[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]





 CARING FOR AMERICA: LEGISLATION TO SUPPORT PATIENTS, CAREGIVERS, AND 
                               PROVIDERS

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

                             HYBRID HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 26, 2021

                               __________

                           Serial No. 117-55








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     Published for the use of the Committee on Energy and Commerce

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                        energycommerce.house.gov
                        
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                 U.S. GOVERNMENT PUBLISHING OFFICE 
                 
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                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California              Ranking Member
DIANA DeGETTE, Colorado              FRED UPTON, Michigan
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          BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida                DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland           ADAM KINZINGER, Illinois
JERRY McNERNEY, California           H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
PAUL TONKO, New York                 BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York           BILLY LONG, Missouri
KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California                RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California          TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan             EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas                JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire         GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice       NEAL P. DUNN, Florida
    Chair                            JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California    DEBBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia         GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
DARREN SOTO, Florida                 JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona              KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
                                 ------                                

                           Professional Staff

                   JEFFERY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                  NATE HODSON, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
G. K. BUTTERFIELD, North Carolina    BRETT GUTHRIE, Kentucky
DORIS O. MATSUI, California            Ranking Member
KATHY CASTOR, Florida                FRED UPTON, Michigan
JOHN P. SARBANES, Maryland, Vice     MICHAEL C. BURGESS, Texas
    Chair                            H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
TONY CARDENAS, California            LARRY BUCSHON, Indiana
RAUL RUIZ, California                MARKWAYNE MULLIN, Oklahoma
DEBBIE DINGELL, Michigan             RICHARD HUDSON, North Carolina
ANN M. KUSTER, New Hampshire         EARL L. ``BUDDY'' CARTER, Georgia
ROBIN L. KELLY, Illinois             NEAL P. DUNN, Florida
NANETTE DIAZ BARRAGAN, California    JOHN R. CURTIS, Utah
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
ANGIE CRAIG, Minnesota               JOHN JOYCE, Pennsylvania
KIM SCHRIER, Washington              CATHY McMORRIS RODGERS, Washington 
LORI TRAHAN, Massachusetts               (ex officio)
LIZZIE FLETCHER, Texas
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     2
    Prepared statement...........................................     4
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, prepared statement...................     6
    Prepared statement...........................................     8
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................    12
    Prepared statement...........................................    14
Hon. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................    16
    Prepared statement...........................................    18

                               Witnesses

J. Corey Feist, JD, MBA, President and Founder, Dr. Lorna Breen 
  Heroes' Foundation.............................................    24
    Prepared statement...........................................    27
    Answers to submitted questions...............................   254
Lisa Macon Harrison, M.P.H., President, National Association of 
  County and City Health Officials...............................    35
    Prepared statement...........................................    37
Brooks A. Keel, Ph.D., President, Augusta University.............    41
    Prepared statement...........................................    43
Victoria Garcia Wilburn, D.H.Sc., OTR, F.A.O.T.A., Assistant 
  Professor, Occupational Therapy, School of Health and Human 
  Sciences, IUPUI................................................    47
    Prepared statement...........................................    49
    Answers to submitted questions...............................   256
Alan Levine, CEO, President, Ballad Health.......................    52
    Prepared statement...........................................    54
 Stephanie Monroe, J.D., Director, Equity and Access, 
  UsAgainstalzheimer's, Executive Director, AfricanAmericans 
  AgainstAlzheimer's.............................................    64
    Prepared statement...........................................    67
Jeanne Marrazzo, M.D., Director, Division of Infectious Disease, 
  University of Alabama at Birmingham............................    72
    Prepared statement...........................................    74

                           Submitted Material

H.R. 1474, the Alzheimer's Caregiver Support Act, submitted by 
  Ms. Eshoo......................................................   133
H.R. 1667, the Dr. Lorna Breen Health Care Provider Protection 
  Act, submitted by Ms. Eshoo....................................   138
H.R. 3297, the Public Health Workforce Loan Repayment Act of 
  2021, submitted by Ms. Eshoo...................................   148
H.R. 3320, the Allied Health Workforce Diversity Act of 2021, 
  submitted by Ms. Eshoo.........................................   156
H.R. 5583, the Helping Enable Access to Lifesaving Services Act, 
  submitted by Ms. Eshoo.........................................   163
H.R. 5594, the Enhancing Community Health Workforce Act, 
  submitted by Ms. Eshoo.........................................   165
H.R. 5602, the Bolstering Infectious Outbreaks Preparedness 
  Workforce Act of 2021, submitted by Ms. Eshoo..................   167
Letter of October 25, 2021, from Peter M. Leibold, Executive Vice 
  President, Chief Advocacy Officer, Ascension, to Mr. Palloneand 
  Mr. McMorris Rodgers, submitted by Ms. Eshoo...................   181
Letter of October 25, 2021, from George C. Benjamin, M.D., 
  Executive Director, the American Public Health Association, to 
  Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..............   183
Letter of October 22, 2021, from Orly Avitzur, M.D., President, 
  American Academy of Neurology, to Ms. Eshoo and Mr. Guthrie, 
  submitted by Ms. Eshoo.........................................   185
Letter of October 26, 2021, from Ada D. Stewart, M.D., Board 
  Chair, American Academy of Family Physicians, to Ms. Eshoo and 
  Mr. Guthrie, submitted by Ms. Eshoo............................   187
Statement of American Association for Respiratory Care, October 
  26, 2021, submitted by Ms. Eshoo...............................   192
Letter of October 22, 2021, from Mark Rosenberg, DO, MBA, FACEP, 
  President, American College of Emergency Physicians, to Ms. 
  Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..................   194
Letter of October 25, 2021, from A. Lynn Williams, Ph.D., CCC-
  SLP, President, American Speech-Language-Hearing Association in 
  to Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo...........   199
Letter of October 25, 2021, from Charles J. Fuschillo, Jr., 
  President and CEO, Alzheimer's Foundation of America, to Ms. 
  Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..................   200
Letter of October 26, 2021, from Sharon L. Dunn, PT, Ph.D., 
  Board-Certified Clinical Specialist in Orthopaedic Physical 
  Therapy,President, American Physical Therapy Association, to 
  Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..............   202
Letter of October 26, 2021, from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Mr. Pallone and Ms. McMorris 
  Rodgers, submitted by Ms. Eshoo................................   205
Letter of October 13, 2021, from Beth Feldpush, DrPH, Senior Vice 
  President of Policy and Advocacy, America's Essential 
  Hospitals, to Mr. Schumer, et al., submitted by Ms. Eshoo......   208
Letter of October 26, 2021, from Jane M. Adams, Vice President, 
  Federal Government Affairs, and Lauren Moore, Vice President, 
  Global Community Impact, Johnson and Johnson, to Mr. Pallone 
  and Ms. McMorris Rodgers submitted by Ms. Eshoo................   213
Letter of October 21, 2021, from Melissa B. Miller, Ph.D., Chair, 
  Clinical and Public Health Microbiology Committee and Stacey L. 
  Schultz-Cherry, Ph.D., Chair, Public and Scientific Affairs 
  Committee, American Society for Microbiology, to Ms. Trahan and 
  Mr. McKinley, submitted by Ms. Eshoo...........................   215
Letter of October 25, 2021, from 15 Independent Children's 
  Hospitals, to Mr. Pallone, submitted by Ms. Eshoo..............   217
Letter of October 11, 2021, from Jerome Siy, M.D., MHA, 
  President, Society of Hospital Medicine, to Ms. Wild and Mr. 
  McKinley, submitted by Ms. Eshoo...............................   221
Letter from Jason Delamarter, Chief Operating Officer, Prestige 
  Care Inc., to McMorris Rodgers, submitted by Ms. Eshoo.........   222
Letter of October 25, 2021, from George M. Abraham, M.D., MPH, 
  MACP, FIDSA, President, American College of Physicians, to Mr. 
  Pallone and et al., submitted by Ms. Eshoo.....................   225
Letter of October 22, 2021, from 36 Organizations, to Ms. Trahan 
  and Mr. McKinley, submitted by Ms. Eshoo.......................   227
Letter of October 26, 2021, from Representative Maxine Waters, to 
  Mr. Pallone and et al., submitted by Ms. Eshoo.................   230
Statement of October 26, 2021, from the Alzheimer's Association 
  and Alzheimer's Impact Movement, submitted by Ms. Eshoo........   236
Statement of October 26, 2021, from J. Nadine Gracia, M.D., MSCE, 
  President and CEO, Trust for America's Health, to Ms. Eshoo and 
  Mr. Guthrie, submitted by Ms. Eshoo............................   239
Statement of October 26, 2021, from the American Hospital of 
  Association, submitted by Ms. Eshoo............................   241
Report of the Government Accountability Office, ``Health Care 
  Workforce Federally Funded Training Programs in Fiscal Year 
  2012,'' August 15, 2013, submitted by Ms. Eshoo \1\

----------
\1\ The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF14/
  20211026/114166/HHRG-117-IF14-20211026-SD018.pdf.
Letter of October 25, 2021, from Members of Congress, to 
  President Biden, submitted by Ms. Eshoo........................   244
Letter of October 25, 2021, from Members of Congress, to Ms. 
  Brooks-LaSure, submitted by Ms. Eshoo..........................   246
Statement from Ron Kraus, Clinical Nurse Specialist at Indiana 
  University Health Methodist Hospital and 2021 President of the 
  Emergency Nurses Association, submitted by Ms. Eshoo...........   249

 
 CARING FOR AMERICA: LEGISLATION TO SUPPORT PATIENTS, CAREGIVERS, AND 
                               PROVIDERS

                              ----------                              


                       TUESDAY, OCTOBER 26, 2021

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The Subcommittee met, pursuant to call, at 10:30 a.m., in 
the John D. Dingell Room, 2123 of Rayburn House Office 
Building, and remotely via Cisco Webex online video 
conferencing, Hon. Anna Eshoo (chairwoman of the subcommittee), 
presiding.
    Members present: Representatives Eshoo, Butterfield, 
Matsui, Castor, Sarbanes, Welch, Schrader, Cardenas, Ruiz, 
Dingell, Kuster, Barragan, Blunt Rochester, Craig, Schrier, 
Trahan, Fletcher, Pallone (ex officio), Guthrie (subcommittee 
ranking member), Upton, Burgess, Griffith, Bilirakis, Long, 
Bucshon, Mullin, Hudson, Carter, Dunn, Curtis, Crenshaw, Joyce, 
and Rodgers (ex officio).
    Also present: Representatives Rush, Schakowsky, Latta, and 
Pence.
    Staff present: Shana Beavin, Professional Staff Member; 
Waverly Gordon, Deputy Staff Director and General Counsel; 
Tiffany Guarascio, Staff Director; Zach Kahan, Deputy Director 
Outreach and Member Service; Mackenzie Kuhl, Press Assistant; 
Aisling McDonough, Policy Coordinator; Meghan Mullon, Policy 
Analyst; Juan Negrete, Junior Professional Staff Member; Tim 
Robinson, Chief Counsel; Chloe Rodriguez, Clerk; Andrew 
Souvall, Director of Communications, Outreach, and Member 
Services; Kimberlee Trzeciak, Chief Health Advisor; Caroline 
Wood, Staff Assistant; C.J. Young, Deputy Communications 
Director; Alex Aramanda, Minority Professional Staff Member, 
Health; Sarah Burke, Minority Deputy Staff Director; Theresa 
Gambo, Minority Financial and Office Administrator; Seth Gold, 
Minority Professional Staff Member, Health; Grace Graham, 
Minority Chief Counsel, Health; Nate Hodson, Minority Staff 
Director; Peter Kielty, Minority General Counsel; Emily King, 
Minority Member Services Director; Bijan Koohmaraie, Minority 
Chief Counsel, Over and Investigations Chief Counsel; Clare 
Paoletta, Minority Policy Analyst, Health; Kristin Seum, 
Minority Counsel, Health; Kristen Shatynski, Minority 
Professional Staff Member, Health; Olivia Shields, Minority 
Communications Director; and Michael Taggart, Minority Policy 
Director.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order.
    Due to COVID-19, today's hearing is being held remotely, as 
well as in person.
    Good morning, colleagues. For members and witnesses taking 
part in person, we are following the guidance of the CDC and 
the Office of the Attending Physician. So please wear a mask 
when you are not speaking. For members and witnesses taking 
part remotely, microphones will be set on mute to eliminate 
background noise. Members and witnesses, you will need to 
unmute your microphone when you wish to speak.
    Since members are participating from different locations at 
today's hearing, recognition of members for questions will be 
in the order of subcommittee seniority.
    Documents for the record should be sent to Meghan Mullon at 
the email address we have provided to your staff, and all 
documents will be entered into the record at the conclusion of 
the hearing.
    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

    In the first year of the pandemic, over 3,600 U.S. 
healthcare workers died fighting COVID-19, and this is 
according to the Guardian, and Kaiser Health News. And since 
February 2020, about one in five healthcare workers have quit 
their jobs. For those still on the job, almost all report 
experiencing stress and most report being emotionally and 
physically exhausted.
    As a country we have responded, really, with mostly 
symbolic support: ticker tape parades, ``healthcare hero'' yard 
signs, and Time Magazine dedicating its cover to frontline 
health workers. Congress provided Federal aid to support 
healthcare institutions through the $175 billion Provider 
Relief Fund, but it has been difficult to track how much of 
that aid made it to the workers themselves.
    On the West Coast, more than 24,000 nurses and other 
healthcare workers have authorized a strike over pay and 
working conditions as we meet this morning. Public health 
workers, as well as doctors and nurses, also report being 
physically threatened. In my district, Dr. Sara Cody, the top 
Santa Clara County public health official, was stalked and 
threatened over her decisions to protect public health during 
the pandemic. And Asian-American healthcare workers have faced 
a new wave of racial harassment in the workplace during COVID-
19.
    This is the urgent backdrop as we meet in this hearing 
today. We are considering seven bills, five of which are 
bipartisan, focused on supporting current caregivers, as well 
as rebuilding the pipeline of future workers. Three of the 
bills set up loan repayment programs for the healthcare 
workforce, which will directly reward future workers for their 
important contributions. Two other bills, the Dr. Lorna Breen 
Health Care Provider Protection Act and the Alzheimer's 
Caregiver Support Act recognize that current caregivers need 
stronger support to help them weather their physically and 
emotionally draining work.
    Our Subcommittee is honored to welcome Mr. Corey Feist and 
Ms. Jennifer Breen Feist. They are the brother-in-law and 
sister of Dr. Lorna Breen, who died by suicide after 
experiencing the mass death of the first wave of COVID-19 
patients and then contracting the virus herself. Since their 
sister's death, they have dedicated themselves to addressing 
clinician burnout and suicide.
    What an honor to have you here with us today.
    The Dr. Lorna Breen Health Care Provider Act provides grant 
funding for suicide prevention and peer support at healthcare 
facilities. It also makes sure that healthcare professionals 
can ask for mental help without facing negative consequences in 
their careers.
    We are also honored to welcome back to the Congress 
Stephanie Monroe, who has served as Chief Counsel to the Senate 
HELP Committee during her 25-year career on the Hill. Ms. 
Monroe now serves as the Executive Director of African 
Americans Against Alzheimer's, and is the current caregiver for 
her 84-year old father, who is living with Alzheimer's. She 
will testify in support of the Alzheimer's Caregivers Support 
Act, which provides grants to expand support services for the 
unpaid caregivers of people living with Alzheimer's and other 
dementia.
    The final two bills being considered today will reauthorize 
grants and fellowship programs for clinicians in medically 
underserved communities--and we have so many members that 
represent those communities--and volunteers for community 
health centers.
    This hearing, I believe, is the first step toward treating 
our nation's healthcare workers as heroes. We have called them 
that, but now we have to act. I look forward to today's expert 
testimony that will be provided by our witnesses.
    We thank you for traveling the distances that you have to 
be with us and to moving these important bills through our 
Subcommittee as swiftly as possible. We want this to get to the 
finish line. We want these bills to get to the finish line, 
send them to the President for his signature into law, and then 
the words on the pages will walk into people's lives.
    [The prepared statement of Ms. Eshoo follows:]

                  Prepared Statement of Hon. Ann Eshoo

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Ms. Eshoo. The Chair now recognizes the Ranking Member of 
our Subcommittee, Mr. Guthrie, for his 5 minutes of opening 
statements.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
        CONGRESS FROM THE COMMONWEALTH STATE OF KENTUCKY

    And it is great to see you and be with you today.
    Mr. Guthrie. Thank you, Chair Eshoo, it is great to be with 
you, as well, and thanks for holding this important hearing. 
And thanks to have all of our witnesses with us here today.
    Today we are examining bills that aim to support patients, 
caregivers, and providers. Now, more than ever, due to the 
COVID-19 pandemic, our country is facing severe workforce 
shortages, and the healthcare industry is no exception.
    Since the beginning of the pandemic, healthcare workers 
have stepped up to the plate, and have been on the front lines 
fighting against this terrible virus. I want to take a moment 
and thank each and every healthcare worker for their selfless 
attitude as you continue to go to work and help our nation at a 
crucial time in our history.
    I think we all agree on the importance of increasing 
recruitment and retention in our nation's healthcare workers. 
However, I am concerned, and I want to point out about the 
impact of President Biden's COVID-19 vaccine mandate on the 
workforce. Numerous Kentuckians have told me that the 
anticipated Center for Medicare and Medicaid Services and 
Occupational Safety and Health Administration rule is leading 
to many people to quit their jobs.
    This is--there is confusion. The mandates were announced 
months ago, but rules have yet to be released. Many questions 
remain, including how will someone get an exemption, will prior 
infection count, and is testing an alternative to comply.
    Another hurdle in attracting and retaining people to the 
healthcare workforce is the high cost of obtaining a medical 
degree. I continually hear from constituents that the reason 
for not pursuing a degree or certificate in healthcare is due 
to the financial burden of tuition costs. To help alleviate 
this distress, I introduced the Public Health Workforce Loan 
Repayment Act, along with Representatives Eshoo, the chair, 
Burgess, and Crow.
    This bill, this bipartisan bill, would establish the Public 
Health Workforce Loan Repayment Program to promote the 
recruitment of public health professionals at local, state, and 
tribal public health agencies. I believe a strong public health 
infrastructure starts with health professionals at its core.
    Additionally, we continue to encourage private entities and 
states to create innovative solutions in order to tackle 
staffing shortages in the healthcare field. For example, one of 
the most vital healthcare needs confronting Kentucky is the 
shortage of physicians, particularly primary care doctors 
serving in community settings. I am proud to represent the 
University of Kentucky's College of Medicine Bowling Green 
Campus in my district and my hometown, which aims to address 
this critical need.
    Launched in 2018, the Bowling Green Campus has increased 
the size of the UK College of Medicine by 120 students, a 20 
percent increase. The school provides students two 
opportunities to obtain a combined degree, whether an MD/MPH or 
an MD/MBA.
    Another great example is the Medical College of Georgia 3+ 
program that Dr. Keel will testify before us today. Arkansas--I 
will leave you--leave that to explain your program yourself, 
and--but I will talk about Arkansas, Maryland, and Nebraska 
have launched new recruitment and retention programs. For 
example, Arkansas recently created their first graduate 
registered nurse apprenticeship program, and Nebraska announced 
new online resources to connect with healthcare facilities with 
staffing needs. As co-chair of the Congressional Apprenticeship 
Caucus, I have been a strong supporter of apprenticeships, and 
believe they are a great avenue for workers and employees.
    Lastly, as we discuss these bills before us today, we need 
to keep in mind that Congress has already authorized 5.9 
trillion in funding to provide COVID assistance and relief for 
Americans, including money intended to address workforce 
shortages in healthcare. President Biden's $1.9 trillion 
American Rescue Plan, which was signed into law in March of 
2021, provided significant mandatory funding for workforce 
initiatives, including 7.6 billion for the public healthcare 
workforce.
    I voted for all the previous, but--COVID relief. But to 
make note, and to be fair, I didn't vote for the American 
Rescue Plan. However, I want to point out that many states, 
like my home state of Kentucky, have yet to receive much of 
this funding. We need to ensure the remaining funds that have 
not been dispersed are being spent effectively, and take stock 
of that spending.
    I want to thank all of the witnesses for being here today, 
and I look forward to hearing from each of you as--on ways we 
can better address and find solutions to current healthcare 
workforce shortages.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Mr. Guthrie. Thank you, and I yield back.
    Ms. Eshoo. The gentleman yields back. The Chair is now 
pleased to recognize the Chairman of the Full Committee, Mr. 
Pallone, for his 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman Eshoo. Last week we held 
a legislative hearing to examine bills that would improve the 
health of children and families. And today this Subcommittee 
meet to discuss a slate of bipartisan bills that seek to 
strengthen America's health workforce, and support our 
communities and providers.
    The legislation before us now would foster a robust public 
health workforce and provide support to those who fought on the 
front lines of the COVID-19 pandemic. Throughout the pandemic, 
physicians, nurses, scientists, contact tracers, community 
health workers, and many others have worked tirelessly to 
attend to the needs of patients, and to promote the health and 
wellbeing of our communities. And it is a tribute to their 
selfless work over the last 18 months that we are gradually 
approaching a new normal, but we are not out of the woods yet.
     The pandemic has stressed our healthcare system, with many 
healthcare workers suffering from fatigue and burnout. And 
unfortunately, some workers are leaving the workforce entirely. 
Historically underserved areas, rural and tribal communities, 
in particular, are suffering from a lack of access to basic 
public health services and are experiencing workforce 
shortages.
    And there is also an alarming trend in the mental health of 
healthcare professionals. An April survey from the Kaiser 
Family Foundation and the Washington Post found that a majority 
of frontline healthcare workers say that stress related to 
COVID-19 has had a negative impact on their mental health and 
that same survey found that only 12 percent of healthcare 
workers receive mental health services. An additional 18 
percent reported that even though they thought they needed 
care, they did not seek it due to busy schedules, stigma, fear, 
or financial concerns.
    These issues demonstrate the need for broad investments and 
support for our healthcare workforce. This includes resources 
to recruit and retain talented health professionals and to 
protect their mental well-being going forward. And the seven 
bills before us today recognize the urgency of these issues by 
addressing the mental health burden faced by frontline workers, 
creating incentives and novel pathways for services to 
underserved communities, strengthening workforce capacity so we 
can meet future public health emergencies head on, and 
incorporating the needs of caregivers for Alzheimer's patients.
    I just wanted to mention the bills H.R. 1667, the Dr. Lorna 
Breen Health Care Provider Protection Act authorizes grants for 
mental and behavioral health training for healthcare workers. 
It also authorizes grants for its programs and campaigns to 
improve the mental health and resiliency of healthcare 
providers. This bill was named for Dr. Lorna Breen, the medical 
director of the emergency department at New York-Presbyterian 
Allen Hospital, whose family is here to provide testimony on 
the bill. And I would like--I want to thank them for being here 
today.
    Two of the bills before us aim to build a more diverse and 
community-based healthcare workforce. H.R. 5594, the Enhancing 
Community Health Workforce Act, would improve health outcomes 
in medically underserved neighborhoods by investing in outreach 
through community health workers.
    And then there is H.R.--I guess it is 33520 (sic), the 
Allied Health Workforce Diversity Act, that seeks to increase 
diversity in the physical, occupational, and respiratory 
therapies, as well as audiology and speech language pathology 
professions. And this legislation would accomplish--would, 
basically, authorize grants for scholarship stipends and 
recruitment and retention programs for students from under-
represented backgrounds.
    We are also considering bills that would provide guidance 
on how to expand our pandemic response and strengthen workforce 
resiliency. H.R. 3297, the Public Health Workforce Loan 
Repayment Act, establishes a student loan repayment program for 
public health professionals that complete a period of full-time 
employment with a state, tribe, or local public health agency 
for at least three years.
    And then there is H.R. 5602, the BIO Preparedness Workforce 
Act, that helps grow the infectious disease workforce by 
creating loan repayment programs for healthcare professionals 
who spend at least half of their time engaged in bio 
preparedness and response activities. And they will also be 
eligible if they provide infectious disease care in a shortage 
designation area, underserved community, or federally funded 
facility.
    And then the last bill, H.R. 1474, the Alzheimer's 
Caregiver Support Act, authorizes additional funding to expand 
training and support services for unpaid caregivers of people 
living with Alzheimer's disease.
    So obviously, these are all important. We would like to 
move them forward and I look forward to our discussion and 
hearing more from the panel, Madam Chair.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone Jr.,

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Mr. Pallone. Thank you again, Ms. Eshoo.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the Ranking Member of the Full Committee, 
Congresswoman Cathy McMorris Rodgers, for her 5 minutes for 
opening statement. And she is joining us, I believe----
    Mrs. Rodgers. In person.
    Ms. Eshoo. Oh, you are here. Oh, that is great. I am 
looking up at the screen.

      OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

    Mrs. Rodgers. Thank you, Madam Chair. To all Americans who 
work in healthcare, thank you. You are all heroes who have been 
on the front lines at every stage during this pandemic, caring 
for people who need you. Your sacrifices, especially during 
these most uncertain times, is why we will not stop our 
investigation into COVID-19 origins. We must hold China 
accountable for hiding lifesaving information that could have 
made your job easier.
    I know you are tired. There is great frustration and 
anxiety. Health care providers from my home state of Washington 
are sounding the alarm. Our vaccine mandate took effect on 
October 18th. According to the Washington Hospital Association, 
they expect to lose up to five percent of their entire 
workforce. That is up to 7,500 workers whose patients and 
families are depending upon them.
    I hope that the Biden Administration will learn a lesson 
from these mandates that have made Washington State a difficult 
place right now, and I hope that he will abandon--President 
Biden, will abandon--his top-down federal mandate. This 
approach, these type of mandates, only promote fear and 
control. And they are making the shortages worse.
    Across the country, 11 million jobs remain unfilled. It is 
more expensive to purchase nearly everything, from food to 
fuel. It is getting harder to get by. And ultimately, more and 
more people are facing a choice to either comply with a 
mandate, or lose their livelihood altogether. I have heard too 
many heart-wrenching, heartbreaking stories from individuals in 
eastern Washington in recent weeks. The hard-working men and 
women of this country, especially our frontline healthcare 
workers, our heroes, need solutions, not force and fear that is 
eroding trust in public health.
    I am glad that Mr. Levine is here to discuss what 
challenges he is facing, and how Congress might be able to 
help.
    I have always been a strong supporter of existing federal 
incentives to support health provider training and education, 
including championing the reauthorization of the Teaching 
Health Center Graduate Medical Education Program. Through the 
CARES Act, Congress reauthorized the major health workforce 
programs under title 7 and title 8 of the Public Health 
Services Act, run by Health Resources and Services 
Administration.
    CARES also required a strategic plan to better inform 
Congress on a framework for addressing workforce needs. This 
plan was given to us last night, a month over--after it was 
due. It certainly would have been helpful to have it before 
last night, but we will look forward to looking at that to 
better direct our legislative efforts that we are considering 
today.
    In addition to many existing grant programs that support 
health workforce through CMS payments, the Federal Government 
has spent roughly $16 billion per year on the health workforce 
as of 2015. In December 2020, Congress passed legislation that 
will add 1,000 new GME slots, starting in 2023.
    Further, in the American Rescue Plan, Democrats, although 
they went it alone, they allocated a lot of money on workforce 
programs, including billions for public health programs, 
hundreds of billions for more Medical Reserve Corps, National 
Health Service Corps, Nurse Corps, teaching health centers, and 
behavioral health workforce. In reconciliation, Democrats are 
also providing almost 150 million in mandatory funding for an 
unauthorized program that some are now seeking to authorize 
through one of the bills before us today.
    While I support the intent of this program, this is the 
wrong way to legislate. We need to know what is actually 
working before spending more money, and authorizing more 
programs.
    We should be looking at how states are leading. Governors 
DeSantis and Baker gave more flexibility with staffing ratios, 
including the use of personal care attendants to meet 
requirements. Governor Sununu authorized military service 
members and emergency medical technicians to obtain temporary 
licenses as nursing assistants. Governors Hogan, Hutchinson, 
and Ricketts worked to streamline licensing, by allowing nurses 
from out of state to practice, waiving application fees for 
nursing licenses, and removing red tape for license renewals.
    States are also funding programs and working with medical 
schools on long-term strategies to improve retention in 
underserved areas. Dr. Keel is here today to share how Augusta 
University is leading to reduce medical debt, and encourage 
doctors to work in underserved areas in Georgia. I am excited 
to hear about this, and how maybe it could work in my home 
state of Washington.
    Overall, states regulate the practice of medicine. At the 
Federal level, we need to support states and share best 
practices.
    The healthcare workforce plays a key role in our economy, 
keeps our patients healthy and safe. We owe so much to our 
frontline workers, who have been at the forefront of this 
pandemic. Let's hear from the states. Let's hear from those 
that are on the front lines. I yield back.
    [The prepared statement of Mrs. Rodgers follows:]

           Prepared Statement of Hon. Cathy McMorris Rodgers

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Ms. Eshoo. The gentlewoman yields back.
    The Chair reminds Members that, pursuant to committee 
rules, all Members' written opening statements shall be made 
part of the record, so make sure, members, you get your 
marvelous remarks in.
    I now would like to introduce our witnesses.
    First, Mr. Corey Feist. He is the founder of the Dr. Lorna 
Breen Foundation. He is the brother-in-law of Dr. Breen. And 
with him, seated behind him, is Jennifer Breen Feist, Dr. 
Breen's sister.
    Thank you for being here today, on behalf of everyone on 
the committee. We are very grateful to you for being willing to 
testify.
    Next, Ms. Lisa Macon Harrison, she is the president of the 
National Association of County and City Health Officials. And I 
would like to call on Mr. Butterfield to enhance her 
introduction, because she is his constituent.
    So are you with us?
    Mr. Butterfield. I am with you. Thank you, and good 
morning, Madam----
    Ms. Eshoo. There you are.
    Mr. Butterfield. Madam Chair, and----
    Ms. Eshoo. Good morning.
    Mr. Butterfield. Can you hear me?
    Ms. Eshoo. Yes, very well.
    Mr. Butterfield. OK, thank you.
    Ms. Eshoo. Yes.
    Mr. Butterfield. Good morning, Madam Chair. Good morning to 
all of my colleagues, and thank you to all of the witnesses for 
your testimony today. I will be very brief, but I want to 
introduce to my colleagues Lisa Macon Harrison.
    Ms. Harrison is the--testifying today in her capacity as 
president of the National Association of County and City Health 
Officials. But she is also the health director of Vance County, 
which is in my congressional district, and Granville County, 
which is in the adjoining area. Ms. Harrison has worked at the 
intersection of public health research and practice in my great 
state of North Carolina since 1995. She has a bachelor's degree 
in public health and public policy, and a master of public 
health from the Gillings School of Global Public Health at the 
legendary UNC Chapel Hill.
    She has co-authored more than 30 peer-reviewed 
publications, and is associated with both UNC Chapel Hill and 
the Duke University School of Nursing. Even though these 
schools are competitors in sports, they collaborate every day 
in academics and other endeavors.
    So thank you, Ms. Harrison, for coming today.
    I will conclude by saying that she serves as a member of 
the North Carolina Institute of Medicine, and is a past 
president of the North Carolina Public Health Association. She 
is a current president of the National Association of County 
and City Health Officials, and previously represented five 
southern states on its board of directors.
    As you can see, our witness is well-qualified to testify 
today.
    Thank you very much, Madam Chair. I yield back.
    Ms. Eshoo. Thank you, Mr. Butterfield. Beautiful words 
about Ms. Harrison, and it is always a reminder to me of what 
extraordinary Americans we have in their--whatever their 
capacity is, they come here, and we are better for it.
    Dr. Brooks Keel, he is the president of Augusta University, 
and I would like to recognize Mr. Carter to introduce his 
constituent, Dr. Keel.
    But a warm welcome to you, Doctor. It is great to see you.
    Mr. Carter. Well, thank you, Madam Chair and Ranking Member 
Guthrie, for inviting a great witness to testify today from my 
home state of Georgia, Dr. Brooks Keel.
    Dr. Keel is the president of Augusta University. It is the 
ninth largest medical school in the country. Georgia, as you 
know--we often say there are two Georgians, there is Atlanta 
and everywhere else. And of course, everywhere else is pretty 
much rural. And Georgia has faced severe physician shortages in 
rural areas of our state, and Dr. Keel's leadership has led 
Augusta University to create a unique solution to this problem 
to encourage students to open practices in medically 
underserved areas. I am excited to introduce him today.
    Thank you for being here, Dr. Keel, and I know we are all 
looking forward to hearing more about this innovative program 
that I think is going to benefit all rural areas of our 
country, but particularly, in the beginning, the rural areas of 
Georgia. So thank you very much for being here.
    Ms. Eshoo. Thank you, Mr. Carter.
    Dr. Victoria Garcia Wilburn is an assistant professor of 
occupational therapy at the IUPUI School of Health and Human 
Sciences.
    Welcome to you, a warm welcome. Thank you for being here 
with us today.
    And last, but not least, Alan Levine is the executive 
chair, president, and CEO of Ballad Health, a health system 
serving Northeast Tennessee, Southwest Virginia, Northwest 
North Carolina, and Southeast Kentucky. I would like to 
recognize Mr. Griffith to introduce Mr. Levine, since he is one 
of his constituents.
    Mr. Griffith. Thank you.
    Ms. Eshoo. So you are recognized, my friend.
    Mr. Griffith. Thank you very much. I appreciate it, and I 
would like to welcome Alan Levine here with us today, I have 
known him for many years.
    He is chairman, president, and chief executive officer of 
Ballad Health, which, as you heard, serves a big chunk of area 
in Appalachia. Ballad Health operates 13 hospitals in 
Tennessee, 7 in my district in Southwest Virginia, including 
the Lee County Community Hospital, which opened earlier this 
year in Pennington Gap.
    And I say opened, because it had closed and, working with 
the community, they reopened it. They were able to get it 
reopened about four or five years after it had originally 
closed. That is fairly unusual for hospitals in rural areas 
that close, particularly in rural Appalachia. So we are very 
pleased about that.
    Ballad employs 14,000 individuals, including 800 
physicians, many of whom serve in very rural areas. His wife, 
Laura, is a nurse, and they have two grown children, who also 
have careers in healthcare.
    So, we are very glad to have him with us today, and 
appreciate him taking his time. Even though he couldn't be here 
live with us in the room, he will be participating on the 
video.
    Ms. Eshoo. The gentleman yields back?
    Thank you.
    Ms. Stephanie Monroe, she is the director of equity and 
access of UsAgainstAlzheimer's, and executive director of 
AfricanAmericansAgainstAlzheimer's.
    Thank you for being with us today. It is wonderful to see 
you, and thank you for your extraordinary leadership.
    Dr. Jeanne Marrazzo is a board member of the Infectious 
Disease Society of America and Infectious Disease Division 
Chief of the University of Alabama at Birmingham.
    Thank you, Dr. Marrazzo, to you, as we welcome and 
acknowledge not only all of the brilliance that you each bring 
to the hearing today, but for your life's work. You have made 
our country better, and you do every day.
    So thank you, each one, for joining us. We look forward to 
your testimony. You are probably--I don't know if you are 
familiar with the lights in front of you. Green, just go for 
it. Yellow, warning. And you know what red is.
    So we will start with Mr. Feist for your 5 minutes of 
testimony. And again, thank you for being with us.

  STATEMENT OF COREY FEIST, FOUNDER, DR. LORNA BREEN HEROES' 
 FOUNDATION; LISA MACON HARRISON, M.P.H., PRESIDENT, NATIONAL 
   ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS (NACCHO); 
BROOKS A. KEEL, PH.D., PRESIDENT, AUGUSTA UNIVERSITY; VICTORIA 
     GARCIA WILBURN, D.H.SC., O.T.R., F.A.O.T.A. ASSISTANT 
PROFESSOR, OCCUPATIONAL THERAPY, IUPUI SCHOOL OF HEALTH & HUMAN 
SCIENCES; ALAN LEVINE, EXECUTIVE CHAIRMAN, PRESIDENT, AND CEO, 
  BALLAD HEALTH; STEPHANIE MONROE, J.D., DIRECTOR, EQUITY AND 
       ACCESS, USAGAINSTALZHEIMER'S, EXECUTIVE DIRECTOR, 
AFRICANAMERICANSAGAINSTALZHEIMER'S; AND JEANNE MARRAZZO, M.D., 
  BOARD MEMBER, INFECTIOUS DISEASE SOCIETY OF AMERICA (IDSA), 
  INFECTIOUS DISEASE DIVISION CHIEF, UNIVERSITY OF ALABAMA AT 
                           BIRMINGHAM

                    STATEMENT OF COREY FEIST

    Mr. Feist. Thank you for having me today. My name is Corey 
Feist. As you heard, I am the president and co-founder of the 
Dr. Lorna Breen Health--Heroes Foundation. I am also the chief 
executive officer of the University of Virginia Physicians 
Group, which employs all of the physicians and most of the 
nurse practitioners and advanced practice professionals at the 
University of Virginia Health System in Charlottesville.
    I am also the proud husband of Jennifer Breen Feist, who is 
sitting over my shoulder, who is here with me today, and is 
also welcome to answer any questions that you might have of 
her. Jennifer co-founded the Dr. Lorna Breen Heroes Foundation 
with me in June of 2020, and she is the sister of Dr. Lorna 
Breen.
    I want to start by thanking the chair and ranking member of 
the--for the opportunity to address the committee today. 
Unfortunately, the thousands of healthcare professionals who 
take such incredibly amazing care of us, particularly during 
this pandemic, cannot access mental health support, and it is 
critical that this changes.
    On behalf of the thousands of healthcare professionals, I 
am here to encourage you to immediately consider passing H.R. 
1667, the Dr. Lorna Breen Health Care Provider Protection Act, 
which aims to reduce and prevent suicide, burnout, and mental 
and behavioral health conditions among healthcare 
professionals. The companion legislation to this bill, S.610, 
unanimously passed the Senate on August 6th.
    I would like to extend a special thank you to 
Representatives Wild, McKinley, Krishnamoorthi, and Chu, along 
with Senators Kaine, Reed, Cassidy, and Young for championing 
this first-of-its-kind legislation.
    Let me start by sharing a little bit about my sister-in-
law, Dr. Lorna Breen. This picture in front of me was taken on 
March 10th, 2020, while on a Montana ski trip with our family. 
That is my daughter, Charlotte, with us.
    As Jennifer has said, this was the last week of normal for 
our family, and for many of us across this country.
    Dr. Breen was the medical director of the emergency 
department at NewYork-Presbyterian's hospital, and left our 
Montana ski trip to return home to take care of patients. In 
the three weeks that followed, Dr. Breen treated confirmed 
COVID patients, contracted COVID herself, and returned to an 
overwhelming, relentless number of incredibly sick patients.
    After 12-hour shifts, she and her co-workers would stay, 
because the influx of patients never slowed. Yet she kept going 
back until she, literally, could no longer stand. Despite these 
overwhelming challenges, she pushed on, and tried to push 
through.
    Sharing that the entire time she was concerned that her 
inability to keep up was going to end her career, by April 9th 
Lorna hit her breaking point. She couldn't get out of her 
chair. She called Jennifer on the phone. She was nearly 
catatonic, and needed immediate help.
    Lorna answered the call for her city, for her country. But 
when she needed to take care of herself, she was concerned 
about her job, fearing she would lose her license, or be 
ostracized by her colleagues. She died by suicide April 26, 
2020, 47 days after this picture was taken.
    When Lorna died, we were all looking around, saying, ``Why, 
how did this happen? When did it? Why did it happen?'' We were 
in the news all over the world. And then something that we 
found completely unbelievable happened: people started reaching 
out. The families of doctors and nurses and other healthcare 
providers told us their own stories about their loved ones who 
had died by suicide. All total strangers.
    Many doctors and nurses continue to suffer in silence with 
mental health challenges, due to both cultural and regulatory 
hurdles, which reinforce and often prevent them from obtaining 
help, the same help that we can all get in this room.
    Prior to the pandemic, the suicide rate among physicians 
and nurses was twice the national average in this country. In 
fact, prior to the pandemic, 400 physicians died by suicide 
each and every year.
    Early after Dr. Breen's death we heard about a phrase 
coined the ``parallel pandemic,'' which refers to the mental 
health crisis in medicine. Lorna kept telling us she was going 
to lose her license, lose her job, all because she required 
mental healthcare for the first time in her career. She was 
mortified, fearing her colleagues would never want to work with 
her again. We promised her she wasn't right. And after she 
died, we learned that she was.
    This is not OK. This is not normal. This is not right. We 
believe Lorna died because she was a physician.
    Consider the following statistics before the pandemic: 96 
percent of medical professionals agree that burnout was an 
issue; 42 percent were reluctant to seek mental health 
treatment; 50--and then after the pandemic, 55 percent of 
professionals agree that burnout is an issue; 60 percent say 
that stress has harmed their mental health.
    On top of these statistics, Dr. Breen's case, nearly all of 
the healthcare professionals--nearly half of those 
professionals won't obtain treatment. This is like sending the 
entire healthcare workforce to war, and not supporting them 
when they come back.
    Thank you for consideration of the Dr. Lorna Breen Health 
Care Provider Protection Act, and your support of our 
healthcare heroes.
    [The prepared statement of Mr. Feist follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Mr. Feist.
    I also would like to acknowledge that there are two members 
that are cosponsors of that legislation on the committee, Mr. 
Upton and Mr. Griffith, and we thank you for your fine work. 
Thank you for your testimony.
    Ms. Harrison, you are recognized for 5 minutes.

                STATEMENT OF LISA MACON HARRISON

    Ms. Harrison. Good morning, Chairwoman Eshoo, Congressman 
Guthrie, and members of the subcommittee. My name is Lisa Macon 
Harrison, and I am president of the National Association of 
County and City Health Officials, also known as NACCHO. This is 
the association that represents our nation's nearly 3,000 local 
health departments.
    I am also the local health director of Granville-Vance 
Public Health in North Carolina, serving a rural population of 
approximately 100,000.
    Thank you for the opportunity to speak to you today about 
the critical importance of the nation's public health 
workforce, and legislative opportunities to support them.
    My colleagues across the country in local health 
departments have been the tip of the spear in the pandemic 
response. They have been the voices over the phones, the hands 
in the gloves, the faces behind the masks, the arms in the 
gowns, and the fingers typing away on data updates daily for 
local communities to help others understand how we are getting 
through this pandemic, community by community.
    In my district alone, our 12 public health nurses have 
delivered over 40,000 vaccines, which is over half of the 
COVID-19 vaccines delivered in our counties. While we are still 
in the background, contact tracing, still testing, still 
educating the public, still consulting with local schools and 
courthouses and businesses, so that people can feel safe.
    No other healthcare partners have the same breadth of 
responsibilities for communicable disease control and health-
related policy decisions the same way public health is. Our 
workforce is our most critical asset. However, a decade of 
disinvestment leading up to the pandemic meant that health 
departments were understaffed and overworked long before this 
crisis hit. Local health departments started the pandemic 20 
percent down in workforce capacity, and the pandemic really 
stretched thin our already lean workforce. Preliminary findings 
from NACCHO's 2020 Forces of Change survey show that over 80 
percent of local health departments reassigned existing staff 
from regular duties to the agency's COVID-19 response. That was 
certainly true in my district.
    The response is taking a toll. Turnover is up across 
communities, and some health department staff have actually 
shrunk again during the pandemic. For some, it is the intense 
polarization and threats that drive them away. Others are lured 
away by better paying opportunities in hospitals or the private 
sector, while still others are leaving due to the response's 
effect on mental health. In fact, this past spring, CDC found 
out that over half of public health workers were experiencing 
symptoms of PTSD.
    We expect this migration out of governmental public health 
to be more acute when the pandemic ends, as many of my 
colleagues have stated they are committed to staying the course 
during the crisis, but will leave as soon as the threat is 
abated. I have seen firsthand the turnover rate increase at my 
local health department before the pandemic. Our annual 
turnover was between 2 and 5 percent, annually; right now it is 
closer to 12 percent. In rural areas like mine it can take 
months to fill vacant positions. The public health workforce 
crisis needs our attention, both now and in the future.
    In order to build the public health workforce for the 21st 
century, we have to focus on three different factors: retaining 
the current hardworking, skilled, and experienced staff we 
have; recruiting top new talent; and expanding the workforce 
with more predictable, sustainable funding. That is why we are 
so appreciative that you are considering bipartisan legislation 
that would make a meaningful impact in these efforts, H.R. 
3297, the Public Health Workforce Loan Repayment Act. Thank 
you.
    This bill would create a loan repayment program for public 
health professionals who work at local, state, or tribal health 
departments for at least three years. It is modeled after the 
successful National Health Service Corps, with support from 
clinical healthcare workforce, and would be the first dedicated 
program to help recruit and retain top talent into public 
health departments, where they are so desperately needed.
    Public health loan repayment has support from health 
departments large and small, as well as from over 100 public 
health medical, academic, labor, and consumer stakeholder 
groups. We hope it will have your support, as well.
    While the Public Health Loan Repayment bill will help 
recruit new staff, we must also invest in public health 
infrastructure to provide predictable, sustained, and disease-
agnostic funding to bring back the positions we have lost, and 
support optimal staffing levels.
    Moreover, we must do better to increase salaries and 
benefits for public health department staff, and offer those 
already in the pipeline a career ladder to stay in the field 
long-term. Federal policy plays a role here, as well, as jobs 
tied to specific Federal programs at the local level often pay 
so much less than a living wage.
    The challenges facing the public health workforce are 
incredible, but with your help we can make a meaningful impact 
to support them while they support our communities. Thank you 
for your attention to these issues. I am happy to answer any 
questions.
    [The prepared statement of Ms. Harrison follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much. Excellent testimony.
    Dr. Garcia Wilburn, you are recognized for--oh, I am sorry.
    Dr. Keel--I didn't do that on purpose, Dr. Keel. It is my 
eyesight. You are recognized for your 5 minutes, and welcome 
again. Lovely to have you.

                  STATEMENT OF BROOKS A. KEEL

    Dr. Keel. Chairwoman Eshoo, Ranking Member Guthrie, and 
members of the Subcommittee on Health, thank you very much for 
the opportunity to speak with you today.
    And thank you, Representative Carter, for your 
introduction, and for the continuing service to our great state 
and to this country.
    My name is Brooks Keel. I am the president of Augusta 
University. AU is one of four public research intensive 
universities in the State of Georgia, and the home of the 
Medical College of Georgia, or MCG, which is the thirteenth 
oldest and ninth largest medical school in the country. We are 
the only public medical school and the only public academic 
health center in the state.
    It is no secret that the entire country is facing a 
physician shortage. Where primary care physicians are in short 
supply everywhere, the lack of providers in rural settings is 
especially acute. Georgia has a severe shortage of physicians, 
ranking forty-first in the country in physicians per capita. 
Currently, eight counties in Georgia have no practicing 
physician at all.
    One contributor to the physician shortage is the staggering 
amount of debt incurred while pursuing a medical degree. While 
MCG offers scholarships to the neediest of students, more than 
80 percent of MCG students graduate with debt, sometimes 
exceeding $130,000. This debt can discourage future physicians 
from practicing in the very areas where their need--where the 
need is the greatest, and may also dissuade medical students 
from choosing a career path in primary care, as specialty 
fields often prove to be more financially lucrative.
    Today I want to share with you the details on a program 
created at the Medical College of Georgia termed MCG 3+, which 
aims to eliminate medical school tuition debt and reduce 
disparities, by increasing access to care in rural and 
underserved areas across the state, and begins to tackle the 
extreme physician shortage that we are experiencing in one of 
the top ten most populous states in the country.
    First, by employing a unique and novel curriculum, the 3+ 
program shortens medical school from four years to three years. 
Right away, this reduces medical school debt by 25 percent.
    Second, we are asking first-year medical students who have 
a passion for primary care, and a propensity for practicing in 
rural Georgia, to commit to primary care residency in the State 
of Georgia. This alone will significantly enhance the chance 
that these students will continue to stay in practice in the 
state once they complete their training.
    And in this context, I am referring to primary care in the 
broadest of terms, to include family medicine, internal 
medicine, pediatrics, but also psychiatry, obstetrics, 
gynecology, emergency medicine, and general surgery.
    Third, if these motivated students will commit to 
establishing their clinical practice in an underserved rural 
area in Georgia, and will agree to practice in these areas for 
at least three years after completing their residency training, 
we will waive their medical school tuition. In other words, 
free medical school in return for a year-for-year clinical 
service commitment in rural Georgia.
    I should point out that, while the primary impetus for the 
3+ program was to incentivize physicians to establish a 
clinical practice in rural and underserved Georgia, this 
overall approach should also lead itself to tackle other vital 
needs the state may have. For example, we are exploring whether 
the 3+ program will allow us to address a critical shortage of 
medical examiners and forensic pathologists in the state.
    Additionally, as I mentioned earlier, psychiatry is one of 
the seven primary care pathways identified in MCG's 3+ program. 
We are, therefore, excited about how the reauthorization of 
H.R. 5583, Helping Enable Access to Lifesaving Services Act, 
might indeed play a role in our 3+ program.
    The 3+ was implemented in the fall of 2021, and MCG has 
contracted with nine first-year medical students to join this 
program. We hope to add another ten next year. We recently 
received a $5.2 million gift from Peach State Health Plan, a 
subsidiary of Centene Corporation, in support of the 3+ rural 
program. This was matched by another $5.2 million from the 
State of Georgia, allowing us to establish the $10.4 million 
endowment to cover the cost of tuition for these physicians.
    We are aggressively seeking additional public and private 
philanthropic opportunities that will allow us to support 
additional students who desire to take advantage of this 
program. Our goal is to create a continuing pipeline of 
physicians who are dedicated to meeting the healthcare needs of 
the state, both now and well into the future.
    We believe that leveraging the combined efficiencies of the 
accelerated three-year M.D. curriculum, coupled with tuition-
free medical education and an in-state primary care residency 
experience, MCG will dramatically enhance our contribution to 
Georgia's physician workforce, and significantly impact the 
health and economic prosperity of all Georgians, especially 
those living in our rural and underserved areas.
    Madam Chairwoman and Ranking Member Guthrie, thank you once 
again for your interest in Augusta University and the Medical 
College of Georgia, and for allowing me to be here today. I 
will be happy to answer the questions you or the committee may 
have.
    [The prepared statement of Dr. Keel follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Dr. Keel. That is helpful. 
It is not only helpful, it is hopeful, and we all need hope.
    Dr. Wilburn, it is indeed your time for your testimony.
    Dr. Wilburn. Thank you.
    Ms. Eshoo. Welcome again.

