[Senate Hearing 117-389]
[From the U.S. Government Publishing Office]
S. Hrg. 117-389
RECRUITING, REVITALIZING & DIVERSIFYING:
EXAMINING THE HEALTH CARE WORKFORCE
SHORTAGE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON EMPLOYMENT AND WORKPLACE
SAFETY
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
ON
EXAMINING THE HEALTH CARE WORKFORCE SHORTAGE, FOCUSING ON RECRUITING,
REVITALIZING AND DIVERSIFYING
__________
FEBRUARY 10, 2022
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
__________
U.S. GOVERNMENT PUBLISHING OFFICE
48-900 PDF WASHINGTON : 2023
Available via the World Wide Web: http://www.govinfo.gov
-----------------------------------------------------------------------------------
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
------
SUBCOMMITTEE ON EMPLOYMENT AND WORKPLACE SAFETY
JOHN HICKENLOOPER, Colorado, Chairman
TAMMY BALDWIN, Wisconsin MIKE BRAUN, Indiana
TINA SMITH, Minnesota TOMMY TUBERVILLE, Alabama
JACKY ROSEN, Nevada RAND PAUL, M.D., Kentucky
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
PATTY MURRAY, Washington (ex MITT ROMNEY, Utah
officio) RICHARD BURR, North Carolina (ex
officio)
C O N T E N T S
----------
STATEMENTS
THURSDAY, FEBRUARY 10, 2022
Page
Committee Members
Hickenlooper, Hon. John, Chairman, Subcommittee on Employment and
Workplace Safety, Opening statement............................ 1
Braun, Hon. Mike, Ranking Member, a U.S. Senator from the State
of Indiana, Opening statement.................................. 2
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana,
Opening statement.............................................. 4
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
and Pensions (ex officio)...................................... 42
Witnesses
Flinter, Margaret, Ph.D., APRN, Senior Vice President and
Clinical Director, Community Health Center, Inc., and Chair,
Board of Directors, National Nurse Practitioner Residency and
Fellowship Training Consortium, Middletown, CT................. 6
Prepared statement........................................... 8
Verret, Reynold, Ph.D., President, Xavier University of
Louisiana, New Orleans, LA..................................... 10
Prepared statement........................................... 12
Quinones, Norma, LPN, Nursing Services Manager and National,
Institute for Medical Assistant Advancement (NIMAA) Site
Coordinator, Clinical Family Health, Lafayette, CO............. 18
Prepared statement........................................... 19
Greszler, Rachel, Research Fellow in Economics, Budget and
Entitlements, Institute for Economic Freedom and Opportunity,
The Heritage Foundation, Washington, DC........................ 27
Prepared statement........................................... 28
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Hickenlooper, Hon. John:
13 letters from various organizations submitted for the
Record..................................................... 59
``Protecting Our Front Line" Ending the Shortage of Good
Nursing Jobs and the Industry-creating Unsafe Staffing
Crisis'', National Nurses United........................... 86
``Diversity, Equity, & Inclusion'', Advocate Aurora Health... 142
RECRUITING, REVITALIZING & DIVERSIFYING:
EXAMINING THE HEALTH CARE WORKFORCE
SHORTAGE
----------
Thursday, February 10, 2022
U.S. Senate,
Subcommittee on Employment and Workplace Safety,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:03 a.m., in
room 430, Dirksen Senate Office Building, Hon. John
Hickenlooper, Chairman of the Subcommittee, presiding.
Present: Senators Hickenlooper [presiding], Murray,
Baldwin, Rosen, Braun, Cassidy, Tuberville, and Romney.
OPENING STATEMENT OF SENATOR HICKENLOOPER
Senator Hickenlooper. The Subcommittee on Employment and
Workplace Safety will come to order. Today we are discussing
health care workforce, specifically how we can revitalize and
reinvigorate the workforce we will need for the next several
decades.
Ranking Member Braun, who is even more of an expert than
some of our panelists in his own way as an employer, Ranking
Member Braun and I will each have an opening statement, then we
will introduce the witnesses. After the witnesses have given
their testimony, Senators will have 5 minutes each for a round
of questions.
While we were unable to have the hearing fully opened to
the public or media for in-person attendance, live video is
available on our Committee website, help.senate.gov. Senator
Braun and I have invited Members outside the Subcommittee to
participate in today's hearing, and we will look forward to
them being a part of this conversation as well.
There is no doubt that during the pandemic, health care
workers have worked tirelessly on the front lines and faced, in
many circumstances, unimaginative--unimaginable challenges.
However, the critical needs of the health care workforce were
here before, and we will extend well beyond COVID unless we
act.
The Association of American Medical Colleges estimates that
we will face a shortage of up to 124,000 physicians by 2034. We
will also need to hire at least 200,000 nurses per year to meet
the increased need. Just in Colorado, we are facing an
estimated shortage of 10,000 nurses over the next 5 years.
We are also facing a critical shortage of medical support
staff, like medical assistance and nursing assistants. If we
are going to make a dent in these daunting estimates, we need
to get started now. I am glad to welcome our excellent witness
panel, who are themselves working tirelessly to make progress
in creating a pipeline of talent to take us into the future. We
need to improve the recruitment, retention, and upskilling
opportunities of our health care workers.
If they are--if we are serious about growing the field, we
should make it easier for those without college degrees, for
working parents, and for those without previous experience to
break into early stage health care jobs. For those who are in
mid-career or wanting a change, we should allow more
opportunities to upskill and progress forward. And we need to
recognize the importance of having a health care workforce that
looks like America and brings diverse experiences to the
medical field.
We need to increase diversity of representation among
health care workforce to reflect the communities that they
serve. One way is to invest early in expanding STEM education
and mentorship opportunities for students in the health
professions, particularly students of color. Health care can be
a vibrant, rewarding profession, but we have to give today is
health care workers and future health care workers
opportunities to learn and thrive and grow at every level.
If we want to combat the current burnout and build a
robust, diverse workforce in the future, this has to be a
priority. I can't think of a topic more important, and I look
forward to hearing our witnesses' testimony about how we can
make progress in the weeks and years ahead.
We have got so much outreach and interest in this hearing,
which really does show what a pressing issue it is. I would
like to ask unanimous consent at this point to enter 13 letters
into the hearing record from various organizations, including
letters from the American Academy of Family Physicians,
National Nurses United, and the University of Colorado, among
others. No objections. Good.
[The following information can be found on pages 59 through
85 in Additional Material:]
Now, I will recognize Ranking Member Braun for his opening
statement.
OPENING STATEMENT OF SENATOR BRAUN
Senator Braun. Thank you, Chairman Hickenlooper. This is an
interesting discussion for me because since I have come to the
Senate, the high cost of health care, especially from the point
of view of an employer.
I had my own business for 37 years and it was so small for
so long, shared it with some earlier, that it wasn't really a
concern. It got to be as we grew from 15 employees into that
next and most recent 20 years, 300, and now 1,250. Three of my
four kids, along with a good young executive team run that
business. I stay closely in touch with it.
Health care has been navigating through a lot of
challenges. When you look across the world, we spend about 18
to 20 percent of our GDP on health care. The rest of the world
has similar, if not better outcomes, in some cases for half
that cost. We were in the throes of that challenge and then you
get hit by the biggest pandemic health care challenge, it
really shows a system where its weaknesses are.
I can't talk about it today, but I think beyond what we are
going to try to focus on today, health care has got to be a
priority for the health care consumer. When I changed my plan
15 years ago, most individuals weren't interested in prevention
and wellness, they were interested in remediation at whatever
the cost was. I flipped the paradigm upside down.
I think the industry has catered to mostly remediation, and
I think it needs to focus as we get through shortages in
workforce in offering the health care consumer more information
about how you avoid the system by staying healthy and
prevention. It is the underpinning of what I did, in addition
to making my employees health care consumers. Let us look at
where we are now.
In December 2021, 10.9 million job openings. About 15
percent of these openings were in the health care industry. On
the front line, had to put up with this formidable foe that we
had no idea where it was going to take us. In October 2021, a
report by Morning Consult found that 18 percent of health care
workers, imagine that, quit their jobs. You can see why. They
were there having to put up with the uncertainty of how this
was going to work out, 31 percent thinking about leaving.
I mean, most businesses can't take abruptly a 5 percent
exit, let alone this. You know, when you look at shortages like
this, it is always worse in some places. And I come from a
State like Indiana, many of our States have a rural component.
We found out we don't even have rural broadband in most places
when you need to have it, when you are working away from home,
or even in--as it relates to health care.
It involves other issues as well. How do we get through it
and how do we get workforce in the place that has been most
ravaged by the events, the health care industry itself? I think
it is going to take an interesting combination of the health
care industry, hospitals, practitioners, insurance companies,
even pharma to know that you are going to have to take some of
the burden yourselves. That you can't rely on Government to do
this.
When it comes to how we educate our health care workforce,
we have got to look at that in the same way as we are in many
other areas. In my home State of Indiana, pre-COVID, we had
probably 60,000 to 80,000 jobs that couldn't be filled because
we weren't guiding our kids in middle school and high school to
maybe look at the opportunities.
We were stigmatizing many of these pathways that don't
require a 4-year degree. In my experience in my own business is
when we have a 4-year degree opening, we get flooded with
applicants. We need better life skills, better guidance in
those most formative years, and I think parents would buy into
that. They have had enough issues of a kid gone after a 4-year
degree, ending back in the basement, when maybe they would have
needed just other common sense options put out there.
I think that across the board we spent a lot of money, $178
billion to the provider relief fund. It will take more than
just spending money. And that is what we do best here. We
borrow 23 now, up close to 30 percent of it. We have to have
better ideas that are hard to arrive at a solution.
Most of us in the real world don't have a printing press in
the basement, and we have got to do it with limited resources
in the rigor of competition. I think Government is got to take
some of those cues in terms of what we need to do better. So I
am glad we are having this hearing. Workforce is an issue
across all States.
It is now the biggest deal, the biggest issue in the
biggest sector in our economy. And when you look at the
percentages of how many have left, how many are considering
leaving, we have got to make sure we are at least coming up
with some good ideas and not necessarily just spending money on
the problem.
Senator Hickenlooper. Thank you, Ranking Member Braun. I
appreciate that. I appreciate that perspective. Now what we
will do is allow each of our witnesses to have 5 minutes, and
at some point Chair Murray will be here and we will let her do
her opening statement when she gets here as well.
Senator Cassidy. Senator Hickenlooper, we will have the
opportunity to introduce the witness?
Senator Hickenlooper. You will certainly will. And you
probably have a busy schedule, so I will even let you go first
with Senator Cassidy. So why don't I turn it to you for that
Member privilege.
OPENING STATEMENT OF SENATOR CASSIDY
Senator Cassidy. I appreciate that consideration. Thank
you, Chairman Hickenlooper and Ranking Member Braun. It is my
honor to introduce Reynold Verret, the sixth President of
Louisiana Xavier University, one of Louisiana is historically
black colleges and universities.
Dr. Verret is a proven leader in higher education,
fostering an innovative university environment to address
underrepresentation in medicine and other fields, and to
respond to the workforce needs of today. Dr. Verret is also an
accomplished biochemist and immunologist. And if you look at
his tie, I think that is the periodic table, which I know that
Senator Hickenlooper would recognize.
He participated in the COVID-19 vaccine trials and has been
a vocal advocate in my State for folks to take the vaccine.
From the start of the pandemic, Dr. Verret and Xavier have
worked with local health agencies and hospitals to host mobile
testing centers and to set up a fully operational COVID-19
testing lab to serve local communities and Xavier's campus.
Before being President of Xavier, Dr. Verret was Provost at
Savannah State and Wilkes University, a Dean at the University
of the Sciences in Philadelphia, Faculty and Department Chair
at the Chemistry Departments of Tulane University and Clark
Atlanta University, and an Adjunct Professor of Immunology at
the Tulane and Morehouse School of Medicine and has conducted
cancer research at MIT.
As a former academician, I am impressed with that resume.
But I would say that Dr. Verret's leadership throughout the
pandemic has been equally or more impressive. Dr. Verret
clearly understands the challenges facing HBCUs in today is
environment and the urgent need to address underrepresentation
of racial minorities in the medical and health science fields.
I am pleased to have worked with Dr. Verret on my bill with
Senator Schatz, the John Lewis National Institute on Minority
Health and Health Disparities Research Endowment Revitalization
Act that would provide additional funding to HBCUs to research
health disparities and to promote the diversity and strength of
the science workforce.
We need leaders like Dr. Verret that speak to the
challenges to plot the way forward, and to help find solutions
in recruiting a larger and more diverse health care workforce.
With that, I yield.
Senator Hickenlooper. Thank you. Appreciate that--that warm
introduction. Now I will take over again for two introductions
and then we will revert to Senator Braun for the last
introduction. First, I would like to introduce Dr. Margaret
Flinter from Middletown, Connecticut. She is the Senior Vice
President and Clinical Director of the Community Health Center,
Inc..
She Chairs the Board of Directors, National Nurse
Practitioner, Residency and Fellowship Training Consortium. I
think it is fair to say that over these many decades, she has
helped transform the Community Health Center, Inc. not only
into one of the Nation is largest federally qualified health
centers, but one of the most innovative health system networks
of any category in the country.
I know, I remember firsthand when they first began doing
telemedicine back in the 1990's, before it was common, and
certainly it was difficult to be able to do any billing for it
at all. Anyway, thank you so much for being here, Dr. Flinter.
Next, I am going to introduce Norman Quinones. She is a
Nursing Services Manager for Clinica Family Health in
Lafayette, not Lafayette, Louisiana, but Lafayette, Colorado.
She is a Site Coordinator for the National Institute of Medical
Assistant--Medical Assistant Advancement, NIMAA.
Ms. Quinones started working at Clinica in 1992 as a
Medical Assistant and has served in a variety of leadership
roles, and I know for a fact that she is one of the people that
holds Clinica together and helps them succeed in one of the
most challenging and diverse, geographically diverse, as well
as diverse among people, health care systems in the West and
certainly in Colorado by a long measure.
As I've said, she is from Lafayette, Colorado. I love the
fact that she is next to Dr. Verret. We have the Lafayette kind
of group together. We are delighted to have you here, Ms.
Quinones. And now I am going to turn the last introduction over
to my friend from Indiana, Senator Braun.
Senator Braun. Thank you. You will also be hearing from
Rachel Greszler, a Research Fellow in the Economics, Budget and
Entitlement Center at the Heritage Foundation. Her area of
focus is on labor and retirement policies. And previously
served as a Senior Economist on the staff of the Joint Economic
Committee of Congress for 7 years. Thanks for joining us today,
Rachel. I look forward to hearing from you.
Senator Hickenlooper. Perfect. Alright, so we will then
start. Dr. Flinter, why don't you start and then we will go
right down, right down along the table.
STATEMENT OF MARGARET FLINTER, PH.D., APRN, SENIOR VICE
PRESIDENT AND CLINICAL DIRECTOR, COMMUNITY HEALTH CENTER, INC.,
AND CHAIR, BOARD OF DIRECTORS, NATIONAL NURSE PRACTITIONER
RESIDENCY AND FELLOWSHIP TRAINING CONSORTIUM, MIDDLETOWN, CT
Ms. Flinter. Perfect. Can you hear me?
Senator Hickenlooper. Yes.
Ms. Flinter. Perfect. Well, good morning, Chairman
Hickenlooper and Members of the Senate HELP Committee, and
Members of the Employment and Workplace Safety Subcommittee.
Thank you so much for having me here today. I hope to convey to
you in my few minutes the urgency of the health care situation
and to identify strategies that are working and that we can
build upon.
Primary care is in a crisis, as you have already alluded,
between burnout, early retirement, an aging workforce, and
competition with other medical specialties. As Senator
Hickenlooper said, we are headed for a predicted shortage of
almost 130,000 physicians by 2030.
At the same time, the aging of the U.S. population, the
impact of complex and multi chronic illness, and the persistent
health disparities that we are also aware of all combined to
make the need for every individual, every family, every
community to have access to high quality primary care ever more
important.
The National Institute of Science, Engineering and
Medicine's landmark 2021 report, issued just a few months ago,
has laid out a blueprint of what needs to be done. Where is the
next generation of primary care providers going to come from? I
answered, it is already here.
Nurse practitioners are here in number, and they are
focused on primary care, but they want, need, and deserve the
opportunity for post-graduate residency or fellowship training,
similar to what their colleagues in medicine, dentistry, and
other health professions have enjoyed in order to prepare for,
practice, and settings in which the nurse practitioner is the
bedrock, the core, and the foundation of primary care.
Today I want to speak to what we are doing to address this
and what remains to be done. I am going to focus on primary
care providers today, but my comments are also relevant to
psychiatric mental health nurse practitioners and to these
specialty care and hospital outpatient setting and inpatient
setting.
15 years ago, based on both research and experience, I
recognized it was a time for a major innovation and training
for new nurse practitioners who are committed to being primary
care providers and particularly in our safety net settings like
community health centers, like rural health centers.
We were asking them to embrace the full scope of primary
care practice from the start. But we saw firsthand what one new
nurse practitioner called the shock and awe of seeing just how
sick people can be in primary care and how complex the care was
in our settings like community health centers. And while all
new nurse practitioners are prepared and competent for entry
level practice, what we say is there are very few entry level
patients in our settings and community health centers and in
rural health.
This gap between preparation and practice quickly gives
rise to burnout, frustration, and too often we saw early
departure by nurse practitioners from full scope primary care
roles and the practices that so need them. And so, in 2007, the
Community Health Center developed and piloted the country is
first formal post-graduate residency training program for new
nurse practitioners.
We did it with four new nurse practitioner residents, but
with a commitment to building a model that others could
replicate across the country. This intensive yearlong training
has given rise to a national movement. There are now 250
postgraduate NP residency and fellowship training programs
specializing just in primary care in the United States and many
more in this specialty and acute care settings as well.
Just in community health centers, there are now 75
programs, some are joint nurse practitioner MPA programs. These
programs are very carefully designed and structured to ensure
intensive clinical training with expert preceptors, the
development of mastery and caring for highly challenging
conditions such as opioid use disorder, multi-chronic illness.
But the training also includes the skills to improve
practice as well as deliver care to provide the most effective
prevention and health promotion care, and the resilience to
thrive as primary care providers and members of a high
performing team, which must of course, include our medical
assistance, our nurses, our community health workers, and our
behavioral health clinicians.
What started as a model has grown into a movement and
research indicates that nurse practitioner graduates of post-
graduate training programs remain in primary care and
underserved practices at higher rates compared to national
averages. They are also more likely to mirror their patient
populations. They are more diverse, and they serve more
underserved populations.
An initial concern that creating such programs implied that
nurse practitioners were somehow lacking has given way to a
recognition that this is simply what new nurse practitioners
want and deserve, and 77 percent of newly graduated NPs report
that they would like to do a post-graduate residency program,
if one were available. In 2019, HRSA's Bureau of Workforce
funded 36 of these programs that is only 36 of the 250 in the
country. They required that they be accredited in order to
assure rigor in their program, rigor and quality.
We are happy to say to a Consortium, of which I serve as
chair, is recognized by the Department of Education as an
accrediting organization. I want to say that in my work with
the Consortium, I have had the pleasure of visiting NPR
residency programs across the country, from the State of
Washington to Maine, from Hawaii to Alabama, and many points in
between, including Indiana.
I am deeply impressed by the commitment of the boards, the
executive and clinical leaders, and the frontline clinicians
and staff to this model because it works. It works in
attracting those for whom the desire to serve and care for
people as a primary care provider is both a profession and a
calling.
It works in retaining them in our most challenging
practices as primary care providers and as future leaders in
health care. But these programs need Federal support to
continue this work and for new programs to start. As I have
said, HRSA has stepped up with a small program for 36, but we
need more.
Today, I focused on the nurse practitioner as a primary
care provider, but I know firsthand we need to devote our
attention to every member of the team. I am so glad that Norma
Quinones is speaking to you today about medical assistance.
Thank you for your concern, for your commitment to our
health care workforce, and to our people and communities that
rely on us for this primary care. Thank you so much.
[The prepared statement of Ms. Flinter follows:]
prepared statement of margaret flinter
Good Morning Chairman Hickenlooper, and Members of the Senate
Health, Education, Labor and Pensions Employment Subcommittee. Thank
you for the opportunity to speak to this Committee.
We need to ensure that every person and every family in every
community has the opportunity to get high quality primary care. Thus,
we have a vital need to ensure that we are training the next generation
of primary care providers to make that possible. Today, I will speak
not just to the need, but to what is being done to meet that need. I am
going to focus primarily today on primary care providers and the
primary care setting but my comments are also relevant to psychiatric/
mental health care and specialty care.
We know the United States has an urgent short and long term need
for expert primary care providers. The National Academy of Sciences,
Engineering and Medicine's landmark 2021 report, Achieving High Quality
Primary Care, (Phillips et al., 2021) has laid out a blueprint of what
must be done to achieve high quality primary care for all people but it
does this against a backdrop of a projected shortage of 130,000
physicians. (Zhang et al., 2020) This comes at a time when the
healthcare needs of the population have never been more intense due to
an aging population, the burden of chronic illnesses, and persistent
health disparities by race, income and ethnicity. And of course, COVID
has left its mark everywhere.
Where will the next generation of primary care providers come from?
I answer: they are already here. They are nurse practitioners. But we
have to give them the opportunity to train and prepare for practice and
settings in which they are the bedrock, core, and foundation of primary
care in the U.S.
Nothing is static in life or health care. Fifteen years ago, based
on research and decades of experience, I recognized that it was time
for a major innovation in training for NPs committed to being primary
care providers, particularly in community health centers and rural and
underserved areas. We needed them to be ready and able to embrace the
full scope of primary care practice when they entered practice right
from the start. We saw firsthand the ``shock and awe'', as one new NP
described it, at just how sick the patients are, and how complex the
care is. While all new NPs are prepared and competent for entry level
practice, we recognized that there are few ``entry level'' patients in
our very busy and stressed underserved communities and settings. This
gap quickly gives rise to burnout and frustration. Too often we
witnessed early departure of nurse practitioners from the very settings
that needed them the most. The solution we proposed was formal
postgraduate residency or fellowship training. This intensive yearlong
training in the practice setting gives new NPs the opportunity to
develop the confidence, competence, and mastery to undertake full scope
practice in settings both rural and urban, and to embrace the full
range of primary care services.
In 2007, my colleagues and I designed and launched the first
postgraduate residency program to support this level of intensive
hands-on NP preparation at Community Health Center, Inc. (Flinter,
2011) We did it with 4 NP residents and a commitment to designing a
model that could be replicated nationally. Today, there are 250
postgraduate NP residency and fellowship training programs specializing
in primary care in the U.S. Seventy five are sponsored by FQHCs and an
additional 20 six are sponsored by academic partners but carried out in
an FQHC. The programs are carefully constructed to ensure progressive,
intensive clinical training with expert preceptors, development of
mastery in caring for highly challenging conditions such as substance
use disorder, HIV, multiple chronic illnesses, and all intertwined with
adverse social determinants of health and all while promoting wellness,
prevention, and health promotion. The NP Residents are trained in the
science of improving practice as well as delivering care. The programs
provide the experience and skills for new NPs to practice as part of a
high performing team, which leverages the contributions of medical
assistants, RNs, behavioral health clinicians and, increasingly,
community health workers.
What started as a model has grown into a movement because it works.
Research indicates that graduates of postgraduate training programs
remain in primary care and underserved practices at high rates compared
to national averages. In a nationally representative study conducted
last year, primary care NPs with residency training were also more
likely to mirror their patient populations (were more diverse) and also
saw more underserved populations (minority populations with limited
English proficiency. (Park et al., 2022)
An initial concern of some that the creation of postgraduate
training implied that NPs were somehow lacking has given way to
recognition that this is what new NPs want and deserve. In a recent
national survey, 77.5 percent of newly graduated NPs reported they were
either ``willing'' or ``very willing'' to participate in a postgraduate
training program. (Faraz, 2015) We are asking them to be the backbone
of primary care, and they deserve the opportunity to choose intensive
postgraduate primary care training, appropriate in length and content
to today's primary care practice models.
Pragmatically, the model addresses the most urgent need for primary
care organizations: recruiting and retaining an expert primary care
workforce. Today, we recognize that this must include training
psychiatric/mental health NPs as a vital part of the primary care team
to address behavioral health and substance use disorders. Many of the
original NP Residency programs are expanding to include tracts for
psychiatric/mental health NPs. And while today's testimony is focused
on primary care, I want to stress that our colleagues in in-patient and
specialty outpatient settings have identified the same needs, and
concluded that postgraduate residency and fellowship training is
essential for new NPs and PAs in their settings as well.
In 2019, HRSA's Bureau of Health Workforce recognized the value and
impact of postgraduate training for new NPs with a new program, ANE-
NPR, and funded a combination of 36 new and established programs. HRSA
added requirements that programs seek and obtain accreditation, and
also establish academic practice partnerships. It subsequently received
modest appropriations in 2019 and 2020 to further support the program.
In 2020-2021, 368 NP residents were supported by the program according
to HRSA's data warehouse.
The National Nurse Practitioner Residency and Fellowship Training
Consortium (NNPRFTC or simply, ``the Consortium'') was created to
ensure quality and rigor in postgraduate NP training through formal
accreditation. It has earned recognition by the U.S. Department of
Education as a federally recognized accrediting organization. The
Consortium also works with new and existing programs to design their
programs from the start using accreditation standards to provide a
roadmap to a rigorous, successful program.
How much impact can we have on the goal of ensuring that every
person and every family have access to great primary care and a primary
care provider? The Consortium's accredited programs plus a group of
programs with whom CHC has formally collaborated can document 550
alumni. With 250 programs nationally and a conservative estimate of
four postgraduate trainees per program, we can assume up to 1,000 new
NPs may now be able to choose a program--far more than just a few years
ago, but far less than is needed. We are able to track where alumni of
the Consortium's accredited programs practice upon completion of the
program. The vast majority are practicing as primary care providers,
mostly in community health centers and underserved areas. We need to
continue to support the currently funded programs, expand access to new
programs, and support those that have devoted scarce resources to
standing up a program on their own.
In my work with the Consortium, I have visited many programs: from
the Yakima Valley Farmworkers Clinic and CHAS in the State of
Washington, to Cahaba Medical Care in Alabama, from Waianae Coast
Comprehensive Health Center in Hawaii to Thundermist Health Center in
Rhode Island and many points in between. I am deeply impressed by the
top to bottom commitment of boards, executive leadership, and front
line clinicians and staff to this model because it addresses and
resolves much of their highest priority: Recruiting and retaining
expert primary care providers who are deeply committed to their
practice and communities.
Thank you.
______
Senator Hickenlooper. Thank you.
Dr. Verret.
STATEMENT OF REYNOLD VERRET, PH.D., PRESIDENT, XAVIER
UNIVERSITY OF LOUISIANA, NEW ORLEANS, LA
Mr. Verret. Chairman, thank you for having me today.
Chairman Hickenlooper and Members of the Committee, thank you
for the opportunity to address you today. My name--sorry.
Chairman Hickenlooper and Members of the Committee thank you
for the opportunity to testify today.
My name is Reynolds Verret, C. Reynolds Verret. I serve as
sixth President of Xavier University of Louisiana. My
institution is historically a black university, an HBCU. It is
also a Catholic institution. The ultimate purpose of Xavier is
to contribute to the promotion of a just--a more just and
humane society by preparing its students to assume roles of
leadership and of service in a global society.
I was asked testify before the Committee about how Xavier
has employed innovative strategies to address in critical
underrepresentation of blacks in health and other science--
health care and other sciences. I will speak for my
institution, but you may extend many of my comments to the
other 100 accredited HBCUs across the Nation.
Xavier is renowned for its work as a leading institution in
training African-American undergraduates to complete and go on
to complete the MD across the Nation, and also PhDs in the
physical and life sciences. Our considerations when developing
new programs, especially the graduate and professional levels,
includes special criteria. One, whether the programs reflect a
growing demand.
Two, will degrees lead to positions of--with possibilities
for personal growth and flexibility, will degrees earn salaries
that allow students to repay their loans, if the proposed
degrees are of service to the larger society, and especially
underrepresented communities, and most importantly, whether
these degrees offered at Xavier help diversify professions and
increase representation.
Our new programs target professions in which only 1 to 3.5
percent of practitioners identify as African-Americans. The
diversity is critical to provide equitable health care
outcomes. Xavier started this approach many years ago. However,
the challenges of care, of health care equity was highlighted
in the recent disparities demonstrated by the COVID pandemic.
To provide an overall perspective of what we do in Xavier,
since 2016, we have started 23 new programs. New undergraduate
programs include from Bioinformatics, Data Science, Medical
Laboratory Science, Neuroscience, Robotics, and Mechanical
Engineering, and Statistics. At the graduate levels, programs
include Masters of Health Science, Physician Assistant Studies,
Masters of Public Health and Health Equity, Speech and Language
Pathology, and Masters in Pharmaceutical Sciences.
Three upcoming programs that are the MS in Health
Informatics, and also MS in Genetic Counseling, and the
Doctorate in Physical Therapy. While we are proud of the work
we do at Xavier, we and the Nation are challenged to address
the staggering numbers of black doctors and scientists
nationally. Much more must be done to develop a representative
community of health care providers and scientists, physicians
to reduce and eliminate health disparities.
To fully address this need, the pipeline of sending
undergraduate students into schools such as Xavier must be
vastly expanded. This will require providing pathways to all
but most importantly to our first generation students,
including information to families on pathways to college, the
application financially processes, all to make the journey
achievable without the burden of lifelong debt.
America cannot afford to develop only a subset of its
talent, forsaking many whose contributions are needed, losing
them due to socioeconomic barriers. With this being said, I
would like to firmly think Congress for most recent investments
in funding to HBCUs, tribal colleges and universities, minority
serving institutions.
I am also grateful for funding which benefits our student
population directly. Last, may I make a few suggestion
recommendations? We need to double the Pell Grant. Embracing
the only national program that helps low income students
achieve higher education would serve the Nation and ease the
path to needy professions. Revive subsidies for first 2 year
education--for the first 2 years of education at HBCUs. Still
more than 50 percent of all students at HBCUs are first
generation learners. Removing financial impediments will expand
the talent pool to the United States.
Investing in an additional $5 billion to expand the Title
III grant, institutional grant programs at HBCUs will go a long
way to strengthen our institutions. A few historically black
institutions produce a great percentage of the diversity in
health and STEM. Acknowledge this work with more robust
resources to expand their impact and capacity.
Fully fund the HCOP, the Health Careers Opportunities
Program and similar programs. Too few black institutions also
have capacity--too few black institutions have capacity and
resources to function as major research institutions. Why don't
we speak of the R01 status, even though they are actively
nearing that point? More Federal investment, developing and
building capacity at a few HBCUs, Xavier included, will allow
us to continue to expand our work in response to national need.
In President Biden's Joint Families and Infrastructure
plans, HBCUs, tribal colleges, and MSIs, will slate to receive
$90 billion in investment in research related infrastructures.
This is needed and essential. Another point I would say is to
forgive the balance of the HBCU Capital Finance Program debt
for the remaining HBCUs who were excluded from that
forgiveness.
We at Xavier understand that this really should not be
routine. However, there are numerous opportunities in the
Ignite HBCU Excellence Act. Unburden these institutions,
including Xavier. Last but not least, we as a committee of
institutions are still processing the cowardly acts of terror,
which have disrupted so many HBCUs.
I anticipate representations at UNCF and other
representatives of our universities will put forward funding
and policy recommendations for--to the appropriate committees
in the coming weeks. I hope the members of this community will
support these recommendations, mitigating threat and
safeguarding our Nation is most precious assets, which are our
students.
Mr. Chairman, I thank you and I look forward to answer the
questions of the Members of the Committee.
[The prepared statement of Mr. Verret follows:]
prepared statement of reynold verret
Subcommittee Chairman John Hickenlooper and Members of the
Subcommittee, thank you for the opportunity to testify today.
My name is C. Reynold Verret, and I serve as the 6 President of
Xavier University of Louisiana (Xavier). Xavier was founded by Saint
Katharine Drexel of the Sisters of the Blessed Sacrament. My
institution is Catholic and considered a historically Black college and
university (HBCU).
The ultimate purpose of Xavier is to contribute to the promotion of
a more just and humane society by preparing its students to assume
roles of leadership and service in a global society. This preparation
takes place in a diverse learning and teaching environment that
incorporates all relevant educational means, including research and
community service.
