the American Association of Colleges of Osteopathic Medicine

PURPOSE
The purpose of this hearing was to examine how various public health programs are working and better understand any gaps that may need to be addressed.

MEMBERS PRESENT
Chairman Guthrie (R-FL), Vice Chair Bucshon (R-IN), Ranking Member Eshoo (D-CA), Chair of Full Committee McMorris Rodgers (R-WA), Ranking Member of Full Committee Pallone (D-NJ), Reps. Burgess (R-TX), Latta (R-OH), Griffith (R-VA), Bilirakis (R-FL), Johnson (R-OH), Hudson (R-NC), Carter (R-GA), Crenshaw (R-IN), Joyce (R-PA), Harshbarger (R-TN), Miller-Meeks (R-IA), Sarbanes (D-MD), Cardenas (D-CA), Ruiz (D-CA), Kuster (D-NH), Kelly (D-IL), Barragan (D-CA), Blunt Rochester (D-DE), Schrier (D-WA).

WITNESSES
• Carole Johnson, Administrator, Health Resources and Services Administration, U.S. Department of Health and Human Services (HRSA)

KEY TAKEAWAYS
H.R. 2559, the Strengthening Community Care Act of 2023

H.R. 2559, the “Strengthening Community Care Act of 2023” authored by Rep. Joyce (R-PA), Rep. Blunt Rochester (D-DE), Rep. Stefanik (R-NY), and Rep. Fletcher (D-TX) would extend funding for the Community Health Center Fund and National Health Service Corps for five years.
Administrator Johnson highlighted the need for stable funding for these programs, as they are critical to providing services and addressing workforce shortages in rural and underserved communities. Representatives showed support for these programs, especially the work of Community Health Centers (CHCs) in their communities.

H.R._____, to extend funding for the Teaching Health Center Graduate Medical Education

Program H.R.___, would extend funding for the Teaching Health Center Graduate Medical Education (THCGME) program for three years.
Administrator Johnson discussed how this innovative program trains people in underserved communities and encourages them to remain in these communities after training. However, she noted that the lack of guaranteed funding complicates recruitment, as the funds cannot even be ensured through the full course of residency. Representatives seemed to understand the value of these programs for rural and underserved communities.

H.R. 2569, the Doctors of Community or the DOC Act

H.R. 2569, the “DOC Act”, authored by Rep. Pallone (D-NJ) would make the Teaching Health Center Graduate Medical Education program permanent and increase its funding to $582.7 million by FY33.
Administrator Johnson emphasized the need for consistent funding for this program to ensure it is operating at its full potential. It appeared that more representatives supported the extension of funding rather than ensuring permanent funding.

H.R. 2544, the Securing the U.S. Organ Procurement and Transplantation Network Act

H.R. 2544, the “Securing the U.S. Organ Procurement and Transplantation Network Act” authored by Rep. Bucshon (R-IN) and Rep. Kelly (D-IL) would amend section 372 of the Public Health Service Act to allow for additional flexibilities within the Organ Procurement and Transplantation Network (OPTN).
Administrator Johnson explained that opening contracts for the OPTN and creating competition for these contracts will help ensure all aspects of the system are operating efficiently and effectively. She highlighted that this would help increase access and ensure more equitable access to organ transplants. Representatives expressed support for this modernization effort.

There was significant discussion surrounding the exploitation of 340B savings by non-profit hospitals and Pharmacy Benefit Managers (PBMs). Rep. Carter (R-GA), Rep. Griffith (R-VA), Rep. Burgess (R-TX), and Rep. Joyce (R-PA) urged transparency and accountability in this space.

