSH cuts were implemented by--what legislation brought forth
the DSH cuts? Do you know?
Mr. Barker. The ACA.
Mr. Guthrie. And the concept--and I understand the question
of my friend from California who was asking about States that
didn't expand.
I am from Kentucky and we did expand Medicaid. We also set
up exchanges that Kentucky fully embraced and I know our
current Governor has made some changes but still essentially
fully embraced the Affordable Care Act with--given some
changes, going from State marketplaces to the Federal exchange,
but still there.
And my hospitals still--well, first of all, to the
hospitals you described closing the DSH cuts have never taken
place. There has been no cuts in DSH is my understanding. Is
that correct, I think, Dr. Waldrum?
Dr. Waldrum. I believe that is correct.
Mr. Guthrie. It is correct. So this is----
Dr. Waldrum. It is the lack--it is the lack of the covered
lives by expansion.
Mr. Guthrie. Well, Kentucky is having similar issues and we
have the same--we did expand. Do you know--Dr. Barker--Mr.
Barker, so the concept was that you wouldn't have to have DSH
because everybody is going to be covered if they expand and
created the exchanges.
Kentucky expanded and created the exchanges, and our
hospitals they'll have to close if they--some hospitals if they
didn't have DSH. We are seeing consolidation.
Do you know why the premise of the Affordable Care Act in
terms of DSH hasn't worked?
Mr. Barker. My understanding was exactly what you said,
which is that the thinking was that as the number of uninsured
individuals declined, there would be less need for DSH--both
Medicare DSH and Medicaid DSH.
Mr. Guthrie. Right. But so that didn't happen, did it? I
mean, Kentucky expanded Medicaid. Kentucky created exchanges
and still rely on DSH heavily.
So it seems like that didn't work. Whatever the concept was
didn't work. Do you know why it didn't work? I understand the
premise what was supposed to happen, but it didn't work.
Mr. Barker. I can't comment on why it didn't work.
Mr. Guthrie. OK. So the second thing--so Mr. Waldrum, about
DSH--it is something that, you know, I support. We are going to
have to maintain because of what the effects on hospitals,
particularly rural areas.
But let us see if we had a hypothetical to your delay and
then Congress should update the formula to better align the
relationship between DSH allotments in a State and the number
of low-income nonelderly individuals.
So my question, Dr. Waldrum, would your State--would your
hospital--how would--if we realigned that formula, would your
hospital be affected positively and would all of you commit to
working with us to find a long-term solution that can steer DSH
funding to where it should do the most good?
So would you like to see a change in the formula? I mean--
--
Dr. Waldrum. So I am not an expert in the complex
calculations and how those are passed down to the States and
then how that would be allocated locally. I am really----
Mr. Guthrie. It is to the hospitals. It would be the
hospitals.
Dr. Waldrum. To the local hospitals, correct. And so how
that would flow I am not an expert from a technical
perspective. I am a provider, a physician, and a hospital
administrator that tries to provide services to these
communities and cuts promulgated on, as you described, very
fragile communities and how we serve those folks.
We wouldn't want and would oppose those cuts. And so I am
not here to address the technicalities and I am not an expert
in that area.
Mr. Guthrie. Any comment on that, Mr. Barker, on the
formula of DSH and how DSH is allocated?
Mr. Barker. On the Medicaid side, that's a State-by-State
determination. So the Federal statute----
Mr. Guthrie. Right.
Mr. Barker [continuing]. Sets a minimum threshold for
classes of hospitals that have to be designated as DSH but then
it is up to a State to decide within those parameters.
Mr. Guthrie. But there is a Federal formula that allots
that money, correct? Like Tennessee doesn't get much DSH----
Mr. Barker. Oh, you mean the overall DSH?
[Simultaneous speaking.]
Mr. Barker. I am sorry, Congressman. I didn't understand
your question. Yes, you are right. There is a statutory DSH
cap.
Mr. Guthrie. Right.
Mr. Barker. Tennessee was not getting any DSH funds back in
1992. But that DSH cap was set on the level of DSH spending in
a State in 1991 or 1992, and the reason Tennessee doesn't have
one is because they weren't using any DSH funding back----
Mr. Guthrie. Do you think that should be--I think that
might have been when they had TennCare. I am not sure. I don't
know if there are some Tennesseans who--so do you think that
formula should be--to be fair, to other States, that it be
reallocated instead of based on a 1991-92 number?