I was asked to testify before the Subcommittee today to share how
our institution is addressing issues of underrepresentation of Blacks
in medical and health sciences fields, how this nation can increase the
numbers of Black students achieving advanced and terminal degrees,
share information on the workforce development and new programs we are
launching, and address shortages of practitioners of color in existing
and emerging health science and medical fields.
HBCU History and Statistics
Before I share how Xavier is impacting representation in Health and
Science fields in the Nation with development of innovative academic
programs at the undergraduate and graduate levels and preparing
students to pursue and persist to graduate and terminal degrees, let me
share some general statistics about. HBCUs and their performance.
HBCUs were created as early as 1837 to provide African Americans
access to higher education. Noted for their contributions in educating
Black, low-income, and educationally disadvantaged Americans, the 101
accredited HBCUs today constitute the class of institutions that
satisfy the statutory definition of the term ``HBCU'' as defined in the
Higher Education Act of 1965 (HEA). \1\
---------------------------------------------------------------------------
\1\ The definition of an HBCU can be found in Section 322(2) of
the HEA.
HBCUs disproportionately enroll low-income, first-generation and
academically underprepared college students--precisely the students
---------------------------------------------------------------------------
that the country most needs to obtain college degrees. In 2018:
Nearly 300,000 students attended HBCUs; \2\
---------------------------------------------------------------------------
\2\ U.S. Department of Education, National Center for Education
Statistics. (2020). Digest of education statistics 2019 [Table 313.20].
Retrieved from https://nces.ed.gov/programs/digest/d19/tables/dt19--
313.20.asp
More than 75 percent of HBCU students were African
---------------------------------------------------------------------------
Americans; and
Over 60 percent of undergraduate students at HBCUs
received Federal Pell Grants, and over 60 percent of these
students received Federal loans. \3\
---------------------------------------------------------------------------
\3\ UNCF Public Policy and Government Affairs calculations using
2018 data from the U.S. Department of Education, National Center for
Education Statistics, Integrated Postsecondary Education Data System.
Data shows that out of 257,451 total undergraduate students at HBCUs,
159,101 students were receiving Pell Grants and 162,179 students were
receiving Federal loans.
HBCUs comprised 3 percent of all two-and 4-year non-profit colleges
---------------------------------------------------------------------------
and universities, yet they:
Enroll 10 percent of African American undergraduates;
Produce 17 percent of all African American college
graduates with bachelor's degrees; and
Graduate 24 percent of African Americans with
bachelor's degrees in STEM fields. \4\
---------------------------------------------------------------------------
\4\ UNCF Patterson calculations using U.S. Department of
Education, National Center for Education Statistics, Integrated
Postsecondary Education Data System.
A 2015 Gallup survey confirms that HBCUs are providing African
American students with a better college experience than African
---------------------------------------------------------------------------
American students at other colleges and universities.
55 percent of African American HBCU graduates say
their college prepared them well for post-college life versus
29 percent for African American graduates of other
institutions. \5\
---------------------------------------------------------------------------
\5\ Gallup, Inc. (2015). Gallup-USA funds minority college
graduates report. Retrieved from UNCF Website: https://www.uncf.org/
wp--content/uploads/PDFs/USA--Funds--Minority--Report--GALLUP-2.pdf
HBCUs attained these results at an affordable price for students--
that is, the cost of attendance at HBCUs is about 30 percent lower, on
average, than other colleges--despite limited operating budgets and
endowments that are roughly half the typical size of other 4-year
---------------------------------------------------------------------------
public and private non-profit colleges and universities.
Since our founding, HBCUs have been, and continue to be, under-
resourced institutions. An issue brief produced by ACE (American
Council on Education) and UNCF (United Negro College Fund, Inc.)
revealed the following:
Public HBCUs rely more heavily on Federal, state, and
local funding in comparison with their non-HBCU counterparts
(54 percent of overall revenue vs 38 percent);
Private HBCUs depend a little bit more on tuition
dollars than their non-HBCUs counterparts (45 percent compared
with 37 percent);
Private gifts, grants, and contracts constitute a
smaller portion of overall revenue at private HBCUs compared to
their non-HBCU counterparts (17 percent vs 25 percent);
Public and Private HBCUs experienced the largest
declines in Federal funding per full-time equivalent student
between 2003-2015; and
In both the public and private sectors, HBCU
endowments lag behind those of non-HBCUs by at least 70
percent. \6\
---------------------------------------------------------------------------
\6\ Williams, K.L. & Davis, B.L. (2019). Public and private
investments and divestments in Historically Black Colleges and
Universities. Retrieved from American Council on Education Website:
https://www.acenet.edu/news-room/Pages/Public-and-Private-Investments-
and-Divestments-in-HBCUs.aspx
Despite being under-resourced institutions, HBCUs have a large
economic impact that often goes unnoticed by most. In 2017, UNCF
released a report detailing the economic impact of HBCUs. The report
revealed that in 2014, the impact of HBCUs on their regional economies
---------------------------------------------------------------------------
included:
$10.3 billion in initial spending, which includes
spending by the institution for personnel services, spending by
the institution for operating expenses, and spending by
students;
An employment impact of 134,090 jobs, which
approximately 43 percent were on-campus jobs and 57 percent
were off-campus jobs;
$10.1 billion in terms of gross regional product,
which is a measure of the value of production of all
industries;
A work-life earnings of $130 billion for the Class of
2014, which is 56 percent more than they could expect to earn
without their 2014 certificates or degrees; and
A total economic impact of $14.8 billion. \7\
---------------------------------------------------------------------------
\7\ Humphreys, J.M. (2017). HBCUs make America strong: The
positive economic impact of Historically Black Colleges and
Universities. Retrieved from UNCF Website: https://www.uncf.org/
programs/hbcu-impact
Regarding Xavier University of Louisiana specifically, my
institution had the following economic impact on its regional economy
---------------------------------------------------------------------------
according to the UNCF report:
$200,000,000 in annual economic impact;
1,715 jobs supported annually; and
$1.7 billion in lifetime earnings for one graduating
class.
In addition to the positive impact HBCUs make on the overall
economy, HBCUs also have a strong impact academically when observed at
the State and local level. An upcoming report to be released by UNCF
shows that:
HBCUs comprised 8.5 percent of the 4-year
institutions across the 21 states and territories in the
analysis;
Across the 21 states and territories in the analysis,
HBCUs enrolled, on average, 24 percent of all Black
undergraduates pursuing a bachelor's degree in a college or
university in 2016;
Across the 21 states and territories in the analysis,
on average, 26 percent of all Black bachelor's degree
recipients graduated from an HBCU in 2016; and
In North Carolina, HBCUs are 16 percent of the 4-year
institutions, but enroll 45 percent of all Black undergraduates
and award 43 percent of all Black bachelor's degrees in the
state. \8\
---------------------------------------------------------------------------
\8\ Saunders, K. & Nagle, B.T. (2018). HBCUs punching above their
weight: A state-level analysis of historically Black college and
university enrollment and graduation. Washington, DC: UNCF Frederick D.
Patterson Research Institute
History of Xavier
Xavier University of Louisiana is the only historically Black and
Catholic institution in the Nation, and is nationally recognized for
its science, technology, engineering, and mathematics (STEM)
curriculum, while remaining close to its liberal arts roots. Xavier's
mission is to create a more just and humane society by preparing its
students to assume roles of leadership and service in a global society.
This preparation takes place in a diverse learning and teaching
environment that incorporates all relevant educational means, including
research and community service.
As of Fall 2021, the University has 245 full-time faculty members
who offer courses in over 50 majors on the undergraduate, graduate,
doctoral, and first-professional degree levels. Xavier's current
enrollment is 3,604. Of these, 2,749 are undergraduates and 236 are
graduate students enrolled in the College of Arts and Sciences. In
addition, there are 613 students enrolled in the College of Pharmacy,
which offers the Master of Health Science in Physician Assistant
Studies, the Master of Science in Pharmaceutical Sciences, and the
Doctor of Pharmacy, and 236 students are enrolled in Master's and
Doctoral programs in the College of Arts and Sciences. Xavier's student
body is 77 percent African American, with approximately 39 percent from
Louisiana, primarily from the New Orleans area. The balance comes from
41 other states, the District of Columbia, Puerto Rico, the Virgin
Islands, and several countries. 50 percent of our students have an
expected family contribution of below $2,500. 30 percent of our
students are first generation students. (1st generation students have
lower retention and graduation rates). Xavier welcomes students who are
spread out across the academic profile spectrum and has a proven track
record of meeting students where they are and filing educational gaps
to assist in their perseverance to degree and beyond.
How Xavier Overcomes Obstacles to Student Success
Xavier achieves this student success despite the many obstacles
posed through a strong support system for students through: Intensive
advising by faculty and staff that includes Pre-Health advisors, career
advisors, and graduate school advisors; Workshops and presentations to
assist students on their pathway; Academic Resource Centers--provide
tutoring and supplemental instruction; Early alert system that notifies
key faculty and staff when students need intervention to put them back
on track to success; Residential education program and co-curricular
programs to develop the whole student and grapple with the socio-
economic challenges many of our students face.
According to the U.S. Department of Education, during the past
decade, Xavier has ranked first nationally in the number of African
American students earning undergraduate degrees in Chemistry and the
Physical Sciences overall, and in the top five in Biology. Many well-
prepared, highly motivated students are attracted by Xavier's
reputation in this regard. Conversely, academically disadvantaged
students also are drawn to Xavier because of its track record in
``leveling the playing field,'' especially in the first year of
college. The New York Times Selective Guide to Colleges observes,
``Xavier is a school where achievement has been the rule and beating
the odds against success a routine occurrence.''
According to the Flexner report data for the 13 historically Black
medical schools that were closed and 4 historically Black medical
schools that remained open after the 1910 Flexner report, \9\ an
extrapolation based on data from the medical schools that remained open
indicated that 5 of the closed medical schools might have collectively
provided training to more than 35, 000 graduates by 2019. If these 5
closed schools had remained open, they could have produced a 29 percent
increase in the number of graduating African American physicians in
2019 alone. \10\ While this may seem to many a question purely of
``what if,'' I posit it is an alarming look at how the U.S. could have
had a more diverse mixture in the health professions, because the
percentages of African-American U.S. doctors has remained unchanged
largely throughout my adult life. According to the Association of
American Medical Colleges (AAMC), only 5 percent of all U.S. doctors
are Black or African American. A new UCLA study finds that the
proportion of physicians who are Black in the U.S. has increased by
only 4 percentage points over the past 120 years, and that Xavier has a
long-standing national reputation in producing Black health
professionals. The University has consistently been the No. 1
undergraduate source of African Americans who persist to complete their
MDs. Xavier is nationally ranked as one of the top institution's whose
undergraduates achieve PhDs in the life and social sciences. The
College of Pharmacy has also consistently been among the nation's
leaders in awarding Doctor of Pharmacy degrees to African Americans.
---------------------------------------------------------------------------
\9\ Abraham Flexner and Herman Gates Weiskotten. The Flexner
Report on Medical Education in the United States and Canada (1910).
\10\ Campbell KM, Corral I, Infante Linares JL, Tumin D. Projected
Estimates of African American Medical Graduates of Closed Historically
Black Medical Schools. Retrieved from https://jamanetwork.com/journals/
jamanetworkopen/fullarticle/2769573
Since 2002, graduates have gone on to receive 2,755 master's
degrees, 241 PhD degrees, and 1,529 First Professional degrees since
---------------------------------------------------------------------------
matriculating at Xavier.
Xavier is committed to ensuring that entering first year students
persist and complete their educational goals and recognizes the value
of reaching out to students well before their college years to enhance
skills and habits that will lead to academic success. For over thirty
years, Xavier has coordinated summer programs for high school students
through its Summer Science Academy (SSA). Approximately 500 students
participate each summer in an array of STEM programs including
MathStar, BioStar, ChemStar and analytical reasoning programs.
Xavier also has several programs that support minority student
achievement for its undergraduates, including the LS-LAMP (Louis Stokes
Louisiana Alliance for Minority Participation), BUILD (Building
Infrastructure Leading to Diversity) Program, MICHESS (Materials and
Interfaces Center for High Energy Storage and Sensing) Program, the
Ronald E. McNair Program, HBCU-UP (Historically Black Colleges and
Universities Undergraduate Programs) programs, Upward Bound Math and
Sciences and McNair programs.
Xavier's goal is to provide students the highest level of learning
possible in all areas of the liberal arts and sciences, to help them
develop their own commitment to life-long learning, and to prepare them
for opportunities to enter and succeed in emerging as well as time-
honored careers that require a high level of talent, drive for
excellence, and commitment to service.
Developing Graduate Programs to increase Representation of Blacks in
Careers of Today and Tomorrow
At Xavier we continue to innovate in what programs we will invest
in to better the success opportunities for our students. Our
considerations when developing new programs, especially at the graduate
and professional level include whether the program reflects a growing
demand, if earning this degree will lead to positions that call upon
personal judgment and to possibilities for continued personal growth
and flexibility needed for rapidly changing markets, whether students
who earn the degree will earn salaries that allow them to pay back
their student loans and serve as economic generators for the
communities in which they live, if the proposed degree make possible
personal improvement while being of service to society and most
especially to underserved communities of color.
One of our biggest considerations in development of programs is
whether the degrees offered at Xavier help diversify a profession and
increase representation. Our recently launched programs and planned
programs target professions in which only 1-3.5 percent of
practitioners identify as African Americans. This is critical to
providing equitable healthcare outcomes. While Xavier started this
innovative method of considering programs for development many years
ago, the challenge of health care equity was highlighted by the recent
disparities demonstrated by COVID outcomes in Black communities.
To provide an overall perspective, since 2016, we have started 23
programs: 6 certificate programs, 9 bachelor's degree programs, 6
minors, 4 master's programs, 1 dual degree program.
New undergraduate programs include Bioinformatics, Data Science,
Medical Laboratory Science, Neuroscience, Robotics and Mechatronic
Engineering, Statistics.
New graduate programs include Master of Health Sciences, Physician
Assistant Studies; Master of Public Health, Health Equity; Master of
Science, Speech-Language Pathology; Master of Science, Pharmaceutical
Sciences. Three more in development include Master of Science, Health
Informatics (start Fall 2022); Master of Science, Genetic Counseling
(start Fall 2024); Doctor of Physical Therapy is in its early planning
stages.
Challenges to Our Work
Our greatest challenges to this work are the cost to develop the
programs, space limitations that we and many HBCUs face as we deal with
aging infrastructure and remain undersourced for capital improvement
and expansion projects. The socioeconomic challenges that face our
students and efforts that we must make for them to succeed despite
these challenges. This includes lack of funding for entrance exams,
travel for interviews, need to go directly into career field to
alleviate the debt of achieving undergraduate degrees, and the cost of
the graduate programs.
Mr. Chairman, now that I have informed the Committee on what makes
Xavier perform well at the production of health professionals, I want
to leave you with some recommendations:
1. Double the current Pell Grant. Embracing the only
national program that helps low-income students achieve higher
education would help ease the avenue to graduate and health
professions studies. One of the biggest impediments of Black
and low-income students is finances. Students with aptitude and
no resources all too often stop out of college, and that is a
national tragedy. Doubling Pell, immediately, can immediately
increase the odds of students to stay enrolled despite their
circumstances.
2. To that end, every effort to provide subsidies to the
first 2 years of education at an HBCU should be revived. Still
in 2022, above 50 percent of HBCU students are first generation
learners. Allowing financial impediments to be diminished will
allow those learners to choose the institution which has a
proven track record of producing minority health professionals.
These financial impediments prevent much of our talent pool
from ever pursuing a graduate degree.
3. HBCUs' institutional funding is so often in jeopardy. The
institutions are more reliant on tuition, room, and board. An
additional $5 billion to expand the Title III institutional aid
grants to HBCUs would go a long way to strengthen their
academic, administrative and fiscal capabilities, such as
creating or expanding educational programs in high-demand
fields like the health professions, STEM, computer sciences,
nursing and allied health. We are limited and delayed by
financial restrictions as we attempt to launch new and
innovative programs. Limited by space restrictions,
infrastructure restrictions, seed funding to hire talented
faculty and staff.
4. There are only a few historically Black institutions
which produce a great percentage of the diversity in health and
research. Those institutions should receive more robust
resources for being excellent at what they do. I know there are
programs like the Department of Health and Human Services'
(HHS) ``Centers of Excellence'' and National Institutes of
Health's (NIH) ``Research Endowment'' programs, but if you look
at persistent health disparities and the national inability to
grow the number and percentage of African American health
professionals, more robust funding is needed. If you are
interested, we can share proposed funding numbers with you,
such as an additional $2 billion directed toward building a
pipeline of skilled health care workers with graduate degrees.
5. I also mentioned that part of Xavier's success has been
various programs to prepare our students for the rigors of a
health professions education. Those programs have never been
fully funded, including the ``Health Careers Opportunities
Program'' (HCOP). HCOP and similar programs, and what Xavier
has learned from administering them, has allowed our
institution to excel and do as much as possible to increase
national diversity across the health sector.
6. Too few Black institutions have capacity and resources to
function as major research institutions, often described as R01
status. We at Xavier and many other Black institutions are
creating huge results in the production of Black scientists and
contributing to research at the leading without the Federal
investments needed to attain this status that allows more
laboratory time for our faculty who are stressed with heavy
teaching loads and their institutions fiscal limitations to
release them for research. Investing in developing a few key
HBCUs, starting with Xavier, will allow us to continue and
expand our work and advance development of talent and ability
in response to national need. This investment will multiply the
number of Black students who go on to serve the physical and
life sciences (STEM), the health sciences, social sciences, and
research and innovation needs of the Nation. Xavier has been
historically proven by its success in this work. We urge you to
make investments in us and similar institutions now to build
capacity of our institutions to achieve R01 status.
7. While historically Black colleges have always done ``more
with less,'' the year 2022 should be the year that changes. In
President Biden's joint families and infrastructure plans,
HBCUs, tribal colleges, and minority serving institutions
(MSIs) were slated to receive over $90 billion in investments
in research related infrastructure. This is essential. An
influx of funding is a recognition that HBCUs have
systematically been underfunded; and despite that, HBCUs have
excelled beyond the expectation. However, if the playing field
is leveled, with a backlog of deferred maintenance transformed
into the laboratories necessary to attract and educate the next
generation of health professionals, our production level can
increase.
8. Forgive balance of HBCU Capital Finance Program debt for
remaining HBCUs: The long-term impact of the Federal Government
providing permanent relief the HBCU Capital Finance
institutions in December 2020 will be felt for generations.
Xavier knows this impact having survived the impact Hurricane
Katrina. We continue our recovery from the recent Hurricane Ida
However, the provisions of the Consolidated Appropriations Act
of 2020 State that only obligated funds borrowed from the
Department of Education's program were eligible for relief.
When Xavier, undertaking an opportunity to finally tackle a
backlog of deferred maintenance, borrowed $100,000,000 from the
HBCU Capital Finance Program, the subsequent permanent relief
proved to have little to no institutional impact. As an issue
of fairness for similarly situated institutions, the remaining
(and existing) HBCU Capital Finance Program loans should also
undergo permanent relief. We at Xavier understand that this
relief should not be routine; however, there are numerous
measures in the 117th Congress which include this permanent
relief, including the Institutional Grants for New
Infrastructure, Technology, and Education for (IGNITE) HBCU
Excellence Act.
9. Last, but not least, we as a community of institutions
are still processing the cowardly acts of terror which have
disrupted so many HBCUs. I expect our representation at UNCF
will put forth funding and policy recommendations to the
appropriate appropriations subcommittees in the coming weeks. I
hope the Members of this Committee will support those
recommendations.
Mr. Chairman, thank you. I look forward to answering the questions
of the Members of the Committee.
______
Senator Hickenlooper. Thank you.
Ms. Quinones.
STATEMENT OF NORMA QUINONES, LPN, NURSING SERVICES MANAGER AND
NATIONAL, INSTITUTE FOR MEDICAL ASSISTANT ADVANCEMENT (NIMAA)
SITE COORDINATOR, CLINICAL FAMILY HEALTH, LAFAYETTE, CO
Ms. Quinones. Good morning. What an honor for me to be
here. My name is Norma Quinones, and I am the Nursing Services
Manager at Clinica Family Health, a community health center in
Lafayette, Colorado, that serves low income individuals.
I applied to Clinica Family Health as a Medical Assistant
in 1992, when our organization just had one clinic with six
exam rooms and about 25 employees. I have been able to grow
with Clinica over the past 30 years, and we will never forget
being given the opportunity to start my career as an MA. Within
Clinica's support, I became an LPN and worked as a nurse team
manager for several years.
I am now the Nursing Services Manager for Clinica. I love
what I do. I get to dedicate my time to staff and students as
they do deliver medical, dental, mental health care to
thousands of patients. Part of my job is helping coordinate the
NIMAA program at Clinica, which means I get to support future
MAs on their own educational journey.
The National Institute for Medical Assistance Advancement
is unique, nationally accredited non for-profit post-secondary
program formed in 2016 by two leading FQHCs, Salud Family
Health Center in Fort Lupton, Colorado, and Community Health
Center, Inc. in Middletown, Connecticut. NIMAA is a model for
addressing primary care health workforce shortages, creating an
accessible entry point for long term health care careers and
diversifying the U.S. workforce.
Before working with NIMAA, we had trouble finding qualified
medical assistance prepared to work in our demanding
environment. Some who graduated from expensive programs
incurred a lot of debt, making it hard for them to resist
higher paying jobs in the for-profit sector. It was hard to
find good MAs and harder to keep them.
NIMAA's program has helped us build a workforce pipeline
within our community and reflective of our community. It
provides an affordable option that allows students to work part
time while they are completing the program. It prepares
graduates well for demanding primary care settings that--where
MAs are desperately needed.
It is true--it is a true roll your own model that provides
opportunity for nontraditional students, single parents, recent
immigrants, first generation high school graduates, or those of
us that enter the workforce at an older age.
Nationally, 90 percent of medical assistance are female,
and the majority are black, indigenous, or people of color.
NIMAA's program allows us to help participants begin a health
care career that would otherwise be out of reach for them and
earn a livable wage. Over the past 3 years, Clinica has hosted
18 NIMAA externs. We hired 15 of those 18 upon graduation.
Most are still with our organization. This is a valuable
workforce pipeline for Clinica, and it is extremely rewarding
to watch the students grow in their careers as I did. MAs can
enjoy a rewarding career, whether they stay in the MA role or
move to management, nursing, administration, or other roles.
For example, one of the early NIMAA graduates is applying to
become a Nursing Team Manager--or, I am sorry, a Medical
Assistant Team Manager.
NIMAA is an excellent program with student retention of 89
percent, a graduation rate at 84 percent, and national
credential and exam pass rate of 89 percent, and a job--and a
verified job placement at 81 percent. NIMAA's Program has
already graduated more than 250 students, and it is growing
rapidly.
NIMAA has 48 active clinical partners across 14 States,
including community health centers, hospital systems, and other
safety net providers. This successful program could be scaled
to reach thousands more students each year and to help address
critical workforce shortages in diverse urban and rural
communities across the country.
Thank you for the opportunity to share Clinica and our
students' perspective on NIMAA, what it has meant for Clinica,
and how it can serve as a model for health care pipeline and
pathway efforts.
[The prepared statement of Ms. Quinones follows:]
prepared statement of norma quinones
Good morning, what an honor for me to be here. My name is Norma
Quinones and I am the nursing services manager at Clinica Family
Health, a community health center in Lafayette, Colorado that serves
low-income individuals.
I applied to Clinica Family Health as a Medical Assistant in 1992,
when our organization had just one clinic with six exam rooms and about
25 employees. I have been able to grow with Clinica over the past 30
years and will never forget being given the opportunity to start my
career as an MA. With Clinica's support, I became an LPN and worked as
a nurse manager for several years. I am now the Nursing Services
Manager for Clinica. I love what I do. I get to dedicate my time to
staff and students as they deliver medical, dental and mental health
care to thousands of patients. Part of my job is helping coordinate the
NIMAA program at Clinica, which means I get to support future MAs on
their own educational journeys.
The National Institute for Medical Assistant Advancement (NIMAA) is
a unique, nationally accredited, nonprofit post-secondary program
formed in 2016 by two leading FQHCs--Salud Family Health Center from
Fort Lupton Colorado and Community Health Center, Inc. in Middletown
Connecticut. NIMAA is a model for addressing primary care health
workforce shortages, creating an accessible entry point for long-term
health careers, and diversifying the U.S. workforce.
Before working with NIMAA, we had trouble finding qualified medical
assistants prepared to work in our demanding environment. Some who
graduated from expensive programs incurred a lot of debt, making it
hard for them to resist higher paying jobs in the for-profit sector. It
was hard to find good MAs and also hard to keep them.
NIMAA's program has helped us build a workforce pipeline within our
own community, and reflective of our community. It provides an
affordable option that allows students to work part-time while
completing the program. It prepares graduates well for demanding
primary care settings that desperately need MAs. It is a true ``grow
your own'' model that provides opportunities for non-traditional
students, single parents, recent immigrants, first generation high
school graduates, or those re-entering the workforce at an older age.
Nationally, ninety percent of medical assistants are female, and the
majority are Black, Indigenous, or People of Color. NIMAA's program
allows us to help participants begin a health career that would
otherwise be out of reach for them, and earn a livable wage.
Over the past 3 years, Clinica has hosted 18 NIMAA externs. We
hired 15 of those 18 upon graduation, and most are still with our
organization. This is a very valuable workforce pipeline for Clinica,
and it is extremely rewarding to watch these students growing into
their careers, as I did.
MAs can enjoy a rewarding career, whether they stay in the MA role
or move into management, nursing, administration or other roles. For
example, one of our early NIMAA graduates at Clinica is applying to be
a Medical Assistant Team Manager.
NIMAA is an excellent program with a student retention rate of 89
percent, a graduation rate of 84 percent, a national credentialing exam
pass rate of 89 percent, and a verified job placement rate of 81
percent. \1\
---------------------------------------------------------------------------
\1\ 2020-2021 Rates as reported to the Accrediting Bureau of
Health Education Schools.
NIMAA's program has already graduated more than 250 students and is
growing rapidly. NIMAA has 48 active clinical partners across 14
states, including community health centers, hospital systems and other
---------------------------------------------------------------------------
safety net providers.
This successful program could be scaled to reach thousands more
students each year and help to address critical workforce shortages in
diverse urban and rural communities across the country.
Thank you for the opportunity to share Clinica's and our students'
perspective on NIMAA, what it has meant for Clinica, and how it can
serve as a model for health career pipeline and pathway efforts.
Further Description of NIMAA and Medical Assistant Workforce Needs and
Opportunities
Medical assisting provides an accessible entry-point to a health
career and is a critical support role in advanced primary care
practices.
The National Institute for Medical Assistant Advancement (NIMAA)
offers a unique workforce solution that leverages partnerships with
local healthcare providers to provide both a high-quality educational
program and extensive in-clinic experience. This approach results in a
workforce pipeline from within and representative of the partner
clinic's community.
NIMAA and programs like it have the potential to increase rapidly
the medical assistant (MA) workforce across the United States, and to
create a pool of candidates for advancement to other high-demand health
care jobs.
This written statement provides further detail on the demand for
and role of medical assistants, aspects of NIMAA's model that can
inform workforce pipeline efforts, and opportunities and challenges for
maximizing the reach of programs like NIMAA in the current workforce
and educational environment.
Federal support can serve to ensure the availability of effective
programs in rural and medically underserved communities.
The National Institute for Medical Assistant Advancement (NIMAA)
NIMAA grew out of a need identified by Community Health Center,
Inc., of Connecticut, one of the nation's largest federally Qualified
Health Centers, which was spending months providing extensive
retraining for newly hired medical assistants lacking competency in
core skills and education in comprehensive, team-based care. In
consultation with two noted leaders in the field, Thomas Bodenheimer,
MD, MPH, and Edward Wagner, MD, MPH, CHC's President and CEO Mark
Masselli formed a team and invested initial resources in developing a
new way of providing MA training and education. After a period of
incubation, NIMAA was formed in partnership with Salad Family Health
Centers of Colorado. The Colorado Health Foundation recognized NIMAA's
importance as a critical element in the redesign of primary health care
and workforce development, and thanks to the Foundation's vision and
support, NIMAA was established in Colorado. NIMAA remains an affiliate
of Community Health Center, Inc., which provides operational support
for this program and has facilitated its national growth.
CHC was the first FQHC in the Nation to form its own research and
education center, the Weitzman Institute. Founded in 2007, Weitzman is
grounded in community health, and committed to improving healthcare for
the vulnerable and underserved through research, education, and policy.
The Institute is an incubator for programs such as NIMAA, and its
experts and faculty conduct training and education through the on-line
Project ECHO platform, hosting programs for thousands of providers in
the U.S. and abroad annually.
NIMAA enrolled its first class of 13 students in 2016, with its two
founding partners as clinical externship sites. Since then NIMAA has
grown substantially, and in the 2021-2022 calendar year will enroll
over 135 students, with clinical externships offered in 40
organizations across 14 states.
NIMAA's growth to date, illustrated in the chart below, has been
organic, as word of the program continues to spread and additional
clinical practices learn about NIMAA and decide to participate.
A focused investment in NIMAA and similar programs will greatly
accelerate the rate at which the current health care workforce shortage
is addressed while providing access to meaningful jobs and career
advancement in communities economically impacted by the COVID 19-
pandemic in particular.
NIMAA Student Outcomes
NIMAA collects and reports performance (outcome) data that meets
the standards of its accrediting body, the Accrediting Bureau of Health
Education Schools (ABHES). NIMAA's graduation, retention and placement
rates all exceed ABHES standards and are considerably higher than those
of many vocational education programs.
For the 2020-21 school year, NIMAA reported an 89 percent
retention, 84 percent graduation, 89 percent credentialing exam pass
rate and 81 percent verified job-placement of graduates.
Several unique characteristics of NIMAA's model contribute to these
strong outcomes:
NIMAA's extensive externship requirement (10 hours
per week, beginning in the first week of the program) is
consistent with the needs of adult learners, and ensures that
students are confident in their hands-on skills and have a full
understanding of the practice environment upon graduation.
NIMAA's curriculum is tailored to the needs of
primary health care providers and is regularly updated to
reflect emerging needs and practices.
As discussed above, NIMAA's program structure is accessible to and
affordable for residents of medically underserved communities,
resulting in strong retention and graduation rates.
Scalability of the NIMAA Model
NIMAA's distance (on-line) education model allows NIMAA to grow
rapidly. School operations are supported from NIMAA's Colorado-based
office and do not require the establishment of a local physical campus
to deliver the program. NIMAA instructors work from four US time zones,
allowing them to be accessible to students when students need help.
NIMAA is able to offer its program in any community where an
appropriate primary care practice is interested in serving as an
externship site, and where NIMAA has completed the required regulatory
process to offer its educational program to State residents. \2\
---------------------------------------------------------------------------
\2\ Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the Roles
of Medical Assistants: Who Does What in Primary Care? JAMA Intern Med.
2014;174(7):1025--1026. doi:10.1001/jamainternmed.2014.1319
---------------------------------------------------------------------------
Reach in Rural Communities
Distance learning models, like NIMAA's, are available to rural and
other underserved communities without the investment of capital
infrastructure; they also eliminate the need for students to travel
long distances to attend classes in person.
Key resources need to be in place for models like NIMAA to be
successful in rural communities:
Broadband internet access is critical for students to
use advanced on-line learning tools, such assimulation software
and interactive learning modules.
Rural clinical partners must have the human resources
to bring the program into their communities and to support the
extensive externship hours that are a key component of the
learner experience.
Smaller practices, which includes many rural providers, are usually
able to host only two or three student externs. However, the training
provider expends the same resources on relationship management, program
infrastructure, and support as it would for partners who host two or
three times as many students. Thus, the per-student training cost is
higher in rural areas.
UpSkilling the MA Workforce
The critical role of Medical Assistants in the delivery of primary
care is borne out by the projected growth of Medical Assistants over
the next 10 years. The Bureau of Labor Statistics, Occupational
Handbook projects a growth in MA jobs of 18 percent from 2020-2030,
higher growth than for health care jobs overall. The BLS projects
104,400 medical assisting openings annually, and a net growth of
132,600 jobs over 10 years. \3\
---------------------------------------------------------------------------
\3\ Bureau of Labor Statistics, U.S. Department of Labor,
Occupational Outlook Handbook, Medical Assistants, at https://
www.bls.gov/ooh/healthcare/medical--assistants.htm (Visited February 3,
2022).