OPENING STATEMENTS
Chairman Guthrie (R-KY) stated that the Health Subcommittee is taking important steps to reauthorize important programs that increase healthcare access to Americans. He said that the Strengthening Community Care Act of 2023 (H.R. 2559) allows millions of Americans in underserved communities access to primary care services. He said he is committed to extending funding for the teaching Health Center Graduate Medical Education Program. He added that these programs should not be made permanent at this time. He discussed the National Nursing Workforce Center Act of 2023 (H.R. 2411) and said that it would provide targeted investments that reflect the needs of local communities. He also plugged his Building America’s Healthcare Workforce Act, which addresses workforce shortages in the long-term care community. Also, he mentioned the reauthorization of two type-I diabetes programs. He explained that the Securing the US Organ Procurement and Transplantation Network Act (H.R. 2544) would increase transparency and access to care for over 100,000 individuals in need of an organ transplant. Lastly, he discussed the proposal to improve transparency in the Covered Countermeasures Injury Compensation Program to ensure claimants are receiving adequate information in a timely manner.
Ranking Member Eshoo (D-CA) discussed the importance of HRSA’s grants in driving policy. She stated that the hearing would focus on eight bills to extend critical public health programs, bolster the health workforce, and address the broken organ transplant system. First, she highlighted a bill to extend mandatory funding to community health centers (CHCs) and the National Health Service Corps (NHSC) for five years. The Community Health Center Fund provides support to nearly 14,000 CHCs across the country, providing care to 1 in 11 Americans. She expressed disappointment that funding for these programs has not been adjusted for inflation, but she supports the bipartisan reauthorization. She discussed the importance other programs they are considering to improve access to primary care, such as the THCGME Program. She said this program needs more funding, and she supports the motion to permanently authorize the program.
Chair of Full Committee McMorris Rodgers (R-WA) discussed the goal of the hearing. She explained that the Strengthening Community Care Act of 2023 will reauthorize the Community Health Center Fund and the National Health Service Corps to help address primary care workforce shortages. She discussed the work CHCs in her district are doing to address these issues. She named New Health’s initiatives to create workforce pipelines from local and rural high schools and to create workforce training centers. She added that Chaz Health is giving high school students the opportunity to attend training sessions. She stated that these efforts will increase the healthcare workforce in the community. Additionally, she expressed support for extending funding for the THCGME Program. She also discussed the National Nursing Workforce Center Act of 2023 to enhance state-based nursing workforce centers. She added that the Securing the US Organ Procurement and Transplantation Network Act will bring organs to more people in need with more competitive contracts. Furthermore, she highlighted the proposal to improve transparency in the Covered Countermeasures Injury Compensation Program. Finally, she noted the Special Diabetes Program Reauthorization Act of 2023 and the Special Diabetes Program for Indians Reauthorization Act of 2023.
Ranking Member of Full Committee Pallone (D-NJ) highlighted his bill the DOC Act (H.R. 2569) which permanently authorizes and increases funding to the THCGME Program, which supports the training of primary care and dental residents in underserved communities. The program was reauthorized multiple times but needs permanency to ensure the program can work to its full potential. He also noted the importance of reauthorizing the Community Health Center Fund and added that the funding should be at a higher level. Additionally, he discussed the importance of the Special Diabetes Program and the Special Diabetes Program for Indians Program. He discussed the need to improve the Organ Procurement and Transplant Network (OPTN). Finally, he called on the Committee to schedule a hearing to examine the health impacts of judge decisions to negate Federal Drug Administration (FDA) drug approvals.

TESTIMONY
Administrator Johnson emphasize the importance of HRSA programs and thanked the committee for bipartisan support of these programs. She highlighted three important HRSA programs. First, she discussed the Community Health Center Program and explained that CHCs are a vital source of care for rural and underserved communities. Next, she discussed the NHSC, which provides scholarships and loan repayment to clinicians in exchange for working in workforce shortage areas. Finally, she highlighted the THCGME Program. The President’s Budget included three years of mandatory funding for these programs. She explained that multiyear funding for these programs would provide stability and assurance for these programs and the students and clinicians that participate in them. She added that the proposed funding for CHCs would sustain current services and allow for the expansion of services at additional sites. The funding for the NHSC would sustain the current historic level of practicing providers in health worker shortage areas. Finally, the funding for Teach Health Centers would expand programs and help new programs come online. These programs help bring physicians into rural and underserved communities and keep them there long-term.

QUESTIONS AND ANSWERS

Chairman Guthrie (R-KY) asked how HRSA measures success within programs that bring medical providers into underserved communities. Administrator Johnson said HRSA tracks how long people practice in these communities as part of their service and whether they stay in these communities. She stated that HRSA the two-year retention rate post commitment to service is 86%. She said HRSA is also building capacity to monitor this past the two-year survey. Chairman Guthrie asked how many residents practice in workforce shortage areas. Administrator Johnson said that the THCGME Program does not have the same service commitment requirement as the loan repayment programs. She explained that the goal of the Teaching Health Centers is to encourage providers to stay in the areas they are trained. She said more than half of the individuals trained in this program have stayed in these communities. Administrator Johnson said HRSA measures the success of these programs is evidenced by the demand for these programs among providers, as many state they would have not been able to work in these areas without the loan incentives and training opportunities. She added that the fact that many of these providers remain in these areas is an important measure of success. Chairman Guthrie emphasized the importance of programs like these in increasing access for rural and underserved communities.