Mr. Barker. I do think--Dr. Burgess raised this issue
earlier. Yes, I do----
Mr. Guthrie. Sorry. I was in another meeting.
Mr. Barker. No. No. No. No. I think that it would be a good
idea to revisit the DSH allocations.
Mr. Guthrie. OK. Thanks. I appreciate that. With my last 10
seconds, you know, that DSH was a big pay for the Affordable
Care Act and here we are, and we are going to need to do it. I
am not saying we don't need to do it. But now reallocating
money that has already been allocated to make sure that
hospitals don't close.
So I appreciate the time, Madam Chair, and I yield back.
Ms. Eshoo. The gentleman--let us see. I now would like to
recognize the gentleman, and he is a gentleman, from Oregon,
Mr. Schrader, for his 5 minutes of questioning.
Mr. Schrader. Thank you again, Madam Chair. I appreciate
it.
I will follow up a little bit on the line of concern that
Congressman Guthrie and Congressman Burgess--Dr. Burgess--had
talked about because it sounds like from what we have heard
today that the DSH payment thinking with the ACA didn't work
out quite as well as we had thought.
Charity care has decreased. That is a good thing. Medicaid
care has increased and, as we all know, Medicaid doesn't pay
full freight. So I think some of the hospitals, perhaps in Mr.
Guthrie's district, are still having some trouble balancing the
commercial rates, obviously, with the increase in Medicaid
population.
But I think it gets to the central point that, you know,
big proponent of making sure, you know, we make sure these
hospitals and rural hospitals in particular stay in place. You
know, prefigure, recontour this formula that is 20-plus, maybe
30-plus years old at this point in time makes sense.
I would put in though, as a person whose State actually did
to the Medicaid expansion that whenever if we redo this formula
we should take into account the fact that those States that
stepped up and actually provided healthcare for our low income
people there ought to be no penalty at least for them having
done so.
The original Senate language, you know, that was finally
implemented when this was all done many years ago, talked about
low income and I think that should still be the major guiding
force for how we approach these payments.
To me, you know, based on what we have heard today, the
MACPAC stuff will be a great starting point in terms of how we
deal with any gradual elimination or reduction--probably not
elimination but reduction in the DSH payments with some tweaks
to make sure that we take into account what's actually
happened, you know, over the last 20 years and particularly
since the ACA has put into effect.
Mr. Riccardi, just chat a little bit if you don't mind and
follow up--I talked about this a little bit and it has been
talked about with the previous panel, you know, how important
the FQHCs and the CHCs are for delivering healthcare for a lot
of folks that are uninsured or don't have access to healthcare,
basically.
In trying to incentivize aligning the quality metrics,
Oregon has gone a long way in trying to match up managed care
metrics, you know, with those for FQHCs and trying to make all
your guys' lives hopefully a little bit easier. You have enough
widgets to count. Be nice just to count, you know, one widget
for--one metric, if you will, for each of those widgets.
So while the States are starting to do some stuff--and I
have some folks in my State rather it just be a State function.
I don't know if that is the best way to go.
Would you support aligning these, you know, quality metrics
between managed care, Medicaid basically, in the FQHCs and
CHCs?
Mr. Riccardi. Yes. In New York there is an example. I am a
member of a work group where we are partnering with the public
and the private sector, looking at, you know, a variety of
quality metrics in determining, you know, what makes the most
sense for patients and also for providers and other healthcare
professionals to ensure that that information is readily
understandable by the healthcare workforce and also the
patients who need that information.
So I do see that collaboration happening. But I think there
is, you know, more that can be done and that's something that
we are supportive of.
Mr. Schrader. So I wonder if it is the role of the Federal
Government to help provide an opportunity or incentivize that
and then let the States, depending on their own culture, figure
out what outcomes are most important to them to align
themselves with and hopefully run through CMS, at the end of
the day.
Mr. Riccardi. Yes, and I think that's why it is so
important that an organization like National Quality Forum is
supportive because they are able to assist, you know, every
State with these measures. And so agreed.
Mr. Schrader. Good. Well, that's all the questions that I
had, Madam Chair. Thank you much and I will yield back.
Ms. Eshoo. The gentleman yields.
And I recognize the gentleman from Georgia, the only
pharmacist in the Congress, Mr. Carter. How is that?