While NIMAA's curriculum includes knowledge and skill-building
specific to the medical assistant's role in a team-based primary care
setting, the majority of Medical Assistants entering the workforce will
be trained in traditional programs. These graduates will need
upskilling in skills and competencies related to team-based care to be
effective team members in the emerging primary care environment.
Medical assistants already in the field will need continuing education
to maintain their national credentials and ensure their skills are
---------------------------------------------------------------------------
evolving along with the practice environment.
NIMAA clinical partners requested that NIMAA develop UpSkilling
courses in team-based care topics to support traditionally trained MAs
to be successful in an advanced primary care setting where the medical
assistant has an expanded role within the team.
NIMAA has developed a set of UpSkill NIMAA courses, offered through
the Weitzman Institute, and continues to add courses in response to
industry demand. For example, the immunization course has been updated
to include topics related to COVID19. UpSkill NIMAA courses have been
used by both individual practices and accountable care organizations
wishing to support implementation of an advanced primary care model in
their practices.
The UpSkill NIMAA courses are delivered on-line, and can count
toward the continuing education hours needed to maintain a medical
assisting certificate. UpSkill NIMAA courses can also support the
advancement of medical assistants along an MA career ladder that meets
the health care practice's needs. For example, an MA may be required to
complete the Inter Professional Team-Based Care, Quality Improvement
and Making the Data Count, and Professionalism and Communication
courses, and demonstrate related competencies, to move from MA1 to MA2.
Funding Opportunities
Authorization of national programmatic appropriations funding by
the U.S. Congress in support of NIMAA would allow the nonprofit to
scale its operations to meet primary care workforce needs nationwide,
provide robust support to students, and reduce barriers to
participation of small and rural primary care practices.
About Medical Assistants and Medical Assistant Workforce
The Role of Medical Assistants in Primary Care
Well-trained medical assistants are essential to the delivery of
effective and efficient care in advanced primary care settings, and to
provider retention and satisfaction.
Primary care practices are increasingly adopting a delivery model
that requires integrated team-based care in which all members--
behavioral, oral and physical health providers; care coordinators;
health educators; front office staff; and medical assistants--work
together to meet individual patients' needs and manage population-based
health prevention and screening efforts.
Medical assistants serve as the ``choreographer'' in this model,
ensuring that team members are prepared, facilitating the flow of the
visit, coordinating follow-up care and ensuring screening, referral and
other relevant data are documented and shared appropriately. The
medical assistant's preparedness has a tremendous impact on the team's
functioning and on the quality of care provided.
The Center for Excellence in Primary Care at the University of
California, San Francisco argues that medical assistants can be
utilized in expanded roles such as health coaching, team documentation
and panel management under the direction of a provider. This improves
patient access while reducing the demands on primary care clinicians,
positively affecting the work life of clinicians.
Dr. Tillman Farley, Chief Medical Officer of Salud Family Health
Center and member of NIMAA's Board of Directors says of Medical
Assistants in his practice:
``I am in awe every day of the amazing individuals that do
our MA work. We put an incredible amount of work and
responsibility on them, and they carry that burden every day
with smiles on their faces . . . They are truly the lynchpins
of our organizations. We all need a superpower, and our
superpower is our MAs.''
Medical Assistant Workforce Diversity and Equity
The medical assistant workforce in the U.S. is diverse: 90 percent
are women, 19 percent Latino and 42 percent Black. The median age of
medical assistants is 37.
NIMAA students are recruited from health center service areas, and
they reflect the diversity of their communities in race and age.
NIMAA's student body over the past 2 years was 64 percent Hispanic/
Latino (of any race); 7 percent American Indian/Native American; 9.6
percent Asian; 6 percent Black or African American; and 4 percent
Native Hawaiian/Pacific Islander. Fifty-four percent of NIMAA students
were 25 years old or older, and approximately one third were single
parents.
Y NIMAA's program is deliberately structured to be accessible
to low-income students and non-traditional learners.
Y NIMAA's tuition of $6,000 is much less expensive than the
$15,000 to $40,000 often charged by for-profit schools, making
it more accessible to low-income students.
Y NIMAA's 8-month program is shorter than most, which reduces
students' opportunity costs to participate, and permits the
program's graduates to move more quickly to paid employment.
Y The NIMAA distance-learning educational model allows
students to complete their coursework at times that are
convenient for them, and lets them balance their education with
their part-time employment and/or other responsibilities.
Y NIMAA's student services and instructional staff build one-
on-one relationships with students and support them in
addressing personal and academic challenges.
Y NIMAA applicants are interested in advancing their health
careers over time, and NIMAA's training in team-based care
provides students with a strong foundation they can build upon
with addition education and training.
Career Pathways for Medical Assistants
Medical assistant training is unique in that it encompasses a broad
range of skills, including front-office administrative functions,
billing and coding, patient communication, and medical (back office)
skills. NIMAA's program includes curriculum and skills related to the
team-based care model and empowers students to acquire knowledge and
experience foundational to a number of career pathways.
NIMAA's clinical partners report that staff who began their careers
as medical assistants now work in many different roles, including as
clinic managers, immunization program coordinators, care coordinators,
operations managers and directors, billing managers, nurses, chief
nursing officers and physician assistants, to name a few.
Ms. Quinone's testimony delivered before the Senate HELP
Subcommittee on February 10, 2022, illustrates this opportunity for
advancement. A NIMAA graduate in the first group of students hosted by
Clinica shared this with Ms. Quinones about her experience in NIMAA and
as a medical assistant:
``I am writing to express my sincere gratitude to you for
making the NIMAA program here at Clinica possible. Three years
ago I was thrilled to learn I had been chosen as one of the
first candidates to participate in the NIMAA program. Clinica
and NIMAA gave me the opportunity to become a medical assistant
and I can honestly say I love what I do. My job gives me a
sense of accomplishment when I'm able to help patients and my
fellow co-workers. I've had the privilege of training two NIMAA
students by sharing my vision, experiences and also mistakes.
NIMAA has given me the knowledge, skills and courage to apply
for a leadership position. I will always be grateful for this
opportunity.''
Medial assistant training and experience provide a foundation for
many career pathways. However, those pathways and the related education
needed to pursue them are not well documented. Thus, it is often up to
the individual to identify and navigate these pathways, and for
individual employers to provide the combination of experience and
additional training or education that supports career advancement.
Better documentation of ``organic'' career pathways that build upon
medical assisting skills can create a pipeline for in-demand
administrative, managerial and clinical roles in primary care settings.
NIMAA is passionate about contributing to the delineation and further
development of these pathways in collaboration with the health care
industry and higher education partners.
Most national health professions training initiatives, such as the
National Health Service Corps, and the Teaching Health Center Graduate
Medical Education (THCGME) Program, are focused on encouraging entry
into health careers at the bachelor's or advanced degree levels, and
bringing health professions into medically underserved areas. NIMAA,
and other programs like it, create an additional workforce development
strategy that facilitates entry into a health career for residents of
medically underserved areas who need to maintain an income stream while
starting a career, and for whom a 4-year course of study is not
immediately feasible.
Demand for Medical Assistants and other Allied Health Workers
Nationally and in Colorado
The Bureau of Labor Statistics Employment Projections Program
estimates medical assistant job growth from 2020-2030 will be 18
percent, much faster than the average for all occupations (8 percent)
and, faster than other healthcare support occupations (16 percent).
The Bureau of Labor Statistics Reports describes the demand for
Medical Assistants as follows:
About 104,400 openings for medical assistants are projected
each year, on average, over the decade. Many of those openings
are expected to result from the need to replace workers who
transfer to different occupations or exit the labor force, such
as to retire.
The growth of the aging baby-boom population will continue
to increase demand for preventive medical services, which are
often provided by physicians. As a result, physicians will hire
more assistants to perform routine administrative and clinical
duties, allowing the physicians to see more patients.
An increasing number of group practices, clinics, and other
healthcare facilities will also need support workers,
particularly medical assistants, to complete both
administrative and clinical duties. Medical assistants work
mostly in primary care, a steadily growing sector of the
healthcare industry.
In Colorado there are an estimated 1,890 MA openings annually, with
MA positions expected to grow by 36 percent with 4,110 jobs added by
2028. \4\ The Colorado 2021 Talent Pipeline Report identifies medical
assisting as one of Colorado's top jobs statewide, and in five of the
state's eight regions, with 10-year growth rates in those regions of
between 23 and 43 percent. \5\
---------------------------------------------------------------------------
\4\ Projections Central https://www.projectionscentral.com/
Projections/LongTerm
\5\ 2021 Colorado Talent Pipeline Report. Colorado Workforce
Development Council and Talent Found. Accessed at https://
cwdc.colorado.gov/blog--post/2020--talent--pipeline--report--released,
2.3.2022.
While medical assistant wages and cost of living vary regionally,
medical assisting jobs in the US generally pay a livable wage. The
living wage for a family of four in the US in 2019 was $16.54/hour,
while the median wage for medical assistants in the US in 2020 was
$17.23 per hour. Many health care providers require medical assistants
be certified through one of the national credentialing bodies, and
provide a higher wage to medical assistants who have passed a national
certification exam.
Reducing Barriers to Innovative Training Approaches
Regulatory Considerations
The primary barrier that limits NIMAA's ability to expand
nationwide is the lack of regulatory reciprocity across states for
full-distance vocational programs, like that which exists among 4-year
colleges with SARA (State Authority Reciprocity Agreements). NIMAA is
regulated by the Colorado Department of Higher Education, Division of
Private and Occupational Schools, and complies with all relevant
Colorado regulations. However, some states still require that NIMAA go
through the same application process as a school physically located in
their State would, which can take months or even years. Other states do
not regulate full-distance schools, or have a separate set of
requirements for such schools. As a result, NIMAA must comply with
multiple sets of regulations and requirements. The fees charged by
State regulatory bodies (in addition to the fees NIMAA pays in
Colorado, which cover all enrolled students regardless of residence),
and the administrative burden of tracking and reporting on these
regulations, is extremely costly. In several cases, it is not feasible
for NIMAA to offer its program in a State even where it has willing
clinical partners because the cost of the regulatory processes and
barriers is too high.
NIMAA fully understands and supports the importance of protecting
students from predatory practices. However, many of the regulatory
hurdles placed in front of NIMAA seem redundant for a non-profit school
that has national accreditation and is in full regulatory compliance in
its home state.
Apprenticeship and Health Workforce Needs
Apprenticeship, and other models that allow students to earn a
salary while participating in training, can facilitate engagement of
low-income and non-traditional students in training programs.
Several of NIMAA's clinical partners have medical assistant
apprenticeships in which NIMAA's on-line didactics fulfill the related
instructional requirement, and where completion of the NIMAA program is
one of the requirements of the apprenticeship, which then continues
beyond graduation from NIMAA.
NIMAA has encouraged its clinical partners to explore the
apprenticeship model, and has facilitated conversations with local
workforce offices to that end. Several aspects of apprenticeship limit
participation by NIMAA partners, including:
The 2,000-hour requirement of federally registered
apprenticeships is considerably longer than the 960 hours of
NIMAA's program.
The industry-recognized credential for medical
assisting is a national credentialing exam, while an
apprenticeship completion certificate is not.
The uncertainty regarding which or how many students
will qualify for apprenticeship support.
The administrative tasks required to establish and
maintain registered apprenticeship programs.
The lack of financial support for participation of
non-profit health care employers in apprenticeship.
In addition, states sometimes limit the availability of
apprenticeship programs or funds for training provided by specific
types of training providers, such as Community Colleges. This restricts
the participation of non-profit training providers like NIMAA.
Workforce Resources and Health Workforce Needs
Many workforce efforts are delivered through the workforce
infrastructure, including local workforce boards. A strength of the
workforce system is that local workforce boards prioritize programs
according to local needs. Such a system, however, is challenging for a
national distance-education solution like NIMAA, as it requires making
connections and maintaining relationships with dozens of local
workforce offices.
NIMAA is very interested in engaging workforce program clients in
its program, and has had success doing so. NIMAA has also facilitated
introductions between its clinical partners and local workforce boards,
as many are unaware of the role of workforce boards and are not
familiar with the boards in their region.
The Department of Labor in each State maintains lists of eligible
training providers from which workforce participants may receive
training and obtain support while doing so. NIMAA is on the Eligible
Training Provider List (ETPL) in most states where it enrolls students.
However, in some states there are challenges to ETPL participation.
Some states require that a training provider be regulated by the State
department of higher education to be on the ETPL, but does not regulate
distance-only programs. Others require that a training participant
themselves request that a school be added. Some local workforce boards
will not support training by distance-education providers, regardless
of whether that training entity is on the list.
Recommendations for Expanding Access to Health Careers through Medical
Assisting
Career pathways for medical assistants should be better documented
within career pipeline and pathway efforts to:
Identify paraprofessional or non-clinical roles (such
as certified nursing assistant, front desk staff, patient care
technician) for which medical assisting is a natural next step.
Assist medical assistants with their long-term goal
of becoming a nurse or provider, and ensure they are aware of
the educational and career steps and that will allow them to do
so.
Provide information to medical assistant students
regarding the many career pathways that stem from medical
assisting outside of provider roles.
Assist health care employers in developing employee
retention and advancement initiatives and partnerships.
Facilitate the development of stackable credentials
and articulation agreements in educational systems that reflect
and support the career pathways that exist organically in the
health care industry.
Workforce funding should be available to facilitate
the participation of non-profit community-based health care
providers, including small and rural clinics as host sites for
students, and support pipeline development and internal career
advancement efforts.
State and local efforts to expand healthcare
apprenticeships should include funding to support participation
by non-profit health care providers and should support training
provided by non-profit vocational schools in addition to
community college programs.
Ensure that distance-education (on-line) training
providers are eligible to be included on Eligible Training
Provider Lists in all states, and streamline the process for
inclusion on State lists.
______
Senator Hickenlooper. Thank you.
Ms. Greszler.
STATEMENT OF RACHEL GRESZLER, RESEARCH FELLOW IN ECONOMICS,
BUDGET AND ENTITLEMENTS, INSTITUTE FOR ECONOMIC FREEDOM AND
OPPORTUNITY, THE HERITAGE FOUNDATION, WASHINGTON, DC
Ms. Greszler. Good morning and thank you for the
opportunity to testify today. As an economist who focuses on
labor policy, I would like to first discuss the current labor
force shortage across the U.S. and then look specifically
within the health care sector.
The current labor shortage is unlike any before in U.S.
history. We have an unemployment gap of at least 4 to 5 million
workers. Job openings, which are currently at 10.9 million, are
40 percent above their pre-pandemic record, and they are more
than double the prior 10 year average. And employers are
struggling, as 49 percent of businesses have positions that
they are unable to fill.
Nearly half of all businesses have increased compensation
in December alone and 32 percent plan to increase over the next
3 months. Those higher wages are a great thing when they come
from workers becoming more productive, but when it is simply
employers having to pay people more to do the exact same thing,
that translates into higher prices.
We have seen today with a 40-year record high inflation
that those wage gains have been entirely erased and real wages
are actually dipped down. Resignations are also at record
highs, with nearly one in three workers quitting their jobs in
2021. Replacing workers is extremely costly and this adds to
burdens and creates higher costs. COVID-19 is not the main
cause of the labor crisis, but rather bad policies that have
restricted the labor supply and $6.6 trillion in deficit
finance spending has artificially increased demand for goods
and services.
Instead of spending more Federal money and imposing more
labor market distortions, policymakers should remove the
employment barriers that they have created. That includes
eliminating welfare without work policies, reducing tax burdens
that are prohibiting higher wage and productivity gains,
letting people pursue the work that they want, and expanding
childcare options by allowing parents to use Federal head start
funding dollars at a provider of their choice.
The health care workforce shortage includes both long
standing issues as well as pandemic related ones. So prior to
the pandemic, health care employment had been growing faster
than overall employment, but that has since reversed, and
especially so since the implementation of COVID-19 vaccine
mandates. If health care employment had grown at the same rate
as total employment over just the past 3 months, we would have
73,000 more health care workers today.
It is one thing if we are frustrated by long waits at
restaurants, it is certainly a major disruption to have
canceled flights or school busses that don't show up. But when
hospital units close or people have delays and surgeries and
simply can't access health care that significantly impacts
people's health and even their lives. The CMS vaccine mandate
could remove 70,000 or more health care workers from their
jobs.
Congress should prevent this by protecting medical
providers' right to set their own vaccine policies. The longer
term health care workforce is primarily a State issue. State
Governments need to eliminate unnecessary licensure, scope of
practice, and certificate of need laws that limit the health
care workforce. Doctors and nurses should be able to practice
their professions where the need is greatest and not simply
within the geographic confines of their license.
It is particularly ludicrous when a provider can't have a
telehealth visit with a regular patient simply because they are
out of the State at that time. Also needlessly restricting
nurse practitioners from performing services that they were
trained to provide limits care and drives up costs, and
certificate of need laws have consistently proven anti-
competitive and harmful.
While States are the primary gatekeepers of the health care
workforce, the Federal Government can renew unnecessary burdens
and promote competition and flexibility to better meet
America's health care needs.
Some specific actions include adjusting Federal and State
health care payments to shift the burden of bad policies like
certificate of need laws onto the States that impose them.
Expanding the use of telemedicine. Improving the graduate
medical education system to meet more communities' needs. Not
shortchanging home health care workers by sending part of their
paychecks to unions without their consent. And reducing the
regulatory burdens required by Federal health care programs.
The time is spent on paperwork and regulatory compliance is
time that is not spent treating patients. 58 percent of doctors
list paperwork and regulatory burdens is their biggest
complaints, and nearly half of all physicians say that they are
considering retiring earlier than planned because of changes in
the health care system.
Lives are literally at stake because of the health care
workforce shortage, and many regulations are needlessly making
this worse. Congress should immediately stipulate the vaccine
mandates are decisions for health care providers, and State and
Federal policymakers should reduce barriers and burdens to
better respond to Americans' increasing health care needs.
Thank you.
[The prepared statement of Ms. Greszler follows:]
prepared statement of rachel greszler
My name is Rachel Greszler. I am a Research Fellow in Economics,
Budgets, and Entitlements at The Heritage Foundation. The views I
express in this testimony are my own and should not be construed as
representing any official position of The Heritage Foundation.
My area of expertise is in economics and labor policies, so I would
like to focus first on the unprecedented labor shortage in the U.S.
today, including why it exists and how policymakers can help alleviate
it.
I will then discuss recent trends in health care employment and
provide recommendations for State and Federal policymakers to allow the
health care workforce to more freely expand to meet growing health care
demands.
It is important to note that since State licensing laws serve as
the gatekeepers to the health care workforce, the Federal Government
has limited the ability to increase the supply of health care workers.
Federal policymakers must take these limits into account to avoid
wasting taxpayer dollars.
The Labor Shortage
The U.S. is in the midst of a labor shortage unlike any other in
U.S. history. This is affecting every sector of the economy and exists
across all levels of jobs. Total employment today is between 4.1
million \1\ and 5.3 million \2\ below where it might have been without
the pandemic and absent other changes in economic conditions. \3\ This
employment gap is entirely a labor-supply problem. Without the shortage
of willing workers, employment would likely be above trend right now,
with an employment surplus instead of a gap.
---------------------------------------------------------------------------
\1\ The 4.1 million estimated gap relies on total employment
figures from unpublished tabulations from the Current Population Survey
(CPS) of the U.S. Bureau of Labor Statistics (BLS).
\2\ The 5.3 million estimated gap relies on total payroll
employment figures from the Current Employment Statistics of the BLS.
Payroll employment figures are lower than total employment figures in
the Current Population Survey because they do not include some workers
such as the self-employed.
\3\ For methodology of the employment gap, see Rachel Greszler,
``What Is Happening in This Unprecedented U.S. Labor Market?, February
2022 Update,'' Heritage Foundation Backgrounder No. 3684, forthcoming,
http://report.heritage.org/bg3684
This is the opposite of what was expected at the start of the
pandemic, and in many ways is the result of bad policies that have
restricted the supply of willing workers while simultaneously pumping
large amounts of deficit-financed Federal spending into the economy
---------------------------------------------------------------------------
with the effect of increasing the demand for workers.
Labor Shortage Demographics. Throughout the pandemic, different
groups of workers have been affected differently. For example, at the
beginning of the pandemic, lower-wage workers and women who were
caregivers were more likely to have lost or dropped out of employment,
and older workers who were at greater risk from COVID-19 were more
likely to stop working.
Table 1 provides a breakdown of the employment gaps for various
groups of workers, as measured by the percentage difference between
current employment (December 2021) and where it would have been if,
absent the pandemic, employment had followed steady-State employment
growth. \4\ (All tables and charts are also provided in full-size
graphics at the end of this testimony).
---------------------------------------------------------------------------
\4\ All demographic employment data comes from unpublished
tabulations from the Current Population Survey of the BLS. According to
the BLS, these data are based on a very small number of observations
and should be interpreted with extra caution. For further information
on the CPS, see BLS, ``Labor Force Statistics from the Current
Population Survey:
Survey of the BLS. According to the BLS, these data are based on a
very small number of observations and should be interpreted with extra
caution. For further information on the CPS, see BLS, ``Labor Force
Statistics from the Current Population Survey: Technical
Documentation,'' http://www.bls.gov/cps/documentation.htm (accessed
---------------------------------------------------------------------------
January 31, 2022).
Employment gaps are widespread. Women's employment gap is slightly
higher than men's, and parents' gap is significantly higher than non-
parents. Notable, however, is that the parental employment gap is
entirely the result of lower employment among parents of school-aged
children (ages 6--17) as opposed to younger children (under 6). In
fact, the 1.9 percent employment gap of workers with young children is
lower than the 2.1 percent employment gap of workers without children,
and significantly lower than the overall 2.6 percent employment gap.
This implies that while parents struggle with finding accessible and
affordable childcare, this is not unique to the COVID-19 pandemic and
is not a cause of the recent labor shortage.
The rationale for large employment gaps of both men (5.1 percent)
and women (5.2 percent) with school-aged children is unclear.
Initially, parents consistently experienced lower employment gaps
than non-parents. That changed in late spring 2021. One factor that
could have been weighing on parents' employment in the latter half of
2021 was Congress's passage of the American Rescue Plan including
monthly child payments (beginning in July 2021) that were not
conditioned on work.
A study by researchers at the University of Chicago estimated that
making the child payments permanent would reduce the labor-force
participation and employment of parents by 2.6 percent, which is 1.5
million workers. \5\ With these payments now expired, future economic
studies may help reveal the impact of unconditional child payments on
parents' work decisions.
---------------------------------------------------------------------------
\5\ Kevin Corinth, Bruce D. Meyer, Matthew Stadnicki, and Derek
Wu, ``The Anti-Poverty, Targeting, and Labor Supply Effects of the
Proposed Child Tax Credit Expansion,'' Becker Friedman Institute for
Economics at the University of Chicago, October, 2021, https://
bfi.uchicago.edu/wp--content/uploads/2021/10/BFI--WP--2021-115-1.pdf
(accessed February 4, 2022).
---------------------------------------------------------------------------
Labor Shortage Creating Tremendous Struggles for Employers, Consumers
Businesses across nearly every industry in the United States are
desperate for workers and have expanded their pay and benefit packages
in response to the shortage of willing workers. Yet the number of job
openings in the United States remains at record levels, with 10.9
million job openings in December 2021--the equivalent of 1.7 jobs
available for each of the 6.3 million unemployed workers.
The current 10.9 million job openings are 3.4 million above the
pre-pandemic high (November 2018) and reveal how difficult it is for
employers to find the workers they need. \6\ Simultaneously, workers
are quitting their jobs at record-high rates. In 2021, 47 million
workers quit their jobs, requiring employers to replace 11 million more
workers than they had to in 2020, and 14 million more than the average
between 2011 and 2020. \7\
---------------------------------------------------------------------------
\6\ BLS, ``Job Openings and Labor Turnover Survey,'' https://
www.bls.gov/jlt/ (accessed February 2, 2022).
\7\ Ibid.
With 4.3 million or 2.9 percent of workers quitting their jobs each
month over the past 6 months, this pace translates into employers
having to replace 35 percent of their workers (more than one of three)
---------------------------------------------------------------------------
over the course of a year.
According to the National Federation of Independent Businesses, 49
percent of businesses had job openings that they were unable to fill in
December 2021, with 95 percent of those businesses saying that they had
no or few qualified applicants. \8\
---------------------------------------------------------------------------
\8\ National Federation of Independent Businesses, ``Labor Market
Challenges Breaks 48-Year Record as Biggest Issue Impacting Small
Businesses,'' November 2021, https://assets.nfib.com/nfibcom/2021-Nov-
Jobs-Report-FINAL.pdf (accessed date January 12, 2022).
Adding to Inflation. The labor shortage has caused employers to
raise compensation, with a record-high 48 percent of businesses
reporting that they increased compensation in December, and another 32
percent saying that they plan to raise compensation over the next 3
months. \9\ Although hourly pay increased by an above-average 4.7
percent over the past year (December 2020 to December 2021), real
average earnings (taking into account the effect of inflation) were
down 2.4 percent. \10\ for all employees on private nonfarm payrolls,
seasonally adjusted, December 10, 2021, https://www.bls.gov/
news.release/realer.htm (accessed January 13, 2022).
---------------------------------------------------------------------------
\9\ Ibid.
\10\ BLS, ``Real Earnings News Release,'' Table A-1: Current and
real (constant 1982-1984 dollars) earnings for all employees on private
nonfarm payrolls, seasonally adjusted, December 10, 2021, https://
www.bls.gov/news.release/realer.htm (accessed January 13, 2022).
When employers have to pay workers more to perform the same jobs,
they have to raise their prices, which has contributed to a four-decade
high in annual inflation of 7.0 percent in December 2021. \11\
---------------------------------------------------------------------------
\11\ BLS, U.S. Department of Labor, Consumer Price Index Summary,
December 2021, https://www.bls.gov/news.release/cpi.nr0.htm (accessed
January 12, 2022).
---------------------------------------------------------------------------
Causes of the Current U.S. Labor Shortage
While some factors related to COVID-19 may be affecting certain
workers' employment, it does not appear that the pandemic itself is
weighing significantly on employment. Rather, some of the policies
enacted in response to the pandemic have reduced workers' willingness
and capacity to work. Maximum employment requires not only that it pay
to work, but also that it not pay to not work.
Compensation Is Rising. Wages have been rising and workplace
benefits have expanded (though high levels of inflation have reduced
the value of wage gains). Over the past decade, average hourly earnings
of all employees in the U.S. increased by 35.3 percent while average
hourly earnings in health care increased 32.5 percent. Within the
health care sector, average hourly earnings at hospitals rose 34.7
percent and earnings at nursing care facilities increased 39.5 percent.
Since the start of the pandemic, in February 2020, overall average
earnings in the U.S. have increased 9.9 percent (through December
2021), but health care has experienced significantly larger wage gains
of 11.6 percent across all health care, 12.4 percent within hospitals,
and 16.1 percent in nursing care facilities.
Welfare-without-work Policies. Various government programs and
policies enacted in the name of COVID-19 have made it easier for people
to not work, and almost certainly continue to play a role in weak
employment, particularly among lower-and middle-wage workers. Those
include $600 weekly bonus unemployment insurance benefits, a 21 percent
increase in food stamps, massive expansion in Obamacare subsidies, and
an eviction moratorium and rental assistance.
A measure called the reservation wage, which is the lowest wage at
which individuals will accept a job, surged 26.4 percent between March
2020 and March 2021 for workers making less than $60,000 (from $40,197
to $50,825). It has since declined significantly as the bonus
unemployment insurance benefits ended.
Evidence from past studies of welfare--without-work benefits find
that they tend to reduce the supply of work, and a recent National
Bureau of Economic Research study on the effects of the pandemic
unemployment insurance benefits found that they significantly
restricted employment. \12\
---------------------------------------------------------------------------
\12\ Harry J. Holzer, R. Glen Hubbard, and Michael R. Strain,
``Did Pandemic Unemployment Benefits Reduce Employment? Evidence from
Early State-Level Expirations in June 2021,'' National Bureau of
Economic Research Working Paper No. 29575, December 2021, https://
www.nber.org/papers/w29575 (accessed February 5, 2022).
Federal Spending Spree. The Federal Government has spent $6.6
trillion on COVID-19 packages--the equivalent of $51,600 for every U.S.
household. All this deficit-financed spending--over half of which has
been purchased by the Federal Reserve--increases the demand for goods
---------------------------------------------------------------------------
and services, which requires more workers to meet those demands.
Vaccine Mandates. Various states, private businesses, and medical
facilities began implementing COVID-19 vaccine, or vaccine-and-testing,
mandates in the late summer and fall of 2021. The Federal Reserve's
October 2021 Beige Book noted that vaccine mandates were contributing
to high turnover and production slowdowns, and that impending ``Federal
vaccine mandates were expected to exacerbate labor problems.'' \13\
---------------------------------------------------------------------------
\13\ U.S. Federal Reserve, The Beige Book, October 20, 2021,
https://www.Federalreserve.gov/monetarypolicy/files/BeigeBook--
20211020.pdf (accessed October 22, 2021).
Comprehensive data does not exist on how many health care workers
have lost their jobs because of the vaccine mandate, but employment
growth in health care between September 2021 and December 2021 was more
than 60 percent below total U.S. employment growth over the same
period. Had the health care sector experienced the same growth rate as
total employment over just those 3 months, there would be 72,900 more
health care workers today. \14\
---------------------------------------------------------------------------
\14\ BLS, ``Employment, Hours, and Earnings from the Current
Employment Statistics Survey,'' available for download at https://
www.bls.gov/data/ (accessed February 2, 2022).
This was during a time in which only some states had imposed
vaccine mandates on the health care sector, and the legality of the
Center for Medicaid and Medicare Services (CMS) vaccine mandate was
still in question. With the CMS mandate going into effect across 25
states and the District of Columbia between now and February 28th, the
---------------------------------------------------------------------------
health care worker shortage will almost certainly increase.
The experience thus far of health care providers subject to vaccine
mandates shows that they have had a significant impact on employment
and operations. While some providers have been able to keep
terminations over vaccine requirements down to 0.5 percent or less of
its workforce, some providers have had to terminate 2 percent or more
of their employees. A sampling of news reports documenting significant
effects include:
New York State's largest health care provider, Northwell Health,
had to lay off 1,400 workers--nearly 2 percent of its workforce. \15\
---------------------------------------------------------------------------
\15\ Joseph Choi, ``Largest New York Health Care Provider Fires
1,400 Employees over Vaccine Refusal,'' The Hill, October 4, 2021
https://thehill.com/homenews/state--watch/575283-largest-new-york-
healthcare-provider-fires-1400-employee-over-vaccine (accessed February
5, 2022).
The Mayo Clinic fired roughly 700 workers--about 1 percent of its
staff--due to the vaccine mandate. \16\
---------------------------------------------------------------------------
\16\ Chantal Da Silva, ``Mayo Clinic Fires 700 Workers Who Failed
to Comply with Covid Vaccine Mandate,''NBC News, January 5, 2022,
https://www.nbcnews.com/news/us--news/mayo-clinicfires-700-workers-
failed-comply covid-vaccinemandate-rcna11004 (accessed February 7,
2022).
UVM Health Networks in New York reported that, ``vaccination
mandate for healthcare workers has brought long-standing
healthcarestaffing shortage into sharper focus.'' \17\ With 55
employees voluntarily resigning for a variety of reasons since the
mandate went into effect and another 30 leaving or being terminated as
a result of the mandate, UVM has had to temporarily close units and
delay inpatient surgeries by a week.
---------------------------------------------------------------------------
\17\ The University of Vermont Health Network, ``UMV Health
Network NNY Affiliates Continue to Provide Care Despite Mandate,''
Champlain Valley Physicians Hospital, September 28, 2021, https://
www.cvph.org/News/Detail/297 (accessed February 8, 2022).
Mowhawk Valley Health System (MVHS) in New York State had to fire
nearly 5 percent of its employees--180 in total--which increased the
system's vacancy rate from 13.7 percent to 17.5 percent, meaning the
hospital had only about four employees for every five positions. \18\
---------------------------------------------------------------------------
\18\ ``MVHS Outlines COVID-19 Vaccine Mandate Impact on Health
System,'' September 28, 2021,https://www.mvhealthsystem.org/news/2021-
09-28/mvhs--outlines--covid-19--vaccine-mandate-impacton-health-system
(accessed February 5, 2022).
When vaccine mandates leave hospitals and health care providers
short-staffed, this reduces patients' access to care and can diminish
the quality of care they receive. One of my own family members had to
take her 4-year-old daughter to a hospital in another state, 160 miles
away, for emergency diagnosis and surgery because the nearest
Children's Hospital was experiencing significant staffing shortages due
---------------------------------------------------------------------------
to the vaccine mandate.