              STATEMENT OF VICTORIA GARCIA WILBURN

    Dr. Wilburn. Chairwoman Eshoo, Ranking Member Guthrie, and 
members of the Health Subcommittee, thank you for inviting me 
to speak to you today in strong support of H.R. 3320, the 
Allied Health Workforce Diversity Act.
    This legislation is crucial, as our nation looks to recover 
from the pandemic and have an allied health workforce that 
mirrors the makeup of our nation.
    I want to thank Representatives Rush and Mullin for their 
leadership on this bill.
    I also want to thank Ranking Member McMorris Rodgers, who 
has been such a champion for this bill since it was first 
introduced in the 116th Congress, passing unanimously out of 
the House of Representatives as part of the larger title 7 
workforce program's reauthorization package.
    When reflecting on this legislation, I think about how 
different my life would have been if the Allied Health 
Workforce Diversity Program had existed when I was on my 
trajectory to becoming an occupational therapist. I would have 
been provided a distinct pathway to my career, instead of 
spending countless hours navigating potential college majors as 
a first-generation student. I would have had improved mental 
health, and perhaps my academic achievement would have been 
greater with more support.
    After my parents moved to Chicago--after my parents 
married, they moved to Chicago for the booming industry jobs. 
My father was in construction for 30 years, and my mother, who 
didn't finish the eighth grade, worked in a factory at night, 
while my four older siblings slept. When we were old enough, 
she enrolled in cosmetology school. Her cosmetology diploma was 
the first degree to ever hang in our home.
    My parents strongly believed education equaled opportunity. 
But as the youngest of five, my parents' ability to provide 
financial support was limited. Financial support from Boston 
University and Federal student loans allowed me to afford a 
bachelor's degree in occupational therapy. But it is because of 
the network of mentors and career counselors who became like 
family at BU that I speak to you today, as a licensed 
occupational therapist and member of the board of directors of 
the American Occupational Therapy Association.
    The Allied Health Workforce Diversity Act would provide 
thousands of future students of respiratory therapy, 
occupational therapy, physical therapy, speech language 
pathology, and audiology with access to additional, targeted 
supports beyond what I received, like mentorship and tutoring. 
Students who are disadvantaged and from under-represented 
communities bring a unique perspective to our healthcare 
system, and improve health outcomes. If we, as a nation, want 
to improve patient care and reduce health disparities, we must 
increase our efforts to recruit, train, and support these 
students.
    The Allied Health Workforce Diversity Act creates a grant 
program in title 7 of the Public Health Service Act, 
administered by the Health Resources and Services 
Administration. Grants would be awarded to accredited higher 
education programs of respiratory therapy, occupational 
therapy, physical therapy, speech language pathology, and 
audiology to support efforts to increase the opportunities of 
students from under-represented and disadvantaged backgrounds.
    The funding the grant provides would support efforts by the 
program to attract, recruit, and retain individuals under-
represented in these professions. It will fund community 
outreach efforts, mentoring and tutoring program creation or 
expansion, and financial support directly to the students in 
the form of scholarship and stipends.
    The program is modeled after a similar successful program, 
the Nursing Workforce Diversity Act. According to the Bureau of 
Labor Statistics data, since its creation in 1998, the 
Workforce Diversity Program has doubled the percentage of 
nurses from a diverse background. H.R. 3320 seeks to duplicate 
the success of the nursing program, while providing HRSA with 
the flexibility to continuously define which communities are 
considered under-represented, to grow with an ever-changing 
healthcare workforce.
    While the bill cites people from ethnic or racial 
minorities, or those with a disability as an example for an 
individual under-represented in the profession, HRSA would have 
the authority to fund programs seeking to increase the share of 
students from other backgrounds, such as those from rural, 
military, or agricultural communities.
    A study published in JAMA in March, 2021 stated, 
``Fostering a diverse, inclusive workforce is critical to 
increasing access to care and improving aspects of healthcare 
quality.''
    The research shows two important findings. First, health 
professionals from under-represented and minority backgrounds 
are more likely to practice in medically underserved areas. 
Patients who receive care from healthcare professionals of 
their own cultural background tend to have better outcomes.
    The same study shows the higher education pipeline of the 
allied health professionals are less diverse than the current 
workforce findings, which match an analysis of the national 
college progression rates by the National Student Clearinghouse 
Research Center. Between 2019 and 2020, the national college 
enrollment rate fell 9.4 percent for students from high 
minority high schools.
    I thank the committee for the opportunity to come here 
today and discuss this important issue. The Allied Health 
Workforce Diversity Act as an opportunity to move our nation 
along the path to recovery.
    I look forward to working with you, and I am happy to 
answer any questions you might have.
    [The prepared statement of Dr. Wilburn follows:]

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    Ms. Eshoo. Well, bravo. Let it be noted that the baby the 
family came and testified before the Congress of the United 
States of America. Bravo to you, bravo.
    Next, Mr. Levine, who is the chair of the board and chief 
executive officer of Ballad Health, welcome to you, and thank 
you for your testimony to the committee this morning.

                    STATEMENT OF ALAN LEVINE

    Mr. Levine. Thank you, Madam Chair, and thank you, members.
    Before I begin, I would like to say that, in my opinion, I 
do not believe that we, as a nation, have shown enough respect 
for the nurses and frontline caregivers in a manner worthy of 
the sacrifice and labor they have given us. And I am grateful 
to you and to your committee for affording us the opportunity 
to embark upon correcting this, and providing them with the 
support they deserve, and I agree with the advocacy you have 
heard from my colleagues on your panel.
    My name is Alan Levine, and I have the honor of serving as 
the chairman of Ballad Health, which is an integrated health 
improvement organization serving the incredible Appalachian 
Highlands, a non-urban and rural region of about 29 counties 
the size of New Hampshire. Proudly, also the twenty-ninth best 
employer for diversity in America, according to Forbes Magazine 
in 2020.
    The Appalachian Highlands is unique for its beauty, low 
cost of living, and friendly culture. But it is not unique, 
however, when it comes to an emerging national crisis. And that 
crisis is the supply and resiliency of our nation's healthcare 
workforce. In particular, our nursing professions.
    As some of the legislation before you today thankfully 
recognizes, this challenge to our workforce has a 
disproportionate impact on our nation's non-urban and rural 
communities, which make up 85 percent of America's landmass. 
Despite the financial headwinds brought on by the combination 
of the pandemic and the major investments necessary in wages 
due to the shortages, Ballad Health yesterday announced a major 
partnership with East Tennessee State University, making a $10 
million commitment to create what we hope will be a nationally-
recognized Center for Nursing Advancement, focused on studying 
and acting on the issue of nursing resiliency and supply.
    As the data in my written testimony supports, the nursing 
shortage was a crisis before the pandemic. But the pandemic has 
now revealed the problem of resiliency and the major mental 
health and behavioral aspects of the last two years. Consider 
that, since 2016, the average American hospital has turned over 
about 83 percent of its nursing staff. Twenty-four percent of 
registered nurse turnover is occurring in the first year, which 
points to the issue of resiliency. And for the first time now, 
retirement is one of the top three reasons given for nursing 
turnover, which is a frightening fact.
    The cost of this, in terms of quality of care and 
sustainability, is enormous. And as I detail in my written 
testimony, Ballad Health, an important system operating on a 
slim two percent margin prior to the pandemic, has now 
invested, this year alone, a recurring $100 million into 
mitigating the turnover issue. Once the very generous federal 
pandemic support is gone, I do fear this could have a lasting 
impact on our sustainability, as a rural health system.
    With 180 rural hospitals already having closed nationally, 
it is an obvious worry, especially given that we are now paying 
fourfold for contract labor, with rates as high as $140 per 
hour for med-surg nurses. Most rural health systems can't 
afford to do this for very long, and in our case we have 
nowhere to turn. Seventy percent of our payer mix is 
government-established payment, while only twenty-one percent 
is commercially market-based insured. Government payment is not 
and cannot keep up with the inflation we are seeing in the 
market right now, and it is further harmed by the arcane and 
frustrating Medicare Area Wage Index.
    Rural health systems like Ballad Health are critical to the 
health and overall well-being of the communities we serve. Not 
only are we serving the current disproportionately high chronic 
health needs of our population and the demands of COVID-19, but 
as leading providers of preventive services, health education, 
social care navigation, and employment, community-led hospitals 
and health systems are important catalysts for overall 
community health improvement.
    In Ballad Health's case, our programs aimed at helping 
pregnant women combat addiction, and focusing on the needs of 
pregnant women whose newborns are likely to experience trauma, 
childhood trauma, rely heavily upon a skilled workforce, 
including community health workers, something I hope to expand 
upon during the Q&A session.
    I have included numerous citations in my written testimony, 
but Linda Shepherd, the chief nursing officer at our Johnston 
Memorial Hospital in Abingdon, Virginia, and president of the 
Virginia Nurses Association, summed up our current situation 
best: ``Our nurses''--and I quote--``Our nurses are mentally 
depleted, exhausted, and traumatized, experiencing pandemic-
related PTSD with little or no time to seek mental health 
services. Suicide among nurses and other members of the medical 
community is also on the rise.''
    Clearly, many of the provisions you are considering here 
today are intended to get to the heart of this problem. Ballad 
Health was proud to support, for instance, the introduction of 
the Dr. Lorna Breen Health Care Provider Protection Act, which 
should help improve healthcare providers' mental health, and 
reduce burnout. And while not on today's agenda, Ballad Health 
has also been working with Congress, including many of you on 
this committee, to gain passage of the Save Rural Hospitals Act 
to establish a permanent national minimum Area Wage Index to 
ensure our healthcare manpower is compensated fairly.
    I would like to thank you, Madam Chair and the ranking 
member, for the invitation to participate in today's hearing, 
and I especially want to thank Congressman Griffith for his 
unwavering advocacy for our region.
    I would be happy to discuss Ballad Health's initiatives or 
any other legislative or administrative proposals impacting 
rural hospitals during the upcoming Q&A portion of this 
hearing. Thank you.
    [The prepared statement of Mr. Levine follows:]

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    Ms. Eshoo. Thank you, Mr. Levine.
    Next, Ms. Monroe, you have 5 minutes for your testimony. 
And welcome again, and we are all grateful to you.
    Ms. Monroe. I will put myself on talk.
    Ms. Eshoo. That is it. Now we can hear.

                 STATEMENT OF STEPHANIE MONROE

    Ms. Monroe. Good morning, Chairman Eshoo, Ranking Member 
Guthrie, and members of the committee. I really appreciate 
being able to be here to share a little bit about my story, but 
also the things I think this committee is doing excellently, 
and ways that you can continue to support Alzheimer's families 
and their caregivers.
    So, as I mentioned--as was mentioned previously, I am a 
Capitol Hill veteran of about 25 years. I am a former assistant 
secretary for civil rights at the Department of Education. I 
have had a lot of honors and privileges in my lifetime. This, I 
would say, is the best job I have ever had. I was working in 
the U.S. Senate for all of that time.
    Despite that fact, and being knowledgeable, as I thought I 
was, about healthcare and the needs of very vulnerable 
communities, and the fact that my brother is a physician at 
Vanderbilt University, and that my sister is a trained 
professional educator in Baltimore, Maryland, we were all 
completely blindsided when, eight years ago, my father received 
a diagnosis of Alzheimer's.
    Now, we shouldn't have been surprised, I guess, because 
seven years before he started displaying certain symptoms. It 
took us that long to get a doctor to actually tell us what was 
going on. And that was lost time that we can't ever get back, 
and it was unfortunate, and it was unnecessary.
    So we received the diagnosis, we were given a prescription, 
we were given the name of a doctor to go to see who was a 
neurologist. And we were basically sent along our merry way in 
a daze.
    This is something that you are just not prepared to hear, 
no matter how extensive your--you think your knowledge is. This 
is your father. This is the man who did everything in your 
household, all the electrical, the painting, even if he didn't 
know how to do it, it got done by him.
    So we left there, and we were like, you know, where do you 
start? You know, you are given medications. What do you expect? 
How do you manage this condition? What does it mean, in terms 
of long and short term? What are the financial realities of 
this?
    My parents were working class people. They didn't have 
long-term care insurance. What are we going to do, as a family? 
We knew we were going to come together and make this work, but 
what do we really do?
    You are not given any support, you are not given--connected 
to any resources that might be able to help you along this 
journey, just a script and a ``good luck.''
    You don't even know what questions to ask, because you 
don't know what you don't know. You don't know what resources 
exist, or whether they would even be helpful to you. You don't 
seek caregiver support because, like a parent doesn't consider 
him or herself to be a child care provider, you don't consider 
yourself to be a caregiver. You are the mother, daughter, 
sister, spouse of a loved one, of a father, of a mother. So you 
are just lost in that moment.
    So I am here today, and I know I am just one person, but I 
want to let you know that I represent the 6.2 million Americans 
living with Alzheimer's. The scary thing is that number is 
expected to double by 2060. Thirteen percent of Americans in 
the U.S. are African American. Twenty percent of persons living 
with Alzheimer's are African American. Yet, unfortunately, only 
three percent of African Americans are included in clinical 
trials to find better treatments for everyone. So I would say 
we have got a real problem on our hands that we have to 
address.
    So I am here today to urge consideration of the bills on 
the agenda as a lifeline for caregivers who, unfortunately, are 
forced often to deny their own health and well-being while 
caring for others. Too often this results in physical and 
emotional deprivation, sometimes resulting in the caregiver 
becoming sicker and dying sooner than the loved one that they 
are taking care of.
    The Alzheimer's Caregivers Support Act authorizes the 
Secretary of HHS to award grants to public or private 
nonprofits to expand and offer training and support services 
for families.
    And at UsAgainstAlzheimer's, we have done surveys of 
caregivers and their families to understand exactly what 
mattered most to them. We found that the majority of caregivers 
reported that their own healthcare provider knows that they are 
caregivers, butpercent report that the doctor hasn't mentioned 
anything about resources that might be available to that 
person. For those who actually did receive training, about 50 
percent said they did not receive it at the appropriate time, 
and fewer than half felt it addressed the situations that they 
actually faced.
    So I would like to thank Representative Waters and Smith 
for their leadership, and introducing this important piece of 
legislation, and working to improve it.
    I know that I am out of time, but I just have a little bit 
more to say, just for a few seconds, if that would be OK.
    I first want to associate myself with all of the comments 
that were made by Dr. Wilburn. Having a qualified, well-
trained, diverse workforce will be essential to all that we do 
in this space, as the United States continues to brown and age. 
We will be the new majority, and we already are in seven 
different states in this country.
    Finally, I just might like to thank and mention a couple of 
other bills that are before the committee, and a policy that I 
hope all of you will support.
    The CHANGE Act sits before the committee. That will help 
ensure that we have early and accurate diagnosis for people 
like my dad, where we didn't have to waste seven years.
    The ARPA-H legislation that the chairman has graciously 
introduced will help us understand and make sure that we have 
innovation and research that we can hopefully prevent and treat 
this disease, with critical innovations that are necessary.
    And then the paid leave, which currently is pending before 
Congress, is absolutely a lifeline for America's caregivers. I 
am grateful that I live in a position--I have a position where 
I am able to access paid leave, but only 77 percent--77 percent 
of American workers do not have that. So I really feel like 
that is an important lifeline in the strategy that we need that 
will allow people to be able to take the time that they need to 
care for themselves, and to make sure that their loved ones 
with Alzheimer's get the support and the care that they need. 
Thank you.
    [The prepared statement of Ms. Monroe follows:]

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    Ms. Eshoo. Thank you, Ms. Monroe, very powerful testimony, 
both professionally and personally. Thank you.
    And I think if--the top criticism of the chairwoman of the 
subcommittee is allowing both members and those that testify to 
go over time, but everyone has such good things to say that it 
is hard for me to lower the gavel on them. So mea culpa.
    Dr. Marrazzo, you are now recognized for 5 minutes, and 
thank you again for being with us, and your willingness to 
testify.

                  STATEMENT OF JEANNE MARRAZZO

    Dr. Marrazzo. Thank you, Chair Eshoo, Ranking Member 
Guthrie, and members of the subcommittee. Thanks for the 
opportunity to testify. I am Dr. Jeanne Marrazzo, I am the 
director of the division of infectious diseases at the 
University of Alabama at Birmingham. I am also the treasurer of 
the Infectious Disease Society of America, and I have served on 
the governor of Alabama's COVID task force.
    On behalf of IDSA, I am pleased to support the bill that we 
are here considering today, the Bolstering Infectious 
Outbreaks, BIO, Preparedness Workforce Act, and to speak about 
why this bill is needed.
    I also offer support for the Public Health Workforce Loan 
Repayment Act and the Dr. Lorna Breen Health Care Provider 
Protection Act.
    Addressing bio preparedness and ID workforce shortages is 
important to me, because I have seen firsthand the devastating 
effects of COVID-19, with disproportionate impacts on our most 
vulnerable Alabama residents. The pandemic and recent natural 
disasters have exposed insufficient bio preparedness and ID 
workforce capacity at healthcare facilities across the country.
    More than 80 percent of U.S. counties lack an infectious 
disease physician. In Alabama, our smaller and more rural 
communities have little or no access to ID care. During the 
pandemic, nearly everyone who required intensive care had to go 
to regional medical centers, which quickly became overwhelmed. 
Most hospitals in Alabama have limited ID expertise, and rely 
on informal telephone consultation with regional experts, such 
as myself.
    During the pandemic, I personally received phone calls from 
physicians caring for people with COVID in rural hospitals, 
with questions ranging from indications for monoclonal antibody 
treatment, to antiviral therapy in pregnant women, to 
management of antimicrobial resistance secondary infections 
acquired during prolonged hospital stays for COVID.
    UAB also serves as a critical hub for HIV and hepatitis 
care for over 25 counties. While telehealth is an option for 
many, many Alabama residents do not have reliable internet 
access. ID workforce shortages limit our ability to prevent and 
treat HIV and viral hepatitis, and infections associated with 
opioid and other substance use. A study of the HIV workforce in 
14 southern states, including Alabama, found that more than 80 
percent of those states' counties have no experienced HIV 
clinicians, with disparities greatest in rural areas.
    Despite the urgent need for a robust bio preparedness and 
ID workforce, the pipeline for ID physicians lags behind all 
other specialties. In 2020, only 75 percent of our ID training 
programs were able to fill, while many other specialties did 
so. The average salaries for ID physicians are below nearly all 
other medical specialties, and below general internal medicine, 
although ID specialization requires an additional two to three 
years of training. With average medical student debt of 
$200,000, the ID specialty is not financially feasible for 
many.
    Of great concern as we work to improve our workforce 
diversity, individuals from populations under-represented in 
medicine are more likely to have educational debt, making 
financial concerns a barrier for them to enter ID, as well. 
This Workforce Act will address this problem by providing loan 
repayment for these professionals, with an explicit goal of 
workforce diversification.
    Every community needs a strong workforce to mount rapid, 
effective responses to ID threats. Trained staff develop and 
update surge capacity plans, train healthcare personnel, 
purchase and manage protective equipment, optimally manage 
patient flow, perform infection prevention, and oversee 
antimicrobial stewardship to ensure that ID treatments are used 
appropriately.
    For example, the availability of new COVID-19 therapeutics 
was often limited, and their administration often complex. 
Antimicrobial stewardship teams were critical to determine the 
most effective ways to deploy these tools to fight COVID.
    This workforce was also instrumental in conducting COVID-19 
clinical trials. Nearly all the patients that we enrolled at 
UAB into these trials were from the Birmingham metropolitan 
area. These patients thus have the advantage of early access to 
new treatments under study. A larger and more diverse workforce 
statewide that is more distributed appropriately through our 
state would expand access to clinical trials, and ensure that 
these trials reflect the populations that we serve.
    In addition to pandemics, bio preparedness and ID 
professionals are critical in responding to natural disasters 
like hurricanes and wildfires. Skin infections frequently 
complicate common wounds. Overcrowding in shelters increases 
spread of infection. Gastrointestinal infections occur when 
sewage systems or access to clean drinking water is 
compromised. And waterborne and vectorborne infections also 
increase after floods.
    Finally, ID physicians are essential in caring for patients 
receiving transplants or cancer chemotherapy. Early 
intervention by an ID physician for patients hospitalized with 
serious infections is associated with significantly lower 
mortality and readmission, shorter hospital and ICU length of 
stay, and lower Medicare costs.
    In conclusion, the bipartisan BIO Preparedness Workforce 
Act will help ensure an adequate supply of bio preparedness and 
ID professionals by providing loan repayment. We are deeply 
grateful to Representatives Trahan and McKinley for their 
leadership on this legislation.
    We are also pleased to see the Public Health Workforce Loan 
Repayment Act, as well as the Dr. Lorna Breen Health Care 
Provider Protection Act that has been introduced.
    Thank you very much for this hearing. We welcome the chance 
to advance these critical pieces of legislation to ensure we 
have the workforce we need for the future.
    [The prepared statement of Dr. Marrazzo follows:]