Ranking Member Eshoo (D-CA) stated that the OPTN needs modernization and efficiency. She asked why it is necessary that HRSA can create more competitive contracts for the OPTN. Administrator Johnson said that this system is critical for Americans, but it is not fair or run well. She said HRSA believes that all aspects of the system should not be under the same non-competitive contract. Ranking Member Eshoo asked if the legislation the committee is considering fulfills this request. Administrator Johnson said that HRSA is still providing technical assistance to the committee surrounding this bill, but they are excited to work on this going forward. Ranking Member Eshoo asked how CHCs were impacted when the CHC Fund lapsed in 2019. Administrator Johnson said that instability in funding creates disruptions in day-to-day services and in the ability to compete for workers. Rep. Eshoo discussed how CHCs are preparing for Medicaid unwinding. Administrator Johnson said that CHCs will need to see the individuals who lose their Medicaid coverage and fall through the cracks.

Rep. Burgess (R-TX) said that he has several questions on the 340B program but may need to submit them to the record in interest of time. He discussed a concept proposed by Rep. Sarbanes last year to encourage physician reentry. He asked if a physician reentry program would work if federal dollars were used strictly to offset the costs of training, credentialing, and reentering physicians. Administrator Johnson said that conceptually this is a great goal and is true of nurses and the workforce at large. Rep. Burgess asked if HRSA collects data on the effectiveness of the current workforce programs. Administrator Johnson said that HRSA collects data on who participates and the associated outcomes. She said HRSA is constantly evaluating these programs to see if they are ass accessible, effective, and efficient as possible. Rep. Burgess asked if there is data on if the physicians coming from the NHSC go to work for large companies like Optum. Administrator Johnson said HRSA does the two-year post-commitment assessment and is working to increase tracking beyond that time. Rep. Burgess said that he hopes this committee will work on the concept of physician-owned hospitals.

Rep. Sarbanes (D-MD) thanked Rep. Burgess for his support of physician reentry. He also expressed support to enact policies to support a stronger, more diverse workforce. He discussed the National Nursing Workforce Center Act. He noted that workforce solutions must span provider types and geographic areas. He asked if she could emphasize what it would mean to increase our commitment to the NHSC and other service-based programs. Administrator Johnson said that workforce is a top priority for health centers right now. She added that innovation to improve how we can improve and expand community-based training and removing barriers to entry is essential.

Chair to Full Committee McMorris Rogers (R-WA) asked how many workforce programs HRSA currently administers and how performance is tied to these programs. Administrator Johnson said there are 50 different workforce funding opportunities. She said performance outcomes are a weighted factor in determining future funding for these grants. Chair McMorris Rogers asked how using existing American Rescue Plan Act (ARPA) funds to increase funding to Teaching Health Centers will impact that existing centers. Administrator Johnson said that the President’s Budget is built so that HRSA can take advantage of existing funds to help current awardees and support new centers. Chair McMorris Rogers asked how health center revenues have changed since 2017. Administrator Johnson said that health centers have continued to be the resource in underserved and underinsured communities regardless of Medicaid expansion status. Chair McMorris Rogers expressed concern for the number of individuals that are denied an organ transplant based solely on disability status. She asked what steps HRSA has taken to address this discrimination. Administrator Johnson said that HRSA is working to increase accountability and oversight of the OPTN system. She said increasing transparency and equity is essential.

Ranking Member Full Committee Pallone (D-NJ) emphasized his concern with the recent court decisions negating FDA approval of mifepristone. He asked what impact these decisions will have on the healthcare workforce. Administrator Johnson said that it is essential to respect the privacy and respect of the patient-provider relationship. Ranking Member Pallone asked Chairman Guthrie if he will hold a hearing on this issue. Chairman Guthrie said that oversight of the FDA is in the committee’s authority. Ranking Member Pallone asked about the value of training medical residents in community settings over hospitals. Administrator Johnson said that this innovative program has changed the game for what primary care training can and should look like. She said the program provides relevant training that will inform and encourage future practice in those communities. She added that it is difficult to plan for and recruit future students without guaranteed funding.