As a labor policy economist, I have focused this Causes section on
the current widespread labor shortage. I include some longer-term
causes of health-care-specific labor shortages in the Solutions
section.
Health Care Labor Shortage
Shortages of health care workers--especially primary care doctors--
existed before the pandemic and are projected to grow drastically
as the population of people ages 65 and older is expected in
increase by 50 percent with the aging of the baby boomer population.
Older people have more medical problems and more complex problems that
result in higher medical utilization and costs.
A 2018 analysis by the Association of American Medical Colleges
predicted that the by 2030, there will be a shortage of between 42,600
and 121,300 physicians in both primary and specialty care. \19\ There
are also current and rising shortages in other health care positions
such as nurses, home health care workers, and nursing home health
aides. Too few health care providers translates into limited access to
health care and worse health outcomes.
---------------------------------------------------------------------------
\19\ Tim Dall et al., The Complexities of Physician Supply and
Demand: Projections from 2016 to 2030 (2018 Update), IHS Markit Ltd.,
for the Association of American Medical Colleges, March 2018, https://
aamcblack.global.ssl.fastly.net/production/media/filer--public/85/d7/
85d7b689--f417-4ef0-97fbecc129836829/aamc--2018--workforce--
projections--update--april--11--2018.pdf (accessed August 24, 2018)
Prior to the pandemic, health care employment had been growing
faster than overall employment, but not fast enough to keep pace with
growth in the aging population that consumes the most medical care.
Between December 2011 and the start of the pandemic in February 2020,
total employment grew by 14.8 percent while health care employment grew
---------------------------------------------------------------------------
16.7 percent.
Since the start of the pandemic (February 2020 through December
2021), health care employment has been particularly hard-hit,
experiencing a 2.7 percent employment decline compared to the overall
2.3 percent workforce decline.
Factoring in where employment would otherwise have been if the
economy had experienced steady-State employment growthsince February
2020, the overall employment gap is 3.5 percent \20\ and the health
care employment gap is 3.9 percent, or 644,000 fewer health care
workers than might otherwise have existed absent the employment changes
that occurred since the pandemic.
---------------------------------------------------------------------------
\20\ This employment gap is based on the BLS's Current Employment
Statistics Survey. This is larger than the 2.6 percent gap reported in
the demographic data because they include different populations and
sample sizes. The demographic data is a survey of workers (not
employers), and it has a smaller sample size and also a different
method of measuring employment. (The demographic data can include self-
reported employment whereas the health care and total employment
figures mentioned above are based on firms' payroll employment).
---------------------------------------------------------------------------
Federal Government's Role in Health Care Workforce
The Federal Government has a limited ability to affect the supply
of health care workers because State licensing boards regulate who can
obtain professional licenses and what medical services they can
perform. Nonetheless, the Federal Government's role in health care
through federally funded health care programs has created barriers to
the health care workforce. Many of the rules and regulations of these
Federal programs affect the supply of the health care workforce.
Significant Control of the Graduate Medical Education (GME) System.
The Federal Government currently spends billions of dollars each year
on GME, or residency programs. Prior to the mid-20th century, hospitals
usually absorbed the cost of GME without government subsidies, but in
the 1960's, Federal funding for GME became part of Medicare spending.
These Federal subsidies were supposed to be temporary, but have become
the primary source of GME funding. By providing about $15 billion in
funding per year, it is likely that the Federal Government has crowded
out financing that might otherwise have come from various other
stakeholders.
The U.S. GME system fails to produce a sufficient number and
adequate allocation of doctors to meet Americans' health care needs.
Factors such as a 25-year-old cap on the number of Medicare-funded
residency slots and the direct payment of GME funds to hospitals
instead of being tied to students' results is a focus on teaching
hospitals' needs instead of the health care needs of the American
population as a whole.
Recent Federal Investments in Health Care and the Health Care
Workforce. Pandemic legislation, including the Coronavirus Aid, Relief,
and Economic Security (CARES) Act of 2020 and the American Rescue Plan
(ARP) of 2021 provided huge investments in the U.S. health care
workforce. Some of those investments include $12.7 billion of increased
Federal Medicaid matching funds to increase the workforce for home-and
community-based services; $8.5 billion for rural health providers; $7.0
billion to invest in the public health care workforce; $1.55 billion to
address unmet health care needs and expand health care workforce
programs in underserved communities; and about $250 million for
behavioral health workforce expansions. \21\
---------------------------------------------------------------------------
\21\ Angela J. Beck et al., ``Investing in a 21st Century Health
Workforce: A Call for Accountability,'' Health Affairs, September 15,
2021, https://www.healthaffairs.org/do/10.1377/
forefront.20210913.133585/full/ (accessed February 6, 2022).
These recent funds are an enormous investment and will take
significant time for their potential benefits to accrue. Congress
should focus on ensuring the efficacy and accountability of these funds
---------------------------------------------------------------------------
to meet their designated needs.
Instead of jumping to spend more Federal money to increase the
health care workforce, policymakers should allow time (with proper
oversight) for the existing tens of billions of dollars in investments
in the health care workforce to play out. Moreover, Federal lawmakers
should not spend money in areas where existing state-imposed barriers
to the expansion of the health care workforce and health care access
will prevent those Federal dollars from achieving their full value.
Veteran's Administration Not a Gold-Standard for Care. The Federal
Government's direct provision of health care through the Veteran's
Health Administration (VHA) and Veterans Affairs (VA) facilities falls
short it its delivery of quality, timely, and affordable care.
According to a 2016 report from The Heritage Foundation:
Since 2014, investigations of the Veterans Health
Administration (VHA) have revealed glaring issues with the
Administration's policies and practices, including excessively
long wait times and secret waitlists for health care at
hundreds of Veterans Affairs (VA) facilities. A report from a
VA whistleblower \22\ shows that as many as 238,000 veterans
may have passed away before receiving care. \23\
---------------------------------------------------------------------------
\22\ Ryan Grim, ``Leaked Document: Nearly One-Third of 847,000
Vets with Pending Applications for VA Health Care Already Died,'' The
Huffington Post, July 13, 2015, http://www.huffingtonpost.com/2015/07/
13/veterans-health-care-backlogdied--n--7785920.html (accessed June 14,
2016).
\23\ John O'Shea, ``Reforming Veterans Health Care: Now and for
the Future,'' Heritage Foundation Issue Brief No. 4585, June 24, 2016,
https://www.heritage.org/health--carereform/report/reforming-veterans-
health-care-now-andthe-future.
The VA is uniquely structured to provide care for veterans and has
plenty of need to improve on access, quality, and accountability. The
VA should not become a means of expanding the government's role in
---------------------------------------------------------------------------
health care beyond veterans.
Federal Government's Failed Track Record in Job-Training Programs
Evidence It Should Not Enact Health Care Workforce Training Programs.
In light of the health care worker shortage, it may be suggested that
the Federal Government embark in health workforce job-training
programs. But the Federal Government has a terrible track record on
job-training programs.
A gold standard evaluation of the Workforce Investment Act found
that despite the Department of Labor's directive to provide training
for in-demand services, only 32 percent of participants found
occupations in their area of training, and the majority of
participants--57 percent--did not believe that their training helped
them find employment. \24\ Moreover, individuals receiving the full
workforce training were less likely to obtain health insurance or
pension benefits, their households earned several thousand dollars
less, and they were more likely to be on food stamps than participants
who received minimal services.
---------------------------------------------------------------------------
\24\ Sheena McConnell, Kenneth Fortson, Dana Rotz, Peter Schochet,
Paul Burkander, Linda Rosenberg, Annalisa Mastri, and Ronald D'Amic,
``Providing Public Workforce Services to Job Seekers: 15-Month Impact
Findings on the WIA Adult and Dislocated Worker Programs,'' Mathematica
Policy Research, May 30, 2016,https://www.mathematica.org/publications/
providingpublic-workforce-services-to-job-seekers-15-monthimpact-
findings-on-the-wia-adult (accessed February 4, 2022).
Annalisa Mastri, and Ronadl D'Amic, ``Providing Public Workforce
Services to Job Seekers: 15-Month Impact Findings on the WIA Adult and
Dislocated Worker Programs,'' Mathematica Policy Research, May 30,
2016, https://www.mathematica.org/publications/providing-public-
workforce-services-to-job-seekers-15-month-impact-findings-on-the-wia-
---------------------------------------------------------------------------
adult (accessed February 4, 2022).
The National Job Corps Study (a youth job-training program), found
that a Federal taxpayer investment of $25,000 per Job Corps participant
resulted in participants being less likely to earn a high school
diploma, no more likely to attend or complete college, and to earn only
$22 more per week, on average. \25\
---------------------------------------------------------------------------
\25\ David B. Muhlhausen, ``Job Corps: An Unfailing Record of
Failure,'' Heritage Foundation WebMemo No. 2423, May 5, 2009, https://
www.heritage.org/jobsandlabor/report/jobcorps-unfailing-record-failure.
It is not surprising that Federal job-training programs are out of
touch with the needs of employers in high-demand occupations because
politicians and bureaucrats will never know businesses' needs better
than employers themselves. Politicians are particularly ill-equipped to
understand and meet the needs of the health care industry. Any training
efforts they may attempt to undertake would not only be thwarted by
existing government regulations, but in the fast-paced and rapid-
response health care industry, Federal efforts would almost certainly
come up a day late and a dollar short.
Solutions to Increase Health Care Workforce, Health Care Access
The severe labor shortage across the U.S. has had
disproportionately large effects on the health care workforce, at the
same time as the pandemic has increased the demand for health care and
required new health care protocols that have made the provision of
health care more costly and time-consuming.
Even prior to the pandemic, however, the U.S. faced a shortage of
health care professionals. According to the Health Resources and
Service Administration, 88 million Americans live in areas designated
to have shortages of primary care health professionals. \26\
---------------------------------------------------------------------------
\26\ Health Resources and Services Administration, ``Shortage
Areas,'' U.S. Department of Health and Human Services, https://
data.hrsa.gov/topics/healthworkforce/shortage-areas (accessed February
7, 2022).
Although there are some actions Federal policymakers can take to
make it easier for international medical professionals to enter the
U.S., most barriers to expanding the health care workforce and access
to health care rely on removing state-level barriers. No matter how
much money the Federal Government may spend attempting to increase
employment in and access to health care, it will be of limited use so
long as states continue to restrict entry into health care occupations
and unnecessarily restrict the services health care workers can
---------------------------------------------------------------------------
provide.
There are steps, however, that Federal policymakers can take to
enable greater flexibility for the health care industry to respond to
Americans' health care needs, as well as to remove unnecessary burdens
in Federal health care programs that limit health care access and
prevent more innovative and cost-effective care.
It is also important for the Federal Government to ensure proper
accountability and effectiveness of the tens of billions of Federal
dollars recently allocated to expanding the health care workforce. This
may require the Federal Government working with states to encourage
them to remove barriers to that funding to achieve its intended
purposes.
First, Ensure a Well-Functioning U.S. Labor Market
Foundational to expanding the health care workforce--or any
sector's workforce--is a well-functioning U.S. labor market with ample
participants. For individuals, that requires that it pays to work and
does not pay to not work. To help encourage more people to pursue their
productive capabilities, policymakers should:
Limit Taxes and Reduce Regulations so that individuals and
employers can enjoy higher returns to work (such as greater pay, higher
productivity, and increased opportunities). \27\
---------------------------------------------------------------------------
\27\ Adam N. Michel, ``The Tax Cuts and Jobs Act: 12 Myths
Debunked,'' Heritage Foundation Backgrounder No. 3600, March 23, 2021,
https://www.heritage.org/taxes/report/the-tax-cuts-andjobs-act-12-
myths-debunked.
Enable Greater Natural Wage Increases by making it easier and less
expensive for people to obtain income-enhancing education and skills,
and by eliminating the double tax in investments that boost
productivity and wages. \28\
---------------------------------------------------------------------------
\28\ Jamie Bryan Hall and Mary Clare Amselem, ``Time to Reform
Higher Education Financing and Accreditation,'' Heritage Foundation
Issue Brief No. 4668, March 28, 2017, https://www.heritage.org/
education/report/time-reformhigher-education-financing-and-
accreditation.
Make Welfare Work Better Through Work-Oriented Programs that help
---------------------------------------------------------------------------
people achieve independence (and also help break cycles of poverty).
Let People Pursue the Work They Want by not forcing workers into
unions, by not enacting laws that prohibit companies from doing
business with independent workers, and by clarifying the definition of
``employee'' across Federal laws based on the level of control the
individual maintains over his work.
Expand Accessible, Affordable Childcare by allowing parents to use
Federal childcare subsidies and Head Start funds at a provider of their
choice. \29\
---------------------------------------------------------------------------
\29\ Rachel Greszler and Lindsey M. Burke, ``Rethinking Early
Childhood Education and Childcare in the COVID-19 Era,'' Heritage
Foundation Backgrounder No. 3533, September 30, 2020, https://
www.heritage.org/sites/default/files/2020-09/BG3533.pdf.
Do Not Increase Government Spending. Passing big spending bills
with new unfunded entitlement programs in addition to the recent $6.6
trillion in COVID-19 spending and atop the $30 trillion U.S. Federal
debt would be reckless and further interfere in the already troubled
---------------------------------------------------------------------------
labor market.
Second, Remove Barriers that Restrict the Healthcare Workforce
Abandon Federal Vaccine Mandates. The Federal Government's vaccine
mandate for Medicare and Medicaid providers extends to about 14 million
workers. An October 2021 ``Vaccine Monitor'' survey from the Kaiser
Family Foundation reported that 5 percent of adults say they would
leave their job if their employer required them to get a vaccine or get
tested weekly, and that figure jumped to 9 percent if weekly testing
was not an option. \30\
---------------------------------------------------------------------------
\30\ Liz Hamel et al., ``KFF COVID-19 Vaccine Monitor: October
2021,'' Kaiser Family Foundation, October 28, 2021, https://
www.kff.org/coronavirus--covid--19/pollfinding/kff-vid-19-vaccine-
monitor-october-2021/ (accessed October 31, 2021).
While health care workers may be less likely than the general
population to quit their jobs over a vaccine mandate, if even 0.5
percent of the 14 million workers subject to the CMS COVID-19 mandate
---------------------------------------------------------------------------
quit, this would result in a loss of 70,000 health care workers.
The Federal Government should abandon the CMS mandate and instead
allow health care providers to set their own vaccination policies,
based on their simultaneous goals of providing safe environments and
ensuring access to quality care.
Third, State and Federal Lawmakers Need to Remove Barriers to Entry
and Eliminate Unnecessary Burdens in Health Care Delivery
Reform the Graduate Medical Education System. Becoming a practicing
physician in the U.S. requires between seven and 10 years of education
that involves the certification of at least four different medical
accreditation boards and councils. \31\ Dr. Kevin Pham explains that
while these organizations originally arose ``to weed out sham schools
and shoddy practitioners,'' their safeguards have become a bottleneck,
and the ``organizations are becoming monopolistic.'' \32\
---------------------------------------------------------------------------
\31\ Kevin Pham, MD, ``America's Looming Doctor Shortage: What
Policymakers Should Do,'' Heritage Foundation Backgrounder No. 3343,
September 5, 2018, https://www.heritage.org/sites/default/files/2018-
09/BG3343--1.pdf.
\32\ Ibid.
These barriers and the GME system's reliance on Federal funding
makes it extremely difficult for smaller and rural community hospitals
to sponsor residency programs, which results in a shortage of residency
---------------------------------------------------------------------------
spaces and a misallocation of physicians across the U.S.
Policymakers should improve the GME system by consolidating GME
financing into a single funding stream based on the cost of training
residents; allocating GME funding management to the states based on
agreed-upon criteria; having funds follow the residents rather than the
training programs; and by including all stakeholders--not just
governments--in GME financing. \33\
---------------------------------------------------------------------------
\33\ John O'Shea, MD, ``Reforming Graduate Medical Education in
the U.S.,'' Heritage Foundation Backgrounder No. 2983, December 29,
2014, http://thf--media.s3.amazonaws.com/2014/pdf/BG2983.pdf.
Moreover, policymakers should break the accreditation monopoly to
---------------------------------------------------------------------------
encourage the development of additional and innovative GME programs.
Allow Provisional Licensing for Medical School Graduates Who Do Not
Receive a Residency Position. Completing a residency program is
generally necessary for medical school graduates to begin practicing
medicine on their own. Yet, between 2014 and 2018, an average of 8,444
medical school graduates per year did not find a position in a
residency program (which operates through a monopoly matching system).
\34\ States could potentially utilize the talent of these highly
educated individuals by allowing for provisional licensing of medical
graduates to work under the supervision of qualified physicians. A
publication by Kevin Dayaratna, Paul Larkin and John O'Shea recommends
that such provisional licenses, issued by state licensing boards,
should include ``earning a medical degree from an accredited medical
school, passing the USMLE, and collaborating with a supervising
licensed physician.'' \35\
---------------------------------------------------------------------------
\34\ Kevin Dayaratna, Paul J. Larkin, Jr., and John O'Shea, MD,
``Reforming American Medical Licensure,'' Harvard Journal of Law and
Public Policy, Vol. 42, No. 1, http://www.harvard-jlpp.com/
wplicensingcontent/uploads/sites/21/2019/02/Larkin-Final.pdf (accessed
February 7, 2022).
\35\ Ibid.
Accelerate Visas for International Medical Graduates (IMGs).
According to the Council on Graduate Medical Education, IMGs make up
about 20--25 percent of the physician workforce, but visa restrictions
and delays limit their ability to come to the U.S. and help fill unmet
health care needs. According to the American Medical Association, ``The
proportion of residency programs sponsoring H-1B visas for training has
gradually decreased in the last few years as the immigration
requirements are multistep, costly (for the employer), and often
complicated with bureaucratic immigration nuances.'' \36\ U.S.
immigration laws should make it easier for the U.S. to fill unmet
physician needs through International Medical Graduates.
---------------------------------------------------------------------------
\36\ American Medical Association, ``International Medical
Graduates (IMG) Toolkit: Types of Visas and FAQs,'' International
Medical Education, https://www.ama--assn.org/education/
internationalmedical-education/international-medical-graduatesimg-
toolkit-types-visas (accessed February 6, 2022).
Streamline Entry for Experienced Medical Professionals from Abroad.
To obtain a license to practice medicine in the U.S., many experienced
doctors from foreign countries have to spend years completing the same
type of internship and residency program as U.S. medical school
graduates, even though many of those foreign doctors have already
completed similar education and have years of practical experience.
\37\ American medical licensing boards should streamline the process
for experienced foreign doctors to practice in the U.S., potentially
utilizing a provisional licensing system. \38\
---------------------------------------------------------------------------
\37\ Dayaratna, Larkin, Jr., and O'Shea, ``Reforming American
Medical Licensure.''
\38\ Australia's Medical Board provides a promising example
whereby foreign medical professionals that are licensed in their own
country and have passed the Australian licensing exam or similar
equivalent can obtain a provisional license. Provisionally licensed
doctors are granted one of four different levels of practitioner
supervision, based on their qualifications. After proving their
competence, foreign practitioners are eligible to obtain a full medical
license.
American medical boards could also establish reciprocity agreements
with other countries, so that the U.S. could accept certain levels of
education and experience in other countries toward American licensure.
Both of these policies would help reduce the shortage of spots in
---------------------------------------------------------------------------
America's Graduate Medical Education system.
Reduce Administrative and Regulatory Burdens. According to Dr.
Kevin Pham, ``The essential health care interaction occurs between the
physician and the patient, and anything that interferes with that
relationship makes the best practice of medicine harder.'' \39\ The
more time that doctors and medical professionals have to spend
complying with administrative and regulatory burdens, the less time
they can spend doing what they were trained and desire to do--treating
patients.
---------------------------------------------------------------------------
\39\ Pham, MD, ``America's Looming Doctor Shortage: What
Policymakers Should Do.''
Excessive regulatory burdens that make it less desirable to work in
health care can cause workers to prematurely leave their professions.
---------------------------------------------------------------------------
According to a Physicians Foundation survey,
49 percent of doctors feel often or always burned out, and 58.3
percent of doctors' primary complaints are the paperwork and regulatory
burden. \40\ Moreover, almost half of physicians are considering
retiring earlier than planned because of reasons related to changes in
the health care system. This includes 41.2 percent of physicians
younger than 45, and 50 percent of those 46 and older. \41\
---------------------------------------------------------------------------
\40\ The Physicians Foundation, 2016 Survey of America's
Physicians, Practice Patterns & Perspectives, 2016, pp. 7-17, https://
physiciansfoundation.org/wp--content/uploads/2018/01/Biennial--
Physician--Survey--2016.pdf (accessed February 8, 2022).
\41\ The Physicians Foundation, 2016 Survey of America's
Physicians, Practice Patterns & Perspectives, pp. 29-33.
Some of the most significant administrative burdens include
quality-reporting measures, prior authorization requirements, and
excessive documentation of details in clinical encounters. For example,
an American Medical Association study found that a small, three-
physician practice will complete an average of 100 prior authorizations
per week. And Medicare requires doctors to recertify durable medical
equipment every year for patients with chronic medical conditions, such
as insulin pumps for individuals with type 1 diabetes. \42\ The Federal
Government, through the CMS should reduce and eliminate unnecessary
administrative burdens. \43\
---------------------------------------------------------------------------
\42\ Pham, MD, ``America's Looming Doctor Shortage: What
Policymakers Should Do.''
\43\ Ibid. This report includes the following recommendations:
``Ease policies driving administrative burdens in the form of paperwork
requirements; ease documentation requirements for clinical visits;
rescind the mandate to use EHRs in order to receive full compensation
by Medicare; and respect and support the role the private sector has to
play in developing products that meet doctors' needs.''
Do Not Reduce Home Healthcare Workers Paychecks Through ``Dues
Skimming.'' The Biden Administration seeks to force more workers into
unions by extracting union dues from home healthcare workers' Medicare
---------------------------------------------------------------------------
and Medicaid payments, without their consent.
Docking the paychecks of home healthcare workers'--or any
workers'--paychecks and requiring them to cede control over their work
to union officials will make healthcare work less attractive. The fact
that only 6.1 percent of private sector workers are union members \44\
shows that unions do not benefit all workers, and they would likely
prevent some would-be healthcare workers from continuing in their jobs
due to the higher costs and restricted autonomy that comes with union
membership. No government--Federal nor state--should ever require
workers to join a union as a condition of performing their desired
jobs.
---------------------------------------------------------------------------
\44\ BLS, ``Union Members-2021,'' News Release, January 20, 2022,
https://www.bls.gov/news.release/pdf/union2.pdf (accessed February 8,
2022).
Reform State Licensure Laws and Accreditation Rules. State
licensing laws determine who can perform various health care
professions within a state. In many instances, State licensure boards
function as political monopolies to prevent new entrants into the
market, as opposed to public safety protectors. There are many ways
states can and should prevent unnecessary licensure barriers, including
by taking power away from monopolistic licensing boards, by reducing
and eliminating unnecessary licensing requirements, by expanding
options for individuals to obtain health care education, and by
---------------------------------------------------------------------------
enacting reciprocity agreements with other states.
Reform State Scope of Practice Laws. Scope of practice laws act as
a second barrier to the delivery of health care by restricting the
range of health care services and procedures that already licensed
professionals can provide, and by requiring varying levels of
supervision for these professionals to practice in their field.
Most often, scope of practice laws apply to nonphysician providers
such as nurse practitioners, or Advanced Practice Registered Nurses
(APRNs). Currently, 25 states plus the District of Columbia provide
Full Practice Authority (FPA) for nurse practitioners to perform all of
the services and procedures they were trained to perform. \45\ The
other 25 states reduce or restrict the ability of nurse practitioners
to engage in one ore more element of their practice and require career-
long collaboration or supervision.
---------------------------------------------------------------------------
\45\ American Association of Nurse Practitioners, ``State Practice
Environment,'' https://www.aanp.org/advocacy/state/state-
practiceenvironment (accessed February 7, 2022).
A Federal Trade Commission explains how scope of practice laws can
limit the supply of primary health services and restrict competition
---------------------------------------------------------------------------
between different types of practitioners:
Physician supervision requirements may raise competition
concerns because they effectively give one group of health care
professionals the ability to restrict access to the market by
another, competing group of health care professionals, thereby
denying health care consumers the benefits of greater
competition. In addition, APRNs play a critical role in
alleviating provider shortages and expanding access to health
care services for medically underserved populations. For these
reasons, the FTC [Federal Trade Commission] staff has
consistently urged State legislators to avoid imposing
restrictions on APRN scope of practice unless those
restrictions are necessary to address well-founded patient
safety concerns. Based on substantial evidence and experience,
expert bodies have concluded that ARPNs are safe and effective
as independent providers of many health care services within
the scope of their training, licensure, certification, and
current practice. \46\
---------------------------------------------------------------------------
\46\ Federal Trade Commission, ``Competition and the Regulation of
Advanced Practice Nurses,'' Policy Perspectives, March 2014, https://
www.ftc.gov/system/files/documents/reports/policy-perspectives-
competition-regulation-advancedpractice-nurses/
140307aprnpolicypaper.pdf (accessed
Eliminate State Certificate-of-Need (CON) Laws or Require States to
Bear Financial Burden. Imagine if opening a business required procuring
detailed analysis and projections, hiring lawyers, lobbyists, and
consultants, and convincing existing competitors to not oppose your
entry into the market. This is what hospital offices and medical
providers must do to prove to a State agency that there is a ``need''
for the new or expanded facility they want to build. Academic studies
show that Certificate-of-Need (CON) laws that exist in 35 states and
the District of Columbia lead to lower quality, reduced access, and
higher costs, including 30 percent fewer hospitals and 11 percent
higher healthcare costs. \47\ The FTC and the Anti-Trust Division of
the Department of Justice (DOJ) have consistently come to the same
conclusion under both Democratic and Republican Administrations. \48\
---------------------------------------------------------------------------
\47\ See State Policy Network, ``Certificate-Of-Need Laws: Why
They Exist and Who They Hurt,'' SPN Blog, April 1, 2021, https://
spn.org/blog/certificate--ofneedlaws/text--The percent20Kaiser
percent20Family percent20Foundation percent20found,residents
percent20across percent20the percent20entire percent20'State (accessed
February 8, 2022).
\48\ Maureen K. Ohlhausen, ``Certificate of Need Laws: A
Prescription for Higher Costs,'' Antitrust, Vol. 30, No. 1, Fall 2015,
c 2015 by the American Bar Association, available at: https://
www.ftc.gov/system/files/documents/public--statements/896453/
1512fall15-ohlhausenc.pdf (accessed February 8, 2022).
States should eliminate CON laws and Congress should consider
evaluating the extent to which CON laws are driving up Federal
healthcare costs and adjust payments to the states accordingly, to
prevent Federal taxpayers from bearing the financial burden of states'
bad policies. \49\
---------------------------------------------------------------------------
\49\ Robert E. Moffit, ``State Certificate-of-Need Laws Deserve a
Federal Response,'' Real Clear Health, January 10, 2022, https://
www.realclearhealth.com/articles/2022/01/10/state--certificate--o--
fneed--laws--deserve--a--Federal--response--111288.html (accessed
February 8, 2022).
Expand the Use of Telemedicine. Access to telemedicine can be
extremely beneficial for all populations, and especially those in rural
areas and older people or individuals with disabilities for whom it can
be more difficult to travel to appointments. Ongoing private
investments along with a recent $48 billion in Federal investments in
broadband services will greatly expand broadband access. Federal
lawmakers should provide parity of payments within Federal programs for
telehealth and in-person visits. And State lawmakers should remove
barriers that prevent healthcare practitioners in one State from
providing telehealth services to patients in another state.
Summary
The U.S. is experiencing a labor shortage unlike any before in U.S.
history, and the health care sector has been particularly hard-hit.
The Federal Government has limited availability to affect the
supply of the health care workforce and it should not be in the
business of directly training health care workers.
Ultimately, states control the entry gates to the health care
workforce. States need to eliminate unnecessary licensing and scope of
practice restrictions. Unless or until they do so, any
Federal funding aimed at expanding the health care workforce will
be of limited value.
Federal policymakers should immediately focus on removing barriers
that are contributing to the nationwide labor shortage, such as vaccine
mandates, welfare-without-work programs, and restrictions on
individuals' ability to work in the ways that work best for them.
Moreover, policymakers should refrain from enacting further massive
Federal spending bills that would artificially and unsustainably pump
up the demand for workers.
Within existing Federal funding and health care programs,
policymakers should enable greater flexibility to respond to America's
health care needs, and remove unnecessary burdens in Federal health
care programs that limit health care access and that prevent more
innovative and cost-effective care.
The Heritage Foundation is a public policy, research, and
educational organization recognized as exempt under section 501(c)(3)
of the Internal Revenue Code. It is privately supported and receives no
funds from any government at any level, nor does it perform any
government or other contract work.
The Heritage Foundation is the most broadly supported think tank in
the United States. During 2020, it had hundreds of thousands of
individual, foundation, and corporate supporters representing every
State in the U.S. Its 2020 operating income came from the following
sources:
Individuals--66 percent
Foundations--18 percent
Corporations--2 percent
Program revenue and other income--14 percent
The top five corporate givers provided The Heritage Foundation with
1 percent of its 2020 income. The Heritage Foundation's books are
audited annually by the national accounting firm of RSM US, LLP.
Members of The Heritage Foundation staff testify as individuals
discussing their own independent research. The views expressed are
their own and do not reflect an institutional position of The Heritage
Foundation or its board of trustees.
Employment Gaps by Gender, Presence of Children, and Age
Difference Between Actual Employment Levels and Counterfactual
Employment Trend,\1\ February 2020 To October 2021\2\
------------------------------------------------------------------------
Employment Gap, Employment Gap, Share of Total
Group Individuals Precentage Employment Gap
------------------------------------------------------------------------
All Workers -4,137,893 -2.6 percent 100 percent
------------------------------------------------------------------------
Men -1,996,801 -2.4 percent 48.3 percent
------------------------------------------------------------------------
Women -2,141,091 -2.9 percent 51.7 percent
------------------------------------------------------------------------
Workers with children -1,889,868 -3.8 percent 45.7 percent
------------------------------------------------------------------------
Workers without -2,248,024 -2.1 percent 54.3 percent
children
------------------------------------------------------------------------
Men with children -823,138 -3.2 percent 19.9 percent
under 18
------------------------------------------------------------------------
Women with children -1,066,730 -4.3 percent 25.8 percent
under 18
------------------------------------------------------------------------
Men without children -1,173,663 -2.1 percent 28.4 percent
under 18
------------------------------------------------------------------------
Women without -1,074,361 -2.1 percent 26.0 percent
children under 18
------------------------------------------------------------------------
Workers with children -1,490,634 -5.1 percent 36.0 percent
6 to 17, none
younger
------------------------------------------------------------------------
Workers with children -399,234 -1.9 percent 9.6 percent
under 6
------------------------------------------------------------------------
Men with children 6 -731,803 -5.1 percent 17.7 percent
to 17, none younger
------------------------------------------------------------------------
Women with children 6 -758,831 -5.2 percent 18.3 percent
to 17, none younger
------------------------------------------------------------------------
Men with children -91,335 -0.8 percent 2.2 percent
under 6
------------------------------------------------------------------------
Women with children -307,899 -3.1 percent 7.4 percent
under 6
------------------------------------------------------------------------
\1\ Counterfactual trend is based on a definition of steady-state
employment growth from the Federal Reserve, equal to monthly growth of
about 84.000 (0.053 percent)
\2\ SOURCE: Unpublished tabulations from the U.S. Bureau of Labor
Statistics' Current Population Survey. Data should be interpreted with
caution as they are based on small sample sizes
______
Senator Hickenlooper. Great. Thank you very much. Thank all
of you. I look forward to beginning the question. And I before
we get to that, I would like to turn the microphone over to the
Chair of the overall HELP Committee. This is the Subcommittee
on Employment and Workplace Safety. But Chair Murray is here,
so I would like her opening statement.
OPENING STATEMENT OF SENATOR MURRAY
The Chair. Thank you very much, Senator Hickenlooper, for
organizing this hearing to talk about how we can support our
health care workforce. And thank you to all of our witnesses
for offering your insights on this really important topic. The
discussion about how we can diversify our health care workforce
is so important to improving health care for communities of
color and increasing health equity.
I am really glad to be able to join for a few minutes today
and really highlight the challenges I have been hearing about
from health care workers in particular, something I know is a
big priority for all of us. I have heard from so many nurses
and doctors and other health care workers back in Washington
State about how hard this pandemic has been, and I know there
are similar stories across the country.