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    Ms. Eshoo. Thank you very much, Dr. Marrazzo.
    Excellent testimony across the board. OK, we will now move 
to member questions, and the Chair recognizes herself for 5 
minutes to do so.
    To Mr. Feist, the American Rescue Plan provided $140 
million to address burnout among healthcare professionals. How 
does this legislation, in your view, work in conjunction with 
that law to address the mental health crisis that you so aptly 
described?
    Mr. Feist. Thank you for your question, Chairwoman Eshoo. 
This is an excellent question.
    The Dr. Lorna Breen Health Care Provider Protection Act 
provides the policy language that directs the distribution of 
those funds from the American Rescue Plan. And in fact, this 
summer, when HRSA was allocating through the grant process, 
those funds, I heard from hospitals across the country, chief 
wellness officers from across the country, who were interested 
in applying for those funds.
    It is clear to me that those funds are going to be used 
soon. They will be allocated in the next 30 to 45 days, from 
what I understand, and they will go a long way towards 
impacting the well-being of the healthcare workforce, current 
as well as the future.
    Ms. Eshoo. Well, that is highly instructive to us. Thank 
you very much.
    To Ms. Macon Harrison, I am proud, along with Congressman 
Crow, Ranking Member Guthrie, and Dr. Burgess, to put forward 
the Public Health Workforce Loan Repayment Act. Obviously, it 
establishes a student loan repayment program for public health 
professionals, and everything that you outlined shows that, I 
think, if that fund were in place now, there would be a run on 
the money, because the needs are so great.
    How do you currently recruit new local public health staff, 
especially in rural areas? I mean, can you actually recruit?
    Ms. Harrison. Yes, ma'am, thank you for the question. I 
appreciate that.
    It is definitely one of the main challenges of my role, as 
a local health director, to--excuse me--to recruit against a 
lot of the larger systems that are just an hour away.
    Ms. Eshoo. Right.
    Ms. Harrison. So often, across the United States, you see 
individuals who are well trained and experienced in their work 
travel to larger areas, where the pay is greater, and the 
benefits might also be.
    So recruitment is one of the issues that this loan 
repayment program really will help us with, and it directs some 
of that funding also to local health departments.
    Ms. Eshoo. Good.
    Ms. Harrison. Often times we see public health sort of 
connected together to lots of healthcare workforce, and we 
certainly share the responsibility with lots of healthcare 
partners. But local health departments really need the help 
with this in rural areas, as you mentioned. It is very 
difficult to do that recruitment well.
    Ms. Eshoo. Thank you very much.
    The first ten years of my elected public service was on a 
board of supervisors, and I chaired our county hospital's board 
of directors. I must have spent 80, 85 percent of my 
legislative time on healthcare, working with the public health 
department, with--overall, the health department in the county. 
So I know those operations well, and it is very sad to me that 
they have been left behind.
    So I think that there is an important Federal role to play, 
and I think, as we ramp that up, that it sends a real message 
to county governments, local governments, and those that are 
responsible for them, that they need to jack up those budgets, 
as well.
    Mr. Levine, I am going to enter into the--this into the 
record, but I am curious how North Carolina's and Tennessee's 
refusal to expand Medicaid has affected your system's 
financials.
    I mean, in my view, surely, avoiding uncompensated care 
would help. And there is really trusted statistics on that --on 
this, that being in a Medicaid expansion state decreases by 62 
percent the likelihood of a rural hospital closing. And 
conversely, being in a non-expansion state makes it more likely 
that a rural hospital will close.
    Do you care to comment?
    Mr. Levine. Well, Madam Chair, thank you. We, Ballad 
Health, did support the expansion of coverage for the poor and 
low-income populations. In Virginia they did do that, and we 
saw that it did assist us with our programs for the low-income 
populations.
    In the absence of expansion, we began the Appalachian 
Highland Care Network, providing coordinated delivery for 
patients that are uninsured, and who suffer from diseases like 
diabetes and other things to reduce----
    Ms. Eshoo. But I asked you what this has done, relative to 
your financials and hospital closures.
    Mr. Levine. Well, certainly----
    Ms. Eshoo. I am not so sure about your answer.
    Mr. Levine. Well, certainly, I believe that providing more 
coverage to people who currently do not have coverage would 
help rural hospitals with their financial situation. That is--
clearly, that is part of why we were able to reopen a rural 
hospital in Southwest Virginia.
    Ms. Eshoo. Thank you. My time has expired.
    The Chair now is pleased again to recognize the wonderful 
Ranking Member of our Subcommittee, Mr. Guthrie, for your 5 
minutes of questions.
    Mr. Guthrie. Thank you very much, and thanks for everybody 
being here, and particularly those sharing personal stories, 
putting a name to an issue, and faces to issues that we have 
here and you have talked about. It moves Congress from what we 
all know we should do to what we absolutely need to do and get 
done. So thanks for sharing that.
    I actually want to direct a couple of my questions to Dr. 
Keel, because, similar to you, we have major cities in 
Kentucky, but we also have a lot of rural area, and I know we--
I wish that we could have our discussion we had yesterday when 
you came by the office in public, because it is concerning.
    We are trying to do things in Kentucky. The University of 
Kentucky has put a medical campus in Bowling Green, where I 
live, a growing town, but it is the surrounding counties and 
other counties we are most worried about. And so innovation is 
kind of--we are moving forward.
    And going from, I guess--medical schools have been four 
years since--I am 57 years old. I can't remember when it 
wasn't. And I know when they went to internships and direct 
residencies, that was a big controversy.
    So what did you face, and how important are public-private 
partnerships?
    And then what barriers when you say, ``We are going to go 
to a three-year medical school?''
    And then how did you ensure that people are adequately 
trained?
    And what barriers did you say to say, ``We can still train 
these people in three years, and get them to where they need to 
go''?
    So you just share your story a little bit.
    Dr. Keel. No, that is a great question. And, as you would 
imagine, that is one of the first questions I get asked. When 
you say we are going to be reducing medical school from four 
years to three years, it gives the impression that we are 
short-cutting, or we are short-changing the physician training, 
and nothing could be further from the truth.
    Most traditional, four-year medical schools, including ours 
just a couple of years ago, that fourth year is used almost 
entirely for electives that the students choose. And a lot of 
it is used for preparation for interviews for residency 
programs throughout the state, and throughout the country. The 
vast majority of the actual core, the curriculum core that 
prepares the physician, is--it takes place in those first three 
years, even in traditional environments.
    What we have done, then, is removed the summer experience 
that a lot of those students have, so they go through the 
summer. That gives us several months to be able to continue 
this education in the three-year period of time.
    We are using small-group sessions, which provide students 
with a greater opportunity to have interaction with faculty to 
learn the material.
    We are putting them in the clinics at a much earlier stage. 
The first-year medical students actually--not just standardized 
patients, which provides good training, but they get their 
hands on real patients at a very early stage in their career, 
and that helps them matriculate what they learn in the 
textbooks, and apply it directly to that.
    Now, for those students that want to go on to a more 
specific residency program, like dermatology or neurology or 
orthopedic surgery, they can use that fourth year to get 
additional training, going to those residencies. But an 
individual that wants to go into primary care can go straight 
from that third year straight into a residency program.
    Mr. Guthrie. Great. Well, I know innovation does come up 
from the states, and we appreciate that.
    Mr. Levine, I am really interested in value-based 
agreements, and how we enter those into--and how we pay for 
healthcare. In the context of hospitals, instead of fee-for-
service, how would supporting value-based agreements instead of 
fee-for-service with healthcare providers encourage a stronger 
workforce?
    Mr. Levine. Well, that is actually a great question, sir. 
We have put that to practice.
    We began doing these value-based arrangements three years 
ago. And since then, we have reduced the number of avoidable 
hospital admissions by 16,000 per year, which, number one, has 
saved taxpayers and payers and employers about $200 million a 
year in reduced healthcare costs. But imagine if we had 16,000 
more admissions to our hospitals that we had to contend with 
during the pandemic. We couldn't have staffed for it.
    So the combination of the value-based arrangements, and the 
partnerships we have with the primary care physician workforce 
has really helped better manage patients and reduce the cost of 
healthcare, taking the burden off of our team members.
    So we encourage, and Ballad Health will certainly continue 
to lead the way in trying to lean into these risk-based and 
value-based----
    Mr. Guthrie. OK, thank you.
    And I have a question, Mr. Monroe. I am concerned, as you 
say, that we don't get enough minorities in our studies, in our 
tests. And I know that I went to a Pfizer study in Bardstown, 
Kentucky, and one of the people who set up the test--I 
understand, and I believe that, setting up the tests, we 
absolutely have to focus on that as we set up the test--and 
they were trying to get more minorities into the testing, and 
had a substantial minority population in that area. They just 
were having trouble recruiting and getting people to come to 
the test.
    So I know we have to set them up and recruit minorities to 
get into the test. But how do you--what do we need to do to get 
more minorities to be more acceptable to come into the testing?
    Ms. Monroe. Well, one of the things that has been 
interesting to me, I have traveled to 27 cities, talking about 
recruitment, and mentoring different sites about how to employ 
strategies. When we have surveyed over 30,000 people, about 80 
percent of minorities said that they had never been asked. And 
so that is the first step, is to ask.
    Mr. Guthrie. Absolutely, I agree with you.
    Ms. Monroe. Not be embarrassed about past things that may 
have happened, or your fear that they are going to say no. Give 
them the opportunity.
    But I think the workforce issues are important, too. If you 
go into a place that you don't know, you don't necessarily feel 
welcome, there is no one who looks like you there, you speak 
Spanish, no one there speaks Spanish, those are things that put 
a barrier before you even get to the place where you are ready 
to roll up your arms and take a test.
    But the National Institutes of Health, I was privileged to 
serve on their strategy for recruitment and inclusion, and they 
came up with wonderful suggestions, in terms of what sites can 
actually do to bring more minorities to the door.
    Mr. Guthrie. And you saw success in that?
    Ms. Monroe. If implemented, we would see success. But we 
also need--we need, I think, a series of carrots and sticks. 
Right now we just have sort of the goodwill of entities wanting 
to get higher numbers.
    But again, if you are coming in at three or four percent, 
and that drug is allowed to go to market to everyone, without a 
label that discloses the lower percentage points, I think that 
is a challenge. And I think we should be looking to see if FDA 
would make some kind of an allowance when that happens, or 
require a commitment for a phase four trial that will be really 
focused on getting minorities engaged.
    Mr. Guthrie. Thank you. I have expired my time.
    Thanks for being indulgent, and I appreciate it.
    That is a great answer. I appreciate it. Thank you.
    Ms. Eshoo. The gentleman's time has expired. The Chair now 
recognizes--Mr. Pallone is not here--Mr. Butterfield of North 
Carolina, the gentleman from North Carolina, for your 5 
minutes.
    Mr. Butterfield. Thank you, Madam Chair. Again, thank you 
so much for this important and informative hearing today. I 
have listened to all of the witnesses, and they are so 
resourceful. I thank all of you for your testimony. Let me 
begin with Ms. Harrison.
    Ms. Harrison, you shared with us that public health 
departments across the country have been hemorrhaging 
employees, and that it has been difficult to retain and 
actually hire new staff. My staff is informed that your 
department here, in North Carolina, has a turnover rate of some 
10 to 12 percent for the past two years. I don't know if that 
is accurate or not. You can correct the record, if it is not.
    But could you discuss some of the unique challenges that 
rural public health departments face in attracting and 
retaining employees?
    Ms. Harrison. Yes, sir, thank you for the question, and 
thank you for that kind introduction, it is always nice to see 
you.
    I, unfortunately, have experienced about a 12--even over 
the last few weeks that has increased a little bit more--
percentage of turnover that really rarely happens in local 
communities that are rural. We are fortunate that we do have a 
lot of staff from our local area, and they are incredible.
    I think the challenges we face are low salaries, and salary 
bands that are not updated frequently at the state level.
    I do believe that these loan repayment program 
opportunities will help us with recruitment, because they are 
better targeted to local public health, in particular. And as 
you know, it is sometimes assumed at the Federal level that all 
the money that you all approve gets to the local level. But 
that is not always the case.
    Mr. Butterfield. So you are----
    Ms. Harrison. There are state budgets that don't always 
pass----
    Mr. Butterfield. So you are supportive of loan forgiveness 
programs, is that right?
    Ms. Harrison. Yes, sir.
    Mr. Butterfield. All right. Let me move over to Dr. 
Marrazzo.
    Thank you so much for your testimony, as well. Duke 
University Medical Center--which is in North Carolina, we all 
know that--operates two infection prevention and antibiotic 
stewardship networks. These are designed to help community 
hospitals prevent superbugs and hospital-acquired infections.
    Most of participating hospitals do not have an infectious 
disease-trained clinician on their own. This shortage was a 
problem before the pandemic, but COVID and the strains it 
placed on the--on community hospitals simply laid bare the 
problems that can occur without this type of expertise, with 
inappropriate antibiotic use and increased hospital infections. 
Experts in North Carolina are concerned that hospitals not 
connected to networks like Duke's are faring even worse.
    And so, Doctor, are the challenges that physicians in North 
Carolina experience, are they similar to the challenges that 
you face in Alabama?
    And how will the BIO Preparedness Workforce Act helps 
smaller hospitals address infectious diseases?
    Dr. Marrazzo. Mr. Butterfield, thank you very much for that 
excellent question. You describe a very, very similar situation 
to what we are experiencing in Alabama.
    And indeed, we have some smaller programs that are able to 
do that, but nothing that really can meet the need of the 
state. So very much echoing, I think, what--your experience and 
what many states across the country are experiencing.
    The BIO Preparedness Workforce Act will help by expanding 
the necessary bio preparedness and ID workforce, and 
incentivizing these providers to work in these underserved 
communities, so you can actually make it worth their while to 
get out there and do the service in the places that really need 
it.
    Mr. Butterfield. Thank you. Let me move over to Dr. Monroe.
    Thank you as well for your testimony. In waiting my turn to 
ask questions, I researched your bio, and you have impeccable 
credentials. And just thank you for your years of service.
    Dr. Monroe, 10,000 Americans turn 65 every day. Seventy 
percent of these individuals will need long-term care. However, 
since March of 2020, senior living facilities have lost over 
380,000 caregivers, and 96 percent of assisted living 
communities currently face shortages. And so do you think the 
legislation before us goes far enough to address the caregiving 
shortages in long-term settings, such as memory care and 
assisted living?
    If not, what additional efforts should we consider?
    Ms. Monroe. Well, that is a great question. I think we need 
to do much more than we are doing. I am not sure exactly what 
it will take, but certainly these are extremely hard-working 
individuals. They are not necessarily well-trained. Many of 
them are just receiving minimum wage, and that is a challenge.
    In fact, I can tell you, from personal experience, even as 
of last week, at the independent/assisted living facility that 
my parents reside in, my mom has had to, on a weekly basis, 
turn away the professional caregivers that come in, because 
they are unvaccinated.
    Mr. Butterfield. Thank you. It looks like----
    Ms. Monroe. And there has not been a----
    Mr. Butterfield. Thank you, Ms. Monroe, thank you. The 
Chair has been very patient with us, but I think we had better 
yield back.
    Before yielding back, Madam Chair, let me ask unanimous 
consent to enter a statement into the record from a new 
healthcare organization, qualified health center organization, 
called Advocates for Community Health. I would like to get that 
into the record, and my staff will send it over to you. Thank 
you, I yield back.
    Ms. Eshoo. So ordered, Mr. Butterfield, thank you.
    [The information appears at the conclusion of the hearing.]
    Mr. Butterfield. Thank you.
    Ms. Eshoo. A pleasure to--and he yields back--to recognize 
the ranking member of the full committee, Mrs. McMorris 
Rodgers, for your 5 minutes of questions.
    Mrs. Rodgers. Thank you, Madam Chair. I too want to thank 
all the witnesses for being here and sharing your insights. I 
especially want to recognize Mr. Feist, and appreciate you 
sharing the story of Dr. Lorna Breen. It highlighted, I 
thought, what you said about the parallel pandemic of mental 
health and suicide, which is so important for us to be focusing 
on, also.
    Dr. Keel, I wanted to thank you for being here, and sharing 
about your innovative novel curriculum that is improving the 
pipeline of practicing primary care physicians in Georgia. I 
wanted to ask, do you think that this is a model that could be 
replicated in other states, an accelerated three-year 
curriculum?
    And what else can we be doing, as policymakers, to 
streamline career training for health providers to help reduce 
that debt burden?
    Dr. Keel. No, that is a--and thank you for the question.
    I certainly believe this is a model that any state in the 
Union could take advantage of, not only from reducing medical 
school from four years to three years, which takes quite a bit 
of work, as you might imagine. There are some 20, from what I 
am told, medical schools across the country already that have 
some form of an accelerated MD program, although I don't 
believe it is that the scale at which we are doing it, not the 
entire incoming class that we are doing, but certainly that 
would be one aspect of it.
    But this is the problem, or putting physicians in rural 
health--this--what we are doing is not--that is not going--that 
is not the silver bullet that is going to completely solve 
everything. We know that. It is going to take support from the 
individual states, just like we were able to match a major a 
contribution towards this program by state funds. That the 
state appropriated it in order to do that certainly will--goes 
towards that.
    But I think the states themselves are going to have to step 
up, and the local communities themselves are going to have to 
step up, as well, to try to participate in this. It is not just 
eliminating the debt, but it is also finding ways to cover the 
cost of setting up a practice in a rural area that--I think 
that gets to the more local aspects of what might take place.
    So this can clearly be implemented in any state, and we 
will be happy to talk with anyone about what we are doing, and 
how we are doing it. But it is going to be a program that is 
going to require a tremendous amount of work across the board.
    Mrs. Rodgers. Thank you, thank you.
    Mr. Levine, CMS provided flexibilities during the global 
pandemic related to staffing through the 1135 waivers. Some 
flexibilities help expand access to an array of skilled nurse 
aides for nursing homes. Some helped waive requirements from 
NTALA to ensure flexibility in screening and delivery of care 
while hospitals were overwhelmed during surges, while others 
helped ensure access to lifesaving telehealth, so our doctors 
could more easily meet the needs of their patients during the 
worst of the pandemic.
    I think that we should be looking also at the impact on 
patient safety, and if there is any flexibilities that should 
remain in place during--or after that pandemic. And would you 
speak to the ways that the pandemic flexibilities helped Ballad 
Health, and then which ones should be considered for permanency 
after the public health emergency ends?
    Mr. Levine. Well, thank you, Representative. First of all, 
what I would start with, going back to something you said in 
your opening comments, you are 100 percent right, that states 
really did lean into this at the state level, and the 
flexibility that started with the states by deploying the 
National Guard, and some of the other things they did to assist 
us, were extremely helpful.
    One of the things I think CMS did that I think particularly 
helped us was the expansion of the use of telemedicine. Here, 
in a rural or non-urban region of the country, the use of 
telemedicine is important if you are going to bring services, 
particularly children who suffer from health issues, and--as 
well as adult addiction. So the flexibilities with 
telemedicine, particularly if we can get broadband deployment 
in non-urban communities in America, that will help.
    And I do think some of the flexibilities with staffing, 
particularly--and something that was said earlier--as the 
pandemic subsides, when we get in the rearview mirror, we are 
going to see a lot more turnover. And, as we see more turnover 
amongst our staff, we need the flexibility of other healthcare 
professionals, like paramedics, EMTs, nursing assistants in 
ways that perhaps in the past we haven't used them before----
    Mrs. Rodgers. Yes.
    Mr. Levine [continue]. Flexibilities would help.
    Mrs. Rodgers. Thank you. As a--I also wanted to note that 
in your testimony you discussed the increases in the diseases 
of despair, such as substance abuse disorders and suicides. Can 
you further elaborate on what you think maybe are some 
strategies that we can be using to help address the diseases of 
despair?
    Mr. Levine. You know, I will speak first to the non-urban 
and rural parts of America, which, of course, is 85 percent of 
our land mass. And, you know, they are facing economic 
challenges.
    You look at the--pre-pandemic, you look at the unemployment 
rate, and then you look at the workforce participation rates, 
and you really have to recognize that there is a lot of despair 
in our region of the country, where we have lost the coal 
industry, and nothing has replaced it. And so economic despair 
is one of the big drivers for--poverty and economic despair are 
the drivers for those types of behavioral--and so I would lean 
very heavily on economic growth, and find ways to help these 
regions expand and grow their local economy and, therefore, 
workforce opportunity.
    Mrs. Rodgers. OK, thank you. Thank you, everyone. I yield 
back.
    Ms. Eshoo. The gentlewoman yields back. The Chair is 
pleased to recognize the gentlewoman from California, Ms. 
Matsui, for her 5 minutes of questions.
    Ms. Matsui. Thank you very much, Madam Chair, for convening 
this very important hearing, and I want to thank the witnesses 
for being with us today.
    Today's discussion around healthcare workforce needs is 
particularly timely, as the pandemic has exacerbated mental 
health challenges for people of all ages, especially our 
nation's youth.
    As with COVID-19 and other health conditions, when it comes 
to behavioral health we know that people of color, including 
children, face disparities in vulnerability and access to care. 
Coming out of the pandemic, we have an opportunity to save 
lives by bolstering Federal resources that support community 
mental health and substance use services. That is why I 
encourage this committee to consider my legislation that 
extends and expands the CCBAC Medicaid demonstration program.
    My bill supports clinics that hire and train more staff 
that make it possible for people to receive timely and high-
quality care under a comprehensive primary and behavioral 
health treatment model.
    Moreover, we know that we need to take a multifaceted 
approach to responding to the growing and unique needs of our 
communities.
    I am deeply concerned about the shortage of over four 
million behavioral health service providers we have seen across 
the country, so I am pleased that we are discussing legislation 
today that would extend funding for critical provider education 
and training programs.
    Dr. Keel, I would appreciate your perspective on the need 
for and benefits of these programs, particularly as you share 
that psychiatry is one of the seven primary care pathways in 
your program that aims to address provider shortages.
    Dr. Keel, you note in your testimony that the behavioral 
health workforce education and--program is particularly 
important to students at your public academic medical center. 
How does this program assist in your students' field placement 
clinical experience?
    Dr. Keel. And thank you very much for the question. We have 
not had an opportunity to study the--that particular 
legislation well enough to be able to comment on that at this 
time. We most certainly will do that.
    But if I can speak to the issue of mental health, 
especially as it relates to campuses, we are seeing an 
extraordinary increase in the need for mental health services 
on our university campuses. I know this won't be a big surprise 
to you, as well.
    Ms. Matsui. Right.
    Dr. Keel. And clearly, anything that can be aimed towards 
not only providing educational opportunities for students to 
understand that, if they are having issues, they need to reach 
out to get those services, but also how we, as universities and 
as--and how we, as health systems, can provide those sort of 
services to the individuals that need it the most, whether it 
is our student population, who are very vulnerable, or whether 
it is to the rural and underserved areas, and also the minority 
populations of our community, who also find themselves in a 
position where they just don't have access to that.
    Ms. Matsui. Dr. Keel, I want to ask you about another 
program that you highlighted, a pilot program that enables 
medical residents and fellows to practice psychiatry in 
underserved community primary care settings.
    In your experience, do integrated services like those made 
possible by training demonstrations and the CCBAC help 
strengthen the state's mental and behavioral health service 
capacity?
    Dr. Keel. Absolutely. And as you may recall from my 
testimony, one of the residency programs that we are--one of 
the specialties that we are emphasizing in this 3+ program is 
psychiatry.
    I am told that, of the 159 counties in Georgia, nearly half 
of those do not have a psychiatrist in that particular county.
    Ms. Matsui. Right.
    Dr. Keel. It provides an incredible lack of access, again, 
especially in the rural and underserved areas, for an 
incredibly much-needed service. So we are certainly hoping that 
some of the legislation has been proposed that would emphasize 
not only behavioral health counselors and that sort of thing, 
but also would emphasize the training of psychiatrists, we can 
incentivize those individuals to go to the areas in which they 
need it the most, as well.
    Ms. Matsui. Certainly. Thank you very much, Dr. Keel. I am 
going to talk about workforce diversity. My colleagues and I 
have been working on numerous proposals to help diversify the 
healthcare workforce, and I am pleased we are considering 
several of these today.
    In fact, many of the proposals in our package, the Build 
Back Better legislation, would also help to increase diversity 
in the provider pipeline, including proposals related to 
perinatal and maternal workforce development, health 
professionals opportunities grants, and graduate medical 
education.
    Dr. Wilburn, the Allied Health Workforce Diversity Act 
would allow HHS to continuously define which communities are 
considered under-represented. Why is this important when it 
comes to training new health professionals?
    Dr. Wilburn. Thank you so much, I am happy to elaborate on 
that.
    It is important for the community to match the community in 
which it serves. So in some areas of our country, under-
represented includes racial minority groups. And for others of 
our country that might be rural and military families. We all 
know that we have better health outcomes when our providers 
match the demographics of their community.
    Ms. Matsui. Well, thank you very much, Dr. Wilburn.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back. The gentleman from 
Virginia, Mr. Griffith.
    Mr. Griffith. Thank you very----
    Ms. Eshoo. For 5 minutes.
    Mr. Griffith [continue]. Much, Madam Chair.
    Mr. Feist and your wife, I am so sorry for your loss. I 
don't have any questions, but I was appalled at the conditions, 
and we are going to do our best, which is why I was proud to be 
an original cosponsor of the bill. So thank you very much for 
being here.
    Dr. Keel, I want to talk to you on another date. I have 
some crazy ideas about residency reform, as well, but I love 
the 3+ program. I think that that is a step in the right 
direction, and I appreciate your innovation there. All right, 
now I am going to go to Alan Levine from down my way.
    As I mentioned in my introduction, Ballad recently was able 
to reopen a hospital in Lee County, Virginia. The community had 
gone--and I shortened it up, because when you are dealing with 
it, sometimes time goes. It was actually eight years that it 
was closed. And when the hospital originally closed down in 
2013, it cited two reasons: reimbursement and recruitment 
challenges.
    So, Mr. Levine, recruitment challenges predate the 
pandemic, don't they?
    Mr. Levine. Yes. Yes, sir, they do. And they absolutely 
did, and it is worse now.
    Mr. Griffith. Yes. And at this point in time, Ballad has 
not imposed a vaccine mandate on its staff. I am correct in 
that, am I not?
    Mr. Levine. Yes, sir, that is correct.
    Mr. Griffith. And my estimate--you tell me if you agree or 
disagree, or have some number, but my estimate is that you 
could lose as many as 15 percent of your healthcare workers if 
you implemented a vaccine mandate. Am I pretty close to the 
mark?
    Mr. Levine. We have had some concern about that. And, you 
know, 63 percent of our team members and 90 percent of our 
physicians are vaccinated. But, you know, a lot has been said 
here about the cultural differences in the delivery of 
healthcare. And cultural differences don't----
    [Audio malfunction.]
    Mr. Levine. We are in a part of the country where, for a 
lot of various different reasons, people have differing 
viewpoints on vaccines. And so we have tried very hard to lean 
heavily into educating people, being a resource, a source of 