Mr. Carter. That is very good. Thank you.
Ms. Eshoo. I know that. What was my first clue?
[Laughter.]
Mr. Carter. Thank you, Madam Chair, and thank all of you
for being here. This is certainly important and we appreciate
your being here and helping us with this.
I wanted to start by saying that, you know, I am very
honored to be the Republican lead on H.R. 3031, working with
Representative Chu and Engel on the National Quality Forum.
I think it is very important. It is very important because
it is a valuable resource for making sure that we have and that
we achieve cost-efficient and high-quality and value-based
healthcare that ensures that all Americans will have quality
healthcare, and we certainly need to continue this program and
that is why I am proud to be a part of that.
I will start with you, Mr. Riccardi, and just ask you, you
mentioned it in your testimony and I wanted to ask you if you
could just expand a little bit more on the value of the
National Quality Forum, particularly as it relates to Medicare
recipients.
Mr. Riccardi. Thank you for that question, and to add, you
know, the saying goes that it is important that an individual
gets the right care at the right time at the right setting. You
may want to add also at the right cost.
And the National Quality Forum has created the highest
level of quality standards that are available to States and
agencies and both, as I mentioned, the private the public
sector.
And, in particular, with the Medicare program with the
preventable readmissions program, we have seen some success and
decrease in those admissions, and I know from my background I
also am a lecturer at the Columbia School of Social Work, and a
number of my students have been involved in some of those
demonstration programs, helping prevent readmissions.
And the accessibility and the use of those quality measures
have been key to ensure that people are receiving the right
care at the right time in the right setting.
Mr. Carter. I can't help but remember--I was a consultant
pharmacist in long-term care for many years and we used to have
the seven rights of drug administration--the right drug for the
right patient in the right dose at the right time, the right
administration, so on and so on.
So you are exactly right and I appreciate you reiterating
that.
Mr. Barker, I want to change gears real quick and talk
about DSH payments. I have got a very rural district in Georgia
and south Georgia particularly--very rural area--and my
district, certainly to the western portion of my district is
very rural, and DSH payments are extremely important to our
rural hospitals.
And some of them are totally reliant on this. So I
understand that there are some hospitals or some States that
aren't using their full DSH allotment and I find that hard to
believe, and just wondered if you can--if you can explain how
that can happen and what's going on there.
Mr. Barker. So my understanding is that there are three
States--if I am not mistaken, there are three States that are
not using their full DSH allotments, and I assume that that is
because that there is, as well as a State-specific cap, in DSH
there is also a hospital-specific cap.
Medicaid DSH payments cannot exceed the amount of
uncompensated care that a hospital has. And so the only thing
that I can think of is in those three States those hospitals
are being paid at least the cost of their uncompensated care.
Mr. Carter. MACPAC had made some recommendations that--on
potential reforms, and I think you may have mentioned some of
these. Do you have any other ideas or any other suggestions on
what we can do in Congress to make sure that this program is
being utilized like it is supposed to be?
Mr. Barker. Thank you for that question.
You are right, I did mention the MACPAC recommendations and
one of them addresses exactly the issue that you mentioned,
which is applying the DSH reductions to those States that have
not expended their full allotment, which is--would sort of hold
for at least a portion of the DSH cuts hold everyone harmless.
Another recommendation that MACPAC made is to rethink the
way that the DSH caps are allocated right now because they
don't really bear any relationship to low income or uninsured
patients.
Mr. Carter. That is important. Thank you for bringing that
up because we do need to look at that, and if there is reform
needed we need to address it.
Mr. Barker. Thank you, sir.
Mr. Carter. Well, again, thank all of you for being here.
This is extremely important. We all understand that. I am
concerned about how we are going to pay for all this.
But at the same time, there is no question that these are
quality programs that need to be continuing on and, certainly,
whereas we need to look at some reforms on certain programs
like the DSH payment system, you know, I want to make sure that
particularly the rural hospitals understand that we understand
how important it is to them for their survival.
So thank you, Madam Chair, and I yield back.
Ms. Eshoo. The gentleman yields back, and I want to thank
each one of the witnesses. I think you have given really high-
value testimony today. I know that I have learned from you and,
Ms. Bohan, the numbers in your program are really stunning--
really stunning--and I think when the time comes that the
secretary has to review your pilot I want to be able to lean in
at that time because when you talk about those wait times being
brought down and reaching out to people, it is exactly what we
need in our country.