Health care workers have handled long hours, overcrowded
facilities, fighting a deadly new virus, often while receiving
low pay. They have worried about whether they have the
equipment they need, or whether they are safe at work, or would
get sick, or bring a deadly virus home to their family, and
whether they could make ends meet on the wages they were paid,
let alone if they had to stay home to care for themselves or
for a loved one.
They have had to patiently deal, and compassionately deal
with patients and family members who may have been afraid they
may never see their loved ones again, frustrated by steps
required to keep everyone safe, or even skeptical about the
threat of this virus due to misinformation and angry with
health care professionals who are just trying to help. They
have seen the pain of this pandemic up close and personal, and
it is taken a real toll.
Far too many health care workers have been killed by this
virus, and many more are dealing with the trauma, mental health
challenges, and burnout in its wake. That is why I pushed for
historic investments in the American Rescue Plan to further
support our health care workforce, including robust funding for
workplace safety and health protections from COVID-19, as well
as address some of the personal challenges facing these
workers.
This pandemic has really made it clearer than ever how
important it is that our health care workers are paid what they
deserve, that they have a voice in the decisions about how we
should recruit and train and retain health care workers, have
safe workplaces which are adequately stocked and staffed, and
are protected from infectious diseases and workplace violence.
We also need to make sure that all workers have paid leave
for when they need to care for themselves and their own
families so they can get mental health care when they need it
and can choose to join a union and collectively bargain for
better wages and working conditions.
After all they have done for our communities, we owe it to
our health care workers and everyone on the front lines of this
pandemic to listen to their experiences and respond to the
challenges they are dealing with. As we work to improve
recruiting, retaining, and training for health care workers,
one critical aspect of this is ensuring we improve the working
conditions.
I am glad we are having this discussion today on ways we
can support our health care workforce. And I am committed to
making sure we include health care workers in this important
conversation as it continues. And before I finish, I would just
like to know we will have letters I plan to submit for the
record and ask consent to do so.
Senator Hickenlooper. Without objection.
[The following information can be found on pages 59 through
85 in Additional Material:]
The Chair. Thank you, Mr. Chairman.
Senator Hickenlooper. Terrific, thank you very much. I know
we will start our questioning and I--my only guidance, I
usually instruct witnesses to keep your answers concise because
there is I think you will be amazed how many questions we have,
and we will get two more questions if we can be concise.
I realize I always hold that 45 seconds or 30 to 45 seconds
is a goal. I realize that is usually not always possible. Let
me start with Dr. Verret. Your university led the way in
producing students and alumni who excel in various health
professions. In particular, the Xavier is focused on intensive
faculty advising, academic research centers, and co-curricular
programs appears to have been critical to the success exhibited
by your--achieved by your students.
I mean, this is a clearly a successful model. Xavier has
been consistently for a number of years the No. 1 university
and as a source for African-American students who go on to
become doctors. Now you described certain additional
investments that the Federal Government could make.
How else at the Federal level can we replicate, I mean,
really tried to take the success that you have achieved with
Xavier's programs and replicate it in schools across the
country?
Mr. Verret. Well, I would say that--to begin first is that
clearly what we do in the pipelines before, in the pre-
collegiate experience is an important piece. I would add that.
Because what are--in preparing students who may not be aware of
the access, the opportunities themselves because in many cases
they have not--they are only hearing of college toward the end
of their high school years.
It is a crucial piece in getting that type of pipeline. The
other piece is that we also--it is important that we help
students discover their weaknesses, because all students come
with weaknesses, early in the education, so that what we do in
providing academic support is first in the discovery process
for students to discover what they know, where they are strong
and where they are weak, and what support they would need.
The other piece that is a difficult one to replicate easily
is actually the intentionality of forming a faculty that is
committed to that kind of work. And how the faculty reflect--is
committed to actually recognizing that not all students come
with the education that they fully deserve. Not--most children
do not choose the schools that they attend, at least not yet,
in this country.
Students come with different--with different deficits. And
the important thing is that deficit does not mean a lack of
talent, ability. It is important that we remedy those deficits
early in the experience, not later. It is important because
what we discover in the first or second year, we can repair. In
the third or fourth year is more difficult.
It is important that we confront that, and I use the
expression of one of our students in understanding that even
though they may complain that the faculty--of the staff or
other things at Xavier, they will say that the faculty has our
back because they know that commitment and that, and faculty
committed is an important element.
Senator Hickenlooper. Excellent. And I just learned last
week that the College Board, now known--is not just AP,
advanced placement tests that they give, there are enough high
schools all across the country recognizing the need for health
care professionals that they are going to have an AC test so
kids in high school will have it, it will be an advanced career
opportunity and allow them to get some recognition and credit
for taking these early, and during high school preparations for
a health care career.
Dr. Flinter, during the COVID-19 pandemic, obviously
burnout reached an apex. Millions of workers are reevaluating
what they value in their job or their career. I mean, even
before the pandemic, burnout in the health care workers was a
major challenge given the nature of the work, the intensity.
Dr. Flinter, how can upskilling opportunities like nurse
practitioner training programs help reduce burnout and address
long term retention among the health care workers?
Ms. Flinter. Well, thank you for the question. And let me
say it was our honor to serve in the COVID pandemic.
I think in my organization, we often felt like we were on
the frontlines of a battle, unlike anything we had ever seen,
and whether we were outside in the freezing cold or the burning
heat of July, people were very grateful to serve and to make a
contribution through first testing and then vaccine.
But the work is very difficult, inherently. People sign up
for the difficult work of health care, right to meet humanity
sometimes at its most vulnerable moments, and to also work to
keep them well. If in addition to that, you don't have the
skills to provide the level of care that is needed by the
population you care for, and again, I speak to our safety net
settings in our rural areas where primary care is where
everybody comes, they don't go off to a specialist on the first
pass, you significantly increase the difficulty.
If you don't have behavioral health clinicians as part of
your primary care team, you significantly increase that
difficulty. If you don't have the MAs who can help manage and
make automatic, what should be automatic in prevention and
screening, you increase the difficulties.
Training is a big piece of it, making sure that we have the
whole team and not just part of the team to have the most
effective primary care, I think is another piece. And then the
third, of course, is its every organization's responsibility to
ensure that they are providing both the safe workforce, as
Senator Murray alluded, but also providing the ongoing
training.
We participate in the NIMAA program. We welcome students,
more than 200 a year, from all the disciplines and all the
health care institutions in Connecticut to make sure that we
are building that pipeline that can continue to increase that
skill level.
Senator Hickenlooper. Great. Thank you very much. I have
more questions and hopefully we will have time for a second
round. If not, I will make sure I submit them in writing. I now
turn over to Senator Braun for his questions.
Senator Braun. Thank you, Mr. Chairman. Touched on it
earlier in my opening statement that I feel a lot of what we
are navigating through currently addressing COVID, it was a
feisty foe. None of us knew much about it. I know in my own
company which in discussing what we were going to do when I
touched base weekly, it was about treating it with respect.
It was about doing those things that we all know now that
the science is saying what did work and what didn't work. And
so often you get the political science involved in the
discussion and it keeps us off the mark. I was going to ask Ms.
Greszler about vaccine mandates. I led the charge in the Senate
with the Congressional Review Act about why that didn't make
sense.
Life is not fixed ever from the top down. It would be
different if we were knocking it out of the park here at the
Federal level. And in my 3 years, I have so many people come
here wanting more of it, heard some from the panel that we need
to spend more money.
The reality check is we borrow almost 25 percent of
everything that we spend here, and that is up close to 30
percent. It is a bad business plan to probably look for more of
that. I agree, on the other hand, that these are real issues.
But do we keep shoveling more into a broken system or do we
take a more entrepreneurial, a different approach?
The results say do something different. It is 20 percent of
our GDP. It is 10 percent elsewhere. Ms. , you, tell me what
you think about vaccine mandates. That was going to be my first
question. Being an economist--my degree was in economics after
I thought I was going to be a biology major. And when I found
out it took 9 years to become a surgeon, I didn't get into the
field.
That is part of the issue too, how long it takes, how
costly it is for practitioners, for doctors on the firing line.
How much of what we struggle with is due to the fact that I am
a one of a lonely voice of Republicans that says the industry
itself, no competition, no transparency, it is a business of
remediation not prevention, increasingly dominated by large
corporations that do not want to do the things that before you
start throwing more Federal dollars at it, how do you fix the
system itself?
Is the health care industry broken in the fact that it
doesn't embrace competition, transparency, all kinds of
barriers to entry, not to mention that we have a health care
consumer that really isn't interested in her or his own well-
being other than fix it when it is broke?
Ms. Greszler. Yes, let me start there with the immediate--
and you mentioned the vaccine mandates, and that is where I
think that you know what it is like as an employer. The medical
facilities that are out there know the needs of their
communities, they know the needs of their workers, and they are
the ones that are better able to make the decision to balance
the safety needs and the needs of actually having people there
to treat their patients that come in.
That is why the decisions need to be made there. And we
have seen in places that have implemented these mandates,
having to lay off up to 2 percent of their workforce. That is
an enormous number if you multiply that across potentially 14
million workers. And the particular problem is for more rural
areas. I know a lot of you are from rural areas and those are
smaller facilities.
If they lose 2 percent of their workforce, that is really
difficult for them. I know I had a family member myself that
had a pediatric emergency and was told, you need to travel to
another State 160 miles away to that hospital because the
nearby Children is Hospital is having shortage because of the
vaccine mandates.
That is an immediate problem, but there are many long
standing issues here. Ultimately, the States are the
gatekeepers of who gets to practice medicine within their
State. And so a lot of it comes down to that. And certainly, it
doesn't make sense to be throwing Federal money at a gate that
is not going to be opened up. We have seen more than $10
billion invested recently.
I think it will take time to--for that money to play out.
You can't increase the workforce overnight. And so we need to
wait and see what happens there. But there are also things
immediately that don't even cost any money, just removing those
regulatory burdens that are out there. Part of the burnout
issue is you want to have more time----
Senator Braun. Ms. Greszler, before we run out of time, and
I will come back and ask it again, removing regulations, all of
that. What about the industry itself? You are an economist.
Does it embrace competition, transparency, and does it have
barriers to entry? Give me your quick kind of pass on that, and
if I need more, I will ask it on a second round.
Ms. Greszler. Yes, there are absolutely barriers to entry
out there, and there are interests that are fighting against
the competition that could lower costs and that could improve
the quality of care. And part of that has to do with, I would
say, an excessive level of Federal money and Federal rules and
regulations that kind of dictate the system.
Senator Braun. Thank you.
Senator Hickenlooper. Thank you.
Alright, Senator Baldwin.
Senator Baldwin. Thank you, Chair Hickenlooper. Thank you,
panelists, for your testimony today. I really appreciate your
focus on this critical issue. Certainly what you have been
discussing as a parent in the State of Wisconsin, in my
discussions with health care leaders and advocacy groups for
the health professions.
One thing I want to hear thoughts about is it in terms of
preparation, especially in nursing. We have an urgent nursing
shortage in the State of Wisconsin, in hospital settings, in
clinical settings, in nursing home settings.
Although at the same time, there are eligible students who
are turned away from potential training because of the shortage
of nursing faculty. And the aging of that workforce only
suggests it is going to get worse rather than better. I wonder
if Dr. Flinter and Dr. Verret, if you could both speak to those
issues as you see them.
Ms. Flinter. Excuse me. Thank you for the question. I think
it is multi factorial, right, in terms of the issue. Certainly
of the aging of the nursing workforce, including faculty, maybe
one that is also a compression, often in clinical training
sites.
That is part of why I think nationally, community health
centers have really tried to step forward and say, remember,
training in primary care is very critical for our ends as well
and really stepped forward to welcome more students, and that
is one way we contribute in that setting to it.
Beyond that, we need to recognize that nursing is a broad
profession, and that people may find their place where they can
make the greatest contribution as faculty people, they may find
it in private settings, they may find it in our safety net
settings and to support people and having opportunities for
really good preparation for those roles at the graduate level,
as well as at the entry practice level.
We have just initiated a program with universities in
Connecticut to make sure that their fourth year students
actually have a capstone experience in a high-performing
community health center to remind them that is an option as
well. And we need to emphasize all of those pathways, research,
practice, education.
Mr. Verret. I would just want to add--I would just want to
add that also we have, as Dr. Flinter mentioned, there are many
factors, the shortage on the number of nursing programs,
faculty and all that drives the issue. But also the other
factor is the pipeline of students.
That we have--the number of barriers to students,
especially our students who are of modest means, who are making
decisions based upon, can I afford it? Can my family afford it?
What is the impact and how we actually create pathways where
the barriers are not as high to access those fields because
there is a lot of talent in our second, third, fourth and fifth
grades? But I don't think we have also all the talent that we
have on the table as a Nation.
Senator Baldwin. We have been talking a lot about primary
care, but the complexity, Dr. Flinter, of primary care, it
doesn't suggest necessarily a healthy population, etcetera. I
have been focusing in on some of the urgent shortage issues,
whether it is the infectious disease area of practice or the
palliative and hospice care workforce or the perinatal
workforce.
I wonder if you can talk about why it is important to fully
build out the workforce and training pipeline when we think
about shortages in these areas. And then Dr. Verret, if you can
speak to particularly the necessity for a diverse workforce in
all of these areas, but I think so strongly about the perinatal
workforce.
I am involved in the Perinatal Workforce Act because even
before the pandemic, black women in Wisconsin faced
significantly higher rates of maternal complications and deaths
than white women.
The Perinatal Workforce Act, which I sponsored with my
colleague, Congresswoman Gwen Moore, to improve access to
maternity care and grow diversity of the perinatal workforce,
it is--this is critical to addressing some of the staggering
maternal health inequities that we face as a country. So if you
could start, Dr. Flinter.
Ms. Flinter. I will, and I want to thank you for your
comments about the critical issue of maternal infant morbidity
and mortality. And I want to tell you that is front and center,
I think, of all of our efforts wherever we are. You know, when
it comes to the specialties and the pipeline, every specialty
is critical.
You speak to your passion of speaking to primary care
today. But we could not do what we do without those specialties
when the time comes. I think the most effective thing we can do
in primary care is to make sure that we are practicing to the
maximum competence that we can within primary care and then
sending on the people that really need that specialist.
If I may, one innovation that has been proven to reduce
costs overall and to increase access and improve outcomes, is
something called an e-consult. And we are used to in safety net
settings in particular, you would wait months, months to get an
appointment with an endocrinologist, with an allergist of just
about any kind.
We developed a model, we call it e-consults now through a
group called ComfortMed, where we can get, a primary care
provider can get an excellent, in-depth consultation within 2
days and decide. And then it turns out about 75 percent of the
time they don't need to follow-up in person. They can give
guidance to the primary care provider.
That means there is room in that specialist practice to see
the people who really need to be seen, and I think that is
absolutely critical. I know others that may decide what those
numbers are, how many in each specialty. We need the right care
from the right people at the right time.
I think that is part of avoiding the kind of excess cost
that people talk about. You need to see the right person at the
right time. HIV used to be a disease of specialists. We trained
all of our primary care providers to be HIV specialists, just
as an example.
Mr. Verret. What I would add to the diversity question, why
diversity? I would first begin by that it does create an
essential element of trust in the health care system, that is a
barrier. It is not so much about having a physician--it is not
so much about having your physician as the someone of the same
sex, race, ethnicity as you are.
But the presence within the health care system of people
who resemble you creates trust in the system and that is one
social factor. And as we mention in medicine often, the social
factors are as important as the technical and clinical factors
as well.
The other piece that I would say is that we have to
actually understand that our most precious resource as a
Nation, as any nation, are our children and the brains that
they have, and that we have in the last 100 years that we have
dependent upon assuming that we could rely upon only a fraction
of the resource of our population for talent.
We do know that there is genius that is available to us,
whether it is in architecture, construction, in medicine, or in
science or wherever. That by not educating students who
actually can become and aspire to join us in many of the
professions we need, teaching, nursing, medicine wherever, we
are driving this workforce shortage that we have--the talent
need.
I would even elevate the talk to talk to a high question
that if the U.S., like any nation, aspires to lead
internationally, globally on any dimensions as economically,
from a geopolitical point of view, it needs to have the brains
that--it needs to cultivate its own brains. And that begins in
K-through-12.
We have to funnel them to whatever level of education
allows for them to refine those skills. And that is where we
are seeing in health care that we need that presence, but we
need those numbers. Those numbers are scary because as you and
I are all getting old, we will need care, and that care may not
be there.
Senator Hickenlooper. Thank you.
Now, I will turn it over to Senator Tuberville.
Senator Tuberville. Thank you, Mr. Chair. Thank you very
much. Thanks for being here. I continue to hear from hospitals
in my home State of Alabama that our nursing shortage has
reached a State of emergency. We have so few nurses to go
around that hospitals have resorted to contracting with nurse
staffing agencies to fill empty slots.
These agencies pair nurses who are willing to travel with
hospitals facing large vacancies, and in many cases, they fill
a very important need. I am concerned, however, that these
agencies might be taking advantage of a very dangerous
situation. They are able to charge a high percentage cut for
their services, and hospitals have no choice but to pay their
prices. It is huge in our State of Alabama.
I want to be clear, nurses with the backbone of our health
care system and they have been on the front line heroes, our
frontline heroes throughout COVID-19 pandemic. Every nurse
should have the right to take the high salary available. I do
not want my question to be interpreted as undervaluing nurses
worth in our health care system, but I am concerned, however,
that these staffing agencies might be exploiting are already
overwhelmed health care system.
I would like for all four of you to say something about
this briefly. This question is for everybody. What do we
currently know about these agencies, and the cut they get from
our lucrative contracts with struggling hospitals, and what can
be done to address this issue?
Ms. Greszler. I will start. I don't know a lot about the
agencies themselves, but the fact that so many are going to
those agencies and needing that, and two things there is just
the burdens that are placed on the nurses and those burdens
were increased because of COVID-19, and some of them were
necessary, some of them weren't and a lot of underlying things
before them were, and so how can we reduce the amount of time
that nurses and the doctors need to spend on needless paperwork
and regulatory burdens so that they can have more time to be
treating patients.
That effectively gives you more workers because it is more
worker time. And then also just addressing the State laws so
that you can, the demand can go where it is needed most, and we
don't have those barriers that are needlessly preventing people
from practicing where they should be.
Senator Tuberville. Thank you.
Ms. Quinones. I am sorry, I don't know enough about
nursing. That is out of my scope where I work, so I have no
comment.
Senator Tuberville. Thank you.
Mr. Verret. I too don't know much about the agencies, but I
am aware of--but there is, we have effectively a shortage of
nurses. And so there is a supply issue, but also clearly it is
becoming a compensation issue for many of our hospitals as
well, how we compensate them will be an issue. But clearly that
problem has to do with basically a shortage of nurses that
hospitals are competing among themselves for nurses, even
within the same city.
Senator Tuberville. Thank you.
Ms. Flinter. Thank you, Senator. May I say I just had a
chance to visit Cahaba Medical Care in Alabama and a nurse
practitioner residency program. There, you all are doing a
great job down there and meeting the needs of your rural
population. You know, the travel agencies have always been with
us, I think, for decades so this is not new. I think they
fulfill a certain role most of the time.
There is a portion of people who like that lifestyle.
Wouldn't work for me as a nurse, but they like the lifestyle of
traveling to different organizations, and they play probably a
vital role when, not in COVID times in the same way, when there
is a shortage of people in one area or another of a hospital.
Where we have an issue, where I have an issue is when we are
losing valuable experienced nurses from positions because that
position is no longer attenable. And often that position is no
longer attenable because it is been understaffed for a long
time or under-resourced and people are just frustrated.
I think the issue is to support our host organizations and
making the environment for nursing practice, whether that is
thinking about the patient workload so you can give safe care,
the other people on team to make that organization a place that
nurses want to commit to and stay. I don't think people lightly
give up a satisfying practice as a nurse to do travel nursing.
But I think the travel agencies also play some role on an
ongoing basis. Again, COVID threw everything to the wind. State
policy, I think, can sometimes aggravate or help this.
I will say my State of Connecticut took broad action to
credential a whole group of people is what they called Tier 2
vaccinators during the COVID pandemic in order to not have to
rely only on nurses or physicians, PAs to give vaccines.
Our dentists, our dental hygienist, podiatrists were able
to come and get trained and get an additional certification. So
we need to, I think, always look at these things from a variety
of perspectives. But the core is to make practice satisfying
where nurses are in their communities, I think.
Senator Tuberville. Thank you very much. Thank you.
Senator Hickenlooper. That was an instructive row of
answers to a good question. Now, and I am sure you are aware--I
should have said this earlier. We do have this virtual hearing,
it is a bilateral hearing, so we have now Senator Rosen from
Nevada on virtual. So, she is next.
Senator Rosen. Well, thank you, Chair Hickenlooper, and of
course, Ranking Member Braun for holding this really important
to me hearing today. And of course, the witnesses, for
everything you do and for being here with us. And of course, it
is so important that we lower those barriers for providers.
We all know that because health care providers with
advanced training, such as physicians or some of you just
mentioned dentists, they have to complete residency trainings
in order to care for patients. They often exit the training
with significant student loan debt. The debt is made far worse
by the fact that interest accrues while they are still in
residency training. They are not actually in practice.
That creates additional financial barriers for providers
otherwise interested in serving patients in rural areas or
underserved areas, of course, all across this country. All 17
counties in Nevada, unfortunately, are designated as health
professional shortage areas, and our health outcomes are
especially likely to be worse among rural and minority
residents than those in more urban centers.
In order to improve health outcomes, to address our
Nation's doctor shortage, we have to do more not only to
encourage providers to serve in rural and underserved
communities, but also to reduce those existing barriers. And
that is why I am working on bipartisan legislation with Senator
Boozman that would allow medical and dental residents interest
free deferment on their student loans while serving medical,
dental, internship or residency programs Dr. Flinter, someone
who found America's first nurse practitioner residency program,
how could pausing student loan interest accruing during
residency help provide flexibility for providers who opt to
serve patients in rural and underserved areas?
What other incentives do you think the Federal Government
should be looking at to make it easier for us to get the really
good quality health care we need all across this Nation?
Ms. Flinter. Well, thank you for that question. I will tell
you that facing that mountain of debt, as you are coming into
your residency program, those mandatory payments, is a daunting
challenge for providers who are still in their training phase.
I think that what you have proposed, Senator Rosen, pausing
student loan interest accrual during residency is what I would
call a very pragmatic, reasonable thing that probably makes a
big difference for people. I think the issue is that debt
influences people is choice of where they are going to
practice, as you have used the example of the State of Nevada,
so I think that is a very pragmatic and useful idea.
I want to point out that is part of a constellation of
strategies that we have here in the United States that all
could be expanded to make it easier for people to tackle the
training and then to choose the practice setting based on where
they want to serve and where their passion is.
I will tell you that when I was an undergraduate student
earning my Bachelor's degree in nursing long time ago, I worked
off my student loans through a Federal loan repayment program
as a rural public health nurse.
When I chose to go back to the school, to the Yale School
of Nursing and become a nurse practitioner, I was fortunate
enough to be taken into the National Health Service Corps,
which had an obligated period of service afterwards. They sent
me to what was then a small community health center that
Senator Hickenlooper knows on Main Street in Middletown.
I think 47 years of practice is a pretty good return on the
Federal Government's investment in those loans. This is what we
see in my own organization. There are many people with decades
of experience who started in community health service in
underserved areas because they had help from something like
Federal loan repayment or the National Health Service Corps. So
this would be one more tool, I think, in the toolkit to help
people.
Senator Rosen. Well, that is great, because I want to build
on exactly this because we not only have this area of just in
overall physicians and dentists, nurse practitioners, and the
like.
We have, especially in my State, shortage of certain
medical specialties. And so we have our urban, our underserved
communities, and particularly our rural, our far frontier
communities, they have to go with that specialty care at all.
And so I am currently working on some legislation to create a
loan forgiveness program for specialists who care for patients
in rural areas.
Can you speak about maybe the challenges that primary care
providers have in trying to bring specialists either in-person,
maybe even virtually through telehealth? We have to ask people
to refer them to. And what do you think we can do to help with
that and just building on what you said before.
Ms. Flinter. Great. Well, thank you. I think a few months
ago, I addressed the issue of what we can do with e-consult
access from primary care to specialists so that which can be
done by primary care, often in consultation with the
specialist, so not the specialists necessarily directly seeing
the patient, is a very important piece of that.
We have done the research on that. It is clear that is now
becoming a national best practice. And the people seeing the
specialist are the people who really need to see the
specialists and others can be done in management between
specialists and primary care providers. Telehealth has
certainly been a huge benefit to us, I think we would say.
It certainly is true of rural areas, but even in urban
areas, I think we have all seen how difficult it can be to
connect primary care providers and specialists. And how much
additional double work you can eliminate if you can connect
with people virtually as opposed to in-person. But beyond that,
we need the training programs. We need the training programs
for our specialists.
They should have experience in caring for people in rural
and underserved communities and for care and for all
populations. One of the things that we know about training, and
I think Dr. Verret would agree with me, that where you train
has an awful lot to do with where you practice. If you can even
have a part of your training experience in a rural area, in
underserved communities with underserved populations, there is
a much greater chance, I think we call it imprinting, and you
are continuing to care for that population and remaining in
that area.
Like everything we are talking about today, there is not
one strategy that is an answer. There are multiple strategies,
and we need to embrace all of them. Technically, in terms of
training, in terms of financial support for trainees, and in
making sure that we get the right people to the right kind of
provider at the right time.
Senator Rosen. Well, I couldn't agree more. Addressing the
medical workforce shortage across the spectrum, having a broad,
good strong broadband base to potentiate care through
telehealth and qualified professionals all along the way, all
of it makes a difference.
All of that matters, and I am trying to work on and getting
us all there. So appreciate you all for being here today. Thank
you, Mr. Chair. I see my time is up.
Ms. Flinter. Thank you.
Senator Hickenlooper. Thank you, Senator Rosen.
Senator Cassidy.
Senator Cassidy. Yes. Dr. Flinter, you call it imprinting,
I call it marrying a local.
[Laughter.]
Ms. Flinter. That works, too, I guess.
Senator Cassidy. As a man, it is my observation that men
live where either Uncle Sam or the wife tells them to, and so
that is mine. I rarely start off with a personal anecdote, but
I am today because it is something that is so powerful in my
experience, in my professional life. As many of you may know, I
am a physician who works in a public hospital for the uninsured
for over 25 years or about 25 years.
There is a woman who happened to be African-American. Her
nickname was Olive. She started off as an LPN, or maybe even a
medical assistant, went back to school, single mom, went back
to school part time, became, say the LPN. Went back to school
and continued to education and became an RN. Kept going back to
school and then got her master is in nursing. And when the
nurse supervisor of the clinic retired Olive took her place.
Now one, it is a great success story for her personally,
but it demonstrates to her children and a community the power
of education, aside from giving us a crackerjack nursing
supervisor. And so although I have not seen Olive since her
hospital was literally blown up, that is the kind of facility
it was, you just discarded it, she did an incredible job taking
care of patients who otherwise would not have received such
good care.
That said, I am heartily in favor of creating this
opportunity for folks who perhaps would be the first in their
family, first generation in their family to go to school. But
there is other issues that separate. Dr. Verret, I am the
author of the John Lewis National Institute for Minority
Health, Research and Endowment Revitalization Act that would
revitalize the Research and Endowment Program or the REP at the
National Institute on Minority Health and Health Disparities.
The REP was established to assist minority serving
institutions with low endowments to develop institutional
capacity to successfully compete for NIH funding with their
well-endowed, non-minority school counterparts. Now, Xavier
College of Pharmacy has been a beneficiary of this program.
Can you talk about the challenges that universities like
Xavier face in trying to be more competitive for Federal
research dollars, and why revitalizing this program would be
important to Xavier, to others, and to our nation?
Mr. Verret. Well, that endowment program, I think which was
paused some years ago, as for schools like Xavier, is the
resource by which we build out the quality--bring the quality
of faculty that our students need to encounter, but also
facilities and in order to be competitive as research----
Senator Cassidy. So the facilities are as important as the
faculty?
Mr. Verret. As important as the faculty. Because one needs
laboratories. One needs the equipment. For example, as was
mentioned of putting a testing facility for HIV means that you
have to have the thermal cyclers. But that the equipment and
also--and the faculty.
That is faculty, for example, who are researchers in a
variety of areas, have to be able to set up laboratories or
their computer systems for the work they do. So that one needs
to be able to compete and place those faculty with those
students. And also understanding that the research that we do
at schools like Xavier is not separate from the instructional
program.
Our students enter as researchers with faculty in their
research programs early as undergraduates in their second year.
Likewise, it is about doing the practicing on the discipline.
Our students do not only learn as biologists or learn as
chemists, they become--they do chemistry the same way they do
history, the way our musicians do music as well.
That research--because that is different between the
higher-ed and what we call secondary school.
Senator Cassidy. I think it is safe to say the role model
of somebody who is successfully doing research can inspire. I
have a professor that inspired me to become a hepatology, just
a liver specialist, because of a couple of them. Between the
two of them, they were so remarkable, I wanted to be like them.
Mr. Verret. One becomes a junior colleague, as a
researcher. And so that experience, and also it readies them
for whether they go into professional school or whether they go
into a PhD program. It is amazing that some of these students
were actually following into the MDP speed track also.
Our pharmacy students also who are pharmacists who are not
only going into the retail sector as was traditional for many
pharmacists, who are taking the higher status of the pharm D
and becoming part of the clinical sector or managing the
therapeutics or the chemotherapy programs in some hospitals.
They are being taught to practice at the highest level of
their license.
Senator Cassidy. Yes. And of course, been a springboard. I
mentioned to you earlier, a family friend, Dr. Holden,
originally went to Xavier Pharmacy School from Missouri, but
that was when educational opportunity was not available for
African-Americans. And after going to Xavier Pharmacy School, I
went to DO school in California and practiced in California, a
large pediatric practice in South Central, L.A., and changed a
lot of lives that way. Thank you for your mission. I yield.
Senator Hickenlooper. Thank you, Senator Cassidy. I think
we have time to--we are going to, Senator Braun is going to be
back in the second to do a, let's call it a lightning round.
No, I guess that is inappropriate. But I do, I think we do have
a few more questions. Ms. Quinones, I was going to ask the
projections we have been hearing from everybody about the
critical need to start growing our health care workforce,
yesterday.
Obviously, the key there is to do it now, and we need to
make it easier for those who don't have any experience to break
into the field instead of creating barriers and making it
possible to expand the workforce. We have heard a variety of
people mention that over this last hour and a half. So you have
unique experience because you came in as an entry level
assistant in Clinica, to kind of begin your career in nursing.
What were some of your experiences and what are some things
you think might be applicable, could be useful to other
institutions, other health care providers that are looking to
expand their workforce and provide, become a conduit for people
coming into the profession?
Ms. Quinones. Yes, thank you for the question. So one of
the unique situations at Clinica is that I recruit within our
organization, because No. 1, somebody already has made the
decision that this employee is a fit for Clinica. And the other
thing that we focus on is development and growth within our
system. And so we recruit within Clinica, go through the
process of the NIMAA program, and I facilitate and coach them
and be a--how do I want to say, a connection between Clinica
and NIMAA.
This is the way that we really grow our own. They are
already--they are already in the system, they know our culture,
they know our mission. And so we have found out through other
conversation is that this model really works for us because the
commitment is already there from our staff.
They go through their training and upon graduation--they
are already trained, I would say greater than 85 percent. So as
soon as they graduate, they pass their MA exam, they are ready
to start working as soon as they complete the 8 month program
through NIMAA. And so that is a huge benefit for our MA staff
and nursing staff as well, because one thing that we encourage
at Clinica is to work at the top of your license.
This is a way that the medical assistants that have been
working with Clinica for a while can support providers, nurses,
and continue on.
Senator Hickenlooper. Interesting. Interesting. Dr. Verret,
you mentioned a little bit about the reaching out to high
school students in the summer--was it Summer Science Academy,
the Xavier Summer Science Academy, it is five 500 kids, to
participate in, it sounds like a cross-section of sciences,
biology, and math, yes let's call it STEM. How do you get, how
do you reach out to find those students in the high school
network? Are they from--all from within Louisiana or are they
from around the country?
Mr. Verret. The majority are from within Louisiana, but
some come from around the country, a significant number,
because we have a long history. The graduates of the program to
a high number of go on to college. Many of them do not go to
Xavier, but they go to other colleges, to us a success. It is
what I call our external mission.