truth for the community on it. And we are going to continue to 
lean into doing that.
    Of course, with the mandates that may be coming down from 
Medicare, that certainly will change our perspective, because 
we certainly, with 70 percent of our----
    [Audio malfunction.]
    Mr. Levine [continue]. Government, we can't afford to lose 
that reimbursement.
    Mr. Griffith. Right. And the problem is, if you get a 
mandate from Washington, DC--and sometimes in our area--and 
people don't realize it--and you mentioned the cultural 
differences--we actually see some of these things coming out of 
Washington to be kind of cultural colonialism by Washington, 
DC. And there is a resistance to the Federal Government, no 
matter what, in our area.
    I am often reminded of the song, Rocky Top, which is 
actually the anthem of one of the colleges there, in Tennessee, 
where it says once two strangers went up Rocky Top, looking for 
a moonshine still. Strangers ain't been seen again, guess they 
never will. I paraphrased that a little bit, but that is--you 
know, there is just a resistance to the folks coming in from 
outside trying to tell everybody what to do.
    And I am concerned that there will be a lot of people, a 
lot of healthcare professionals, who will just say, ``Forget 
it, I will go do something else.'' And in this time, where we 
have--we still have a lot of unemployment in some sections, 
particularly in the coal fields, but in other sections of where 
you serve, there is an employee shortage. Isn't that also true, 
for all kinds of things, not just healthcare?
    Mr. Levine. That is correct, sir. And I think the concern 
we have--again, a one-size-fits-all approach doesn't always 
work. The difficulty in recruiting--if a team member leaves--
and we, right now, have openings for 700 nurses--if a team 
member leaves, getting a new one to replace him is very 
difficult in a rural region. And so we have been a bit hesitant 
to impose a mandate, while we continue to try to work with and 
educate our team members.
    We certainly are for them getting vaccinated. But the 
issue----
    Mr. Griffith. Yes.
    Mr. Levine [continue]. Of a mandate pushing them away is--
obviously, has been a concern for us.
    Mr. Griffith. Well, I think my attitude reflects it. I am 
vaccinated, but it reflects the area that I represent. I will 
never vote for a mandate, because that is just going to make 
more resistance to the vaccine, and more distrust of the 
Federal Government.
    How much has Ballad relied in the past on traveling nurses, 
and how much are you relying on them now?
    Mr. Levine. It is--you know, I have served as a secretary 
of health in two states through hurricanes, the pandemic, H1N1, 
and the oil spill in Louisiana. And you know, I know attorneys 
general, generally, will prosecute and go after organizations 
that gouge consumers in the aftermath of a disaster, like 
supplies or gas.
    Here we sit, where we are now paying $140 an hour for 
contract nurses. I have got a nurse at one of my hospitals in 
Johnson City from Vanderbilt----
    [Audio malfunction.]
    Mr. Levine [continue]. Nurses here, four hours away, is 
because they could get three times more money from contract 
agencies.
    And so we are getting--right now we have 400 contract 
nurses in our system. That is helping to offset the 700 need 
that we have. But I think this is going to get worse----
    [Audio malfunction.]
    Mr. Levine [continue]. After this. And I am very concerned 
about the impact--the incremental cost and the impact on 
quality an over-reliance on contract agencies has, and I do 
hope somebody can look----
    [Audio malfunction.]
    Mr. Griffith. I appreciate it. My time is up, and I yield 
back.
    Ms. Eshoo. The gentleman, well, yields his time.
    I would just like to state a factoid here. At Tyson Foods, 
96 percent are vaccinated, 60,000 people vaccinated, thanks to 
their requirement.
    I don't know if--I have to tell you, if I went to Stanford 
University Hospital, which is a couple of miles away from me, 
as a patient, I wouldn't want any doctor, any nurse, anyone 
coming near me that was not vaccinated. I don't go to the 
hospital to become infected, so I just--I wish that we were all 
on the same page, because I think this back-and-forth on 
vaccinations, it is--at the end of the day, I think it is 
holding us back. Honestly, it is hurting us in our country.
    If we were all one, we would march forward, and put this 
pandemic behind us. Instead, we are going back and forth, back 
and forth, back and forth, and it is--we are here, we are doing 
all this wonderful work with these bills, and yet we can't be 
sensible enough to listen to those that know what they are 
talking about.
    We want to train more of them. We want to train more of 
them. We want more in the pipeline, and then we are going the 
other way.
    So excuse my two cents here, but I guess you get to do this 
every once in a while, as--chairing the committee.
    I am pleased to recognize the gentlewoman from Florida, Ms. 
Castor, for her 5 minutes of questions.
    Ms. Castor. Well, thank you, Madam Chair, and I agree with 
you. We have a safe and effective vaccine, and we are so 
fortunate that--to live in America, where we have been able to 
distribute it widely. And it is an unnecessary debate, that has 
cost lives.
    But I want to thank our witnesses, especially, for sharing 
your expertise here today. The frontline healthcare workers, 
the doctors, the nurses, the therapists have been nothing less 
than heroic throughout the pandemic. And the burnout in the 
stress is very real, though.
    I--one of my best friends, back home in Tampa, is a long-
time nurse at Tampa General Hospital. She has worked there for 
about 30 years. And it was the first--this summer was the first 
time I ever heard her say she didn't want to go to work. And 
then, when we had our very preventable COVID surge this summer, 
in August, September, when Florida led the nation in the COVID 
death rate, she just shared she was so tired of seeing people 
die unnecessarily.
    And then I was heartened, though, because another very good 
friend, who is a mental health therapist, said, ``You know, 
Tampa General has just hired me to go in and talk to the 
healthcare workers, and be there for them, and counsel them.'' 
And I think this was even before the HRSA money out of the 
American Rescue Plan was distributed. So what a godsend to 
those frontline heroes.
    So, Corey and Jennifer, thank you very much for your 
testimony, and turning your grief into action that will help 
other healthcare heroes on the front lines. During your 
advocacy work in speaking to frontline providers about the need 
for better mental health recognition and services, what do you 
hear most often from them?
    What are the common barriers you hear from those frontline 
workers on seeking healthcare, mental healthcare service?
    Mr. Feist. Excellent question. This answer requires a look 
at regulatory barriers, as well as just the culture of medicine 
and the operations.
    On September 9th we published an article in U.S. News and 
World Report that summarized six of the barriers that we had 
heard for the last 18 months from the health--mental health--
sorry, the healthcare workforce around some of the things that 
prevent them from getting mental health treatment: those we--
those are state licensure questions that go above the Americans 
with Disabilities Act, hospital credentialing application 
questions, commercial insurance questions, malpractice 
application questions, medical plan design, or hospitals that 
require their mental health treatment for patients to come to 
their own hospitals.
    And then, something that completely boggled my mind, which 
is that physicians' mental health medical records can be 
subpoenaed in a malpractice lawsuit in many states, and those 
are not protected from disclosure during a malpractice lawsuit. 
So those are just six of the areas. But this is a--this is 
something that is so incredibly pervasive across the industry.
    You know, Dr. Breen was convinced she was going to lose her 
license to practice medicine in New York, but she was 
incorrect. The licensure law in New York doesn't even ask 
questions about mental health past. She was incorrect, but that 
thought is pervasive across the healthcare industry, which is 
why one of the things that we did this year, in honor of 
National Physician Suicide Awareness Day, on September 17th, 
was to ask every hospital in this country to publish for their 
own workforce just what the what the facts are in their own 
institution and in their own state. Those that one group of 
regulatory barriers that I just identified for you need to be 
all knocked down.
    In addition, we have got tons of cultural issues about just 
healthcare workforce looking out for themselves and their 
colleagues, because they go into the business looking out for 
patients first.
    Ms. Castor. That is kind of unbelievable to me, that there 
are so many barriers. So did Dr. Breen--did you--would you say 
that again, that she may not have sought help because she was 
afraid of something involved with her license?
    Mr. Feist. Absolutely. Not only that, though, but once she 
received help for the first time ever in her career, after she 
was discharged from the inpatient unit at the University of 
Virginia, she was convinced beyond any doubt that she was going 
to lose her license to practice medicine, and she ultimately 
took her life only a handful of days later. And she--and New 
York State doesn't even ask that question. But the thought of 
loss of licensure is incredibly pervasive.
    I will give you one other example. Every year, new 
residents come out of medical school and they start their 
residency in the summer. We have heard from many residents 
across the country that, as soon as they start their residency, 
they stop taking their anti-depressants. They stop taking 
medications. They stop going to see a therapist. They will pay 
in cash. They will use a pseudonym, all because of this stigma 
and these regulatory issues.
    And I will give you one last example. We heard from a 
physician in Oregon who received mental health treatment for 
the first time in her career because she had a reaction to an 
allergy medicine that created a mental health condition for 
her. It took her ten years of fighting to get her license back 
after that one issue.
    This is just incredibly widespread. Now that we have spoken 
about this issue, others are coming out, and they are talking 
about it all over the place.
    Ms. Castor. Thank you very much. I yield back.
    Ms. Eshoo. The gentlewoman yields back. The Chair 
recognizes the gentleman from Florida, Mr. Bilirakis, for his 5 
minutes of questions.
    Mr. Bilirakis. Thank you so much, Madam Chair. I appreciate 
it. And thanks to the witnesses for their testimonies today.
    While I appreciate the intent of this hearing to focus on 
workforce issues within our healthcare systems and, in 
particular, the inclusion of a bill that I have cosponsored, 
the Dr. Lorna Breen Health Care Provider Protection Act, I do 
want to speak to some of the broader significant challenges we 
have been seeing during the pandemic amongst our hospital 
systems, nursing homes, assisted living facilities, and other 
providers.
    And I wonder if we are missing a real opportunity to do 
more to address these challenges. For example, the Florida 
Hospital Association and Safety Net Hospital Alliance of 
Florida recently commissioned a report with projections from 
the healthcare workforce in my home state of Florida, which 
found that, if the current trends hold up, by 2035 the state 
will be short of supply by more than 65,000 registered nurses 
and 26,000 licensed practical nurses. And that was using the 
2019--actually, year 2019 as a baseline, not counting the 
potential worsening effects of COVID-19, the pandemic.
    Even now, one of my local Tampa-area hospital systems, 
Advent Health's West Florida Division, has told me that they 
currently have 1,022 RN openings, and it is not getting any 
better.
    Unfortunately, it is not unique to the hospitals alone, as 
other providers are also seeing their demand pushed, while 
their supply is stretched extremely thin. In the mental health 
space, SAMHSA has estimated an over four million-provider 
shortage of behavioral health services across the country. Very 
unfortunate.
    Amongst our nursing homes, 94 percent nationwide are 
currently facing staffing shortages, and the problem is only 
being exacerbated, as you know, by the pandemic.
    We must continue to do what we can to ensure we are 
supporting clinical education and training, increasing facility 
faculty, of course, and clinical sites for nursing programs, 
and allowing for additional flexibilities in our current 
workforce incentive programs across the system. I believe this 
is all a non-partisan issue. We all agree on this.
    In that vein, I was very glad to see Governor DeSantis sign 
legislation this summer that created a personal care attendants 
program, with new entry-level position opportunities for these 
types of caregivers to count towards nursing assistant 
requirements in long-term care facilities, along with a path 
towards certified nursing assistant careers.
    This is thinking outside the box. This is what we need, 
flexibility. We need innovative ideas such as this to ease the 
burden to our industry by making it attractive for individuals 
to enter into the workforce with a robust support system to 
grow our labor supply.
    Another way we can ease this burden is by reducing the 
demand. So I have a question to my friend from this--well, 
originally from the State of Florida, and did an outstanding 
job as the Department of Health head under Governor Bush, very 
innovative ideas, and we did a lot together. I served for eight 
years in the legislature, while he was there doing an 
outstanding job on behalf of the great people of the State of 
Florida.
    So Alan, Mr. Levine, you mentioned in your testimony the 
importance of deliberately working towards admitting fewer 
patients and lowering inpatient hospital admissions by moving 
towards outcomes-based care at Ballad Health. I could not agree 
more that we should be promoting value-based care centered on 
outcomes, which is what Medicare Advantage does so well.
    Can you tell us more about the ways you think we can not 
only increase the supply of the workforce, but also 
specifically reduce the demand for these services?
    Mr. Levine. Well, I--Congressman, it is great to see you 
again, my friend, and I want to go back to one quick thing that 
Congressman Griffith said earlier. He was referencing Rocky 
Top. I do want to point out I am a Florida Gator.
    So--but your question is right on target. All of these 
movements towards value-based, risk-based payment to our health 
systems incentivizes us to provide a lower-cost way of 
delivering care. For instance, Ballad Health was just approved 
for our new Hospital at Home program that we are going to trial 
with CMS, because we learned during the pandemic, if we were 
able to take care of people at home, based on certain criteria, 
we kept them out of the hospital, and this took the burden off 
the nurses at the hospital. And that happens with telemedicine 
and the use of technology. We are going to be moving in that 
direction.
    So anything we can do to avoid going to a hospital is 
helpful in reducing the burden on nursing staff in the bedside 
setting. It doesn't diminish the need for healthcare and 
healthcare settings, but it does diversify the healthcare 
manpower----
    Mr. Bilirakis. Very good. Thank you. And it is great to be 
a Florida Gator. I appreciate that, and I think we have a shot 
against Georgia this weekend. I know it is a stretch, but I am 
always confident. I am the eternal optimist.
    With that, I will yield back. Thank you.
    Ms. Eshoo. You always are, Mr. Bilirakis. OK, the chairman 
of the full committee, Mr. Pallone, you are recognized for 5 
minutes for your questions.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman Eshoo. I wanted to start 
out with some questions of Ms. Harrison.
    I know your members are local health departments who are 
often the first and last resort for our local communities. You 
know, they are on the ground, setting up the vaccination 
clinics, and all the things that are so important.
    The Public Health Workforce Loan Repayment Act is designed 
to make a significant impact in repairing the public health 
workforce--well, and I would say in repairing a broken 
healthcare system, you know, trying to help with the workforce, 
capture new talent who might not have pursued these careers 
before the pandemic. So I wanted to ask some questions about 
that legislation to you in that vein.
    We have heard today from witnesses on the shortages of 
providers in several specialties. There are two workforce areas 
which we know are expecting workforce gaps, due to burnout or 
leaving for higher-paid positions in the private sector. So--
and if you could tell me, just in a yes-or-no response, would 
the Public Health Workforce Loan Repayment Act be helpful to 
address public health nursing shortages, yes or no?
    And then what about computer science, or IT professional 
shortages? Yes or no, because I have more questions of you.
    Ms. Harrison. Yes, sir. On both counts, yes.
    The Chairman. OK. So let me ask this. There are differences 
in the authorization levels between the House and Senate 
versions of this bill. So, in your view, what is the 
appropriate authorization level needed to have a successful 
program?
    Ms. Harrison. Thank you for that question----
    The Chairman. That is not a yes or no.
    Ms. Harrison. Thank you, yes, sir.
    So the House bill, in my understanding, authorizes 100 
million for the first year, and then 75 million after that, 
whereas the Senate bill authorizes a full 200 million. And so, 
I think, you know, speaking on behalf of nearly 3,000 local 
health departments across the United States, in this case more 
is more, and each dollar goes toward supporting new 
opportunities to have recruited high-level staff in local 
health departments.
    And so, you know, even with that $200 million, that would 
support approximately 6,000 staff at the local level. That is 
just two people, or approximately two people for most local or 
state health departments. That would not even do the trick, but 
close.
    The Chairman. So we, obviously, have to go for the higher 
amount, at a minimum, is what you are saying.
    Ms. Harrison. More is more. Yes, sir.
    The Chairman. OK. So then the last question I have of you--
and then I want to ask another question of Mr. Feist--we have 
heard from some that investments made in the American Rescue 
Plan should be sufficient to address public health workforce 
concerns. So how would the--and I am not saying I agree with 
that, but how would the Public Health Workforce Loan Repayment 
Act complement the one-time workforce-directed funding that was 
provided by this committee in the American Rescue Plan?
    Ms. Harrison. Yes, sir. Thank you for that.
    The difference is long-term versus short-term funding. So 
when we have the shorter-term funding that comes down in 
American Rescue Plan Act, it is very prescriptive, once it gets 
to the local level, about what we may and may not use that 
funding for. And it is also very short-term. So it doesn't make 
a lot of practical sense for us to hire new individuals into 
our agencies, if we know that money is going to run out.
    And I think the more sustainable infrastructure building 
workforce supportive approach is this loan repayment plan, 
which is more long-lasting.
    The Chairman. All right, thank you. Now I want to go to Mr. 
Feist.
    In the--again, going to the American Rescue Plan, in the 
American Rescue Plan Congress provided funding to support key 
areas included in the Dr. Lorna Breen Health Care Provider 
Protection Act. So some view the ARP, the Rescue Plan funding, 
as sufficient in addressing the mental health needs of the 
provider community, and I view the Lorna Breen Act as the 
roadmap for sustained investments to ensure the success of 
these endeavors.
    So sort of the same question. In your view, why is this 
legislation even needed, even with the investments that we made 
from the Rescue Plan?
    Mr. Feist. We are thrilled that the American Rescue Plan 
included the monetary provisions of the Lorna Breen Act. But as 
you just said, sir, the Lorna Breen Act will not only create 
the policy for the distribution and allocation of those funds, 
but it will also create a future roadmap for us, with a 
comprehensive study provision that really addresses the root 
cause of these issues, and it creates a road map of this--to 
take care of the healthcare workforce, now and in the future.
    Mr. Pallone. All right, thank you so much.
    Thank you, Madam Chair.
    Ms. Eshoo. The gentleman yields back. The Chair is pleased 
to recognize the gentleman from Indiana, Dr. Bucshon, for 5 
minutes of questions.
    Mr. Bucshon. Thank you, Madam Chairwoman. While I support 
many of the proposals we are discussing today, I must ask one 
important question: Where is the support for physician 
providers right now?
    My friends in the majority are planning to spend trillions 
of dollars, yet nowhere in their spending package is their help 
for our providers facing looming reimbursement cuts in the 
Medicare physician fee schedule set to take effect at the start 
of next year, as well as sequester cuts and PAYGO cuts that 
could result in up to a ten percent reimbursement cut--and 
decreased access to care, by the way.
    Just last month, here in this committee, I offered an 
amendment during the reconciliation markup that would have 
alleviated most of these looming cuts for one year to provide 
our heroes on the front lines with some relief, as we work in 
Congress to find a long-term solution to better value their 
work. However, the amendment was rejected.
    So I ask: If not today, when is the right time?
    This hearing is focused on supporting providers, which I am 
all in favor of, providers across the spectrum. How are we not 
focusing on one of the key issues facing doctors at this time, 
an issue that will force more early retirements, and continue 
the trend of our best and brightest students choosing other 
professions with more financial promise, all of which is 
leading to physician shortages, especially in rural America?
    We all keep hearing from our providers that this will have 
grave consequences, and directly threaten access to care. To my 
friends and colleagues, let's work together to make this a 
priority for this committee--this subcommittee, also--so we can 
better support our providers.
    Also, I want to voice my strong opposition to the HHS rule 
on surprise billing, and my disappointment that there is not 
strong opposition from the majority committee leadership. The 
rule, in my view, does not reflect congressional intent, and 
may, in fact, violate the law. I urge all of my colleagues to 
stand up on behalf of Congress and our ability to write the 
laws and a two-year bipartisan process.
    So now, switching gears, Dr. Keel, I want to applaud the 
work you are doing at the Medical College of Georgia with the 
accelerated three-year medical school program. I was a 
cardiovascular surgeon, so I did four, and four, and seven 
years of residency for primary care--critical shortages in 
rural Indiana, of course. I know firsthand that the length of 
medical school and the student loan debt students leave is a 
major factor for why our best and brightest students are 
choosing different professions. In fact, my three adult kids 
aren't doctors, and my wife and I both are.
    In your experience, do you think more colleges can offer 
accelerated medical programs like you are doing at yours?
    And have you looked at accelerated programs like this for 
other medical specialties, as well, including surgeons?
    Dr. Keel. Absolutely. As I mentioned earlier, I think this 
program that we have put together in Georgia can be implemented 
in just about any state in the Union that is willing to take 
the time and effort to change their curriculum. And I think 
that is certainly something that should be considered.
    I think to try to eliminate that debt for the reasons that 
you pointed out just a few moments ago is critical, because--to 
encourage these individuals to go into the primary care 
disciplines because of the reasons that you just alluded to----
    Mr. Bucshon. Yes.
    Dr. Keel [continue]. In terms of the opportunity to really 
earn an income and help pay off that particular debt.
    We have used the term ``primary care'' very broadly, to 
include not only the things that you would recognize right 
away, the members would recognize right away: family medicine, 
internal medicine, pediatrics. But we have also included OB/
GYN, emergency medicine, psychiatry, and general surgery.
    We have right now a rotation that physicians--in some of 
the more rural parts of our state--take a surgery rotation in 
those areas, so they can understand what it is like to be a 
surgeon, a general surgeon, in some of those greatest--areas of 
greatest need.
    So yes, I think this can be applied broadly, and we 
certainly hope to be able to expand it to many other areas, 
based on what the need is----
    Mr. Bucshon. Right.
    Dr. Keel [continue]. In a particular area of the state.
    Mr. Bucshon. Right.
    Dr. Keel. Thank you, sir.
    Mr. Bucshon. Personally, I support a six-year medical 
program, and working with colleges to combine the medical 
school and college education that eliminates unnecessary, 
duplicative courses, which--I love--I was a chemistry major. I 
love biochemistry, but I didn't need to take it twice. And 
genetics, the same thing. So other countries can do this. The 
question of whether or not people are properly trained really 
wouldn't be a problem.
    Mr. Levine, I have a question for you to finish up here. 
Has any staff infected a patient at Ballad Health, that you are 
aware of, with COVID-19?
    Mr. Levine. No, sir, not to my knowledge. Our staff are 
required to wear universal precautions. Whether you are 
vaccinated or not, you are wearing PPE, and you are doing 
everything you can to protect our patients.
    Mr. Bucshon. Great, thank you. I yield back.
    Ms. Eshoo. The gentleman yields back. The gentleman from 
Vermont, Mr. Welch, is recognized for his 5 minutes.
    Mr. Welch. Thank you very much, Madam Chair.
    Senator Sanders and I--Senator Sanders convened a workforce 
roundtable with the leaders in our healthcare system in 
Vermont, including the University of Vermont Medical Center, 
which is our largest. And just to recite the incredible 
challenges we have in our small rural state, 3,900 nursing-
related job vacancies; 70 primary care provider vacancies; 571 
long-term care facility vacancies; 386 home health nursing 
vacancies, and a big turnover, about 28 percent.
    The cost of this is brutal. You know, we are a small state, 
but traveling nurses, which has been the go-to place, is $50 
million at the University of Vermont. In a small community, 
Rutland, which is a really vibrant, but not rich community, $25 
million.
    And a concern I have is actually--I don't know who owns 
these nursing--traveling nurse agencies, but it is like now a 
business model, where there is incredible profiteering, and it 
creates the dynamic where nurses who are, for instance, on 
staff at the University of Vermont go on a per diem, and then 
go down 90 miles the road to Dartmouth-Hitchcock as a traveling 
nurse, and make a lot more money, and there is no benefit to 
the community. And I would really welcome thoughts on how to 
deal with that.
    But Mr. Levine, I want to ask you, because in your 
testimony you discussed how extensive the nursing workforce 
shortage is, especially aggravated with COVID. And the faculty 
issue is a real challenge, particularly with the pay gap. So 
can you be very specific as to the steps we can take--and this 
is bipartisan--to bolster our dwindling nursing force?
    And how can Congress help get at the root cause of the 
dynamic for long-term and sustainable change for our patients?
    Mr. Levine. Well, thank you, sir. I would start by agreeing 
with the advocacy for the Lorna Breen Act, because nursing 
resiliency is one of the most critical issues we are facing 
right now. And the reality is, you know, the East Tennessee 
State University Center for Nursing Advancement that we just 
created yesterday, they are going to be an eager applicant for 
those grant funds to study what causes these issues, and how do 
we intervene before we end up losing a nurse from the bedside.
    The second thing is--you said it when--you just said that--
--
    [Audio malfunction.]
    Mr. Levine. We--our nurse--the data that I have seen in 
2019, I believe, tens of thousands, as many as 80,000 
applicants for nursing school were turned away because there is 
not enough space in the nursing programs.
    I think we have got to lean in to create programs to 
identify high school students with a propensity towards being 
successful in the sciences, and get them exposed to nursing as 
a career where systems like ours would gladly employ them as 
unlicensed workers, so they could get a--they could graduate 
high school with some kind of a certification, and then go into 
a nursing program and come out with a job.
    There are----
    Mr. Welch. OK, thank you. I am almost out of time, but 
thank you very much for that.
    I would like to ask Ms. Harrison about this incredible 
challenge of the traveling nurses. How can we deal with that?
    How can we make--I mean, part of it is making the nursing 
profession more financially competitive, but we can't compete 
with the traveling nurse, where, essentially, it is a stickup, 
and a lot of that extra charge goes to, probably, hedge funds. 
Ms. Harrison?
    Ms. Harrison. Yes, sir. I wish I had a good answer. I think 
this is a struggle across private-versus-public opportunities 
to do healthcare delivery. It--they are very different models, 
and it is a real struggle to work against that, for sure.
    Mr. Welch. So nothing to say about that?
    Ms. Harrison. I don't have a good answer for how to 
eliminate that sense of loss from the public sector to the 
traveling nurse----
    Mr. Welch. You know, the dynamic with the traveling nurse 
is this. You have got hospitals, some of them non-profit, some 
for-profit. But essentially, their ability to serve people is 
based on taxpayer contributions for Medicare and Medicaid 
employers, who are employer-sponsored healthcare. And there is 
a captive market.
    And then the hedge funds, essentially, create this dynamic, 
where it is incredibly attractive to a nurse, understandably, 
to go from Burlington down to Hanover, New Hampshire. But we 
can't sustain that cost.
    I mean, is that a topic of concern among your community?
    Ms. Harrison. Well, in rural areas we don't experience that 
as much. And you know, we have such a short bench, not many 
opportunities for hiring and retaining nurses, whether it is a 
local hospital or a health department, in a rural area. So we 
don't have that dynamic as much as they have in larger 
metropolitan areas.
    Mr. Welch. All right, thank you.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentleman from Pennsylvania, and that he is, Dr. 
Joyce.
    Mr. Joyce. Thank you for yielding, Chair Eshoo, and Ranking 
Member Guthrie, and our incredibly distinguished panel of 
witnesses today.
    Even before the onset of COVID-19, we were facing multiple 
crises in our rural health systems, especially in my district 
in South Central and Southwestern Pennsylvania. Shortages of 
physicians, nurses, physical therapists, occupational 
therapists, other health professionals limited what services 
were available, and often would force patients to travel to 
Pittsburgh, or even to Philadelphia for care.
    COVID-19 has only further stressed a workforce that was 
already in crisis. Burnout has contributed to an uptick in 
retirements and providers leading the field--leaving the field. 
These have had negative impacts, negative impacts on staffing, 
and especially in these rural communities.
    In my community at health facilities like Windber Hospital 
and Excela Health, they have been forced to contract with 
nursing agencies that sometimes double, even quadruple the cost 
for hourly rates, just to stay operational and staffed to be 
able to take care of post-op patients.
    A misguided vaccine mandate that makes no attempt to 
account for natural immunity is also driving more and more long 