And while I am not going to say something to each one of
your individually, I could--thank you. Congress is so dependent
upon the experts that come here to answer our questions and I
am proud of the members of the entire subcommittee because
their questions were all serious and well directed, and you
gave us answers and we can build on that foundation as we move
forward to reauthorize.
So all of our thanks for your participation. I also would
like to submit the following statements or letters for the
record. There are several of them:
A statement from the American Osteopathic Association in
support of H.R. 2815; a letter from American Federation of
State, County, and Municipal Employees regarding certified
community behavioral health clinics; a letter from Oregon
AFSCME in support of H.R. 1767; a letter from AFSCME 1199(j)
and Care Plus New Jersey regarding CCBHCs; a letter from the
American Hospital Association in support of 1767; a letter from
AHA in support of 3022; a statement from the Endocrine Society
regarding the Special Diabetes Program; a letter from
Representatives DeGette and Reed regarding the Special Diabetes
Program; a letter from Friends of NQF in support of 3031; a
letter from Healthcare Leadership Council regarding NQF and
PCORI; a letter from the American Academy of Family Physicians
regarding THCGME and CHCs; a letter from the Alliance of
Community Health Plans regarding the Patient-Centered Outcomes
Research Institute; a letter from the National Kidney
Foundation regarding PCORI; a letter from Friends of PCORI
Reauthorization regarding PCORI; a statement from the PCORI
Board of Governors regarding PCORI; a letter from the Council
of Academic Family Medicine in support of 2815; a letter from
the Leadership Council of Aging Organizations regarding
outreach and enrollment to low-income Medicare beneficiaries; a
letter from the Children's Hospital Association regarding DSH;
a letter from Representatives Engel and Olson regarding DSH; a
letter from America's Essential Hospitals in support of 3022; a
letter from Texas Parent to Parent in support of 2822; letters
from Family-to-Family Health Information Centers regarding
2822; a letter from the Catholic Health Association in support
of 3022.
So are there any objections to these letters and documents
being placed in the record?
If not, so ordered.
[The information appears at the conclusion of the
hearing.]\1\
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\1\ The information has been retained in committee files. The
DeGette/Reed letter is available at https://docs.house.gov/meetings/IF/
IF14/20190604/109583/HHRG-116-IF14-20190604-SD022.pdf. The Family-to-
Family Health Information Centers letters are available at https://
docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=109583.
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Ms. Eshoo. And I think with that, remind Members--there are
only two of us here, but staffers are still here--that,
pursuant to committee rules, they have 10 business days to
submit additional questions for the record to be answered by
the witness who has appeared.
We know that you will be highly cooperative, and full
answers in a straightforward way in a short period of time. How
is that? Everyone agree to that?
I think so. So with that--yes, Dr. Burgess?
Mr. Burgess. If I may----
Ms. Eshoo. Yes.
Mr. Burgess. This afternoon marked the passage finally of
the Pandemic All-Hazard Preparedness Act on the 100-year
anniversary of the Spanish flu. So you are to be congratulated
for this entire subcommittee that worked so hard on this for
the past 3 years, and we have now gotten it across the finish
line.
So I will be looking forward to seeing you at the signing
ceremony down at the White House.
Ms. Eshoo. That will be wonderful, Mr. Burgess.
And huge, huge kudos to Representative Susan Brooks, who
was and is, I think, just the best partner I could ever have on
a bipartisan basis, and certainly to you, Dr. Burgess, to the
chairman of the full committee, and to the ranking member of
the full committee.
They say it takes a village. It takes a team here and----
Mr. Burgess. And your staff.
Ms. Eshoo. I haven't finished. I haven't finished. You
always want to correct me.
Certainly, to the staff, too. Catherine--is it Catherine
Wallens or Willins--on Representative Brooks' staff, and Rachel
Fybel on mine. They work late into many nights with the bouncy
ball going over on what was taking place in the Senate.
But it is about our national security and public health and
response to whatever God has in store for us. So kudos, and
thank you for raising it.
So I don't think that there is anything else to come before
the committee. It is quarter to 4 in the afternoon, and at this
time the Health Subcommittee is adjourned.
Thank you, everyone.
[Whereupon, at 3:44 p.m., the committee was adjourned.]
[Material submitted for inclusion in the record follows:]
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