Rep. Griffith (R-VA) said that some of the non-profit hospital systems have been exploiting 340B to reap huge profits to fuel expansion into affluent communities instead of reinvestment into underserved communities. He said that his district is economically stressed. He said his analysis shows that the hospitals in his area are using 340B funds to help people. He said it is a great program and supports it. However, he claimed there are bad actors. He said that Bon Secours Hospital System used the Richmond Community Hospital, which is 340B-eligible, to expand its use of 340B at the expense of Richmond Community Hospital and its patients. He said that over the years, services were cut at Richmond Community Hospital while Bon Secours was transferring millions out of this hospital and into other hospitals in their system, some of which were as far away as Ohio. He asked how we make reforms and what HRSA plans to do with the information they are collecting. He asked if Congress should pass legislation for more transparency around the 340B program. Administrator Johnson said 340B plays a vital role for safety net providers and we need to ensure accountability of this funding. She noted that HRSA sent letters to certain covered entities recently. She added that the President’s Budget includes authority for HRSA to mandate covered entities to report on savings from the program and how that is benefitting the communities that they serve. She said HRSA would benefit from Congressional clarity on HRSA’s scope and authority related to the 340B program, considering the pending litigation. Rep. Griffith said that his CHCs are reporting predatory actions from PBMs. He said that CHCs are being forced to sign contracts that include provisions giving portions of their savings back to PBMs instead of reinvesting in their communities. He asked if HRSA needs legal authority to address this issue. Administrator Johnson said she would ask for Congress’s assistance there. She said there have also been issues around manufacturers not selling to covered entities via contract pharmacy arrangements. She said clarity about authority and scope is essential.

Rep. Cardenas (D-CA) expressed concern for shortages in pediatric care. He asked what role increased funding for the THCGME program will play in increasing the pediatric care workforce. Administrator Johnson said that the program encourages pediatric primary care training and has produced about 50 pediatric primary care physicians so far. Rep. Cardenas discussed the critical role of CHCs. He said CHCs are a lifeline for families in underserved communities. He said that CHCs are using creative methods to ensure greatest access to care, like mobile health centers and extended hours. He asked what we can do to extend the reach of CHCs in rural and underserved communities. Administrator Johnson said that this aligns with the goals of the President’s Budget. More CHCs, extended hours, and integrating mental health and substance use services are important measures that new funding would support. She also said that this funding is essential to expanding and retaining the CHC workforce.

Rep. Bilirakis (R-FL) explained the legislation being considered on the Special Diabetes Program and the Special Diabetes Program for Indians would provide stable funding for these programs for five years. He asked what role the primary care workforce plays in addressing pre-diabetes and diabetes in the U.S. Administrator Johnson said that these programs are run by other agencies but knows how valuable they are. She said that having an established relationship with a community health provider makes a difference in the prevention and management of diabetes. She said it is difficult for uninsured and underinsured people to maintain a stable provider. Rep. Bilirakis expressed pride in Florida’s CHCs, including their work to establish teaching centers and registered apprenticeships. He asked how HRSA plans to partner with state CHCs to enhance their strengths and their efforts to increase the workforce. Administrator Johnson said the President’s Budget proposed discretionary funding for the Healthcare Workforce Innovation Program that would figure out what models are working in the field and bring these programs to scale across the country.

Rep. Ruiz (D-CA) explained that where a physician is from and where they trained largely determines where they practice. He highlighted the DOC Act, which will permanently fund the Teach Health Centers Program and represents the largest expansion of the program since it began. He asked if there was demand for this program on the physician side. Administrator Johnson said that there is a lot of interest in establishing programs and in recruiting students to this program. She said a major challenge is the instability of program funding. Rep. Ruiz asked how many physicians stay in the communities they train. Administrator Johnson said that over half stay in these communities and that number is growing. Rep. Ruiz mentioned the Special Diabetes Program for Indians Reauthorization Act of 2023 and asked what HRSA is doing to address the growing incidence of diabetes. Administrator Johnson said that these programs are critical. She said that these programs help establish care models that can coordinate response across the country.