and committed professionals out of their fields. This path that 
we are on is not sustainable, and will not result in better 
patient outcomes for the long term.
    In order to address parts of this crisis, I worked to 
introduce the Enhancing Community Health Workforce Act that 
would reauthorize funding for community health workers to help 
improve the care coordination in underserved communities.
    Mr. Levine, and then Ms. Harrison, what impact do you think 
a bill like this could have, especially in rural settings?
    And I will ask Mr. Levine to answer first.
    Mr. Levine. Well, we--thank you, sir. We are actively using 
community health workers now in several programs that we have 
implemented throughout the region, as a health improvement 
organization.
    One of the things that we are focused on is, as I mentioned 
earlier, avoiding hospitalization. So we identified social 
determinant issues. It could be anything from somebody who is 
homeless, or can't afford their medications. We deploy our 
community health workers out to assist them. So anything that 
is done to enhance and solidify their role in the system, I 
think, would be very positive, and we would strongly support 
it.
    And I applaud you on your statement about the contract 
nursing agencies. What they are doing is not only financially 
destroying some of these hospitals, but they are also 
distorting the market for nurses, and it is not helpful, what 
they are doing.
    Mr. Joyce. Thank you for your answer.
    Ms. Harrison, would you please address the same?
    Ms. Harrison. Thank you. Yes, sir. So I am not as familiar 
with the particular program, but recognize the importance of 
any bill that gets more opportunities to work with community 
health workers at the local level, especially in rural areas. 
We do work with local community health workers, and they have 
been wonderful, especially these last few months.
    I think it is important to note that the intent of the 
grants do seem really helpful, in that they are disease 
agnostic. So much of the funding that comes to us is very 
specific. And so I can appreciate what I understand is true 
about that level of flexibility to address healthcare needs 
that might vary community by community. Certainly, COVID funds 
are critical to address COVID, and there are also many other 
public health issues that still will need to be addressed, 
moving forward.
    So hopefully, you know, one program will not be accountable 
to the other. I think we need them all.
    Mr. Joyce. And do community healthcare workers provide that 
ubiquitous care that is so necessary?
    Ms. Harrison. Yes. And originally, also, public health 
workers were our original community health workers. We 
definitely need both.
    Mr. Joyce. Thank you.
    Mr. Levine, in your testimony you spoke at length regarding 
workforce shortage issues, and I have heard from several people 
who run health systems in my district of the challenges of 
maintaining a workforce, especially in this economic climate.
    What should we be doing, as policy-makers, to ensure that 
rural healthcare workers want to stay in these critical roles?
    Mr. Levine. Well, one of the first things that really has 
disadvantaged rural hospitals and non-urban hospitals 
throughout America has been the Medicare Area Wage Index. The 
Save Rural Hospitals Act that has been filed, I think, would 
help solve that.
    When 80-plus percent of the counties in the country are 
below the index of--clearly, there is an imbalance. And that 
imbalance keeps rural hospitals from being able to compensate 
their nurses in a competitive way, with the larger neighboring 
counties, where the wage index is higher. To me, that is the 
first thing that ought to be done.
    Mr. Joyce. Thank you for illuminating that imbalance, 
because we certainly see that throughout my district in 
Pennsylvania.
    Madam Chair, thank you, and I yield the balance of my time.
    Ms. Eshoo. The gentleman yields back. The Chair is pleased 
to recognize the gentleman from California, Mr. Cardenas, for 
his 5 minutes of questions.
    Mr. Cardenas. Thank you very much, Madam Chair, and also 
Ranking Member Guthrie, for having this important hearing on 
these very important topics.
    I want to start with H.R. 1474, Alzheimer's Caregiver 
Support Act. Alzheimer's disease and other forms of dementia 
are truly disabling, as patients eventually are no longer able 
to eat, sleep, or care for themselves. There are more than 
five-and-a-half--approximately five-and-a-half million 
Alzheimer's disease patients in the U.S., and approximately 
600,000 of those are in California.
    Family caregivers suffer terribly trying to care for loved 
ones who no longer recognize them, and the role is often like 
that of a full-time parent doing a hard and thankless task out 
of love. This legislation would help train and support family 
members and other important, but unpaid, caregivers in their 
often unrecognized work caring for Alzheimer's patients.
    Ms. Monroe, can you help explain what this legislation 
would do to help the situation?
    Ms. Monroe. Yes, thank you for that question. Absolutely. 
This legislation would help caregivers who are trying to do 
what is best for their loved ones to be able to access 
resources as they need them in their community.
    There is not a sole source that you can currently go to to 
find out what exists. We do have some agencies like area 
agencies on aging, and sometimes--although we hear now it is 
only about 30 percent of doctors that are connected to 
community resources. But families absolutely need that. That is 
a prescription for their health, and their well-being over the 
long haul.
    When I, for example, have to take my dad to the doctor, I 
have to do that because I am his voice. So it is important for 
me to have access to that information, so I can make sure that 
he does, as well.
    As I mentioned earlier, we see caregivers who not only need 
linkages of services for their loved one, but they themselves 
may need mental health supports, and respite, and other 
healthcare supports for themselves, as this is a daunting, 
often very physical issue. And----
    Mr. Cardenas. Thank you.
    Ms. Monroe [continue]. Find that caregivers are getting 
sicker and dying before the people that they are actually 
taking care of, because----
    Mr. Cardenas. Thank you.
    Ms. Monroe [continue]. You are making a choice sometimes 
between work----
    Mr. Cardenas. Thank you. Thank you, Ms. Monroe.
    Ms. Monroe. Thank you.
    Mr. Cardenas. Thank you very much. In the interest of time, 
I would like to ask a question regarding H.R. 3297, Public 
Health Workforce Loan Repayment Act.
    The COVID-19 pandemic has really shined the light on what a 
shortage we have in this country of healthcare workers, even 
though the ones that we do have have been heroes, always, not 
just during this pandemic.
    This bipartisan legislation helps ensure we have 
professionals in place to keep us safe, so we are prepared for 
future pandemics and the everyday life of caregiving.
    Ms. Harrison, what was the public health workforce capacity 
and infrastructure like before the pandemic?
    And with COVID-19, what have been the effects?
    And also, how would this legislation help?
    Ms. Harrison. Thank you so much for the question. The--over 
time, the recessions and the dips in funding that has come to 
public health really crippled the workforce capacity, even 
prior to the pandemic. So we were already at a deficit. And 
then the pandemic hit, and we were expected to, of course, make 
sure we could continue to do more and more.
    This Loan Repayment Act will help tremendously, with at 
least being able to recruit and retain over the long haul for 
the public health infrastructure, and make up for some of those 
losses.
    The de Beaumont Foundation and the Public Health 
Innovations Committee has actually done a research study that 
requests 80,000 new full-time equivalents to public health at 
state and local levels; 54,000 of those need to come to the 
local level to just shore up regular functions and capabilities 
of public health, community-to-community. And so I believe this 
loan repayment program is a start to fill that gap.
    But certainly, our workforce is tired, and we are losing 
them to burnout. Their cups are empty after 20 months of this 
level of intense and protracted work during the pandemic. So we 
need to make sure that we are addressing our appreciation----
    Mr. Cardenas. Thank you.
    Ms. Harrison [continue]. For the current workforce, and 
recruiting new ones. This will help.
    Mr. Cardenas. Thank you so much. Thank you.
    I would like to, with the remaining time, just say thank 
you for all of us who are supporting 1667, the Dr. Lorna Breen 
Health Care Provider Protection Act.
    And to Mr. Feist and your family, thank you so much for 
putting your time and energy into making sure that such a 
tragedy does not come upon other individuals and caregivers and 
their families. So thank you so much for being here with us, 
and thank you for all that you do.
    With that, I yield back.
    Ms. Eshoo. I thank the gentleman for his beautiful words, 
and he yields back. The Chair is pleased to recognize the 
gentleman from Utah, Mr. Curtis, for your 5 minutes of 
questions, the patient Mr. Curtis.
    Mr. Curtis. Thank you, Madam Chair and Ranking Member 
Guthrie, not only for this hearing and for hearing my bill 
today, but for putting these hearings together in a tough 
environment, with COVID, with votes, and all of our other 
responsibilities. And so thank you for your patience, which we 
don't always recognize.
    The Helping Enable Access to Lifesaving Services Act, or 
the HEALS Act, is my bill, and I am very proud of it. It 
reauthorizes the grant program established by the 21st Century 
Cures Act, something that happened before I came here to 
Congress.
    Funding within the grant would be used to help eligible 
groups to recruit, educate, and provide learning opportunities 
for behavioral healthcare students, including substance use 
disorders, specialties, psychiatrists, psychologists, and 
social workers, just to name a few.
    The HEALS Act is especially important to me, because Utah, 
unfortunately, has seen significant increase in demand for 
behavioral healthcare services throughout the COVID-19 
pandemic, not unlike our nation. As a matter of fact, the 
nation has seen an overdose rate increase by 30 percent, year 
over year.
    Dr. Keel, I don't have a question for you, but perhaps a 
comment and--to you and some of the other panelists. I have 
watched over the last few years my son, who is now practicing 
psychiatry, go through medical school. And you might all enjoy 
that I visited him once, while he was going through medical 
school, and he had his water heater turned off, and he was 
trying to save money to lower his student debt, right, when he 
came out the other side.
    And I know firsthand the difficulty and the sacrifices 
these healthcare workers make. My wife is a physical therapist, 
and does home healthcare visits. Dr. Wilburn, you are smiling 
behind the mask, and I have seen the impact on her firsthand, 
as well.
    So thank you for your testimonies today, and for all that 
you are doing.
    Mr. Levine, I am curious how your doctors have been dealing 
with the increase in demand for behavioral healthcare services 
since the beginning of the pandemic.
    Mr. Levine. Well, it has obviously been a huge concern for 
us. Right now we have expanded our Employee Assistance Program. 
We are leaning in to every hospital. We have 21 hospitals, we 
are leaning in every hospital to make it available. And based 
on what has been said here, I agree, convincing people that it 
is not only necessary to seek help when you have it, it is a 
sign of strength, not weakness.
    Mr. Curtis. Right.
    Mr. Levine. And we are doing a lot of education to try to 
get our physicians and our frontline caregivers with the 
physicians to take advantage of these opportunities.
    Mr. Curtis. If you are familiar with the HEALS Act, are you 
able to comment on how that would help your situation?
    Mr. Levine. I am not familiar with all of the relevant 
details of the HEALS Act, but I can tell you that we would 
definitely be among those that would apply for these brands 
because we think, incrementally, it can help us link further in 
with our physicians.
    Mr. Curtis. You will smile when I say that my district is 
about 80 percent rural. A lot of you here will understand what 
that means. Although I do like to tease my colleagues here from 
the East Coast. I think we have different definitions of rural, 
and we are really rural out in Utah.
    It won't surprise you that telehealth was really critical 
before the pandemic, and has been even more important during 
the pandemic.
    And Dr. Levine, again, as it relates to audio-only 
telehealth services, can you share how Ballad Health, 
specifically, has been dealing with that, in context to 
behavioral health?
    Mr. Levine. It has been a huge opportunity for us. Right 
now we are--six schools throughout our rural region. Many areas 
are very, very rural, and so we have got several behavioral 
programs that we deploy that way, and the audio is really 
important.
    Obviously, we would like to have bandwidth to be able to do 
full video. And frankly, during the pandemic, some of our 
largest physician practices, our very large cardiology group, 
were able to keep up with the patients, purely because of the 
telemedicine and because of audio.
    So I absolutely agree that that opportunity is something we 
would want to continue to expand and take advantage of.
    Mr. Curtis. Do you have any suggestions for Congress, as we 
think about the long-term cost benefits of expanding the audio-
only telehealth behavioral services with Medicare patients and 
others that promote this reliable access to quality care?
    Mr. Levine. I think the payment mechanisms that could 
institutionalize that would be helpful in making them more 
permanent and predictable. I think that it would help create 
more investment into the growth of those mechanisms. And 
certainly, I would always advocate for more broadband to help 
with getting beyond audio.
    Mr. Curtis. Yes, broadband is clearly an issue for rural 
districts.
    I have got just a few seconds left. I don't know if anyone 
else wanted to comment.
    Yes, Ms. Harrison, in just a few seconds, please.
    Ms. Harrison. Thank you. I just want to mention that my 
brother is a nurse in rural Utah----
    Mr. Curtis. Oh, great.
    Ms. Harrison [continue]. And works in a school system. So I 
would just add to the importance of including schools in your 
bill for mental health, behavioral health services, and 
telemedicine.
    Mr. Curtis. Thank you for the exclamation point on my 
comments.
    Madam Chair, I am out of time. I yield back to you.
    Ms. Eshoo. The gentleman yields back. I especially 
appreciate your sharing the story about your son training to 
become a physician, what your wife does. I think it is so 
important for the American people to hear that we, too, are 
very human. So thank you.
    The Chair now is very pleased to recognize the gentlewoman 
from California, Ms. Barragan. Five minutes.
    Ms. Barragan. Thank you, Madam Chairwoman Eshoo, for 
holding this important hearing today. I want to thank all of 
our witnesses for their testimony, and my colleagues who have 
shared.
    You know, the investments in our caregivers are personal to 
me, to my constituents, and the American people. My mother is 
80 years old, has Alzheimer's, and it has been a struggle, not 
just in understanding the disease and what to expect, but in 
finding reliable caregivers for her.
    So, you know, we come from a Latino culture background, 
where we never spoke about this, and we really didn't know 
where to go for help. So it has been incredibly challenging. 
And so to hear the stories here today is something I can relate 
to. But it is something that the American people, especially 
low-income Americans, maybe those who have cultural 
differences, have, you know, certainly a hard time navigating 
our system.
    I--just this week I had to take a red-eye here, to 
Washington, DC, to help make sure I was there to provide care 
overnight. And so it is not easy, and I have to continue to 
educate myself, and navigate my way through our fragmented 
health and caregiving system to understand what resources are 
available.
    One of them, of course, is the in-home care program that we 
are trying to expand under reconciliation, and make sure people 
can stay in their homes.
    And when you hear about the stories of the more than 16 
million people who serve as unpaid caregivers, I know 
firsthand, whether I am one of them, whether I have other 
family members that are, it does take an enormous toll, and it 
is--you know, it takes time, and emotionally is hard, as well.
    So I am supportive of the legislation before us today to 
provide that grant money and availability for that. You know, 
we need to show compassion to those in need, and invest in our 
public health workforce and care economy. And so I support the 
bills today.
    Ms. Monroe, I found your testimony to be so powerful, you 
know, particularly on the lack of culturally appropriate 
resources for dementia diagnosis. We need to use every 
available resource available to fight this disease.
    We also need to continue to work on getting treatments for 
Alzheimer's as soon as possible, and I hope we can continue to 
support the accelerated approval path for medicines to treat 
serious or life-threatening conditions.
    There is a lot of important legislation out there, but what 
would you say is the most important thing that Congress can do 
to help advance the fight against Alzheimer's?
    Ms. Monroe. Excellent question. Gosh, I wish I could come 
up with just one. I think there are probably, I would say, two.
    The first would be to make sure that we have timely, 
accurate, early diagnosis of this disease that will give people 
the ability to plan, and take better care of their loved ones.
    I would also like to see us adopt a national prevention 
strategy, because we know that 40 percent of Alzheimer's could 
be prevented by us addressing a lot of the comorbidities that 
go along with it. And we have been writing letters, and hope to 
have that national strategy implemented with some teeth to it.
    But, you know, recruiting all communities into clinical 
research will be really important to make sure that we know 
that all the medicines and the therapies work well for all 
people. I think that is a great priority for us because, as we 
become a majority-minority country, we will be serving the new 
majority when we do that, and we have just a few years under 
our belt to get ready to do that.
    Ms. Barragan. Well, thank you for that, and thank you again 
for all your work.
    Mr. Keel, in your testimony you spoke about the need for 
future physicians to practice in rural and underserved 
communities. Can you speak to the importance of community 
health centers, and how your program encourages graduates to 
practice in these types of care environments?
    Dr. Keel. No, actually, I am afraid I can't comment on that 
at this time. We rely mostly on academic centers, health 
centers within our community-based campuses to help us 
implement that.
    Ms. Barragan. OK, got it.
    Ms. Macon Harrison, putting your local public health 
official hat on for a second, what role do you--do community 
health workers play in local health districts, such as yours in 
Granville, North Carolina?
    Ms. Harrison. Thank you for that question. In Granville and 
Vance Counties, we do have one local federally-qualified health 
center. It is called Rural Health Group, and we work 
collaboratively with them. We have enough need for the safety 
net for primary care services that half of the local health 
departments in North Carolina do full-scale primary care to 
complement those federally-qualified health centers and 
community health centers that do exist that are so critical 
across rural North Carolina.
    Ms. Barragan. Well, thank you all again for your work and 
your testimony.
    Madam Chairwoman, I yield back.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentleman from Texas, Dr. Burgess, for 5 minutes.
    Mr. Burgess. I thank the Chair, and I apologize for being 
in and out of the hearing today. Trying to stop a friend from 
writing a $5 trillion bad check, and it has just not been easy.
    Let me just address something with you all, and this has 
concerned me for a long time, and that is the repetitive 
provider cuts that are coming the way of our physicians. It 
happened last December 31st, it almost happened with the last--
we kept them from going over the falls. The same thing is 
happening this year. It is an almost ten percent aggregate cut.
    And I know people say we will fix it before the end of the 
year, but it is a risky strategy. Because if you don't, then 
the very people that we have all been describing as our heroes, 
and the people that we have depended upon to deliver the care 
in the worst possible situations, they are going to get hit 
with this.
    And kind of off to the side, we have the agency working on 
a very, very bad interpretation of our surprise billing rule, 
which is going to render doctors almost powerless against the 
big insurance companies.
    So there is a lot on the plate of the practicing physician 
right now, and we have not had a single hearing about how to 
deal with that, how to deal with these cuts. It is a 
misguided--in my opinion, it is a misguided approach.
    Now, in an effort to be bipartisan, Bobby Rush and I have a 
temporary solution that is H.R. 5613, for anyone keeping score 
at home, that would waive the budget neutrality requirement 
from the physician's fee schedule, and then we can offset with 
unobligated funds that still remain in the provider relief 
fund.
    But again, I would just stress it is so risky to wait until 
the last minute, because if something distracts us--and you may 
have noticed that there are a lot of things that can distract 
us--then the provider cuts go into effect.
    And this is not a partisan issue. The basis of--for 
hearings on that, I think, could and should be bipartisan.
    Let me pose a question for Mr. Levine. And again, bearing 
in mind what I just said about the end of this year, the 
provider cuts in Medicare reimbursement, there are solutions we 
can consider that will ensure providers are paid a reasonable 
amount, such as the bill I just referenced, 5612, that would 
waive the budget neutrality adjustments under the physician fee 
schedule.
    But do you have in mind what else we could do to ensure 
that our docs and nurses, their healthcare providers' pay is 
competitive, in order to recruit and retain healthcare 
professionals, and not burden them so severely?
    Mr. Levine. Yes, Dr. Burgess, these cuts couldn't happen at 
a worse time, because they are happening right at the same time 
we are facing the major pressure----
    Voice. Alan?
    Mr. Levine [continue]. The major market pressure on nursing 
salaries. These cuts to the physician community, particularly 
in rural and non-urban America, are devastating. And for those 
who are concerned about more vertical integration in terms of 
antitrust, this is going to lead to more vertical integration.
    These physicians, particularly in rural areas, if they get 
cut, they are coming to the hospitals, and it is going to be--
and that is going to happen more and more, which a lot of 
people are concerned about, rightly so, as are we. So I think 
that is issue number one.
    Of course, the Area Wage Index that I referenced earlier 
severely harms the majority of America's hospitals.
    I think those two things can help, though, both with 
nursing salaries, as well as with physician pay.
    Mr. Burgess. Well, thank you for that, and I agree with 
you, the private equity folks are waiting on the sidelines, and 
are eager to pounce when our providers despair, and are driven 
into the arms of someone else.
    Let me just ask you a question of your health center. You 
don't have a mandate for the vaccine there. It is my opinion 
that the vaccine is a miracle, but mandates are toxic, and 
drive oppositional behavior. How are you handling that?
    Mr. Levine. Our position up to this point has been to 
promote vaccines, educate our team members. We have got about 
60 percent of our team members that are vaccinated, 90-plus 
percent of our doctors. We have started--actually, I have had 
some resignations already, just in anticipation of the Medicare 
mandate that is coming down. So our position has been not to do 
the mandate, but to educate.
    Obviously, that position will likely change with the 
impending Medicare rule that is being----
    Mr. Burgess. Yes, I think that would be a big mistake. But 
thank you, everyone, for your participation this morning. It 
has been a very informative hearing.
    I will yield back.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentlewoman from New Hampshire, Ms. Kuster, for 
her 5 minutes of questions.
    Ms. Kuster. Thank you so much, Madam Chair. The discussion 
we are having today on healthcare workforce and caregiver 
support is critically important in New Hampshire, where we are 
experiencing a COVID surge right now.
    I am consistently hearing from healthcare providers in my 
district about the current workforce crisis. Even before the 
pandemic, New Hampshire was experiencing an urgent healthcare 
workforce shortage, especially in the rural communities in my 
district. The pandemic has exacerbated this issues--these 
issues, and there simply are not enough clinicians to meet 
current demands.
    One hospital leader told me recently they are facing a 
clinical crisis. Cases of COVID are rapidly increasing and 
overwhelming medical providers. Hospital staff are stretched 
thin, and patient care is suffering. So I agree that we must 
examine and support ways to grow, diversify, and strengthen the 
clinical care and health workforce.
    But we also need to think about ways we can immediately 
support the providers who cannot meet the current labor demands 
necessary to care for our communities, especially underserved 
areas. Our frontline providers have experienced relentless 
physical and emotional strain over the last 20 months, and they 
need immediate assistance.
    Dr. Keel, in addition to investing in provider mental 
health and wellness, can you go into more detail about what 
Congress can do to sustain the healthcare workforce now and 
mitigate the immediate ramification of the existing provider 
shortage?
    I am sorry, that was addressed to Dr Keel.
    Dr. Keel. Yes, OK. Could you repeat that question for me 
real quick? Sorry, I couldn't hear that.
    Ms. Kuster. Oh, I am sorry. In addition to investing in 
provider mental health and wellness, can you go into more 
detail about Congress--what Congress can do to sustain the 
healthcare workforce now, and mitigate the immediate 
ramifications of the existing provider shortage?
    And if you would address telehealth, if that is one of the 
solutions?
    Dr. Keel. Yes. No, I think you have hit on an excellent 
potential solution. We have been utilizing telehealth 
extensively for the last several years--in fact, more than a 
decade--dealing primarily with stroke. Initially, we had a 
telehealth stroke program, a hub and spoke program, where we 
are attached through telehealth to some 12 or 13 hospitals in 
some of the more rural areas of our state, and it allows us to 
be able to address that very serious issue on an immediate 
case.
    One thing COVID has taught us, though, is that the use of 
telehealth is now more important than ever. And some of the 
roadblocks that have been in place in past years I think are 
now coming down. We need to make sure that those roadblocks 
stay down, so that we can begin to implement telehealth on a 
more widespread case.
    This allows us to--especially in the rural hospitals, it 
allows us to keep the patients in the rural hospitals if they 
don't need to be transferred to a more tertiary care or 
quaternary care unit like we have. And the telehealth certainly 
does allow us to do that. It provides the opportunity for the 
patient to stay in the hospital. That is financially 
advantageous for the local hospital, certainly, but it also is 
advantageous because that is where the families are located, 
and it contributes greatly to the overall care that the 
patients receive.
    So I am fully convinced that we will see more and more 
telehealth. And I think the more that we can do to try to make 
telehealth more readily available and easier to do, and more 
cost effective to do, it is going to help address the rural 
health problems we have in this country.
    Ms. Kuster. Great, thank you.
    Now, Mr. Feist, from your work on the Dr. Lorna Breen 
Health Care Provider Protection Act, have you learned of any 
unique challenges or experiences faced by providers working in 
predominantly rural or underserved communities?
    Mr. Feist. Apologies, bio break after a three-hour tour.
    [Laughter.]
    Ms. Kuster. No problem.
    Mr. Feist. Would you mind repeating that very quickly?
    Ms. Kuster. Did you hear that, Mr. Feist? I am asking about 
whether you have learned about unique challenges or experiences 
faced by workers in predominantly rural or underserved 
communities.
    Mr. Feist. Absolutely, absolutely.
    Ms. Kuster. And what would you recommend we do?
    Mr. Feist. Absolutely. The Dr. Lorna Breen Health Care 
Provider Protection Act provides funding for the current 
workforce, as well as the future workforce, irrespective of 
where they are, rural or urban.
    The issues that we have on the workforce are ubiquitous, 
regardless of where you are in medicine. And so we need to 
bring programs right now to the workforce to support their 
well-being, whether those be peer support programs, or that is 
redesigning that healthcare delivery system so that it doesn't 
burn out the workforce in the process.
    If we have heard from one physician or nurse, we have heard 
from a thousand, ``Don't just give me another meditation app. I 
need you to help me redesign the healthcare delivery process so 
that I am not burnt out in the process.''
    Ms. Kuster. Right. Regretfully, my time is up. I didn't get 
to discuss Alzheimer's, which is near and dear to my heart, but 
I will follow up with the committee. Thank you.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back. The Chair 
recognizes the gentleman from Oklahoma, Mr. Mullin, for his 5 
minutes of questions.
    Mr. Mullin. Thank you, Madam Chair, and thank you for 
holding this hearing today.
    Dr. Wilburn, I would like to start with you. Can you 
provide just specifics on how the grant program that allowed 
health workers--Allied Health Worker--Health Workforce 
Diversity Act would further benefit American Indians and Alaska 
Native communities?
    Dr. Wilburn. Thank you so much for that question, 
Representative Mullin. This is such an important point, since 
American Indian and Alaska Native communities have been hit so 
hard by COVID.
    The Indian Health Services faced a severe health workforce 
shortage prior to the pandemic, a problem that has only gotten 
worse. This legislation would provide an opportunity for 
Northeastern State University, where 20 percent of its student 
body is American Indian/Alaskan Native, to apply for grant 
funding to support efforts to recruit more individuals from the 
community into all of the higher education programs for all of 
the professions in this bill.
    According to the Post-Secondary National Policy Institute, 
only 17 percent of American Indian/Alaskan Native high school 
students continue on to higher education, compared to the 60 
percent in the U.S. population.
    Mr. Mullin. Thank you. Based on the projected increase for 
the need for healthcare professionals, obviously, there is 
going to be an increased need on that, and we all know that, 
moving forward. How important is it to understand the under-
represented individuals that we need to recruit? And then how 
do we retain those?
    Dr. Wilburn. Thank you again for that question. Recruitment 
and retention is really synonymous, and so the best thing for 
us to do is to be able to support individuals by affinity 
groups, academic counseling, tutoring, and pipeline programs.
    Mr. Mullin. So when you start talking about recruiting 
those individuals, is there a program that we have put out 
there yet that we are thinking about a tool to help recruit 
them?
    I know, for instance, Oklahoma State University, they have 