Funding that has been a challenge because we fund that on
dollars that we have all from foundation dollars when we can.
But because those are not accessible through any funding
program that we normally have. That is one pipeline of getting
students early in their education to consider the science and
to be exposed to that.
We also--what we also do is even weekend academies. For
example, the robotics academy that is done, a work that is done
on weekends, is one way of capturing the imagination of young
people. I like to make the point that, if we remember that for
science and health, it is not like music that students develop,
discover their passions very early in life before high school,
or they are not musicians or decided great musicians at the age
of 18 or 19.
I say the same for sciences and also clinicians as well. So
catching them even before high school is fundamental so that it
is about getting that imagination and seeing that I can be, and
this is a possible pathway. Role models are important. Seeing
older students who are not only maybe three or 4 years older or
and at it is important.
That is--especially given if you are coming from families
when college is a new thing, that no one in this family has
ever attended college, which is a large--we are, in our
campuses, it is in the high 30, 40, 50 percent of students.
Senator Hickenlooper. Wow, that is amazing. Alright. So
thank you.
With that, I will turn it over to Senator Braun.
Senator Braun. Thank you, Mr. Chairman. I am going to
circle back to the structure of the industry again, and my
question is going to be for Dr. Flinter. Years ago, we had a
lot more hospitals, especially in rural areas. Currently, when
you look at the health care dollar, 30 percent give or take
hospitals, 30 percent give or take practitioners, 15 to 20
percent pharma and then insurance.
As these stakeholder that pays all the bills in the
country, meaning any company that does not, is other than a
health care company, it would be the rest of us employers. And
in the transparency issue, even when you can self-insure, has
been challenging.
The other thing is you have fewer options. You get fewer
and fewer hospitals that control a lot of these markets and
even fewer insurance companies. Getting workforce into the
nursing side of it, how difficult is it now when it comes to
the fact that you end up, unless you have a clinic or you are
doing your own thing, which oftentimes are rules and
regulations don't make that as easy it should be, how difficult
is it to be a nurse practitioner, not only with the training
and the cost of that you are talking about, but in terms of the
new structure with the fact that you are working for a
hospital.
Doctors complain about that often. They used to have their
own businesses. Would you want to comment on that a little bit?
Ms. Flinter. Sure. Well, thanks for the opportunity. And it
is actually something I have been thinking about quite a bit
recently, in part because there is a whole area within nurse
practitioner practice of nurse practitioners who are going into
entrepreneurial practice on their own, and there is a network
set up to support them.
What it reminded me is, and there probably is a right place
for everybody, right. For me, the right place is a structure
like a community health center. Takes all comers regardless of
insurance, comprehensive care. There is a tradeoff around how
much you do individually and how much is organizational policy,
but if the organizational policies line up in the direction of
the values that it should, that is a plus, not a minus for me.
For other people, being an independent entrepreneur or a
group nurse practitioner practice, for instance, is the right
structure for them. I think people really have to think very
critically about their employer, and the right employer is an
employer who lines up with your mission, vision, and values for
your own career.
I think people are becoming much more savvy about the kind
of people, the kind of organization, the kind of structure that
they want to practice in, and employers beware. No matter how
big your health system is, you cannot run it without expert
people to care for the patients in it. The emerging legislation
around transparency and billing, about no surprise billing--we
are in community health centers, our patients are the most
savvy consumers of all because they are often paying out of
pocket as people who are fully uninsured.
This is just a part of a fairer economy in which we make it
clear what those prices are. We make sure that people
understand what the deal is, and I think that is true for the
people who work in them, as well as the people who receive
care.
Senator Braun. Thank you. Next question for Ms. Greszler.
Indiana visited last week, and I was shocked that it was only
the second one in the U.S., the other one is in Oklahoma City,
and this is a group of surgeons that didn't like the idea that
their only employment opportunity is now for a huge
corporation. They had a vision of having their own shingle hung
out there and increasingly difficult to do. Here is what caught
me.
They are going to be a cash only surgical outpatient
center. I said, what about inpatient? Oh, there are so many
regulations. If doctors wanting to do that, you couldn't even
get the first base. Listen to this on a gallbladder operation,
in Indiana, to negotiated rate between insurance companies and
hospitals, $22,000.
If you come into the system and you just need it, you have
no insurance, $32,000. They will do it for $8,000. And that is
going to be the same proportionality on a lot of other surgical
procedures. That is entrepreneurism. That is what we have got
to do before we start spending more Federal dollars in terms of
fixing the system.
What do you think when it comes to that kind of breaking
the system apart, how important is that to fix health care in
general?
Ms. Greszler. I think that is extremely important because
as far as I know, the studies have shown that those smaller
practices actually have better outcomes. And there is a lot of
broken parts of the health care market, but this is one of them
where the prices that are charged don't necessarily reflect the
services that were provided, the outcome of those services, the
amount of time, but they instead reflect insurance codes that
they are allowed to bill.
It is in many ways broken. One thing that could be done is
the Federal Government has a lot of programs, they are in
charge of payment rates there, to allow for some innovation and
flexibility in those ones. We have seen that doctors and other
practitioners, they want to move toward having more autonomy
and not just having to go by the books of what they are told
they can charge and what services they can and can't provide.
But just being free to practice is, others are in the
private sector not encumbered by all these burdens that are
imposed on the health care sector.
Senator Braun. I think it is a good point. Yours as well. I
view practitioners and doctors about the same way as farmers in
big Ag. It is so much different from what it used to be. And
whenever we get industries that get too concentrated, the
consumer never ends up being in the best place.
Senator Hickenlooper. On that note, although I think
Senator Braun and I could probably spend the next couple of
hours asking you questions, but I suspect you have other
schedules, other things in your schedule. So I guess I will end
our hearing for today. Let me just thank you all, Dr. Flitter,
Ms. Quinones, Dr. Verret, Ms. Greszler.
I can't remember a more interesting panel and with such
clear translation of your experiences in your lives into, I
think, really valuable testimony that we will take going
forward.
If there are other Senators who are watching at home and
have questions or watching from their office, I shouldn't make
jokes about virtual hearings, questions for the record will be
due in 10 business days, so that is on February 24th at 5 p.m.
The hearing record will also remain open until then for
Members who wish to submit additional materials for the record.
The HELP Committee will next meet, well actually shortly, in
room S-127 at noon to mark up several pending nominations, and
then again on Tuesday, February 15th at 10 a.m. for a hearing
on supporting quality workforce development opportunities and
innovation to address barriers to employment.
Thank you again for all your excellent work today. We stand
adjourned.
ADDITIONAL MATERIAL
american ambulance association
Chairman Hickenlooper, Ranking Member Braun, and Members of the
Subcommittee on Employment and Workplace Safety, the American Ambulance
Association (AAA) commends the Subcommittee for holding this critical
hearing on healthcare workforce shortage issues. Our country's
emergency medical services (EMS) system is facing crippling staffing
challenges that threaten the provision of crucial emergency healthcare
services at a time of maximum need. As we face a pandemic that waxes
and wanes but does not end, our 9-1-1 infrastructure is at risk due to
these severe workforce shortages. The Congress must act if we are to
prevent vital ground ambulance services from disappearing in rural and
underserved urban areas and from the country as a whole, which is
experiencing longer and longer wait times for 9-1-1 services. We
outline some potential congressional actions to address this crisis
below.
The AAA is the primary association for ground ambulance service
suppliers/providers, including private for-profit, private not-for-
profit, governmental entities, volunteer services, and hospital-based
ambulance services. Our members provide emergency and non-emergency
medical transportation services to more than 75 percent of the U.S.
population. AAA members serve patients in all 50 states and provide
services in urban, rural, and super-rural areas.
Our paramedics and emergency medical technicians (EMTs), as well as
the organizations they serve, take on substantial risk every day to
treat and transport patients who call 9-1-1. Our industry's crippling
workforce shortage is a long-term problem that has been building for
over a decade. It threatens to undermine our emergency 9-1-1
infrastructure and deserves urgent attention by the Congress.
The most sweeping survey of its kind--involving nearly 20,000
employees working at 258 EMS organizations--found that overall turnover
among paramedics and EMTs ranges from 20 to 30 percent annually. With
percentages that high, ambulance services face 100 percent turnover
within a 4-year period. Staffing shortages compromise our ability to
respond to healthcare emergencies, especially in rural and underserved
parts of the country.
The pandemic exacerbated this shortage and highlighted our need to
better understand the drivers of workforce turnover. There are many
factors. Chief among them is inadequate reimbursement by governmental
payers. We must have a reimbursement system that matches payments with
the costs of providing services and allows us to increase wages as
competition for personnel intensifies.
Our ambulance crews are suffering under the grind of surging demand
and burnout. In addition, with COVID-19 interrupting clinical and in-
person training for long periods of time, our training pipeline has
been stretched even thinner. The challenge is to make sure that the
paramedics and EMTs of the future know that EMS is a rewarding
destination. Many other healthcare providers have extensive
governmental professional development resources, but that simply often
does not exist for EMS.
One of the most critical gaps in an adequate pipeline of trained
EMS personnel results from the fact that many existing Federal training
programs and other forms of assistance are not eligible for
nongovernmental or for-profit ambulance service providers. We believe
that all providers, regardless of organizational form, should have
access to the full range of Federal and state training and retention
resources that are available.
The following potential congressional actions would help mitigate
the current workforce shortage by expanding and strengthening the EMS
workforce:
Provide eligibility during the current public health
emergency and for at least 2 years thereafter for first
responder training and staffing grant programs administered by
the U.S. Department of Health and Human Services (HHS) such as
SAMHSA Rural EMS Training Grants and HHS Occupational Safety
and Health Training Project Grants to for-profit entities.
Authorize the establishment of a new HHS grant
program open to public and private nonprofit and for-profit
ambulance service providers to fund paramedic and EMT
recruitment and training, including employee education and
peer-support programming to reduce and prevent suicide,
burnout, mental health conditions and substance use disorders.
Provide tax credits to companies for employee
education loan repayment assistance, provisions which would
encourage training and retention of personnel who are often
recruited by other healthcare providers.
Implement minority and low-income recruitment
programs. The AAA is committed to increasing diversity in the
ground ambulance service workforce. We are the healthcare
sector with the lowest barrier to entry, given our shorter
training periods. We are supportive of provisions currently
pending in this Congress, such as the Health Professions
Opportunity Grants, which would provide increased access to
training opportunities.
Reduce barriers that prevent veterans from becoming
certified as paramedics/EMTs. The military has a highly trained
EMS workforce, but bureaucratic red tape, particularly in the
state certification process, can make the transition cumbersome
and time-consuming.
Access unused visas for EMS-trained individuals.
Conclusion
The AAA thanks you for your time and attention to the critical
healthcare workforce shortages facing our Nation today. We stand ready
to work with Subcommittee Members and staff to develop workable
solutions to strengthen the vital ground ambulance service workforce.
The crisis is real. Desperately needed rural and urban services are
closing weekly and many more are at risk in areas of the country where
EMS is often the sole provider of after-hours healthcare services.
______
American Ambulance Association
Washington, DC 20090
February 10, 2022
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.
Dear Chairman Hickenlooper and Ranking Member Braun:
On behalf of the American College of Emergency Physicians (ACEP)
and our 40,000 emergency physicians, and the Emergency Medicine
Residents' Association (EMRA) and our 17,000 members, thank you for
your attention to the issue of health care workforce shortages and
efforts to improve recruitment and to revitalize and diversify the
health care workforce. The health professions, especially those on the
front lines of the pandemic response, have been strained like never
before, and the underlying workforce challenges that existed even
before the COVID-19 pandemic have been exacerbated by the overwhelming
and prolonged effects of and response to this disease. Physicians,
nurses, and other essential health care workers have tirelessly given
their all--often at great personal cost--to provide high-quality care
during this unprecedented public health crisis, and dedicated efforts
are needed to rebuild and maintain the health and well-being of the
individuals who provide our health care safety net.
Workforce shortages are especially pronounced in rural and
underserved areas throughout the country, and numerous barriers to
providing equitable care in these communities persist. Among these are
the inability to recruit qualified and sufficiently experienced,
educated, and trained physicians, nurses, ancillary support staff, and
other health care providers. Despite a 28 percent increase in emergency
medicine residency positions over the past 10 years, there has been no
corresponding increase in emergency medicine residency trained or
emergency medicine board certified physicians working in rural EDs.
This is a complex problem due to a variety of factors, including
limited opportunities for exposure to these communities during
residency training, fewer full time employment opportunities overall
due to ED staffing requirements and continued rural facility closures,
a lack of recruitment tools and incentives such as those provided for
primary care professions, among many others. Additionally, rural EDs,
compared to their urban counterparts, are resource limited, financially
stressed, and experience higher interfacility transfer rates. And while
the COVID-19 pandemic has increased the use of telehealth, rural areas
still suffer from inconsistent availability of telehealth access and
structural challenges like limited/nonexistent broadband access.
Transportation issues also limit many individuals' ability to reach
hospitals, and emergency medical services (EMS) in rural areas also
experience significant transportation delays due to issues with crew
availability.
We hope the Committee's examination of current health care
workforce shortages will include a focus on the ongoing nursing
shortages and the recent practices of nurse staffing agencies that have
resulted in exorbitant increases in costs to already-strained health
care systems. The extreme physical and mental toll of the COVID-19
pandemic response has inflicted enormous trauma and stress on
physicians and nurses, resulting in increased burnout and
dissatisfaction for those on the front lines and greater attrition in
the health care workforce. This has left many health systems desperate
to fill workforce gaps by relying on nurse staffing agencies, some of
whom have imposed extreme rate hikes to supply travel nurses to
hospitals.
Especially during the Omicron wave when hospitals have tried to
continue providing care for COVID-19 patients and other conditions
requiring hospitalization, facilities have been left with no other
choice than to pay substantially inflated rates in their attempts to
maintain staffing levels capable of meeting their community's needs. We
appreciate the recent attention to this issue raised by some in
Congress and other health care stakeholders and encourage continued
investigation and oversight of potentially anticompetitive practices
occurring in the health care workplace.
Such shortages also greatly exacerbate the issue of crowding and ED
``boarding,'' a scenario where patients are 1kept in the ED for
extended periods of time due to a lack of available inpatient beds or
space in other facilities where the patient can be transferred.
Empirical studies have shown boarding contributes to worse patient
outcomes and increased mortality related to downstream delays of
treatment for both high-and low-acuity patients. In addition to
disrupting the ED workflow and creating operational inefficiencies, it
often also creates additional dangers, such as ambulance diversion,
increased adverse events, preventable medical errors, more walkouts by
patients, lower patient satisfaction, violent episodes in the ED, and
higher overall health costs. Solving ED boarding is not an isolated
emergency department issue but rather a hospital-wide imperative.
Reducing boarding and mitigating its effects on all patients is
critical in improving patient outcomes and their overall health,
especially for those with mental or behavioral health needs. ED
boarding challenges disproportionately affect patients with behavioral
health needs who wait on average three times longer than medical
patients because of these significant gaps in our health care system.
Some research has shown that 75 percent of psychiatric emergency
patients, if promptly evaluated and treated in an appropriate
location--away from the active and disruptive ED setting--have their
symptoms resolve to the point they can be discharged in less than 24
hours, further highlighting the need to provide timely, efficient, and
appropriate mental healthcare.
Many emergency physicians report that given ongoing shortages and
the influx of patients (both COVID-and non-COVID-related) that ED
boarding is at an all-time high. Adding to this challenge is the fact
that EDs are also not subject to the same staffing ratio requirements
as other parts of the hospital often are, and as a result, the ED too
often becomes the only place in which to keep many patients. While we
have shared ideas and suggestions with legislators and regulators to
provide both short-and long-term solutions to reduce ED boarding (such
as regulatory waivers and flexibility around documentation requirements
that contribute to burnout among nurses), more fundamental efforts to
address the root causes of nursing and physician shortages are needed
to ensure patients have timely access to care.
Finally, as you work to address these challenges, ACEP and EMRA
urge Congress to ensure that American patients have access to high-
quality lifesaving emergency care. We believe the gold standard for
care in an emergency department (ED) is via a physician-led emergency
care team, with that care performed or supervised by a board-certified/
board-eligible emergency physician. Physician Assistants (PAs) and
nurse practitioners (NPs) can and do serve integral roles as members of
the emergency care team, but do not replace the medical expertise
provided by emergency physicians. The physician-led emergency care team
is the safest care model for our patients and particularly important
for Medicare beneficiaries, who are some of the most medically
vulnerable patients in our population, often suffering from multiple
chronic conditions or other complex medical needs and account for
nearly 20 percent of ED encounters each year.
Supporting physician-led health care teams is also aligned with
most state scope of practice laws. For example, over 40 states require
physician supervision of or collaboration with PAs. Most states require
physician supervision of or collaboration with nurse anesthetists, and
35 states require some physician supervision of or collaboration with
nurse practitioners, including populous states like California,
Florida, New York and Texas. These states represent more than 85
percent of the U.S. population. Moreover, despite multiple attempts, in
the last 5 years no state has enacted legislation to allow nurse
practitioners full-immediate independent practice.
Some have proposed expanding the scope of practice of nonphysician
professionals in order to increase access to care, especially in rural
and underserved communities. However, in reviewing the actual practice
locations of nurse practitioners and primary care physicians, it is
clear nurse practitioners and primary care physicians tend to work in
the same large urban areas. There remain significant shortages of nurse
practitioners in rural areas--the very problem with physician access
that scope expansion has sought to address. This occurs regardless of
the level of autonomy granted to nurse practitioners at the state
level. We believe that the ongoing challenges in recruiting and
retaining all levels of health care professionals in rural and
underserved areas are more complex, and that this persistent issue
requires more innovative solutions to incentivize physicians and other
health care professionals to work in these communities. We would
welcome the opportunity to work with you and your colleagues to find
more effective and durable solutions to these longstanding workforce
challenges to ensure that Americans in rural and underserved areas have
access to high-quality emergency care, recognizing the level of
expertise and training required for independent practice of emergency
medicine and supporting the provision of physician-led team-based care.
Once again, we are grateful for the opportunity to share these
comments with you and appreciate your attention to the ongoing
workforce challenges facing health care professionals, especially in
light of the continued response to the COVID-19 pandemic. ACEP and EMRA
stand ready to work with you and your colleagues to respond to these
challenges and ensure that all Americans have access to the high-
quality health care they need and deserve.
Sincerely,
Gillian Schmitz,
ACEP President.
Angela G. Cai,
EMRA President.
______
american hospital association
On behalf of our nearly 5,000 member hospitals, health systems and
other health care organizations, our clinician partners--including more
than 270,000 affiliated physicians, 2 million nurses and other
caregivers--and the 43,000 health care leaders who belong to our
professional membership groups, the American Hospital Association (AHA)
appreciates the opportunity to submit this statement for the record as
the Subcommittee on Employment and Workplace Safety of the Committee on
Health, Education, Labor and Pensions examines America's health care
workforce shortage.
As America enters the third year of the COVID-19 pandemic, health
care providers are confronting a landscape deeply altered by its
effects. As of Feb. 10, 2022, there have been approximately 80 million
COVID-19 cases and over 900,000 deaths in the U.S., with nearly 30
million cases and approximately 110,000 deaths in just the last 2
months.
Our nation's hospital and health system workers have been on the
front lines of this crisis since the outset, caring for millions of
patients, including nearly 4.4 million patients hospitalized with
COVID-19. During this time, hospitals have continued to face a range of
pressures, with workforce-related challenges among those most critical.
Though managing workforce pressures were a challenge for hospitals
even before the pandemic, these challenges have only grown more acute.
The incredible physical and emotional toll that hospital workers have
endured in caring for patients during the pandemic has, among other
issues, exacerbated the shortage of hospital workers. This shortage has
become so critical that some states and the Federal Government have
deployed military and National Guard resources to help mitigate
staffing challenges at some hospitals. As this shortage has worsened
and COVID-19 hospitalizations have reached record levels, labor costs
for hospitals have increased dramatically. This combination of factors
has been exploited by travel staffing companies and other firms that
provide contract labor resources, driving up workforce costs even more
for hospitals. Hospitals also have incurred significant costs in
recruiting and retaining staff, which have included overtime pay, bonus
pay and other incentives. This is occurring at a time when many
hospitals and health systems are still facing other immense financial
constraints. For many hospitals around the country this has led to an
unsustainable situation that threatens their ability to care for the
patients and communities they serve.
Health Care Workforce Shortages
Hospitals are facing a critical shortage of workers. Approximately,
1,130 hospitals or 27 percent of hospitals that reported data on
staffing to the Federal Government indicated that they were
anticipating a critical staffing shortage within the week of Feb. 8.
Further, 15 states had 33 percent or more of their hospitals reporting
a critical staffing shortage.
Nurses, who are critical members of the patient care team, are one
of the many health care professions that are currently in shortage. In
fact, a study found that the nurse turnover rate was 18.7 percent in
2020, illustrating the magnitude of the issue facing hospitals and
their ability to maintain nursing staff. The same study also found that
35.8 percent of hospitals reported a nurse vacancy rate of greater than
10 percent, which is up from 23.7 percent of hospitals prior to the
pandemic. In fact, two-thirds of hospitals currently have a nurse
vacancy rate of 7.5 percent or more.
Almost every hospital in the country has been forced to hire
temporary contract staff to maintain operations at some point during
the pandemic. According to a survey by AMN Healthcare, 95 percent of
health care facilities reported hiring staff from contract labor firms,
with respiratory therapists being the primary need for many hospitals
and a critical team member necessary for COVID-19 patient care.
As hospitals have looked to bring in more staff, job postings for
both clinical and non-clinical staff have increased from pre-pandemic
levels. Based on data from Liquid Compass analyzed by Prolucent Health,
job postings for clinical staff have increased by 45 percent for nurses
and 41 percent for other allied clinical staff between January 2020 and
January 2022. At the same time, non-clinical staff such as
environmental service and facilities workers, who play in important
role in maintaining hospital operations, have seen job postings
increase nearly 40 percent.
Hospitals were already spending more money on contract labor even
before the latest COVID-19 surge. According to a Definitive Healthcare
study, contract labor expenses for hospitals have more than doubled
over the last decade. However, the prices charged by contract labor
firms during the pandemic have become exorbitant as supply is scarce
and demand is at an all-time high. For example, average pay for
hospital contract nurses has more than doubled compared to pre-pandemic
levels. According to Prolucent Health, there has been a 67 percent
increase in the advertised pay rate for travel nurses from January 2020
to January 2022, and hospitals are billed an additional 28 percent-32
percent over those pay rates by staffing firms. In fact, in some areas
pay rates for travel nurses have been as high as $240/hour or more,
which have contributed to the dramatic increase in hospitals' labor
costs. Labor expenses are up 12.6 percent on an absolute basis, and
19.1 percent on a per patient basis compared to levels in 2019.
With COVID-19 hospitalizations reaching record highs, the staffing
crisis currently plaguing our Nation's hospitals is only expected to
worsen. In 2017, more than half of nurses were age 50 and older, and
almost 30 percent were age 60 and older. According to Bureau of Labor
Statistics data, it is anticipated that 500,000 nurses will leave the
workforce in 2022, bringing the overall shortage to 1.1 million nurses.
And due to significant shortages of faculty, classroom space and
clinical training sites, nursing schools actually had to turn away more
than 80,000 qualified applicants in 2019. These data highlight the need
to develop and implement longer-term solutions to avoid the further
deepening of this crisis, which includes investing in more
opportunities and slots for health care workers in the pipeline.
Supporting the Workforce
Because our workforce is our most precious resource, hospitals and
health systems are committed to supporting them. That's why we've
created programs and developed resources to promote caregiver well-
being and resiliency. Examples include helping to pay back student
loans, providing child care and transportation, offering tuition
reimbursement and training benefits, providing referral and retention
bonuses, and supporting programs that address mental and physical
health.
Hospitals also are developing new team-based care models that allow
health care workers from various disciplines and specialties to provide
customized, patient-centered care. This allows them to manage medical
and social needs across all settings to improve care and enhance
professional satisfaction.
For example, in Virginia, Mary Washington Healthcare collaborated
with a local community college on a clinical education model allowing
student nurses to support the current nurse workforce before they had
graduated, addressing the critical demand for more nurses. In
Pennsylvania, Geisinger provides $40,000 in financial support each year
for up to 175 employees who want to pursue a nursing career and make a
5-year work commitment as an inpatient nurse. And in Maine, Northern
Light Maine Coast Hospital invites financial support from the local
community to help underwrite the cost of programs to train future
nurses and medical assistants and alleviate a crucial shortage of these
professionals.
Policy Solutions
Our workforce challenges are a national emergency that demand
immediate attention from all levels of government and workable
solutions. These include recruiting, revitalizing and diversifying the
health care workforce by:
Lifting the cap on Medicare-funded physician
residencies;
Boosting support for nursing schools and faculty;
Providing scholarships and loan forgiveness;
Expediting visas for all highly trained foreign
health care workers;
Disbursing any remaining funds in the Provider Relief
Fund, as well as replenishing the fund to help providers cope
with increased staffing costs;
Investigating reports of anticompetitive behavior
from nurse-staffing agencies during the pandemic that is
further exacerbating critical workforce shortages;
Pursuing visa relief for foreign-trained nurses; and
Supporting the health of physicians, nurses and
others so they can deliver safe and high-quality care by
providing additional funding and flexibility to address
behavioral health needs and funding for best practices to
prevent burnout.
We urge Congress to enact the Lorna Breen Health Care Provider
Protection Act, which would direct resources to reduce and prevent
health care professionals' suicides, burnout and behavioral health
disorders. This bipartisan, bicameral legislation would authorize
grants to health care providers to establish programs that offer
behavioral health services for front-line workers, and require the
Department of Health and Human Services (HHS) to study and develop
recommendations on strategies to address provider burnout and
facilitate resiliency. The bill also would direct the Centers for
Disease Control and Prevention to launch a campaign encouraging health
care workers to seek assistance when needed.
In addition, we must support state efforts to expand scope of
practice laws to allow health care professionals to practice at the top
of their license. Congress also should increase funding for the Health
Resources and Services Administration's Title VII and VIII programs,
including the health professions program, the National Health Service
Corps, and the nursing workforce development program, which includes
loan programs for nursing faculty. Congress also should consider
expanding the loan program for allied professionals and direct support
for community college education to high priority shortage areas in the
health care workforce.
Finally, Congress should expand and increase funding for Centers of
Excellence and the Health Careers Opportunity Programs, which focus on
recruiting and retaining minorities into the health professions to
build a more diverse health care workforce.
Conclusion
The AHA appreciates your recognition of the challenges ahead and
the need to examine America's health care workforce shortage. We must
work together to solve these issues so that our Nation's hospitals and
health systems can continue to care for the patients and communities
they serve.
______
american association for respiratory care
The American Association for Respiratory Care thanks Chairwoman
Patty Murray, Ranking Member Richard Burr, and Members of the Health,
Education, Labor and Pensions (HELP) Committee for holding this
important hearing on Recruiting, Revitalizing & Diversifying: Examining
the Health Care Workforce Shortage. In particular, we urge the
Committee to consider the Allied Health Workforce Diversity Act as part
of its work on this important topic.
The ongoing public health crisis due to COVID-19 has resulted in
unexpected challenges involving the delivery of healthcare and the need
for long-term recovery. We urge Congress to focus its efforts on
ensuring our Nation can meet these challenges in part by working to
promote a workforce adequate to meet the needs of the country, and one
that reflects the diverse communities it serves. The allied health
professions that include respiratory therapy, physical therapy,
occupational therapy, speech-language pathology, and audiology are well
positioned to assist with both the immediate care and long-term
recovery and rehabilitation of those affected by COVID-19. Diversifying
this workforce will help better enable these health care professionals
to meet the current and future needs of this population.
As the Committee undertakes an evaluation of health workforce
shortages, it is important to point out that the pandemic has resulted
in regional and nationwide shortages of respiratory therapists. Given
the unknown long-term respiratory needs of those individuals who were
diagnosed with COVID-19 and discharged from an inpatient hospital stay,
it is important now more than ever that the Committee address the
market forces that can lead to decreasing enrollment in respiratory
care education programs, escalating burnout in the healthcare
profession, and steadily growing retirement among the baby boomer
generation. According to a recent health resources survey by the
American Association for Respiratory Care, \1\ by 2030, approximately
92,000 respiratory therapists are projected to have left the
profession.
---------------------------------------------------------------------------
\1\ 2020 AARC Human Resource Study. Table 47, page 123. aarc-hr-
study-rt.pdf
As the Committee seeks to address issues around recruiting and
diversifying the healthcare workforce, we strongly believe increasing
diversity will lead to improved access to care, greater patient choice
and satisfaction, and better education experience for health
professions students, among many other benefits. In particular, a
diverse health care workforce can help to both address preexisting
health disparities among the population, as well as those disparities
exacerbated by the COVID-19 pandemic. This is supported by the Centers
for Disease Control and Prevention assessment that there is an
increased ``risk for severe COVID-19 illnesses and death for many
people in racial and ethnic minority groups.'' \2\
---------------------------------------------------------------------------
\2\ Centers for Disease Control and Prevention. COVID Data Tracker
Weekly Review, Interpretive Summary for April 2, 2021. Accessed April
4, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/
covidview/index.html
We appreciate the support of HELP Committee Members Senators Casey
and Murkowski, who have been strong champions for diversifying the
allied health professions by introducing the Allied Health Workforce
Diversity Act (S. 1679), which would create a workforce development
program for rehabilitation therapy providers and audiologists to
increase the percentage of individuals from underrepresented
communities in these professions. We urge you to build on their efforts
to create this new program to support better representation in the
professions of audiology, physical therapy, occupational therapy,
respiratory therapy, and speech-language pathology as the Committee
tackles a wide range of health care workforce issues. We appreciate the
opportunity to provide our comments and look forward to working with
you to improve the diversity of the respiratory care workforce.
______
Workforce Issue Brief
Advocate Aurora Health (Advocate Aurora) has developed a diverse
and inclusive workforce to support the delivery of quality, integrated
inpatient, outpatient, and home-based health services. Our workforce is
comprised of more than 75,000 employees, including more than 10,000
physicians and 22,000 nurses. With 27 acute care hospitals, an
integrated children's hospital and a psychiatric hospital, primary and
specialty physician services, outpatient centers, physician office
buildings, pharmacies, rehabilitation, home health, and hospice care,
Advocate Aurora provides a continuum of service at more than 500 sites
of care in northern Illinois and eastern Wisconsin.
Currently, staffing shortages are the most urgent challenge facing
our hospitals and other sites of care; accompanying these shortages are
higher costs to recruit and retain health care workers and paying the
exorbitant rates some staffing agencies are charging. According to an
AHA report, current labor expenses per adjusted discharge for hospitals
have increased 12.5 percent compared to 2019. \1\ Moreover, in late
January 2022, the Bureau of Labor Statistics reported that compensation
for hospital workers was 4.5 percent higher in December 2021 compared
to the year prior. \2\
---------------------------------------------------------------------------
\1\ https://www.aha.org/fact--sheets/2021--11--data--brief--
health--care--workforce--challenges--threaten--hospitals--ability--care
\2\ https://www.bls.gov/news.release/eci.t05.htm
---------------------------------------------------------------------------
Supporting Federal Initiatives
COVID-19 has taken a heavy toll on our employees who have been on
the front lines of the pandemic for 2 years, and Advocate Aurora is
grappling with health care worker shortages as hospitalizations
increase and ICU capacity decreases across Illinois and Wisconsin with
each wave of COVID variants. Physicians, nurses, and other clinical and
non-clinical health care professionals are critically needed, but
ongoing COVID-19 hospitalizations have created unprecedented levels of
demand that are exceeding supply. Advocate Aurora supports the efforts
of Congress and the Biden-Harris Administration to address the issue of
workforce shortages among health care workers, as well as the following
initiatives:
Make permanent the telehealth flexibilities permitted
during the pandemic, including removing geographic restrictions
on the location of the patient, allowing rural health clinics
and federally qualified health centers to serve as the distant
site, and allowing critical access hospitals the same ability
to offer and bill for telehealth services as other providers.
Provide resources to assist hospitals with
unprecedented staffing and COVID response costs by
appropriating additional dollars through the Provider Relief
Fund (PRF).
Ensure the public health emergency (PHE) period does
not expire until ICU capacity has returned to pre-pandemic
levels.
Extend J1 visas for international health care workers
and ensure a timely process for review, streamlining entry into
the U.S. for clinical staff with approved immigrant visas.
Plan for future workforce shortages by increasing
Graduate Medical Education (GME) residency slots under Medicare
and increasing funding for the Children's Hospital Graduate
Medical Education program to support Federal investment in
pediatric physician training.