Rep. Johnson (R-OH) thanked HRSA for their role in responding to the East Palestine train derailment. He asked what HRSA’s involvement has been in ensuring care access to medically vulnerable populations in East Palestine. Administrator Johnson said HRSA was able to staff the CHCs that served these and other underserved communities. She added that HRSA has a partnership with state primary care offices that typically coordinate community health centers. Rep. Johnson asked why there is a workforce shortage and he pointed to the lack of work requirements tied to federal assistance and to the government paying people to stay home during the pandemic. He asked how the Federal Office of Rural Health Policy is working with rural CHCs to train and place health professionals in regions like Appalachia. Administrator Johnson said that we have asked a lot of the health workforce over the past few years and people have been burnt out. She said HRSA provides support to workforce development to rural hospitals and CHCs.

Rep. Kuster (D-NH) said that cost-effective preventive care is under attack by conservative courts. She said health will suffer if Congress does not reinvest in CHCs. She asked why it is important to increase funding to CHCs. Administrator Johnson said that increased funding is required to fully meet the needs of communities through expansion into new sites and expanding hours. Rep. Kuster said that CHCs play an important role in delivering mental health and substance use care. She asked why it is important to include mental and behavioral health funding in future CHC funding packages. Administrator Johnson said that CHCs are only able to meet 25% of mental health and 6% of substance use needs of their patients. She said more funding is needed to properly address these needs.

Rep. Latta (R-OH) asked what trends HRSA has seen in the distribution of HPSAs and how this distribution is tracked. Administrator Johnson said that the distribution of providers is just as important as increasing the number of providers. She noted that the NHSC incentivizes more equitable distribution of providers by bringing them to communities that need them. Rep. Latta asked if there are regulatory barriers that hinder workforce growth. Administrator Johnson said that the hope of the Healthcare Workforce Innovation Program is to be able to identify and breakthrough these types of barriers. Rep. Latta asked what happens when there is an insufficient number of providers to maintain a facility. Administrator Johnson said that there is more work to be done in this area to ensure people are on a path to the healthcare workforce.

Rep. Kelly (D-IL) said that suicide and substance use are a leading cause of maternal death. She said that women of color are more likely to experience these complications and are less likely to seek services. She asked what resources HRSA has to improve access to mental health services for moms and what additional resources may be necessary. Administrator Johnson said that the Maternal Depression and Screening Program helps OBGYNs get access to mental health consultations while the patient is in the office. Additionally, she said the National Maternal Mental Health Hotline is another important HRSA program that increases access to counseling for moms. She said more funding for these programs would allow HRSA to scale them up and reach more individuals. Rep. Kelly noted the racial disparities in access to organ transplants. She applauded the OPTN Modernization Initiative. She asked how opening the OPTN contracts to encourage competition will improve outcomes. Administrator Johnson said that more competition will improve and modernize the system.

Vice Chair Bucshon (R-IN) said that one way to encourage providers to serve in rural and underserved communities is by stopping cuts to provider reimbursement. He reiterated the importance of the OPTN MODERNIZATION ACT. He urged the need for this act to improve equity and efficiency in the OPTN. He then turned to discuss the 340B program. He said the Rep. Griffith outlined one of the problems that happened in Virginia, and he thinks this problem is widespread. Vice Chair Bucshon said Congress failed to establish clear parameters for the program, forcing HRSA to try to determine how it should be run. He said he is working on legislation to increase the transparency of 340B so that Congress and the public can better understand when the program does and does not benefit patients. He said the goal of the program was to make pharmaceuticals available to underserved populations. He said that he appreciated that Secretary Becerra concurred in a recent hearing that more transparency is needed. He asked what data HRSA collects from 340B program participants. Administrator Johnson said that HRSA is anxious to work with Congress on this issue, as it is a vital safety net program. She said that HRSA collects a series of data related to allocations and acquisitions. She said some of that collection is through mechanisms that are specific to individual providers and manufacturers. She added that HRSA share data to the greatest extent possible. Vice Chair Bucshon asked if HRSA collects the total dollar value of 340B drugs that covered entities are buying. Administrator Johnson said they track the total in aggregate but not individually. Vice Chair Bucshon asked if HRSA regularly posted any sales data on the program before last year. Administrator Johnson said she could not speak to that but would get him an answer. Vice Chair Bucshon said that researchers have had to use Freedom of Information Act (FOIA) requests to obtain limited sales data showing covered entity purchases at the 340B price and that information on discounts and chargebacks have never been provided when requested. He asked why that is. Administrator Johnson said that HRSA has been limited by recent Supreme Court issues related to FOIA. Vice Chair Bucshon said that he strongly supports the 340B program, but we need transparency.