paired with Cherokee Nation to have a program designed to go 
into high schools, and specifically start recruiting people as 
early as freshmen to say, ``Hey, do you want to enter the 
healthcare profession? How do we start working with you?''
    And then they actually opened a medical hospital, and--
partners with Cherokee Nation in Tahlequah, which is, 
obviously, an underserved area that is represented by, you 
know, a large population of Native Americans.
    Dr. Wilburn. So that is an excellent point, and I agree 
that recruitment begins, really, in middle school.
    This program would allow individuals to see themselves in 
those professions already. Financial implications can seem 
insurmountable. So what this program would do is really come 
alongside individuals, and give them a pipeline for financial 
support, which we know is often the biggest barrier to academic 
achievement.
    Mr. Mullin. Well, thank you for that.
    In closing, Madam Chair, I would like to echo the concerns 
among many of my colleagues that said--regarding the Biden 
Administration's vaccine mandates. As this committee knows, and 
as you know, all the last year, through the beginning of the 
pandemic, my son was in a clinic for traumatic brain injuries. 
And the individuals that worked with him every day, they showed 
up understanding the protocols that they had to follow, 
understanding the work that needed to be done with individuals 
that had to have rehab to be able to continue to function on 
their daily life. And they did it in a safe manner.
    We have had a workforce that we depended on with our 
frontline healthcare workers that we depended on every day, 
that we cheered them, and we thanked them for what they were 
doing. And they were good enough to take care of it in the 
heart of the pandemic. Why are we forcing these individuals 
now, that worked all last year without a vaccine? Now we are 
saying that wasn't good enough, even though you were safe, and 
you protected your patients, now we are going to say that you 
have got to have the vaccine, when we already are running a 
shortage, or we are already running short on healthcare 
providers and medical professionals, as we are, as it currently 
stands.
    And so I would like to echo my colleagues and say why are 
we doing this? I think this committee has the opportunity to 
make a strong ask to the Administration to relook at this 
mandate, because they are running out good people when we 
shouldn't be losing anybody right now.
    With that, I yield back.
    Ms. Eshoo. The gentleman yields back. I appreciate your 
comments. Just a very quick reflection. You--we all prayed for 
your son, knowing the condition that he was in, and thank God. 
You know, it is a good news story.
    We didn't know about Delta a long time ago. It is called 
the novel coronavirus because that it is. We keep learning 
about this virus. Remember when they told us, ``Don't touch 
your face''? We don't hear that anymore.
    So--and over 700,000 American souls have been lost, over 
700,000. So this is about saving lives, not losing lives. And I 
don't find this--I just don't think it is menacing. But you 
know what? There are people that don't agree with me, so they 
don't agree. But I would place myself in the company of those 
that know so much more than I do, the very people who we want 
more to come into the system, those that have studied for a 
decade or more, to take care of us. They know what they are 
talking about, in my view, I think they know what they are 
talking about.
    Thank God we have the vaccines. And, you know, as I said to 
a constituent, do you think that, if I had polio, that I have 
the right to infect you? I don't think so. OK.
    The Chair recognizes the gentlewoman from Delaware, Ms. 
Blunt Rochester, for her 5 minutes of questions.
    Ms. Blunt Rochester. Thank you, Madam Chairwoman, and thank 
you so much to you and the witnesses for this very important 
hearing on some very vital bills. And particularly, I want to 
thank the families for their testimony today, as well, as you 
honor your family members.
    Investing in our infectious disease workforce is not only a 
matter of pandemic preparedness, but a matter of health equity. 
Today there are 1.2 million people living with HIV in the U.S., 
and racial and ethnic minorities make up the majority of new 
HIV diagnoses, people living with HIV disease and deaths among 
people with HIV.
    Furthermore, a large proportion of new HIV diagnoses occur 
in the South, as well as other rural areas, often in places 
where there has either been a disinvestment in healthcare or 
natural attrition of providers due to other factors. Given that 
Black and Latinx Americans account for nearly 70 percent of new 
HIV diagnoses in the U.S., I am particularly concerned about 
ensuring that there is a diverse and culturally competent 
infectious disease and HIV workforce that reflects the 
populations most impacted.
    My bipartisan bill, H.R. 2295, the HIV Epidemic Loan-
Repayment Program, otherwise known as the HELP Act, which I am 
leading with Congresswoman Barbara Lee, would address that 
issue head on, by helping to make it possible for HIV 
professionals to live and work in underserved communities. I am 
really proud of the fact that this was led by our late friend 
and colleague, Congressman John Lewis, and we are proud to 
carry on his legacy.
    Dr. Marrazzo, can you share more about how the BIO 
Preparedness Workforce Act will help to recruit diverse 
clinicians to the ID HIV field, and how this bill will advance 
health equity?
    Dr. Marrazzo. Well, thank you very much for that excellent 
question, which is near and dear to my heart, as an ID 
physician based in Alabama, which continues to experience very 
high rates of HIV incidence, as you are aware.
    I agree with you, that having a workforce that reflects the 
populations most heavily affected by HIV and other infectious 
diseases has to be a top priority. We are able to reach the 
patients who are affected because we look like them, and we 
really care about them, and that is really important.
    The bill, I think, is going to be able to help address 
health disparities by reducing some of the financial barriers 
that I mentioned before to the populations that are most under-
represented in medicine, particularly when you factor in the 
challenge that many of these individuals have with paying some 
of the considerable loan balances that have already been 
mentioned. Hopefully, that will really incentivize people not 
only to do HIV and ID, but to work in these underserved 
communities.
    Ms. Blunt Rochester. Thanks. And just as a follow-up, I 
know we have had a lot of conversation about attracting people 
to rural areas. Can you talk about how this bill would help to 
ensure that more providers go into HIV care, where they are 
most needed in these rural areas?
    Dr. Marrazzo. So again, I think part of the challenge with 
going into rural areas for people doing specialty care is 
feeling isolated, feeling like they don't really have a 
community not just to support their work, but who even 
recognize their expertise.
    Again, this bill would support the creation of a network of 
people, and a network of interdisciplinary team providers, 
which you know, especially for HIV, is really critical. You 
need everything from dentists, to social workers, to infection 
prevention people. So creating this kind of interdisciplinary 
opportunity for people to go into this field could really make 
a big difference in making people feel welcome in these 
communities, and like they really want to be there and provide 
the care we need for the populations who most need it.
    Ms. Blunt Rochester. All right, thank you so much. And I 
just want to shift to the nursing shortage, and especially 
during the COVID-19 pandemic.
    We know that hospital-based nursing programs provide a 
desperately-needed pipeline of highly-skilled nurses to 
hospitals, nursing homes, and community settings. Hospital-
based nursing schools act as both an employer and educator, 
delivering successful student outcomes, and nurses who are 
ready to enter the professional healthcare workforce because of 
the experiential education they receive and that they provide. 
Yet these programs are facing drastic cuts because of the 
technical glitch and oversight from CMS that will lead to a 
recoupment of millions of dollars.
    My bipartisan legislation, H.R. 4407, the TRAIN Act, would 
fix this administrative error, and prevent Medicare payment 
cuts to these critical nursing education programs.
    Mr. Levine, I am going to have to ask if you would follow 
up with me afterwards, because my time has expired, but I would 
love to hear you speak to the impact of these cuts to nursing 
programs.
    Mr. Levine. Yes, will do so.
    Ms. Blunt Rochester. OK, thank you so much.
    And Madam Chair, I yield back.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentleman from Georgia, Mr. Carter, for his 5 
minutes of questions.
    Mr. Carter. Thank you, Madam Chair, and thank all of you 
for being here. I know it has been a long hearing, and we 
appreciate your diligence in staying here.
    Dr. Keel, I want to ask you. I am very proud that you are 
here today, very proud of what we are doing and what you are 
doing, specifically, in the State of Georgia, in the sense of 
your 3+ program that shortened medical school from 4 years to 3 
years. I know--as you know, I am a pharmacist, and I have a 
Bachelor of Pharmacy degree, and it was a three-year degree 
after our prerequisites were met.
    And we always--we were always concerned that we only got a 
bachelor's degree, even though it took us three years, as 
opposed to other people, two years. So what they do, they added 
on a year, and gave us a doctor of pharmacy degree that took 
four years. But you are doing just the opposite, and this is 
good. I just want to ask you about it, and to elaborate upon 
it.
    So let me--how do you condense it? Did you condense 
anything that--exactly how does it work?
    Dr. Keel. That is a great question. One of the things most 
traditional four-year medical schools do is that that fourth 
year is aimed at providing students with electives and 
opportunities to interview for residency programs in the 
disciplines that are not considered primary care. That is 
really--they are so competitive to get into dermatology, 
ophthalmology, neurology, those sorts of things.
    We have compressed the program, the core curriculum, into 
three years by eliminating the summers that the students would 
typically have off, and focusing on the core curriculum at that 
point in time. For those students that need that fourth year 
for the electives, they can certainly do that. But for those 
students who really are aimed at trying to serve in rural and 
underserved Georgia, they get to go right into their fourth 
year, and start their residency in the primary care at that 
point in time.
    So we are not shortchanging the education of these students 
a bit. We are just accelerating the opportunity for them to get 
out and get to practice.
    Mr. Carter. In medical school, before you can become 
licensed, you still have to pass the boards. So it is not as if 
you are not as qualified as someone else. I mean, you still got 
to--I know we had to pass the pharmacy boards, as well, after--
even if you got a degree. We had some people who had a degree 
that didn't have a license, because they couldn't pass boards.
    Dr. Keel. Absolutely. And these students really haven't 
been in the program long enough to really have any hard data to 
show you, but these students in the three-year program are 
every bit as successful passing boards as those in the four-
year program. And we certainly will--we are going to keep a 
close eye on that.
    There have been other programs in the country that have 
exercised accelerated programs, and they have shown that the 
opportunities to pass boards are not diminished at all.
    Mr. Carter. As you and I know also well, we struggle in the 
rural parts of our state, in rural parts of our country, and in 
South Georgia, in particular, with attracting physicians to our 
communities. And this is a way that--I understand the financing 
for it is a way that we can get some of the students to locate 
to some of these rural areas that are underserved.
    Dr. Keel. Absolutely. It eliminates the debt before they 
ever accumulate it, and that gives them opportunities to really 
focus on staying in the state, and practicing in those rural 
and underserved areas, without being strapped with upwards of 
$130,000 in debt.
    Mr. Carter. Right. And it is such an important part of the 
rural community because, you know, when people look to go to a 
community--and businesses, especially--you know, they want to 
know about the education, they want to know about healthcare. 
And that gives these communities the opportunity to address 
those issues there.
    Dr. Keel. Absolutely. One of the things we have--and 
rightly so--focused on today is the need for healthcare in 
those rural areas, and the need to put physicians there so that 
they can provide that healthcare.
    But one--the other important aspect about this is there is 
a huge economic development contribution that this program and 
other programs like it are going to have, as well, for the 
reasons that you just mentioned. This is an industry, when they 
choose to locate in an area, regardless of whether it is rural 
or not, they want to know how is the education system, the K 
through 12 system, and how readily accessed is healthcare to 
their employees.
    And so providing physicians incentives to practice in these 
rural and underserved areas is not only going to help the 
health disparities that we see, but it is also going to help 
the economic prosperity.
    Mr. Carter. What disciplines does it cover? Because, as you 
know, we are really struggling with primary care physicians, we 
are really struggling with psychiatry, and a number of 
different disciplines to try to get to the rural areas, right?
    Dr. Keel. And we are focusing on what the greatest needs 
are in our state, not only the more classical primary care 
disciplines, the family medicine, the internal medicine, 
pediatrics, but we are also offering this to emergency 
medicine, psychiatry, OB/GYN, and general surgery, as well, 
because it is not just the need for a physician; some of these 
counties have very specific needs for specialties, and this is 
going to help address that, as well.
    Mr. Carter. Just very quickly, what about financing? How 
are you handling this, as far as scholarships or whatever go?
    Dr. Keel. Right. We were fortunate to get a $5.2 million 
gift from Peach State Health Plan, a subsidiary of Centene. 
That was matched by the State of Georgia to give us an 
endowment that will serve--serves as the basis for these 
scholarships, and we hope to raise more money that can also be 
matched by the state to adjust this, as well.
    The communities are going to be--have a great need to chip 
into this process, too, because it is in their best interest.
    Mr. Carter. Absolutely. Thank you very much, and I yield 
back.
    Dr. Keel. Thank you, sir.
    Ms. Eshoo. The gentleman yields back. The Chair is pleased 
to recognize the gentlewoman from Washington State, Dr. 
Schrier, for her 5 minutes of questions.
    Ms. Schrier. Thank you, Madam Chair, and thank you the 
witnesses for testifying at this really important hearing 
today.
    This pandemic has stressed and maxed out our healthcare 
system in ways we have not seen before, in ways that we will 
see even after the pandemic is behind us.
    Mr. Feist, first, thank you for coming today and sharing 
the story of your sister-in-law. I am so, so sorry for your and 
your family's loss, and I want to also thank you for sharing 
those harrowing facts about provider burnout, and mental health 
strains, and physician suicide, and how many physicians are 
thinking about leaving their profession that they trained so 
hard for years to enter.
    In my state of Washington, 19 months into COVID, our 
providers are exhausted. I heard from a provider at Central 
Washington Hospital in my district that COVID rates are still 
high. The average approximately--this is a rural hospital--
approximately 40 COVID patients each day, about 28 percent of 
their overall census. At any given time, 10 to 15 of those are 
in the ICU. And the nurses, the respiratory therapists, the 
doctors are tired, and they are also demoralized, especially 
since most of these hospitalizations could have been prevented 
with a simple vaccine.
    They have about 150 open nursing positions throughout 
Confluence Health, which is almost a 20 percent vacancy rate. 
And this prolonged high-intensity work, combined with 
understaffing, can take a huge toll on mental health.
    Mr. Feist, you mentioned in your testimony that Dr. Breen 
expressed concern about losing her license if she sought 
psychiatric care, and it is absolutely devastating. As a 
physician, I absolutely relate to that sentiment. We are 
trained to put ourselves on the back burner, to work 36-hour 
shifts, don't ever show weakness, know everything, postpone 
relationships, don't even think about having a family. And so 
it is no surprise to me at all that Dr. Breen felt that way.
    And I want to just say here on the record for all my fellow 
providers in Washington State and elsewhere that seeking help 
should not put your career at risk.
    I am proud that the Washington Medical Commission in my 
state encourages any practitioner in need to seek help, and to 
develop a support plan to address any needs they may have, 
because nothing about seeking mental health treatment or other 
medical treatment risks the license of a Washington physician 
or PA.
    Mr. Feist, in a perfect world there would be no stigma. But 
in the meantime, do you know of any physician-led or provider-
led efforts to create a more supportive environment for 
providers who are going through what Dr. Breen went through?
    Mr. Feist. It is an excellent question. What we have heard 
from the healthcare community through nationwide surveys, 
particularly because of this stigma, is the number one-thing 
that the healthcare workforce wants right now are scalable peer 
support programs. The military has used these type of programs 
in the past, battle buddy programs or peer support programs. 
Physicians, like others, nurses, like others, want to speak to 
someone who has walked the walk a mile in their shoes, and 
those are the things that we have heard repeatedly from the 
workforce themselves.
    And what we have also heard are there are health systems in 
this country that are stepping up, and they are delivering 
those services to the workforce. They are not delivering them 
fast enough, but those are just one significant thing that the 
healthcare workforce is stepping up to do to support them.
    The other big piece of this, though, as I mentioned 
previously, is that we--is that there are systems that are also 
working on trying to figure out how to redesign healthcare 
delivery so that it doesn't burn out the workforce in the 
process. And there are systems. Probably not enough, certainly 
not enough right now that are making inroads to redesign the 
healthcare delivery so that it doesn't burn out the workforce 
in the process.
    Ms. Schrier. I appreciate those comments. You know, 
sometimes it is--it just helps to know that you are not the 
only one. And so those peer programs sound phenomenal.
    I just want to add to your list that Washington Physicians 
Health Program is one program that provides behavioral health 
support to physicians in Washington State.
    I have very few seconds remaining. I just wanted to turn to 
Ms. Harrison.
    Thank you for coming today. Can you talk a little bit about 
the pay of public health providers who simply don't get paid 
enough?
    We need to have the ability to surge public health needs if 
another pandemic or some other thing comes along. I was 
wondering if you had some ideas about how we can boost salaries 
and incentivize students to join the field.
    Ms. Harrison. Thank you for that question. And salary is 
one of the most pressing issues that we deal with in 
recruitment and retention. The last two people I have lost out 
of my health department have been pulled away for similar jobs 
at more than $10,000 a year of an increase in their salary, and 
we just don't have the budget to compete with that.
    I do think that these loan repayment programs will help 
alleviate a little bit of that to give an alternate benefit for 
individuals to come to a local health department. But I do 
think we need to do a better job addressing salary bands and 
ranges across the board for public servants that are dedicating 
so much of their time and energy pre-pandemic, and certainly 
even more during the pandemic. Thank you for that question.
    Ms. Schrier. Thank you. I yield back.
    Ms. Eshoo. The gentlewoman yields back. I am pleased to 
recognize the gentleman from Texas, Mr. Crenshaw, for his 5 
minutes of questions.
    Mr. Crenshaw. Thank you, Chairwoman Eshoo, and thank you, 
Ranking Member Guthrie, for holding this hearing. Thank you all 
for being here. It is an important topic, and I want to echo 
many of my colleagues in thanking the tremendous work done by 
our healthcare workforce over the course of this pandemic. It 
has been a hard strain on them, to be sure.
    But also, it is worth noting that the shortage of 
physicians has been occurring for quite some time now, and 
there is a lot of factors involved in that, which we are 
talking about today. I think some of these bills are an 
excellent start to dealing with some of those problems. But a 
lot of them don't get really quite at the core of the issues, 
and one of which was just mentioned.
    People need basic incentives to be able to deal with the 
work that they are doing. One of those incentives is, of 
course, pay, pay that is proportional to the hardship that they 
are enduring. And the other is workforce environment. Are they 
dealing with endless amounts of red tape and regulations that 
make their daily job just insufferable? And these are things 
that maybe we could affect, here in the Congress.
    One I want to dive into specifically, which is the ever-
changing cuts to reimbursement that comes down from CMS. Any 
time that we might be trying to save money in Medicare, we 
often make cuts to physician reimbursement. And that, of 
course, is a strain on the workforce.
    This question is for Mr. Levine. If we simply continue 
adding more benefits and requirements on a system that is 
indeed antiquated without adding structural changes, how will 
that impact a health system like yours, which is beholden to 
this centrally-planned set of fee schedules and payment 
systems?
    Mr. Levine. Well, that is the core of the problem, 
Representative. A good example is, as fast as wages are rising 
with--for nurses and other healthcare professionals right now, 
70 percent of our payer mix is Medicare, Medicaid, and 
uninsured. The payment system is not keeping up with the 
market.
    So, on the one hand, we have a government pricing model 
downstream, where we are trying to go deal with the free market 
in employment--we are dealing with two competing systems. One 
does not support the other. And so my advocacy would be to, 
again, deal with the Medicare Area Wage Index issue, and move 
more towards a market-based model, where the market can keep up 
with the labor costs.
    And I am telling you, this is going to be a massive crisis 
for rural and non-urban hospitals, because the Medicare payment 
system cannot keep up with how fast the market is moving, in 
terms of the cost of labor.
    Mr. Crenshaw. Do you anticipate losses and--in physicians 
in this country?
    I mean, do you anticipate--and what does that look like? I 
mean, can you paint a picture for us?
    Mr. Levine. Yes, sir----
    Mr. Crenshaw. A little bit more specific?
    Mr. Levine. Yes, it is already happening. The expected cuts 
to physicians that is forthcoming, I have already got 
physicians coming in saying either I employ them, or they have 
to leave, which would be devastating to our rural region.
    And listen, I mean, if you look at just two years ago, I 
paid--for the third quarter that just ended, contract labor 
cost--the quarter that just ended, $23 million for contract 
labor. And we put $100 million into wage adjustments in the 
last year. We only generate a two percent operating margin. So 
that is almost triple our operating income that we put into 
wage adjustments this year that the Medicare system is not 
keeping up with.
    Mr. Crenshaw. So in Houston we are seeing more and more 
physicians flock to the direct primary care model of medicine, 
so that they can see less patients for longer, and actually do 
what they got into medicine to do, which is treat patients.
    I love this model, it keeps patients out of the emergency 
room, gets doctors back to that direct relationship with 
patients. It is affordable for patients. I mean, we are talking 
between 50 and $100 a month for this, what is total access to a 
primary care physician. It doesn't solve the insurance problem, 
but it sure helps us solve the insurance problem.
    Do you imagine that a program like direct primary--or model 
like direct primary care, or other models of direct contracting 
could increase the number of physicians in the workforce, 
especially in the primary care area, where we really see a 
shortage?
    Mr. Levine. Yes, sir. I could tell you, with the move to 
value-based models, for the first time we are seeing primary 
care doctors, pediatricians, and OB/GYNs who are earning more 
money, because it has moved to a market-based model, where, if 
they are able to reduce avoidable admissions, they share in the 
savings of that.
    So five years ago, a pediatrician might make--might have 
made $150,000 a year. Some pediatricians now can make as much 
as $300,000 or $400,000 a year, and it actually cost the system 
less, because they are now are now partnering with us in 
reducing wasted inpatient utilization and other high-cost types 
of care.
    So yes, I think those are the right models.
    Mr. Crenshaw. I appreciate that. I am out of time. I yield 
back, Madam Chairwoman.
    Ms. Eshoo. The gentleman yields back. The Chair is pleased 
to recognize the gentleman from Maryland, Mr. Sarbanes, for his 
5 minutes of questions.
    Mr. Sarbanes. Thank you very much, Madam Chair. Thanks for 
this hearing today.
    As has been testified to today, we know that a well-trained 
workforce is absolutely critical to supporting high-quality 
healthcare delivery, and every other dimension of our 
healthcare system. These issues have, obviously, only become 
more important over the past year-and-a-half during the 
pandemic. It has added some pressures. It has laid bare and 
given transparency to pressures and challenges that were 
already there, of course.
    And we have heard a lot of important testimony today about, 
particularly, the toll that the pandemic has taken on our 
healthcare system and our healthcare heroes, as we have come to 
call them. We have got to make sure that we put more than just 
phrases behind their efforts, that we put real work and 
resources behind them, as well.
    These are issues, the healthcare workforce issues, that I 
have been privileged to be working on for a number of years. I 
was able to work into the Affordable Care Act the establishment 
of a National Health Care Workforce Commission. We are still 
working on getting the funding in place to support that, but 
the idea was to evaluate these workforce needs across the 
country, and then be a resource for us, as policymakers in 
Congress, in making some decisions about how to address the 
shortages.
    And we know how important it is to do that. It is estimated 
there will be a shortage of between 18,000 and almost 50,000 
primary care physicians by 2034, and a shortage of between 20 
and 75,000 physicians in non-primary care specialties.
    Dr. Keel, can you speak to what the value of a national 
perspective on addressing these healthcare shortages, health 
workforce shortages could be, in terms of evaluating where we 
are, and making sure--because I know, for example, during the 
pandemic we saw this situation of healthcare workers traveling 
the country to meet shortages. And at some point there was a 
kind of robbing Peter to pay Paul dimension to this.
    So speak to the value you think, if you do believe it 
offers value, bringing a kind of national perspective, and 
getting that kind of a commission in place.
    Dr. Keel. Well, I--it is really hard to place a value on 
the importance of providing local healthcare in some of our 
most rural and neediest parts of the state. These--we have 
eight counties in the State of Georgia that has no physician, 
whatsoever. I am told that, up until this past year, we had 
three counties in the State of Georgia that had no EMS service, 
and that is a very sobering statistic.
    So the--we aren't going to be able to address this issue of 
healthcare disparities, especially in rural parts of the state, 
until we can tackle the problem of how we incentivize 
physicians to go there and practice, to start off with, which 
is what our 3+ program is really intended to try to do.
    As I mentioned previously, the economic prosperity of these 
areas is also critically dependent upon the availability of 
quality healthcare, whether it is a regional or local hospital, 
or whether it is a----
    [Audio malfunction.]
    Dr. Keel. [continue]. What it means to this country for us 
to finally get a hold on this issue of providing healthcare at 
the local level.
    Mr. Sarbanes. I appreciate it very much. Obviously, 
figuring out how we design the pipeline so they get to the 
places that need these healthcare workers the most is 
absolutely critical. And I imagine, as well, thinking about, in 
particular--in moments of particular need, how you triage the 
workforce, and bring it to bear with certain intensity in key 
places that have that need.
    Mr. Feist, real quickly, comment, if you would--I have got 
a bill I have worked on for years called the Primary Care 
Physician Reentry Act, which is to get retired physicians to 
come back into the practice of medicine to help us with these 
workforce needs.
    Could you speak to how incentivizing that, to bring those 
physicians back in the workforce, could help with the burnout 
and some of the mental health challenges that you have been 
talking about today?
    Mr. Feist. Sure. Briefly, we have a workforce shortage 
right now in healthcare across all fields and all specialties. 
And so the more workforce that we can bring to take care of the 
patients that we have, the better.
    What we also need to do, at the same time, is we need to 
redesign the healthcare delivery at the same time, not just 
throw more people at the problem, if you will. But that would 
be a significant step towards helping this workforce right now 
get out of this pandemic.
    Mr. Sarbanes. Thank you very much. I yield back, Madam 
Chair.
    Ms. Eshoo. The gentleman yields back.
    Next we will--I will recognize the gentlewoman from 
Massachusetts, Mrs. Trahan, for 5 minutes for your questions.
    Mrs. Trahan. Well, thank you, Madam Chair. Thank you to the 
families and the witnesses for giving us their time and their 
expertise today. Also, I just want to thank Chairman Pallone 
and Chairwoman Eshoo for holding this important hearing.
    This hearing is so timely, as the COVID-19 pandemic has 
exacerbated workforce issues that were already present, pre-
pandemic, across the healthcare continuum. You know, I am 
pleased this committee recognizes that, and is highlighting 
legislation that aims to address these issues, including my 
bipartisan bill, the Bolstering Infectious Outbreaks 
Preparedness Workforce Act, or the BIO Preparedness Workforce 
Act, which I introduced with Congressman McKinley.
    Madam Chair, I would love to offer a stakeholder letter of 
support for the BIO Preparedness Workforce Act for the record.
    Ms. Eshoo. Ordered.
    [The information appears at the conclusion of the hearing.]
    Mrs. Trahan. Thank you. As many of my colleagues have 
expressed today, COVID-19 has highlighted longstanding health 
disparities in the U.S.
    In addition to COVID-19, other infectious diseases like HIV 
also disproportionately impact people of color, and people of 
color face greater barriers in access to healthcare. At the 
same time, Black, Latinx, indigenous, and other communities of 
color are under-represented in medical professions.
    The BIO Preparedness Workforce Act authorizes HHS to 