Invest additional resources in nursing education
programs and other initiatives to support nursing school
enrollment, faculty positions, educational programming, and
educational and technological infrastructure.
Consider increased and expanded tax incentives to
encourage health care workers to increase their tenure at their
current positions and reduce turnover rates, which can threaten
patient safety and continuity of care.
Expand and increase funding for mental health
services and other programs to support current health care
professionals to reduce burnout.
Implement student loan forgiveness or assistance, and
provide increased incentives and programs to create a health
care workforce pipeline with features like scholarships,
training, and financial incentives.
Address price gouging by certain nursing staffing
agencies, which have been charging nearly three times the
amount for nurses compared to pre-pandemic rates.
Increase funding for nursing and allied health
programs and the National Health Service Corps program,
directing higher numbers of participants to serve in hospital
settings.
Advance efforts to diversify the health workforce,
including grants to education programs to increase workforce
diversity in the allied health professions.
Advocate Aurora's Workforce Development
While we are calling on Congress and the Administration to enact
policies and programs and provide increased resources to strengthen,
expand, and diversify the Nation's health care workforce, we at
Advocate Aurora are doing our part. Advocate Aurora is focused on
recruiting and retaining a diverse array of team members to inspire
creativity and innovation. We aim to cultivate an atmosphere of
inclusion and compassion to create a welcoming and safe space for all
team members. Specifically, we have sponsored the following initiatives
to achieve positive workforce development:
In 2021, we increased our minimum wage to $18 an
hour. The wage increase, intended to recognize Advocate Aurora
team members' critical work, also reflects another major effort
to create social impact that dramatically improves individuals'
health and well-being. The 10,800 team members directly
impacted by Advocate Aurora's new minimum wage include those in
food service and environmental services positions. An
additional 20,000 team members who already made more than $18
an hour, including pharmacy technicians and licensed practical
nurses (LPNs), also received raises. This $93 million
investment, which included compression adjustments, benefited
more than 30,000 team members and in turn, strengthened our
marketplace and most importantly, enhanced the quality of life
across our communities.
Advocate Workforce Initiative (AWI): With funding
from JP Morgan Chase, Advocate Aurora developed a pipeline of
diverse talent from the greater Chicagoland area by seeking out
individuals who are interested in entry-to mid-skill level
health care careers. Since 2015, our partnership with JPMorgan
Chase has allowed us to bring together stakeholders--health
care systems, education providers, and community-based
organizations--to connect diverse job seekers with health care
career training, support services and employment opportunities.
Advocate Aurora co-led the Chicagoland Healthcare Collaborative
and implemented the AWI. To date, these partnerships have
resulted in training more than 900 community residents. More
than half of the program participants secured employment in
health care, and 84 percent were persons of color. While the
AWI funding sunset in 2020, it will be relaunched in mid-2022.
Advocate Aurora Corporate Internship Program: For the
last 7 years, we have awarded competitive summer internships to
a small group of college students to support hard-to-fill
corporate positions in our organization. To date we have hired
interns from more than 40 colleges across the Nation,
partnering with local organizations that support up to 20
underrepresented students each year. These are paid internships
that focus on corporate careers, such as: Human Resources;
Finance; Accounting; Diversity, Equity, and Inclusion (DE&I);
and Information Technology. The apprenticeship program focuses
on recruiting diverse and underrepresented talent, including
people with disabilities, into these roles. Advocate Aurora had
15 virtual corporate interns in 2021 and will have 23 in 2022.
Earn-While-You-Learn Corporate Apprenticeship
Program: We have partnered with the Wisconsin Department of
Workforce Development and the Wisconsin Technical College
System to offer job seekers the opportunity to earn while they
learn and expand their skills for middle-skill positions. In
2022, Advocate Aurora will be expanding the Culinary
Apprenticeship program to Illinois. In partnership with the
Illinois Department of Labor and the City Colleges of Chicago's
Washburn Hospitality and Culinary Institute, the Culinary
Apprenticeship program will place seven new apprentices to five
of our medical centers--Christ, Lutheran General, Illinois
Masonic, South Suburban, and Trinity hospitals. In total, there
will be 11 full-time Culinary Apprenticeships in Illinois and
four in Wisconsin.
Community Scholarships and Education Reimbursement:
Annually, we partner with both Milwaukee and Chicago businesses
to distribute scholarships--Phase 1 awards 10 community
scholarships up to $5,000 each; Phase 2 awards 20 scholarships
Up to $5,000 Each (10 to Community Members, 10 to Dependents of
Team Members). Priority is given to students in STEM/health-
related or corporate fields of study. Also, Advocate Aurora
operates an Education Assistance Partnership with Bright
Horizons for current employees to receive tuition benefits up
to $5,250 per year for non-nursing programs and up to $7,200
per year for nursing programs.
The Milwaukee Healthcare Workforce Initiative
operates in close partnership with Employ Milwaukee (workforce
investment board), bringing together five community-based
organizations, including the Milwaukee Urban League, and
providing them leveraged funds to help recruit and train
participants for in-demand careers in health care. Advocate
Aurora obtained a $500,000 grant through the Medical College of
Wisconsin's Advancing a Healthier Wisconsin (MCAHW) endowment
to support this important effort. This program is similar to
the AWI program described above.
The Medical Assistant Accelerated Pathway to
Employment Training Project (MAAPET) meets a crucial workforce
need by increasing a diverse talent pool of Medical Assistants
(MAs) working in ambulatory clinics across Southeast Wisconsin.
Advocate Aurora Health is collaborating with our partners in
the Center for Healthcare Careers of Southeast Wisconsin to
launch an accelerated Medical Assistant Training Program with
assistance from a generous grant provided by the Medical
College of Wisconsin Advancing a Healthier Wisconsin Endowment.
This grant-funded program will train 100 new Medical
Assistants. In this pathway program, trainees will be paid to
go through a 14-week training program. The first 10 weeks (400-
hours) will be dedicated to in-class learning and laboratory
demonstrations. Students will then transition into a 4-week
(160-hours) clinical placement. Upon the completion of the 14-
week training program (560-hours), students will sit for the
CCMA (Certified Clinical Medical Assistant) exam through the
National Healthcareer Association.
A key aim of the MAAPET project is to develop an MA workforce that
is reflective of the community that it serves. Key to this is
recruitment of participants from the community who wish to gain a
career in health care. By providing an accelerated, financially
supported training, low income/underrepresented individuals will be
given priority opportunities to enroll. The training team will monitor
overall recruitment achievements and monitor the goal of having at
least 70 percent of each cohort class meet target demographic goals. To
date, 23 AAH team members have enrolled in the program.
The Bridge Initiative Chicago was made possible by a
$1 million dollar grant awarded by JPMorgan Chase to support
workforce development efforts in the Chicagoland area through a
partnership with AAH, Sinai Health and University of Chicago
Medicine (UCM). It has three tracks to encourage and support
individuals in pursuing a career in health care:
COMMUNITY TRACK (``HEALTHCARE FORWARD'') led by Sinai
Chicago incorporates community-facing strategies to increase
engagement in the health care workforce at the entry-level,
including fortified recruitment protocols and industry-focused
training offered at accessible community venues. This track
invites disenfranchised community members, particularly persons
of color (POC), to seek jobs and realize a living wage.
INCUMBENT ADVANCEMENT (``EVOLVE'') track led by AAH
addresses disparity of opportunities for POC within health care
by introducing self-directed digital skills training, cohort-
based training, and career coaching. This track aims to develop
new technical, discipline-specific skills (entry-level to
middle skills).
EMERGING LEADERSHIP (``RISE HIGHER') track led by UChicago
Medicine incorporates a new leadership curriculum and
certificate program to promote career advancement and
leadership skills among incumbents. This track seeks to promote
racial equity and leadership success from middle skill to
management level.
Workplace Transition Policy and Practice: In the fall
of 2020, Advocate Aurora created guidelines to support our
transgender, non-binary, and gender diverse team members who
may be socially, legally, or medically transitioning during
their employment with Advocate Aurora.
LGBTQ Cultural Awareness: Based on feedback we
received from team members participating in the Healthcare
Equality Index (HEI) accreditation process, we are expanding
our LGBTQ cultural awareness initiative and exploring easily
accessible and trackable LGBTQ learning opportunities for our
team members.
Inclusion Council and Core Teams: The Advocate Aurora
Inclusion Council is a newly launched, differentiated model for
integrating DE&I into our health system. This model addresses
the challenge of locally executing our system DE&I strategy by
deploying 11 inclusion council core teams dedicated to leading
DE&I action plans for our patient service areas, corporate
functions, and select ancillary services.
Advocate Aurora Employee Wellness Support: Advocate
Aurora is committed to creating and maintaining diverse,
inclusive, and engaged working environments where team members
can pursue their passion and feel supported, valued, and
recognized. Further, the team member well-being program at
Advocate Aurora is designed to educate team members and
encourage them to manage and improve their health, including
offering incentives, such as discounts at its fitness centers,
indoor and outdoor guided walking paths at each hospital
location and a variety of physical, mental, and social
programs, resources, and interventions to support team members
in their well-being journey.
About Advocate Aurora Health
Advocate Aurora Health is one of the 12 largest not-for-profit,
integrated health systems in the United States and a leading employer
in the Midwest with 75,000 employees, including more than 22,000 nurses
and the region's largest employed medical staff and home health
organization. A national leader in clinical innovation, health
outcomes, consumer experience and value-based care, the system serves
nearly 3 million patients annually in Illinois and Wisconsin across
more than 500 sites of care. Advocate Aurora is engaged in hundreds of
clinical trials and research studies and is nationally recognized for
its expertise in cardiology, neurosciences, oncology and pediatrics.
The organization contributed $2.5 billion in charitable care and
services to its communities in 2020. The Centers for Medicare &
Medicaid Services in 2020 announced that Advocate Aurora Health's three
affiliated Accountable Care Organizations (ACOs) combined saved
taxpayers $87.5 million through the Medicare Shared Saving Program, the
most of any integrated system in the country.
______
american occupational therapy association
Dear Chair Hickenlooper, Ranking Member Braun, and Members of the
Subcommittee:
The American Occupational Therapy Association (AOTA) is pleased to
submit the following comments for the Senate Health, Education, Labor
and Pensions (HELP) Subcommittee on Employment and Workplace Safety
hearing on the growing shortages in the health care workforce.
The American Occupational Therapy Association (AOTA) is the
national professional association representing the interests of more
than 213,000 occupational therapists, occupational therapy assistants,
and students of occupational therapy. The practice of occupational
therapy is science-driven, evidence-based, and enables people of all
ages to live life to its fullest by promoting health and minimizing the
functional effects of illness, injury, and disability.
The ongoing public health crisis due to COVID-19 is a challenge in
two parts and therefore recovery must continue two-fold. First:
treatment and immediate care. Second: recovery in the long term. We
urge Congress to focus its efforts on ensuring our Nation can meet both
aspects of this crisis in part by working to promote a workforce
adequate to meet the needs of the country, and one that reflects the
diverse communities it serves. The Allied Health professions are well
positioned to assist with both the immediate care and long-term
recovery and rehabilitation of those affected by COVID-19 and
diversifying this workforce will help better enable these health care
professionals to meet the current and future needs of this population.
The Allied Health professions play a crucial role in recovery from
COVID-19 infections, as well as treatment of the effects of ``Post-
Acute Sequelae of SARS-CoV-2 infection,'' (PASC), \1\ often self-
described as ``long-haulers'' or ``long-COVID''. Issue 13 of The
Exchange, an information sharing publication produced by the Office of
the Assistant Secretary for Preparedness and Response (ASPR) in the
Department of Health and Human Services, entitled The Work of Hospital
Allied and Supportive Care Providers During COVID-19 states, ``The
articles in this section illustrate the work performed by physical,
respiratory, and occupational therapists to ensure patient comfort and
assist COVID-19 patients through the recovery process.'' \2\
---------------------------------------------------------------------------
\1\ https://www.usatoday.com/story/news/health/2021/02/24/covid-
19-long-haulers-fauci-announces-launchnationwide-initiative/4572768001/
viewed March 4, 2021
\2\ U.S. Department of Health & Human Services. (2021). The work
of hospital allied and supportive care providers during COVID-19. The
Exchange, 13. https://files.asprtracie.hhs.gov/documents/aspr--tracie--
the--exchange--issue--13.pdf
It is vital to anticipate what is required to promote a thriving,
diverse health workforce. Health workforce diversity was important
prior to the pandemic, as the Institute of Medicine raised concerns
about the diversity of the health care workforce in its 2004 study: In
the Nation's Compelling Interest: Ensuring Diversity in the Health Care
Workforce. \3\ The report found that racial and ethnic minorities
receive a lower quality of healthcare than non-minorities. \4\
---------------------------------------------------------------------------
\3\ Institute of Medicine. (2004). In the Nation's compelling
interest: Ensuring diversity in the health care workforce. Washington,
DC: National Academy Press
\4\ Institute of Medicine. (2003). Unequal treatment: Confronting
racial and ethnic disparities in health care. Washington, DC: National
Academy Press.
Overall, increasing diversity will lead to improved access to care,
greater patient choice and satisfaction, and better education
experience for health professions students, among many other benefits.
\5\ In particular, a diverse health care workforce can help to both
address preexisting health disparities among the population, as well as
those disparities exacerbated by the COVID-19 pandemic.
---------------------------------------------------------------------------
\5\ Institute of Medicine. (2004). In the Nation's compelling
interest: Ensuring diversity in the health care workforce. Washington,
DC: National Academy Press.
In addition to these reasons, a more diverse healthcare workforce
---------------------------------------------------------------------------
is important because:
Patients who receive care from members of their own
racial and ethnic background tend to have better outcomes; \6\
---------------------------------------------------------------------------
\6\ Institute of Medicine. (2004). In the Nation's compelling
interest: Ensuring diversity in the health care workforce. Washington,
DC: National Academy Press.
Health professionals from underrepresented and
minority backgrounds are more likely to practice in medically
underserved areas; \7\
---------------------------------------------------------------------------
\7\ Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., Vu, H. T.,
Powe, N. R., Nelson, C., & Ford, D. E. (1999). Race, gender, and
partnership in the patient-physician relationship. JAMA, 282, 583--589.
Minority groups disproportionately live in areas with
provider shortages. \8\
---------------------------------------------------------------------------
\8\ Reyes-Akinbileje, B. (2008, February 7). Title VII health
professions education and training: Issues in reauthorization.
Washington, DC: U.S. Congressional Research Service.
We appreciate the support of Senators Casey and Murkowski, Members
of the full HELP Committee, who have been strong champions for
diversifying the allied health professions by introducing the Allied
Health Workforce Diversity Act (S. 1679), which would create a
workforce development program for rehabilitation therapy providers and
audiologists to increase the percentage of individuals from
underrepresented communities in these professions. We urge you to build
on their efforts to create this new program to support better
representation in the professions of audiology, physical therapy,
occupational therapy, respiratory therapy, and speech-language
---------------------------------------------------------------------------
pathology.
Solving the diversity gap in our Nation's health systems will need
a multistep approach. The step presented in this letter includes the
creation of a workforce development program for rehabilitation therapy
providers. The potential program under the Health Resources and
Services Administration (HRSA) would be the modeled after the Title
VIII Nursing Workforce Diversity program that has successfully
increased the percentage of racial and ethnic minorities pursuing
careers in nursing. This new program would help strengthen and expand
the comprehensive use of evidence-based strategies shown to increase
the recruitment, enrollment, retention, and graduation of students from
underrepresented and disadvantaged backgrounds for the professions of
audiology, physical therapy, occupational therapy, respiratory therapy,
and speech-language pathology. The result would be better care for
individuals who live in areas with provider shortages.
Thank you for the opportunity to provide input on solving the
Nation's health care workforce challenges. We stand ready to provide
any additional information you need, as well as collaborate on any
efforts in this area.
______
physician assistant education association
The Physician Assistant Education Association (PAEA), representing
the 282 accredited physician assistant (PA) programs in the United
States, welcomes the opportunity to submit a statement for the record
regarding health care provider shortages and health workforce
diversity.
Throughout the course of the COVID-19 pandemic, the implications of
chronic underinvestment in the development of our Nation's health
workforce have been starkly illustrated. As hospital systems have been
overwhelmed by COVID-19 patients, an already insufficient supply of
frontline providers has faced unprecedented demands, leading to
significant burnout among clinicians and reduced access to needed care
for patients. As Congress seeks to develop policy to improve
preparedness for future public health threats, ensuring the
availability of a sufficient supply of well-trained, diverse providers
must be a top priority.
To effectively respond to the issue of workforce shortages,
Congress must take immediate action to address the most urgent
challenges limiting both the overall number of graduates being produced
by health professions programs and the diversity of matriculants. As PA
programs have sought to expand, the most challenging barrier that they
have consistently encountered is the availability of clinical training
sites necessary for students to complete their required rotations. As a
condition of graduation, every PA student is required to complete a
series of clinical training experiences in family medicine, emergency
medicine, internal medicine, surgery, pediatrics, women's health, and
behavioral/mental health. According to a recent survey of PA programs,
however, more than 85 percent of respondents indicated that their
clinical training sites are now taking fewer students than prior to the
pandemic. \1\ This dramatic reduction in clinical education capacity
threatens the ability of PA programs to meet the demand of health
systems for graduates and must be addressed to reduce projected
shortages.
---------------------------------------------------------------------------
\1\ Physician Assistant Education Association. (2021). COVID-19
Rapid Response Report 3. https://paea.edcast.com/insights/ECL--
c621408d--c82a-43f5--a067-75a03494d8be
Beyond addressing clinical education limitations, PAEA strongly
supports congressional action to help develop pathways to PA education
for underrepresented minority (URM) students. According to PAEA's most
recent Student Report, only 3.9 percent of first-year PA students
identified as Black or African American while 9.1 percent identified as
Hispanic or Latino as of 2019. \2\ Federal policy can play a critical
role in addressing the barriers that have long prevented URM students
from matriculating into PA programs, successfully graduating, and
providing care to the communities most in need.
---------------------------------------------------------------------------
\2\ Physician Assistant Education Association. (2020). By the
Numbers: Student Report 4: Data from the 2019 Matriculating Student and
End of Program Surveys. https://paeaonline.org/wpcontent/uploads/
imported-files/student--report--4--updated--20201201.pdf.
To address these challenges, PAEA has endorsed legislation in both
the House and Senate. PAEA would encourage the Subcommittee to advance
the following legislation that has been introduced in the Senate and
integrate that which has been introduced in the House into broader
legislative proposals.
The Perinatal Workforce Act (S. 287)
To combat significant rates of maternal morbidity and mortality
among Black women, Senators Tammy Baldwin and Jeff Merkley introduced
the Perinatal Workforce Act in 2021. This bill is intended to ensure
the provision of culturally competent care by facilitating the
recruitment and retention of maternal care providers that are
reflective of the communities that they serve. To break down barriers
facing URM students seeking to become health care providers, the bill
would authorize $15 million annually over 5 years to support PA and
other programs training students intending to specialize in obstetrics/
gynecology/women's health. This bill would support training
experiences, scholarship aid, and other interventions proven to
significantly contribute to the success of URM students.
The Physician Assistant Education Public Health Initiatives Act (H.R.
3890)
In response to the growing issue of clinical site shortages, Rep.
Karen Bass introduced the Physician Assistant Education Public Health
Initiatives Act in mid-2021. Based upon the success of the Teaching
Health Center Graduate Medical Education program in retaining
physicians in underserved communities after the completion of their
residency training, this bill would authorize a Rural and Underserved
Clinical Training Demonstration at $5 million annually over 5 years.
This funding would allow PA programs to facilitate partnerships with
federally qualified health centers, critical access hospitals, and
rural health clinics to both immediately expand clinical site access
and build a sustained pipeline of graduates to these underserved
settings following the completion of their training.
The Physician Assistant Higher Education Modernization Act (H.R. 2274)
Under the Higher Education Act, existing sources of aid intended to
support minority-serving institutions explicitly prioritize the
development of programs for certain named high-demand professions, not
including the PA profession. In early 2021, Rep. Karen Bass and Rep.
David Trone the Physician Assistant Higher Education Modernization Act,
which would explicitly prioritize PA program development at minority-
serving institutions, such as Historically Black Colleges and
Universities (HBCUs) and Hispanic-serving institutions, to create a
sustainable pipeline of diverse PA graduates to the health workforce.
PAEA appreciates the opportunity to share the Association's
perspective on effective policy solutions to promote the development of
a sufficient supply of diverse health care providers and looks forward
to the opportunity to serve as a resource to the Subcommittee. Should
you require additional information or have questions, please contact
Tyler Smith, Senior Director of Government Relations, at
[email protected].
______
children's hospital association
On behalf of the Nation's more than 220 children's hospitals and
the children and families we serve, thank you for holding this hearing
on ways to address the health care workforce shortage. We appreciate
your leadership on this issue and look forward to working together to
improve this imminent need. As you consider program improvements and
other policy options, we urge you to recognize the unique staffing
challenges that our Nation's children's hospitals face and the tailored
support and care children, adolescents and young people we serve need.
Children's Hospital Staffing Needs
Children's hospitals' frontline health care workers are facing
extraordinary burdens as a result of the COVID-19 pandemic. We have
unparalleled numbers of children in need of inpatient pediatric care at
the same time that our frontline providers are themselves coming down
with COVID-19, exacerbating persistent pediatric workforce shortages
that have existed for years. Staff retention is a critical issue for
children's hospitals and is reducing the amount of care they can
provide. We are seeing nurses and other bedside staff reducing their
work hours, with many others leaving health care completely. Some
children's hospitals have been forced to resort to temporary staffing
agencies to fill their workforce gaps, further straining financial
resources. At the same time, many children's hospitals have reduced
their care capacity, with some forced to temporarily close entire
pediatric intensive care units and other critical services.
We urge you to give special consideration to ways to immediately
help the pediatric physical and mental health care workforce so
children can get the care they need when they need it. Solutions must
be pediatric-specific and not based on Medicare metrics as self-
governing children's hospitals operate outside of the Medicare program
and care for very large numbers of pediatric Medicaid beneficiaries. An
immediate targeted investment is needed, as our continued time in this
pandemic is steadily weakening the health care system for our Nation's
children. Several key opportunities for committee action to address our
pediatric workforce challenges are highlighted below.
Immediately address the current pediatric workforce crisis.
Existing loan forgiveness programs can sometimes be difficult for
pediatric specialty providers to access. We therefore support robust
funding for the pediatric subspecialty loan repayment program, which
would provide loan forgiveness for pediatric subspecialists, including
mental health providers, practicing in underserved areas. We strongly
support the $30 million for fiscal year 2022 proposed by Senate
appropriators, but additional funding would expand the reach of this
program to better meet the crisis moment we face. We look forward to
working with you to identify realistic and effective immediate
solutions.
Increase funding for the Children's Hospitals Graduate Medical
Education (CHGME) program. The CHGME program supports the training of
more than half of the Nation's pediatric physician workforce and is
essential to the continued access of children to needed pediatric
specialists. However, CHGME represents only 2 percent of the total
Federal spending on GME. These funding shortfalls must be financed by
children's hospitals' child-patient care operations and are a key
contributor to the overall pediatric workforce shortage. We appreciate
the funding levels included in the House and Senate appropriations
bills, but we would encourage Congress to consider a higher overall
appropriations level to reduce the growing and unsustainable gap
between GME and CHGME funding. Additionally, we believe a future
reconciliation package would be an appropriate vehicle to increase
CHGME funds. CHGME is vital to those self-governing children's
hospitals that cannot receive Medicare GME funding, and other sources
of financial support for training, such as Medicaid GME, are not
available to many children's hospitals.
Children's Mental Health
Congress must address the urgent need to relieve pressure on the
existing pediatric mental health workforce, as well as invest in its
long-term expansion across disciplines to meet the ongoing and growing
mental health needs of our children. Pediatric mental health workforce
shortages are persistent and projected to increase over time.
Nationally, there are approximately 8,300 practicing child and
adolescent psychiatrists and only 5.4 clinical child and adolescent
psychologists per 100,000 children 18 years of age and younger, \1\ far
fewer than needed to meet the existing and increasing demand. Shortages
also exist for other vital pediatric mental health specialties critical
to improving early identification and intervention for children with
mental health needs. Additionally, there is a dire shortage of minority
mental health providers, which represents an added burden on racial and
ethnic minority communities who already face inequitable access to
care. More dedicated support for a larger and more diverse pediatric
workforce is critical to addressing children's mental health needs now
and into the future. Congress can take several immediate steps to
address the current and ongoing mental health workforce shortage.
---------------------------------------------------------------------------
\1\ American Psychological Association. The Child and Adolescent
Behavioral Health Workforce. Accessed Oct. 22, 2021.
Mental and Behavioral Health Education and Training grants. The
Mental and Behavioral Health Education and Training (BHWET) grants
program was introduced as part of the Now is the Time initiative to
increase the mental and behavioral health workforce serving children,
adolescents and young adults. The program supports pre-degree clinical
internships and field placements for doctoral-level psychology
students, master's level social workers, school social workers,
behavioral pediatricians and psychiatric mental health nurse
practitioners, among others. Over the years, the program has expanded
to include programs to train mental health providers and provide
services for individuals across their lifespan. Several children's
hospitals have received funding through this program, and we support
further targeting existing funding toward pediatric providers. We also
support an additional designated pool of funding under the oversight of
the Health Resources and Services Agency (HRSA) to support training and
development in children's hospitals, pediatric practice and clinical
settings and related mental health disciplines providing pediatric
---------------------------------------------------------------------------
behavioral health.
Minority Fellowship Program. The value of a diverse pediatric
mental health workforce prepared to deliver culturally and
developmentally appropriate care cannot be overstated. While all mental
health professionals receive training that prepares them to provide
care with cultural sensitivity and awareness, the ability of a child,
adolescent and their family to connect and identify with a mental
health professional can be critical. Shared cultural beliefs and
experiences can further strengthen therapeutic relationships and lead
to better outcomes for kids and families. The Minority Fellowship
Program provides training, career development opportunities and
mentorship to racial and ethnic minority mental health professionals
and researchers with the goal of reducing health disparities within
minority communities. We support the essential aims of this program and
encourage the Committee to explore how to sustainability expand its
reach, including enhanced support for the participation of fellows who
plan to serve pediatric populations.
Enact H.R. 4944, the Helping Kids Cope Act. At the core of a strong
pediatric mental health care delivery system is a strong,
interconnected network of pediatric mental health providers and
supportive services that are available to deliver high-quality,
developmentally appropriate care. To expand and strengthen these
networks at the community level, the Senate should consider H.R. 4944,
the Helping Kids Cope Act of 2021, bipartisan legislation that supports
flexible funding for communities to support a range of child and
adolescent-centered, community-based services, as well as to support
efforts to better integrate and coordinate across the continuum of
care. It also supports pediatric mental health workforce development
for a wide array of physician and non-physician mental health
professions to expand children's long-term access to providers and
services across the continuum of care.
Pediatric Mental Health Care Access (PMHCA) program. While
workforce shortages persist, innovative solutions like the Pediatric
Mental Health Care Access (PMHCA) program, which this Committee has
championed, help children's hospitals expand the reach of their
workforce and ultimately ensure that more children receive the
behavioral health screenings, assessments and referrals they need. As
of today, 45 states, Washington, DC, tribal organizations and
territories have received a grant from HRSA to create or expand their
programs. Integrating mental health with primary care has been shown to
substantially expand access to subspecialist physicians, such as child
and adolescent psychiatrists, while boosting a pediatric provider's
knowledge of mental health care, improving health and functional
outcomes, increasing satisfaction with care and achieving cost savings.
Expanding the capacity of pediatric primary care providers to deliver
behavioral health through mental and behavioral health consultation
programs is one way to maximize a limited subspecialty workforce and to
help ensure more children with emerging or diagnosed mental health
disorders receive early interventions and continuous treatment.
Thank you again for your commitment to improving the current health
care workforce shortage. Children's hospitals and their affiliated
providers stand ready to partner with you to advance workforce policies
that will make measurable improvements in the lives of our Nation's
children.
Children need your help now.
______
Hon. John Hickenlooper, Chairman,
Hon. Mike Braun, Ranking Member,
U.S. Senate Committee Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety,
428 Dirksen Senate Office Building,
Washington, DC 20510.
Dear Chairman Hickenlooper and Ranking Member Braun:
On behalf of the 75,000 employees, including more than 10,000
physicians and 22,000 nurses of Advocate Aurora Health (Advocate
Aurora), I am writing to thank you for this opportunity to submit
written testimony for the record of the Thursday, February 10, 2022
hearing titled, ``Recruiting, Revitalizing & Diversifying: Examining
the Health Care Workforce Shortage.'' We very much appreciate your
attention to the current health care workforce shortage and, in
particular, highlighting the need to strengthen and diversify the
Nation's health care workforce. We stand ready to work with you and
your colleagues to ensure that the patients, families, and communities
we serve across Illinois and Wisconsin can continue to receive the
emergency, urgent, primary, specialty, post-acute, and home care they
need and deserve in the setting most appropriate for their particular
condition.
As you may know, Advocate Aurora is comprised of 27 acute care
hospitals, an integrated children's hospital and a psychiatric
hospital, and we offer inpatient, outpatient and physician-office based
primary and specialty physician services, pharmacy, rehabilitation,
home health, and hospice care. We provide a continuum of service at
more than 500 sites of care in northern Illinois and eastern Wisconsin.
We maintain a strong commitment to recruiting and retaining a diverse
workforce and creating and maintaining an inclusive, engaged working
environment across all our sites of care, where team members can pursue
their passion and feel supported, valued, and recognized.
Since the COVID-19 public health emergency (PHE) began, our team
members have experienced significant strain and stress due to the heavy
burdens associated with providing care to people infected with COVID-
19. Moreover, many of our team members themselves have been exposed,
requiring quarantine, and/or infected with COVID-19, turning our
caregivers into patients. The negative physical and mental health
impact of the PHE on our team member--and health care employees across
the country--has been sustained and must be recognized and addressed.
We are working hard to ensure our team members have the support
they need, as you will read in the attached Advocate Aurora Health
Workforce Issue Brief, which we submit as our written testimony.
Nonetheless, there remain myriad challenges facing front-line health
care workers as we enter the third year of the PHE and, we--like our
colleagues--continue to experience staff departures, turnover, and
other recruitment and retention challenges. Our normal vacancy rate
across our whole system typically--at any given time is 3,000 open
positions; currently, we have more than 6,000 unfilled positions.
Again, we thank you for holding this important hearing and draw
your attention to the attached Advocate Aurora Health Workforce Issue
Brief, which outlines what we are doing within Advocate Aurora to
diversify, strengthen, and retain our workforce as well as enumerates
the Federal policies and programs we need you and your colleagues to
support so that the Nation can bolster our health care workforce. We
thank you for your attention to our recommendations.
Please do not hesitate to contact me (Meghan.Woltman--aah.org, 312/
933-0455) or Tom McDaniels, Advocate Aurora Director Federal Government
Relations ([email protected], 202/409-0865) if we can answer any
questions or be of any assistance to you or your staff as you consider
next steps following the hearing.
Sincerely,
Meghan Woltman Chief,
Government Affairs Officer
______
american federation of teachers
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.
Chairman Hickenlooper:
On behalf of the 1.7 million members of the American Federation of
Teachers, including 230,000 healthcare professionals, I write to offer
our views on the workforce shortage in our Nation's health care system
in advance of your February 10, 2002, hearing (Recruiting, Revitalizing
& Diversifying: Examining the Health Care Workforce Shortage).
Simply put, there is a staffing crisis in our Nation's hospitals.
As Lucy King and Jonah Kessel powerfully laid out in their Jan. 19 New
York Times video editorial titled ``We Know the Real Cause of the
Crisis in Our Hospitals. It's Greed,'' our Nation's hospitals are
responsible for this crisis, which undermines the access to care and
the quality of care we all depend on, especially during a pandemic.
While the pandemic has strained our Nation's healthcare system and its
frontline healthcare workers to the breaking point and beyond, this is
a crisis that started well before the COVID-19 pandemic. Hospitals were
understaffed, in many cases dangerously so, long before the current
public health emergency. And now, frontline care givers are burned out,
exhausted from the moral injury of being forced to provide inadequate
care, and leaving hospital employment in record numbers.