consider geographic equity, and ensure that contracts help to 
increase the number of under-represented minority individuals 
serving as bio preparedness health professionals or infectious 
disease health professionals.
    I am concerned about the disproportionate impact of COVID-
19 and other infectious diseases on underserved populations, 
including our communities of color, and it is important to 
increase access to culturally competent healthcare, 
particularly during a pandemic or another public health 
emergency.
    Dr. Marrazzo, you mentioned to my colleague, Congresswoman 
Blunt Rochester, how you believe the BIO Preparedness Workforce 
Act would help diversify the bio preparedness and infectious 
disease workforce. But could you elaborate on why a more 
diverse infectious disease workforce is important to advancing 
health equity?
    Dr. Marrazzo. Yes, thank you so much for that question, 
Mrs. Trahan, and I am really grateful that the bill that you 
are sponsoring specifically gives the Secretary of HHS 
discretion to award loan repayment contracts in a way that 
increases the diversity of our workforce.
    As I mentioned before, financial challenges probably pose 
an even greater barrier for individuals from underserved 
communities to pursue careers in infectious diseases and in bio 
preparedness. A more diverse workforce really addresses the 
need for a culturally competent workforce.
    We know, as I mentioned before, that we do better, we 
resonate stronger with providers and people who look like us 
and who understand our specific health challenges. So getting a 
more equitable distribution of ID professionals, not just 
geographically, but also across these different strata of 
society, is really going to be critical to reach the patients 
that we need to reach.
    Mrs. Trahan. Thank you for that. And in addition to 
physicians, many other health professionals are critical to bio 
preparedness and infectious disease care. I mean, many of these 
professionals, including our clinical lab professionals, our 
advanced practice nurses, and others are also struggling with 
workforce shortages and burnout.
    Dr. Marrazzo, can you also elaborate on the types of bio 
preparedness and ID healthcare professionals, including their 
roles, their recruitment challenges, and how the BIO 
Preparedness Workforce Act would help them?
    Dr. Marrazzo. Absolutely. I don't think anything has 
illustrated the need for a team approach more than this 
pandemic. We have all felt it very, very urgently.
    So in addition to physicians, you need a team of healthcare 
professionals, and those include clinical laboratory 
professionals, infection preventionists, ID-trained 
pharmacists, advanced practice nurses, and physician's 
assistants. All of these folks are really critical to staff the 
sort of workforce that we need to deal with these things. And 
very importantly, all of these professionals are included in 
the BIO Preparedness Workforce Act.
    These people are already in short supply. Twenty-five 
percent of healthcare facilities have a vacancy for an 
infection preventionists position, with more than half of long-
term care facilities, which have experienced incredible COVID 
challenges, as we know, having experienced a loss of an 
infection preventionist in the last 24 months. These shortages 
are likely to grow more in the future, as 40 percent of the 
infection preventionists workforce is expected to retire in the 
next ten years.
    The other area is laboratory personnel. There is a very 
high total vacancy rate for clinical microbiologists, just over 
ten percent. And also, that is a field that is aging. Probably 
about 17 percent of them are going to retire in the next five 
years.
    And then finally, pharmacists. We work very closely with ID 
pharmacists to make sure people are safely treated with many 
infectious disease agents, and they are very much in short 
supply. A 2018 survey of the acute care U.S. stewardship 
workforce found that pharmacists and physician staffing ratios, 
particularly in places in the country like ours, are well below 
recommended levels for stewardship to be optimal.
    Mrs. Trahan. Thank you so much for that detailed response, 
and I yield back. Thank you.
    Ms. Eshoo. The gentlewoman yields back. The Chair is 
pleased to recognize the gentlewoman from Texas, Mrs. Fletcher, 
for your 5 minutes of questions.
    Mrs. Fletcher. Thank you so much, Chairwoman Eshoo, and 
thank you for holding this hearing, of course.
    Thank you to our witnesses for joining us today. We 
appreciate all of you taking time from your practice, 
classrooms, and family rooms to join us and share the 
insightful testimony that you have today.
    Certainly, as many of my colleagues have noted throughout 
the hearing today, the last year-and-a-half of this pandemic 
has really inspired a renewed sense of gratitude to our 
healthcare workforce, and the possibility of a normal post-
pandemic reality could not be realized without the tireless 
work of all of the healthcare heroes across our country. And I 
am proud to represent so many of them, so many healthcare 
providers living and working in my district in Houston, in and 
around the Texas Medical Center. We are so fortunate to have 
just this incredible care in our community coming from Houston, 
which is the most diverse city in the country.
    We also know that--and as your testimony highlights, Dr. 
Wilburn--that our healthcare workforce is lacking in diversity, 
and studies have highlighted the alarming under-representation 
of people of color, mostly Black, Hispanic, and Native 
American, in the healthcare field. Obviously, we just talked 
about this in the context of Congresswoman Trahan's questions, 
and I think it matters, you know, across the spectrum, in terms 
of provision of healthcare.
    So, in light of those disparities, in infection that we 
have seen over the last year-and-a-half, the health outcomes 
that we have learned more about, and seeing, as well as, you 
know, longstanding disparities in chronic illnesses, this issue 
is just so, so important.
    So Dr. Wilburn, I wanted to ask if you could describe the 
lack of diversity in allied health professions in terms of what 
groups are most under-represented, and in what fields, and then 
maybe follow up with talking a little bit about what the 
barriers that students of under-represented backgrounds face in 
their pursuit of a career in the healthcare workforce.
    Dr. Wilburn. Absolutely. Well, as I stated in my testimony, 
the JAMA results were not promising for the allied health 
professions. Disparity is large among all of our allied health 
professions. As a reminder, that includes physical therapy, 
occupational therapy, speech language pathology, respiratory 
therapy, and audiology.
    And so what this does is that, when under-represented 
groups are not represented in healthcare, we really miss the 
mark, and we are not able to provide culturally competent or 
culturally humble care. And when that occurs, it is a 
devastating effect, not at the individual level, but at the 
community level, as well. So this could really have great 
devastation among many areas.
    For example, during COVID, urban areas were hit hard, very 
large, and those areas are a very large representation of 
minority groups. So passing this legislation would be key. It 
would give us a pipeline. It would provide supports. It would 
give first-generation students like myself an opportunity to 
see a pathway for a clear trajectory in healthcare.
    Also, thank you, coming from the great State of Texas. My 
parents retired there.
    Mrs. Fletcher. Oh, terrific. Well, I have to say that very 
recently I have been working with--in my own family situation, 
a lot of folks in occupational therapy, and it is so incredible 
to see the quality of care, and the patience, and the 
dedication of our healthcare workforce. It really is 
incredible, what you all are able to do, able to accomplish, 
all of our healthcare professionals, and it is so important to 
the patients and to the families.
    And so I was hoping, with the little bit of time that I 
have left, that maybe you could just--I appreciated the 
thoughts that you shared in your testimony, and how your path 
to occupational therapy would perhaps have been different if 
this bill, H.R. 3320, would have--when you were starting your 
career. And so, with that in mind, I would just like, with the 
time we have left, maybe you could talk about a little bit more 
from your professional perspective now, what benefits are 
associated with an increase in the diversity of the allied 
healthcare workforce for prospective students and patients.
    Dr. Wilburn. Sure. So what I could imagine is, really, a 
spark of innovation. Under-represented groups largely go back 
to the communities in which they came from to serve. So that--
we know those communities best, and we live in those 
communities, we grew up in those communities. And what we can 
offer are perhaps areas of innovation that, you know, non-
majority populations that serve us, or majority populations 
that serve us, haven't thought of yet.
    So really, I see this as an opportunity for a pipeline of 
talent that has not yet gone noticed. This would really improve 
health outcomes. We know, when our providers look like us, when 
they come from the same cultural backgrounds as we do, we have 
improved attendance rate, we have improved compliance with 
interventions, and we are an essential part of the inter-
professional and inter-collaborative teams.
    Mrs. Fletcher. Terrific. Well, thank you so much for that.
    I am out of time, but very grateful, Madam Chair, for 
hosting this hearing. And with that, I will yield back.
    Ms. Eshoo. The gentlewoman yields back.
    You know, with each member that speaks and asks the 
questions, it is a reminder all over again what an 
extraordinary subcommittee this is. And you can see what our 
attendance--I mean, you have been here since 10:30 this 
morning. But to--the attendance of all of the members, and 
their diligence, their work, what they care about is all on 
display, as your testimony is. So I just wanted to say that.
    And we now have members that would like to question that 
are not members of the subcommittee, they are members of the 
full committee. And so they are waiving on, and we welcome 
them.
    And the Chair recognizes the gentleman from Ohio, and that 
he is, very much a gentleman. His father served in the 
Congress, as well.
    Mr. Latta, you have 5 minutes. Welcome to the subcommittee.
    Mr. Latta. Well, Madam Chair, thank you very much for 
allowing me to waive on, and I always appreciated the time that 
I spent on this subcommittee.
    And again, I want to thank the witnesses for you being here 
today, for your testimony, because it is so important for us to 
hear from you, because the only way we can enact good 
legislation is by hearing from you all.
    You know, over the last year-and-a-half, the COVID pandemic 
has tragically taken the lives of hundreds of thousands of 
Americans, and fundamentally changed the way we view the world. 
In the beginning, millions of Americans closed their businesses 
and paused their lives in an attempt to slow the spread of the 
virus. Through it all, our frontline healthcare workers, even 
with PPE shortages and no vaccine, stepped up to the plate to 
serve.
    Prior to the public health emergency, our country was 
already facing a shortage of qualified labor and industries 
across the entire economy. The pandemic has only exacerbated 
this labor crisis, with burnt-out workers and early 
retirements. I don't know how the situation can get any worse.
    But unfortunately, when the President announced his vaccine 
mandate--which I believe is unconstitutional--for all Federal 
workers and 17 million healthcare workers.
    I have seen this across my district, as I have traveled 
across it during the pandemic. I heard from staff in numerous 
hospitals and from other healthcare facilities about their 
concerns with being short-staffed, and it is a great concern. I 
was told at several hospitals that, due to the state vaccine 
mandates in other states, their employees from these other 
states were coming into Ohio, because there were no mandates. 
One healthcare provider stated that it could lose almost 30 
percent of their staff to the vaccine mandates. If this is 
true, there is no doubt that patient care and access will 
suffer, and possibly result in up to 50,000 patients in need of 
finding other facilities.
    And that is why I introduced the Health Care Workforce 
Protection from Mandates Act. While--the legislation would 
prohibit the HHS Secretary from forcing the mandatory COVID-19 
vaccination of workers employed by participating entities in 
the Medicare program, unless the Secretary certifies in writing 
that this mandate would not result in staffing shortages.
    Mr. Levine, if I could start my questioning, we acknowledge 
the importance of educating our employees about the vaccine 
with real-world data and de-politicized science. Given this, 
isn't it true that hundreds of your staff, including critical 
frontline nurses, could or would lose their--leave their 
positions or be fired if you have to enact the COVID-19 
mandate?
    Mr. Levine. Sir, I haven't yet seen the rule come out of 
Medicare, but my presumption is that that could be the case, be 
vaccinated or be fired. I suspect that there would be some loss 
of some of our frontline employees.
    Mr. Latta. Now, just out of curiosity, because, again, as 
I--what we saw from--happening in Ohio, with individuals coming 
in from Michigan to Ohio, especially because my district 
borders the southern boundary of Michigan, that we did see 
people crossing the state line to work in Ohio.
    You know, when you would look at the--you know, you haven't 
really--you said they haven't really looked at the specific 
numbers, but have you had any people that have come to you 
saying that they might even leave the healthcare profession?
    Mr. Levine. I have, and I have had some resignations, just 
from the fact that we are even considering the mandate. We had 
a very public resignation last week.
    We are--and I just want to be clear, I know you have got 
limited time, but no organization has been more invested in 
trying to educate people on why it is important to be 
vaccinated than Ballad Health has. And we think everyone should 
be vaccinated.
    But we also have an obligation to take care of people who 
have heart attacks and strokes who come into our hospitals. In 
a rural region, everybody we lose, it is, right now, very 
difficult to replace them.
    Mr. Latta. Well, you know, you bring up a point, because I 
know that, you know, as I go through my facilities and 
hospitals in my district, and also the different colleges and 
universities that I have, you know, we have got--we are trying 
to get more and more individuals engaged in the healthcare 
profession. We already knew we were going to have a shortage 
because, even before the pandemic, especially when we were 
thinking about individuals out there who are Baby Boomers, as 
we all age, that we are going to need more folks out there, not 
less.
    But, you know, in your opinion, are the mandates the 
appropriate route for the Federal Government to approach this 
right now?
    Mr. Levine. You know, we mandate MMR, we mandate polio, we 
mandate other types of vaccines for team members. I do think at 
some point, when there is more certainty and more data and--
about the longevity of the vaccine, there would be an 
appropriate time to mandate it.
    Right now we believe, right now, that we are leaning 
towards education and being examples. I will say if Medicare 
mandates as a condition of participation, we certainly have no 
choice but to comply with the Medicare mandate.
    Mr. Latta. Well, thank you very much.
    Madam Chair, my time has expired. And again, I want to 
thank my friend for allowing me to waive on today.
    Ms. Eshoo. It is wonderful to have you at the subcommittee.
    I can't help but think that, if someone is unvaccinated, 
that they are highly susceptible to contracting the virus. They 
contract the virus, and they are unvaccinated and working in a 
hospital, they can pass it on to the patients. So this is--I 
just don't get this.
    Anyway, the gentleman from Illinois, Mr. Rush, is 
recognized for 5 minutes.
    And it is wonderful to have you waive on. I keep having to 
look around the hearing room, but remember to look at the 
screen.
    Is Mr. Rush with us?
    If not, then we will go to recognize Mr. Pence, the 
gentleman from Indiana, for your 5 minutes. Welcome to the 
subcommittee.
    Mr. Pence. Well, thank you very much, Chairman Eshoo and 
Ranking Member Guthrie. Thanks for letting me come on today, 
and thank the witnesses today for being here.
    You know, I am encouraged that this committee is taking 
steps to address healthcare workforce shortages affecting 
Hoosiers and all Americans. The pandemic highlighted that our 
nation's overburdened healthcare system is on an unsustainable 
spending path, leading to higher costs and less care, 
particularly in rural America.
    While the bipartisan bills before us today are approaches 
to address workforce challenges, I am concerned that we are not 
conducting the necessary oversight to figure out the root 
causes of this systemic problem. Across Indiana's 6th district, 
the workforce shortage in our hospitals and critical care 
facilities is leaving patients with fewer options and longer 
wait times. Hospitals are struggling to meet the financial 
obligations necessary to adequately staff their facilities.
    In Indianapolis, St. Vincent needed to bring in the Indiana 
National Guard. At King's Daughters' Health in Madison, nurses 
are making double, sometimes triple what they were making in 
2020, as well as in my hometown hospital, Columbus Regional in 
Columbus, Indiana. Some directors of nursing have reported to 
me personally that their nurses are either burnt out from 
battling the pandemic, or finding new employment as much higher 
traveling nurses (sic).
    Meanwhile, vaccine mandates from the Administration are 
compounding this problem, pushing even more nurses out of the 
industry, as told to me by these directors of nursing. 
Unfortunately for rural patients in my district, this trend is 
disrupting available care and treatment.
    Dr. Keel, this August, Governor Eric Holcomb put together a 
commission to look at the State of Indiana's health 
infrastructure, including the nurse and workforce shortage. 
Like your state of Georgia, Indiana faces challenges in 
maintaining health systems in rural areas.
    In your experience dealing with nursing workforce 
shortages, what will be the long-term impact on rural hospitals 
if this shortage and incredible growing cost continues?
    Because, as I have talked to hospitals, their revenues are 
now projected to be 50 percent down, simply because of payroll 
costs in the next rolling 12 months. And that is unsustainable, 
even for the profitable hospitals.
    Sir?
    Dr. Keel. Thank you very much for that question. And yes, 
it is a great concern for our health system. We are facing the 
exact same shortages that you have alluded to, and those 
shortages are due almost entirely to an increase in payroll 
costs. The--and a lot of that is due to having to pay travel 
nurses.
    Yes, nurses are leaving other positions and coming to our 
system as a travel nurse. We have nurses from hospitals that 
are, literally, across the street from us that are quitting 
their positions there, only to fill the travel--the nurse 
shortage that we have in our facility due to travel nurses. So 
it is a great concern.
    One of the--but beyond that, the concern that I have is 
what are we going to do down the road? We cannot sustain the 
cost of the travel nurses at this current rate, and we are 
certainly not going to be able to sustain this once we get 
beyond COVID.
    Mr. Pence. And Dr. Keel, I also serve on a community 
college that--we have a nursing program. Just last week I was 
told that two of the professors that teach the reduced 
applicant student body have just left to become traveling 
nurses. Because, if you do the math, at $150, $190 an hour that 
the traveling nurses are getting paid in Indiana, that is 
$300,000 or $400,000 a year. What can we possibly do? I guess 
we are going to have to pay nurses $300,000 or $400,000 a year.
    Dr. Keel. I--that is not sustainable.
    Mr. Pence. No, sir.
    Dr. Keel. I know you would appreciate that. You know, we 
have had a nursing shortage that goes back well before the 
pandemic.
    And to your point, the primary reason for the nursing 
shortage is, at least from my perspective, is not a lack of 
classroom space, or lack of positions, or an enrollment cap. 
Quite the opposite. It is having the ability to hire nurse 
faculty, when they can go into private sectors and make a lot--
--
    Mr. Pence. Yes, and if I may, as I--as in my opening 
remarks, I am very concerned. We really need to get a handle 
on--you know, you got--you can't fix a problem until you 
identify a problem, and I think we have really got to figure 
out what we need to do to have nurses, because rural hospitals, 
without nurses, the doctors can't get anything done.
    And thank you for letting me on. I yield back.
    Ms. Eshoo. You are always welcome to waive on. I understand 
that Mr. Rush is going to join us.
    Are you there, the gentleman from Illinois, Mr. Rush?
    Mr. Rush. Madam Chair?
    Ms. Eshoo. Four, three, two----
    Voice. I hear a voice.
    Ms. Eshoo. Where are you?
    Mr. Rush. Can you hear----
    Ms. Eshoo. I can--I can't see you, and I--your voice is not 
very loud.
    Mr. Rush. Can you hear me, Madam Chair?
    Ms. Eshoo. Just--you need to turn the volume up, because we 
can't hear you very well.
    [Pause.]
    Ms. Eshoo. He is not on camera. Does he have to be on 
camera?
    Mr. Rush. I am on camera.
    Mr. Butterfield. He is on camera.
    Ms. Eshoo. All right, the gentleman is recognized. We don't 
see you on our screen, but I believe you are on--oh, there you 
are. OK.
    Mr. Rush. Can you hear me?
    Ms. Eshoo. Yes, and we can see you.
    Mr. Rush. All right, wonderful.
    Ms. Eshoo. Begin.
    Mr. Rush. Hey, technology has come through, once again.
    I want to thank you, Madam Chair, for allowing me to 
participate in today's very important hearing, and I am 
grateful that you chose to include my bill, H.R. 3320, the 
Allied Health Workforce Diversity Act, which I introduced in 
this Congress with Representative Markwayne Mullin, and the 
last Congress with the ranking member of the full committee, 
Congresswoman McMorris Rodgers.
    The lack of diversity in the fields of physical therapy, 
occupational therapy, respiratory therapy, speech and language 
pathology, and audiology is very troubling to me and to others. 
Many of these professions, Madam Chair, have been pivotal in 
helping individuals recover from COVID-19, which makes our 
legislation needed now, more than ever.
    Even prior to COVID-19, this lack of diversity was 
extremely problematic. Research shows that this lack of 
diversity leads to less access to these specialists in 
underserved in rural areas, and worse outcomes are attended to 
every--these patients. That is why I was compelled to introduce 
the Allied Health Workforce Diversity Act, H.R. 3320.
    This bipartisan piece of legislation would authorize 
funding to, in fact, recruit and retain students who are racial 
or ethnic minorities, or who are from disadvantaged backgrounds 
to enter and complete programs in these professions.
    And I want to thank you, Dr. Garcia Wilburn, for your 
appearing before the committee today. Your story is inspiring, 
and I hope that you and your family are very proud of what you 
have accomplished and will continue to accomplish.
    As you know, Dr. Garcia Wilburn, the Allied Workforce 
Diversity Act is based on the highly-successful Title VIII 
workforce development program. Can you explain why that program 
was so successful?
    What best practices or lessons should allied health 
professionals take from the Title VIII program?
    Dr. Wilburn. Thank you so much, Representative Rush. I 
really appreciate your question, and giving me the opportunity 
to answer your question.
    First, the funding provided higher education program 
support to focus on recruitment and retention, which we have 
talked about numerous times today for individuals from under-
represented groups. By funding community outreach programs, 
higher education programs were able to show that these under-
represented communities--that the profession has a realistic 
option and pipeline to those healthcare professions. It showed 
that communities--the program would be partners to these 
individuals, with both moral and financial support, as they 
pursued their degree, which is key.
    Second, the success of the Nursing Workforce Development 
Act--although cliche, success breeds success. And I know we 
have some hurdles to currently overcome in the nursing 
profession, but we cannot negate the fact that the nursing 
profession is more diverse than ever. As programs were able to 
see more people from under-represented communities graduate and 
go back to their communities to practice, the idea of pursuing 
nursing as a career became more mainstream at all degree 
levels, from associate to doctorate.
    These programs were used to fund the grant programs, to 
build resources within the programs to help future classes of 
students, in time to see the real benefits of diversity to the 
profession. High school students, middle school students, 
beyond saw people with a similar culture, racial group, 
ethnicity from their own background in a respected profession, 
inspiring those communities long beyond grant funding.
    So this is what led to the Nursing Workforce Diversity Act, 
and its program has nearly doubled in diversity since then, and 
we are hoping to see the same success among the allied health 
professional programs.
    Mr. Rush. Thank you.
    Madam Chair, my time has expired. I yield back the balance 
of it.
    Ms. Eshoo. The gentleman yields back, and we want you to 
know you are always welcome at our subcommittee, Mr. Rush.
    Mr. Rush. Thank you.
    Ms. Eshoo. Thank you.
    The Chair now recognizes another member, last but not 
least, who is waiving on, the gentlewoman from Illinois, Ms. 
Schakowsky, for your 5 minutes of questions. And I think that 
will be it.
    Ms. Schakowsky. Well, thank you so very much, once again, 
for allowing me to waive on to this wonderful subcommittee, and 
the great job that you are doing, Madam Chair.
    I want to say, as the co-chair of the House Democratic 
Caucus on Aging and Families, that the importance of caring for 
America's seniors is, you know, right at the top of my list.
    We know that two-thirds of unpaid family caregivers are 
women. And one in three caregivers are themselves senior 
citizens. And we also know that one in four Americans are in 
the sandwich generation, meaning they are taking care of 
children, as well as elderly parents, so they are very busy as 
caretakers.
    My--but most disturbing is that, according to a 2020 report 
from the Center for Disease Control and Prevention, nearly 31 
percent of family caregivers feel alone in their caregiving, 
and report serious consideration of suicide. I mean, this is a 
real mental health challenge that we have right now, and that 
is because family caregivers continue to be left on their own, 
just trying to figure out how to address this.
    We have never had a real long-term care policy in this 
country, so I wanted to ask Ms. Monroe--are you here, still, 
Witness?
    Ms. Monroe. Yes, I am here.
    Ms. Schakowsky. OK, there you are. OK. I wanted to ask you 
this. I found your testimony so incredibly compelling, and 
really disturbing, that you were somehow completely blindsided, 
that--the seven years to get your father diagnosed, that the 
basic message that she got was--that you got was ``good luck.'' 
And here you are, as you described yourself, as someone who is 
so credentialed, so informed.
    So really, what I need to know from you, how--can you shed 
light on exactly what type of guidance and training has to be 
built-in right away, that people have to understand that they 
are going to get the information, and that the help that they 
need?
    And as Bobby Rush was talking about, you know, there is 
disparate results, as well, especially communities and people 
of--in low-income communities are really, really on their own. 
So what do we need to do?
    Ms. Monroe. Well, I would say one of the biggest, I think, 
helps would have been--so my mom lives with my dad full-time, 
and she is 88, and he is 84. So having us understand----
    Ms. Schakowsky. Does she also have Alzheimer's, or no?
    Ms. Monroe. No, she does not, at least not diagnosed. But, 
you know, we are having to support her, one who is there 24/7 
with him, which is a lot of a different feeling than we have, 
from--I am an hour away, my brother is about--you know, he is 
down in Nashville, and my sister is about 15 minutes away. So 
we are trying to do a construct, where we have three siblings 
working together to try to be a caregiver, but my mom is there 
27/7.
    And the stress on her, and her not really understanding the 
disease, thinking that, you know, we--she knows it is a 
disease, but a lot of times she thinks he is just ``crazy''--
and not being able to get help--help, right now, for my 
parents--and I hate to use an anecdote--would be for my dad 
probably to be in assisted living. But there is no room at the 
inn. And caregivers are not being--you know, are not reliable, 
in terms of being there.
    So we will often get a call, very last minute, saying, 
``The caregivers didn't show up this morning, I can't get your 
dad dressed.'' One of us has got to get in the car and drive to 
do those kinds of tasks. So, you know, reliable services that 
can be there, having facilities that have built-in care 
structures, even on an emergency basis, that you can call upon 
because you are, you know, paying 5,000 or $6,000 a month for 
the purpose of being--having access to these services.
    Helping my family, my siblings and I, plan, come up with a 
timetable, a work plan for how we are going to manage what this 
looks like, who is going to be in charge of the medication, who 
is going to be in charge of the meals, who is going to take the 
parents to the doctors' visits, just someone to really help us 
do a work plan for what that looks like.
    And how do you determine at what point you need to step up 
care, and then where do you go for that?
    Ms. Schakowsky. All right. Thank you so much for that.
    And I also know that, even in your opening statement, you 
talked about the legislation that is being considered. And I am 
very proud to be a cosponsor of the Alzheimer's Caregiver 
Support Act. And all the other bills that you talked about is 
something we need to do. So thank you very much for your 
testimony, for being such an incredible witness.
    And thank you to all the witnesses, and I yield back. Thank 
you.
    Ms. Eshoo. The gentlewoman's time has expired.
    This concludes our hearing today. On behalf of all of the 
members of the committee, to each one of you that have 
testified, you have our lasting gratitude. You have been highly 
instructive on the bills that are before us, and given us a--
well, you have given us very direct answers to our questions, 
which really enhances our understanding of each of the issues 
that are before us. So thank you. And to those that had to 
travel, you took on an additional burden to be here, and we 
thank you.
    Now, Members, as you know, have ten business days to submit 
additional questions for the record. And witnesses, your work 
is not done, because, as members put their questions together 
and submit them to you, we ask that you, as promptly as 
possible, answer those questions. And we know that you will.
    So at this time I request unanimous consent to enter the 
following documents into the record. There are 27 of them, and 
I would love to have the ranking member----
    Mr. Guthrie. We have reviewed the list, and we accept the 
list, as you presented it.
    Ms. Eshoo. That is wonderful. So, with that consent, we 
will enter into the record the 27 documents that we have 
received on the bills.
    [The information follows:]
    Ms. Eshoo. And with that, I think we can adjourn the 
subcommittee. Thank you, everyone.
    [Whereupon, at 2:31 p.m., the subcommittee was adjourned.]
    [The information appears at the conclusion of the hearing.]

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