As one of the Nation's largest unions of healthcare workers, a week
does not go by when we don't hear from frontline workers about
dangerously high patient loads; dangerous working conditions; and the
mental, physical and emotional toll this crisis has taken on them and
their families. The data paints an alarming picture. Since the
beginning of the COVID-19 pandemic, 18 percent of healthcare workers
(nearly 1 in 5) have quit their jobs. And for healthcare workers who
have stayed in their jobs, nearly 1 in 3 (31 percent) has considered
leaving. \1\ In a survey conducted by Mental Health America in summer
2020, 76 percent of healthcare workers reported exhaustion and burnout.
\2\ According to a Kaiser Family Foundation/Washington Post survey, a
majority of frontline healthcare workers (62
---------------------------------------------------------------------------
\1\ Morning Consult: https://morningconsult.com/2021/10/04/health-
care-workers-series-part-2-workforce/
\2\ Mental Health America: https://mhanational.org/mental-health-
healthcare-workers-covid-19
---------------------------------------------------------------------------
percent) say worry or stress related to COVID-19 has had a negative
impact on their mental health; and 13 percent of healthcare workers say
they have received mental health services or medication specifically
due to worry or stress related to COVID-19, with an additional 1 in 5
(18 percent) saying they thought they might need such services, but did
not get them. \3\ So it should come as no surprise that healthcare
workers are quitting; they are not just retiring early. Rather, we are
hearing increasing reports of mid-and early career health
professionals, some still paying off their student loans, quitting
their jobs because they simply cannot take it any longer. They are not
necessarily leaving the healthcare field, but they are definitely
leaving their hospital jobs.
---------------------------------------------------------------------------
\3\ Kaiser Family Foundation: https://www.kff.org/report-section/
kff-the-washington-post-frontline-health-care-workers-surveytoll-of-
the-pandemic/
While the American Hospital Association tries to dance around the
cause of this crisis, there is no denying its culpability in creating
it. The revenue-and profit-driven, often callous, decisionmaking of
hospitals put their economic bottom line ahead of patient care and the
safety of their frontline healthcare workers long before the current
pandemic. Quite simply, too many members of the AHA have failed their
most basic responsibility: providing a safe place for patients to
---------------------------------------------------------------------------
receive care from healthcare professionals.
Early in the pandemic, hospitals' decisions to save money by not
keeping sufficient stockpiles of personal protective equipment
needlessly exposed frontline care givers to infections. As a result, 34
percent of healthcare workers employed in either hospitals or nursing
homes said in the spring that at some point during the pandemic, their
workplace ran out of PPE for its employees. \4\ Sadly, 3,600 healthcare
workers paid the ultimate price, tragically dying during this pandemic.
\5\ Yet hospitals opposed the Occupational Safety and Health
Administration (OSHA) Healthcare Emergency Temporary Standard, which
was enacted far too late, and then following its withdrawal, too many
removed the limited protections that were put in place. And now an
increasing number of hospitals are considering requiring their COVID-
19-positive care givers to return to work before they are COVID-19-
free, denying them the time to get healthy themselves before they care
for others.
---------------------------------------------------------------------------
\4\ Kaiser Family Foundation: https://www.kff.org/report-section/
kff-the-washington-post-frontline-health-care-workers-surveytoll-of-
the-pandemic/
\5\ Kaiser Health News: https://khn.org/news/as-coronavirus-
spreads-widely--millions-of-older-americans-live-in-counties-withno-
icu-beds/
But the indifference of our Nation's hospitals to the safety of
their workforce started long before COVID-19. Hospitals have been one
of most dangerous places to work in America. Healthcare workers are
five times more likely to experience workplace violence than other
workers. In fact, in 2018, long before the COVID-19 pandemic, assaults
on healthcare workers accounted for 73 percent of all nonfatal
workplace violence. \6\ And there is every reason to believe that these
rates have only gotten worse during the pandemic. There is a desperate
need to pass legislation like the Workplace Violence Prevention for
Health Care and Social Service Workers Act.
---------------------------------------------------------------------------
\6\ U.S. Bureau of Labor Statistics: https://www.bls.gov/iif/
oshwc/cfoi/workplace-violence-healthcare-2018.htm
Patient loads before the pandemic undermined the quality of care.
Oppressive patient loads during the pandemic have broken the Nation's
healthcare workforce. Data tells us that adding just one additional
patient to a nurse's workload results in an increased risk of urinary
tract infections and surgical site infections, \7\ a 48 percent
increased risk of a child being readmitted to the hospital within 30
days, \8\ and a 7 percent increased risk of 30-day in hospital
mortality. \9\ This was true before the pandemic and will be true after
the pandemic. To address this issue, the Senate should move reasonable
legislation to require minimum staffing levels such as Sen. Sherrod
Brown's Nurse Staffing Standards for Hospital Patient Safety and
Quality Care Act.
---------------------------------------------------------------------------
\7\ Cimiotti et al., 2012: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3509207/pdf/nihms387953.pdf
\8\ Tubbs-Cooley et al., 2013: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3756461/pdf/bmjqs-2012-001610.pdf
\9\ Aiken et al., 2014: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4035380/pdf/nihms571000.pdf
There are additional strategies to address this crisis, such as
improving the pipeline for healthcare workers through expanded funding
for training programs as well as student financial aid, and making the
compensation more competitive with that provided by staffing agencies.
However, hospitals will continue to lose care givers more quickly than
they can be trained until hospitals stop treating healthcare workers
like disposable parts, and instead treat them like highly trained
professionals and provide them an appropriately staffed, safe place to
---------------------------------------------------------------------------
work that puts the quality of care above hospital profits.
Thank you for considering our views on this crucial topic. The AFT
looks forward to working with you on solutions to address the current
workforce shortages in our health care system.
Sincerely,
Randi Weingarten,
President, American Federation of Teachers.
______
National Nurses United
Silver Spring, MD 20910
February 8, 2022
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety,
428 Dirksen Senate Office Building,
Washington, DC 20510.
Dear Chairman Hickenlooper and Ranking Member Braun:
National Nurses United is the largest union and professional
association of registered nurses (RNs) in the United States,
representing more than 175,000 nurses across the country. Our members
have been on the frontlines of the Covid-19 response for 2 years and
are dealing first-hand with the repercussions of the nurse staffing
crisis that the health care industry is facing today. I write to you
today in advance of your hearing on ``Recruiting, Revitalizing &
Diversifying: Examining the Health Care Workforce Shortage,'' to
provide you with frontline insights into the working conditions that
have created this staffing crisis, and to discuss the important
solutions needed to address this crisis and ensure a robust health care
workforce in the future.
Throughout the Covid-19 pandemic, nurses have been dealing with
dangerous working conditions, including low RN staffing levels,
inadequate health and safety protections, insufficient stock of
critical medical supplies and PPE, and increasing levels of violence in
the workplace. While the Covid crisis has exacerbated these challenges,
nurses have been facing these issues in their hospital workplaces for
decades. The staffing crisis we are experiencing now is the result of
years of industry neglect and intentional policies of short-staffing
and cost-cutting measures enacted by hospital employers.
According to statistics from the National Council of State Boards
of Nursing and the U.S. Bureau of Labor Statistics, there are at least
1.2 million actively licenses registered nurses who are not employed as
RNs. There is no shortage of trained and licensed RNs, but there is a
shortage of good nursing jobs where RNs are valued for their work, have
strong health and safety protections, and are not required to care for
more patients at any given time than is safe for optimal, therapeutic
care. We don't have a shortage of nurses, but we do have a staffing
crisis.
The first step to addressing this staffing crisis is to revitalize
the workforce by increasing nurse retention and bringing licensed
nurses back to work. To do this, it is critical that the Federal
Government implement policies that will require the hospital industry
to provide safe and healthy workplaces.
Nurses are leaving the bedside because their employers refuse to
staff their units appropriately and fail to supply the resources
necessary to provide safe, therapeutic patient care. Many hospitals
have chosen to adopt policies that result in high patient caseloads
that compromise the health and safety of both nurses and patients.
Moreover, hospital employers have failed to implement programs to
protect nurses from infectious diseases, prevent violence, and enable
safe patient handling.
Although working conditions have been deteriorating for decades,
the problems intensified during the pandemic. Hospital employers showed
their disregard for nurses' health and safety by failing to implement
infection control practices and failing to provide appropriate PPE.
Nurses working on the pandemic's front lines are experiencing severe
moral distress and injury (often incorrectly labeled ``burnout'');
mental health issues such as stress, anxiety, depression, and post-
traumatic stress disorder; and physical exhaustion.
To bring nurses back to the bedside and increase nurse retention,
NNU recommends the following solutions:
Congress must mandate minimum nurse-to-patient
staffing ratios, through passage of the Nurse Staffing
Standards for Hospital Patient Safety and Quality Care Act,
sponsored by Senator Sherrod Brown and Congresswoman Jan
Schakowsky.
The Occupational Safety and Health Administration
(OSHA) must issue a final permanent Covid-19 Health Care
Standard to enforce Covid protections for health care workers
and retain its Emergency Temporary Standard until the permanent
standard takes effect. Further, OSHA should issue an Infectious
Diseases standard, so that workplace protections will be
enforced during future infectious disease outbreaks.
Congress must pass the Workplace Violence Prevention
for Health Care and Social Service Workers Act, sponsored by
Congressman Joe Courtney and passed in the House of
Representatives, and introduced by Senator Tammy Baldwin in the
116th Congress. The bill would mandate that OSHA issue a
Workplace Violence Prevention Standard for health care and
social service workplaces.
The Federal Government must do everything in its
power to restore and protect the right of nurses and other
health care workers to organize and bargain collectively.
While there is no general nursing shortage in the United States,
there is a lack of racial, ethnic, cultural, linguistic, and
socioeconomic diversity within the current nursing workforce. This
challenge has resulted from a lack of investment in nursing education,
job placement, and hospital industry practices that have restricted the
pipeline of nurses from socioeconomically diverse and underserved
communities. The Federal Government should take measures to recruit
nurses from underserved communities, and to ensure that hospital
industry practices support a diverse nursing pipeline.
Diversity in the health care workforce facilitates health care
access and health care quality, necessary elements of health equity.
Patient-provider racial, ethnic, and linguistic concordance improves
communication, trust, and health care quality. Black, Indigenous, and
People of Color (BIPOC) communities, along with rural communities,
often have fewer health care professionals practicing locally and even
fewer who are culturally and linguistically competent. Studies show
that Black, Hispanic/Latinx, and Native American health care providers
are more likely to practice in underserved communities. \1\ Similarly,
students from rural areas are more likely to practice in rural
communities. \2\
---------------------------------------------------------------------------
\1\ Pittman P et al. 2021. Health Workforce for Health Equity.
Medical care, 59(Suppl 5), S405--S408. https://doi.org/10.1097/
MLR.0000000000001609. Citing Goodfellow A et al. Predictors of primary
care physician practice location in underserved urban or rural areas in
the United States: a systematic literature review. Acad Med.
2016;91:1313--1321 and Mertz E et al. Underrepresented minority
dentists: quantifying their numbers and characterizing the communities
they serve. Health Aff. 2016;35:2190--2199
\2\ Ibid.. Citing Rabinowitz H et al. The relationship between
entering medical students' backgrounds and career plans and their rural
practice outcomes three decades later. Acad Med. 2012;87:493--497.
MacQueen I et al. Recruiting rural healthcare providers today: a
systematic review of training program success and determinants of
geographic choices. J Gen Intern Med. 2018;33:191--199
To increase diversity within the nursing workforce, investments
must be made to support education and job placement for nurses from
underrepresented communities. This should include the following
---------------------------------------------------------------------------
investments:
Long-term funding for tuition free nursing programs
at community colleges
Increased funding for the Nursing Workforce Diversity
Program
Increased funding for Nurse Corps scholarship and
loan repayment programs
At the hospital level, the industry needs to adjust practices that
have limited the ability for nurses from underrepresented communities
to find work. Most notably, some hospitals refuse to hire nurses with
an associate degree in nursing (ADN), choosing to prioritize hiring of
nurses with 4-year bachelor's degrees of nursing (BSNs). Nurses with
ADN and BSN degrees must fulfill the same education and clinical
experience requirements, and they must pass the same licensing
examination. By choosing to prioritize BSN nurses, hospitals are
restricting diversity in the workforce. A BSN requires a larger time
and financial commitment, and statistics on RN graduates show that
nurses from underrepresented communities, and specifically communities
of color, are more likely to graduate with an ADN. It is important to
note that hospitals refusing to hire nurses with ADNs is happening
while the hospital industry is lobbying to delegate nursing work to
lesser licensed and unlicensed personnel and family members.
As the Committee explores approaches to addressing the current
health care staffing crisis, it is crucial to protect RNs' scope of
practice. We urge you to focus on providing the resources needed to
educate more RNs in 2-year nursing programs rather than on
``upskilling'' other workers. Nursing practice is fundamentally
holistic in nature. Registered nurses have extensive education and
clinical experience that enables them to provide safe, therapeutic
patient care. Attempts to break down registered nursing practice into
tasks, and shifting the tasks to unlicensed workers, undermines patient
care. Even the simplest RN-patient interactions involve skilled
assessment and evaluation of the patient's overall condition. Subtle
changes in a patient's skin tone, respiratory rate, demeanor, and
affect provide critical information to their health and well-being that
can be easily overlooked or misinterpreted by those without an RN's
education and clinical experience.
Attached to this letter is NNU's report, ``Protecting Our Front
Line: Ending the Shortage of Good Nursing Jobs and the Industry-Created
Unsafe Staffing Crisis,'' which contains more detailed information on
the hospital industry practices that have created the nurse staffing
crisis we are experiencing right now, and NNU's proposed solutions to
increase nurse retention and diversity.
We look forward to working with your Committee to protect the
workplace health and safety of nurses, improve staffing levels and
nurse retention, and build a sustainable nursing workforce well into
the future.
Sincerely,
Zenei Triunfo-Cortez (RN),
President,
National Nurses United
______
National Healthcareer Association
Leawood, KS 66211
February 10, 2022
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.
Dear Chairman Hickenlooper and Ranking Member Braun:
On behalf of the more than 380,000 nationally certified allied
health professionals that the National Healthcareer Association (NHA)
represents, thank you for holding the important hearing on Recruiting,
Revitalizing & Diversifying: Examining the Health Care Shortage. This
is an extremely important and timely topic.
Since 1989, NHA has prepared and awarded more than one million
certifications to healthcare students and professionals, providing them
with nationally recognized measurements of competency and easy-to-use
training and study resources paired with high quality, personalized
customer care. NHA is passionately committed to develop, advance, and
advocate for the frontline healthcare worker, resulting in improved
patient care. It does this by working with thousands of secondary,
post-secondary schools, and health care employers across the country to
assist with the training and certification of professionals in the
following areas:
Medical Assisting (Clinical and Administrative)
Pharmacy Technician
Phlebotomy
EKG Technician
Patient Care Technician
Billing and Coding Specialist
Electronic Health Records Specialist
In 2022, more than ever, the healthcare industry is at the core of
our Nation's success. The pipeline to healthcare careers has been
greatly impacted by Covid-19 challenges and shutdowns. Based on
research we conducted in 2021, enrollments of first-year students at 2-
year institutions is down 21 percent compared to pre-pandemic numbers.
For example, in 2019 schools were producing around 60,000 medical
assistants (MA). In March 2021, ZipRecruiter.com had nearly 700,000
open MA positions. We also have data showing that 88 percent of
healthcare leaders report having difficulty recruiting medical
assistants. In addition, female workers represent nearly 70 percent of
the global healthcare workforce and according to the National Women's
Law Center Analysis, four times as many women as men dropped out of the
labor force in September 2020. Please use this link to access these
statics and more compelling articles as a part of NHA's annual allied
health industry journal Access.
As the Committee on Health, Education, Labor & Pensions considers
this important topic, we urge your support for the following principles
and urge the Committee to consider and pass these principles into
legislation as swiftly as possible:
Reauthorization of the Health Profession Opportunity
Grant (HPOG) Program, which provides grants for the purpose of
preparing certain low-income individuals to enter into the
health care profession;
Inclusion of authorization for increased home care
funding to recruit and retain direct care workers and improve
care wages through training, registered apprenticeships, the
creation of career pathways, and mentoring;
Authorization for funding for higher education and
workforce development, including:
Y Adult and Dislocated Worker Employment and Training
Activities and for Youth Workforce Investments under
the Workforce Innovation and Opportunity Act
Y Expanded registered apprenticeships, pre-
apprenticeships, and youth apprenticeships. We urge the
Committee to ensure these opportunities include people
with barriers to employment, people with disabilities,
and populations underrepresented in apprenticeships;
Y Industry or private sector partnerships that would
bring together state and local workforce boards,
employers, labor organizations, and education and
training providers to expand training for high-skill,
high-wage, or in-demand industries such as health care;
Y Authorization and funds for core Title I WIOA
program activities;
Y Dedicated funding for state and local workforce
development boards to implement industry and sector
partnership grants;
Y Inclusion of an increase in the maximum Pell Grant
award;
Y Retention and Completion Grants to eligible states
and state systems to support the development of
practices that have been shown to improve student
outcomes, such as providing comprehensive academic,
career, and student support services; assistance in
applying for financial aid or mean-tested benefits;
accelerated learning opportunities; an improved
developmental education and transfer pathways; and
Y Career and technical education grants for CTE
programs and to carry out an innovation and
modernization programs.
As NHA continues to advance and advocate for frontline healthcare
workers, we strive to create a ripple effect on the healthcare
industry. By working to certify professionals who meet a national
recognized measure of competency, we help improve patient care and make
for a better, more thoughtful patient experience. As the current COVID
pandemic continues to demonstrate, the need for high quality healthcare
workers is more important than ever. Continued support of the above
principles is essential to meet the need for qualified healthcare
workers now and in the future.
Sincerely,
Jessica Langley,
Executive Director of Education and Advocacy,
National Healthcareer Association
______
Federation of American Hospitals,
Washington, DC 20001,
February 10, 2022.
Senator John Hickenlooper, Chairman,
Senator Mike Braun, Ranking Member,
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety,
428 Dirksen Senate Office Building,
Washington, DC 20510.
Dear Chairman Hickenlooper and Ranking Member Braun:
On behalf of the Federation of American Hospitals (FAH), thank you
for the opportunity to comment in advance of the Senate Health,
Education, Labor, and Pensions (HELP) Subcommittee on Employment and
Workplace Safety hearing, Recruiting, Revitalizing & Diversifying:
Examining the Health Care Workforce Shortage.
The FAH is the national representative of more than 1,000 leading
tax-paying hospitals and health systems throughout the United States.
FAH members provide patients and communities with access to high-
quality, affordable care in both urban and rural areas across 46
states, plus Washington, DC and Puerto Rico. Our members include
teaching, acute, inpatient rehabilitation, behavioral health, and long-
term care hospitals and provide a wide range of inpatient, ambulatory,
post-acute, emergency, children's, and cancer services.
Health Care Workforce: Challenges and Solutions
As the third year of the pandemic begins, the mental and physical
toll of the COVID-19 public health emergency (PHE or pandemic) has put
an unprecedented strain on our frontline caregivers and hospital
support staff. The struggle to maintain a robust workforce has been
exacerbated in recent months as Omicron has rapidly spread, while
potential future variants also threaten to sideline critically needed
health care providers. At the same time, caregivers are still bearing
the emotional burden of treating patients throughout multiple COVID-19
waves.
The pandemic continues to have lingering effects on health care
providers, as we are seeing rising instances of burnout and
resignation. According to the American College of Healthcare
Executives' annual survey, hospital CEOs reported `personnel shortages'
as their top organizational concern. \1\ FAH members are experiencing
staffing shortages that existed prior to COVID-19 and have become
significantly more pronounced and problematic due to the strain and
ongoing nature of the PHE. We therefore must implement policy solutions
that will yield short and long-term stability in the recruitment,
retention, and diversification of our health care workforce.
---------------------------------------------------------------------------
\1\ https://www.ache.org/learning--center/research/about--the---
field/top--issues--confronting--hospitals
FAH members are experiencing shortages of medical technicians,
laboratory assistants, and nurses, as well as food service,
housekeeping, and sanitation staff, and in some instances, hospitals do
not have enough staff to operate at full capacity. To ensure that
patient care and general operations are not compromised, hospitals have
been forced to significantly increase their reliance on contract labor
---------------------------------------------------------------------------
and staffing companies.
It has been widely reported that nurse-staffing agencies are
exploiting the COVID-19 crisis with predatory price increases that can
be disconnected from the wages paid to these contract nurses who are
providing needed clinical care to hospitals. Bipartisan Members of the
House and Senate have expressed concerns over these practices and, in
particular, worry that hospitals will be unable to sustain these
exorbitant staffing costs. We join those in Congress to urge the
Administration to investigate nurse-staffing agencies' conduct during
the pandemic through Federal agencies with jurisdiction.
We further urge Congress to prioritize certain
measures to support frontline health care providers and
maintain a strong workforce, including:
Extending the Medicare-funded residency training
slots cap building period to 10 years, as opposed to the
current 5 years, for new teaching hospitals
Enacting the Healthcare Workforce Resilience Act to
recapture 25,000 unused immigrant visas for nurses and 15,000
unused immigrant visas for doctors that Congress has previously
authorized and allocate those visas to international doctors
and nurses
Enhancing investment in provider loan repayment
programs, including the Nurse Corps, to incentivize providing
care in rural and underserved communities
Enacting the Technical Reset to Advance the
Instruction of Nurses (TRAIN) Act, which would prohibit the
Centers for Medicare and Medicaid Services (CMS) from recouping
overpayments made in past years to hospital-based nursing and
allied health education programs when CMS failed to make
technical annual updates to the program, and instead invest
those resources in training the next generation of caregivers
Ensuring any policy that increases Pell Grant funding
makes certain that nursing students are eligible to receive
such benefits to attend high-quality nursing schools,
regardless of the educational institution's tax status
Enacting the Conrad State 30 and Physician Access
Reauthorization Act to extend and expand the Conrad 30 program.
Parity for Tax-Paying Hospitals--and Our Workforce--is Needed Regarding
Eligibility for Federal Health-Related Programs
We strongly urge Congress to expand the eligibility of Federal
health-related programs that currently and unjustly exclude tax-paying
hospitals--and thereby our workforce--to the detriment of our patients
and communities. Tax-paying hospitals are not eligible to apply for
many Federal programs, including some within the Public Health Service
Act, based solely on their tax-filing status. This lack of program
access among tax-paying hospitals, especially in rural communities,
unjustly ignores a significant component of the health care safety net
serving impoverished and uninsured patients.
For example, for years, nurses practicing at tax-paying hospitals
located in a critical shortage area were ineligible to benefit from the
Nurse Corps Loan Repayment program--a key recruitment tactic that
incentivizes patient care in rural and underserved communities. With
the leadership of the Senate HELP Committee and other bipartisan
Members of the House and Senate, this eligibility restriction was
finally struck in The Coronavirus Aid, Relief, and Economic Security
(CARES) Act in the 116th Congress. But we now need an across-the-board
solution that can play a pivotal role in addressing the health care
workforce crisis.
As a first step toward rectifying this matter, we urge the Senate
HELP Committee to direct the Government Accountability Office (GAO) to
prepare a comprehensive analysis of all Federal health care programs
that exclude tax-paying hospitals (and/or providers serving in such
facilities) from eligibility. Such an analysis will shed light on how
this lack of parity is a disservice to the health care workforce and
our patients, and further demonstrate the dire need for Congress to
take corrective action.
We appreciate the opportunity to comment and look forward to
working with you in 2022 to meet the significant challenges that
hospitals face in treating patients during these unprecedented times.
If you have any questions or wish to discuss these issues further,
please do not hesitate to reach out to me or a member of my staff at
202-624-1534.
Sincerely,
Charles N. Kahn, III,
President and CEO.
______
Global Medical Response,
Greenwood Village, CO 80111,
February 10, 2022.
Senator John Hickenlooper, Chairman
Senator Mike Braun, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Employment and Workplace Safety
428 Dirksen Senate Office Building,
Washington, DC 20510.
Dear Chairman Hickenlooper and Ranking Member Braun:
We appreciate the opportunity to submit written testimony for the
Senate Health, Education, Labor, and Pensions Committee's Subcommittee
on Employment and Workplace Safety hearing: Recruiting, Revitalizing &
Diversifying: Examining the Health Care Workforce Shortage. While
workforce shortages are impacting every aspect of the health care
industry, the multiple headwinds facing the private ambulance industry
in particular have resulted in a staffing crisis at a time when our EMS
professionals have been challenged with unprecedented numbers of
acutely ill and injured patients during the COVID-19 pandemic, natural
disasters and other emergencies. We appreciate the attention this
Committee is providing to resolving this crisis and we urge you to
address and incorporate EMS professionals in any of your policy
solutions to help recruitment and efforts to diversify the health care
workforce.
Global Medical Response (GMR) is the largest air and ground medical
transportation company in the United States with more than 36,000
employees, including 25,000 clinicians and 11,000 support staff across
most of the lower 48 states, Alaska and Hawaii. GMR team members
perform a critical intervention every 9 minutes and completed more than
five million patient transports last year, utilizing 8,700 ground
vehicles, 158 fire vehicles, 344 helicopters and 111 airplanes. As the
Nation's largest provider of emergency medical services and medical
transportation, we are on the frontlines both in the communities we
serve, as well as in the areas that needed additional aid to supplement
fellow emergency service providers. We are especially proud to service
rural and underserved areas, where so many Americans rely on our
services to navigate long distances to reach facilities that can
provide the appropriate level of care. GMR provides the ``last mile''
infrastructure that helps secure critical care for over 43 percent of
the rural counties in the United States.
Our mission is to provide care at a moment's notice, and this
guides our emphasis on patient-driven care that can respond to any
health issue in any emergency scenario with the utmost quality. Due to
our emphasis on giving the patient the highest quality care, we provide
extensive training to our paramedics, emergency medical technicians
(EMTs), and registered nurses (RNs). We value the skill set of these
EMS professionals--who are called on to provide care on wheels or in
the sky in high-stress situations--and we work with states and
municipalities around the country to meet their unique requirements and
needs. Many of our workforce moves around the health care field to
serve in other capacities, and we take pride in ensuring that they can
transfer the skills they learn with GMR into other segments of the
industry.
Since the start of the pandemic, GMR's EMTs, paramedics, nurses,
physicians, and other caregivers have led the country's COVID-19
response, risking their personal safety to administer life-saving care.
We have made more than 350,000 COVID-19 patient transports and made
emergency FEMA deployments to 31states including six states represented
on this Subcommittee during coronavirus surges. GMR employees also
screened more than 500,000 passengers for COVID-19 at airports and
other ports of entry.
Proud of our partnership with the Federal Emergency Management
Agency (FEMA), GMR continued to respond to natural disasters, whose
impact have been exacerbated by the pandemic. Since the virus first
appeared in the United States, we participated in 7,874 patient
missions in response to devastating wildfires and led operations
deploying more than 600 ambulances and 25 airplanes in response to
Hurricane Laura, Hurricane Delta, and Hurricane Zeta. To support these
operations, we procured more than 25 million medical and K-95 masks, as
well as 55 million gloves and gowns.
In addition to the substantial time and effort GMR's first
responders have devoted to confronting COVID-19, the company has made
significant economic investments to protect its employees during the
pandemic. Since March 2020, GMR has incurred $230 million in
incremental expenses related to COVID. This includes $70 million in
employee assistance like payments to staffers under quarantine,
childcare stipends, workers compensation and health insurance, and one-
time bonuses. It also included $40 million for personal protective
equipment (PPE) and cleaning costs. Additionally, GMR delivered
approximately $30 million in one-time retention payments, made $90
million in annualized wage adjustments, and approved nearly 93 percent
of its 632 childcare stipend application requests. This has come at
significant financial cost to the company, but we have done it because
without our first responders, we would be unable to service vulnerable
populations under our care.
As a company, GMR has also been proactive in recruiting talent and
training the next generation of EMS providers. Our driving force for
retention and recruitment is the ability to save lives and impact
patient care and outcomes. In 2018, we launched the Earn While You
Learn program, a GMR academy that pays prospective EMTs during their
training and certification process. Since 2018, more than 800 students
have graduated from Earn While You Learn programs at 59 locations
nationwide, over 35 percent of whom were minorities. In addition to our
Earn While You Learn program, 593 students graduated from paramedic and
EMT training programs from GMR's National Training Center in 2021
joining 523 graduates in 2020.
We have put into place a variety of other recruitment and incentive
programs to attract and retain staff. These include reducing hours on
call, providing bonuses and increased wages, providing wellness and
stress management resources. And 10 years ago, the company established
a GMR employee foundation to provide paid time off (PTO) and financial
assistance in times of need to other GMR employees. In the last 2 years
the company has provided over $1 million to employees to cover emergent
personal needs.
Despite our best efforts, this has not been enough. Even before the
pandemic, the EMS workforce was hobbled by a lack of a pipeline to
train professionals, significant burnout and stress, a competitive
market, and unpredictable needs for ground ambulance protocols.
According to a 2021 survey by the American Ambulance Association
involving nearly 20,000 employees and 258 EMS organizations, overall
turnover among paramedics and EMTs ranges from 20 to 30 percent
annually, meaning that ambulance services could face a 100 percent
turnover in a 4-year period. This has only been exacerbated by the
coronavirus pandemic when in-person training was halted for a period of
time further straining an already deteriorating pipeline and the
industry began to face increased competition from others in the
healthcare industry who were able to hire away EMS professionals to
work in other settings for higher pay. These staffing shortages are
problematic, and compromise GMR's ability to respond to healthcare
emergencies.
Despite the essential work our EMS professionals perform, economic
headwinds facing the industry continue to contribute to a staffing
crisis for private ambulance companies. These systemic headwinds have
been left unaddressed for years and we hope to work with this Committee
to enact policy changes that result in a viable, sustainable workforce.
This crisis is driven largely by the low reimbursement rates these
companies receive from Medicare and Medicaid. While Medicare and
Medicaid rates for ground and air transports are well below cost and
comprise close to 70 percent of GMR's total transports along with
uninsured patients, our crews are required to respond to patient
emergency requests regardless of the patient's ability to pay; medical
crews respond to these requests within minutes--day or night, operating
24 hours per day 7 days per week.
GMR strongly believes the best way to alleviate the issue is to
permanently update the Medicare and Medicaid reimbursement rates to
reflect the standard of care. In the meantime, a temporary Medicare
payment increase that reflects costs to increase wages and competes
with the rest of the health care could also infuse additional funds
into the workforce and spur innovative responses to workforce
shortages. Appropriate reimbursement by government payors will allow
private companies to increase wages for EMTs and alleviate the staffing
crisis.
In addition, we support additional steps Congress can take to
alleviate the impact of the workforce shortage. Congress can provide
specific direction and funds to the Health Resources and Services
Administration (HRSA), which can be used to pay for training and
professional development programs. HRSA can also disburse funds through
grant programs to be paid directly to paramedics and EMTs for training
initiatives In addition, Congress should strongly consider expanding
HRSA loan repayment programs to include EMS professionals and establish
a grant program providing funding to payors, public and private
universities, and local governments to reimburse costs associated with
education, loan forgiveness, and relocation for individuals who are
pursuing careers in emergency transportation services.
While a temporary solution, we support a Medicaid Federal Medical
Assistance Percentage (FMAP) increase of 10 percent for emergency
transportation services, identical to what was provided to home and
community-based services during the pandemic.
Finally, we support tax incentives for organizations who absorb
significant costs due to uncompensated care and allocate significant
resources to paying prospective EMS professionals while they get
certified so they may serve their local community.
It is important to note that many of our clinicians further their
medical training to become nurses and even doctors. EMS is a pathway
for recruitment and advancement of medical professionals across the
health care system. We work with our team members to advance their
learning and graduate from medical technician status to paramedic and
to even become flight nurses and partner with hospitals on their
staffing needs. We also invest in recruitment efforts to have our teams
reflect the communities they serve.
The more we can professionalize the emergency response industry and
recognize the essential contributions EMS make to keeping our country
healthy, the better it will be to retain and recruit people at this
critical time while establishing a long-term sustainable workforce.
Unfortunately, in the meantime, healthcare workforce shortages continue
to meaningfully compromise our ability to respond to medical
emergencies. Our workforce delivers services that are integral to the
health care ecosystem. When frontline EMS is not available or delayed
in responding due to staffing issues, the end result can be devastating
to patients in need of critical care within minutes to prevent
irreversible harm or even death. We thank you for your attention to
this essential matter. We stand prepared to assist in ensuring the
continuity of emergency medical care and are eager to work with you on
how revitalize and diversify the heath care workforce.
------
[[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[Whereupon, at 11:39 a.m., the hearing was adjourned.]
[all]