Rep. Blunt Rochester (D-DE) expressed support for the National Workforce Center Act. She said this bill will bolster the nursing workforce and give states the tools to address local conditions. She demonstrated a need for better workforce data collection and analysis to inform policy. She asked if HRSA’s Health Workforce Research Centers Program has the authority to fund a nursing-focused technical assistance center. Administrator Johnson said HRSA is working with their lawyers to understand their authority there. Rep. Blunt Rochester asked how HRSA can collaborate with state entities and how this collaboration would contribute to the stabilization of the nursing workforce. Administrator Johnson said that there are academic centers doing this work, so collaboration would be beneficial. Rep. Blunt Rochester shifted to the Strengthening Community Care Act. She asked how requiring CHCs to provide mental and behavioral health services will help address the opioid crisis. Administrator Johnson said that we are not currently meeting demand for these needs, and leveraging CHCs to deliver these services will increase access.

Rep. Hudson (R-NC) asked where the $5 billion for the proposed NextGen initiative to develop improved COVID-19 vaccines came from. Administrator Johnson said that she cannot speak to the particulars of this project. She added that there may be some resources available through the Provider Relief Fund, but she does not know that they must be transferred to this project. Rep. Hudson noted the need for financial support and workforce development for CHCs. He expressed support for any efforts and innovations HRSA can support and cultivate to support CHCs.

Rep. Barragan (D-CA) noted the shortage of dental providers across the country. She asked what HRSA is doing to address dental workforce shortages. Administrator Johnson said dentists and dental hygienists are included in the NHSC and dental training is an eligible subject in the Teaching Health Centers Program. She said HRSA is training dentists and incentivizing dentists to serve communities in need. Rep. Barragan noted Medicaid’s role in funding CHCs. She asked how HRSA plans to support CHCs mitigate loss of Medicaid funding due to the unwinding and what Congress can do to help. Administrator Johnson said that it is important that people who are disenrolled from Medicaid are connected to other forms of insurance to help ensure funding for CHCs. Rep. Barragan asked how to address workforce shortages. Administrator Johnson said the path laid out in the President’s Budget supports current workforce development programs, reduces barriers to entry to nursing programs, training mental and behavioral health providers, and the Health Workforce Development Innovation Program.

Rep. Joyce (R-PA) discussed the Strengthening Community Care Act, which would extend funding and authorize the Community Health Center Fund and the NHSC. He asked what percentage of CHCs provide behavioral health services in communities today. Administrator Johnson said that most CHCs try to provide some mental health services, but significantly less provide substance use services. She added that when CHCs do provide these services, they are largely unable to meet demand. Rep. Joyce asked how important sustainable federal funding is to CHCs. Administrator Johnson said that sustainable funding is critical to the viability of CHCs. Rep. Joyce asked how CHCs comply with providing emergency services and ensuring a continuity of care for patients. Administrator Johnson said CHCs are closely monitored by HRSA to ensure they comply with all Section 330 requirement. Rep. Joyce said that he is hearing from providers that rely on 340B that large PBMs are pickpocketing their 340B savings through predatory contracts and without sharing any of the savings with their patients. He said there has been plenty of talk about the need for transparency surrounding the 340B program. He asked if HRSA can address these issues through existing authority or if it needs Congress to intervene. Administrator Johnson said that HRSA would benefit from Congress, because they continually reach roadblocks in their authority. Rep. Joyce agreed that Congress should intervene and stop these roadblocks from occurring.

Rep. Carter (R-GA) expressed concerns about the 340B program. He said that rural hospitals depend on these programs, but they are concerned by the manufacturers that are refusing to participate. He said the program needs guardrails and does not need to be eliminated. He urged that it needs to go back to what it was intended to be and serve the populations it was intended to serve. He noted that many health systems are misusing the program. He pointed to investigative journalism finding that non-profit systems and disproportionate share hospitals (DSHs) are exploiting the program. The second thing he pointed out was the PBMs stealing discounts that were intended for the patients. He noted that there has been discussion around starting a 340C program to clarify who the program is supposed to be for. He said he is not proposing that all DSHs are abusing the program, but some are, particularly with cancer patients. He said some of these health systems are buying out oncology practices purely to take advantage of the 340B program. He said Congress stands ready to help HRSA with anything they need to address this. He asked what the agency is doing to curb these abuses. Administrator Johnson said that HRSA has been acting where manufacturers have been refusing to sell to covered entities via their contracts and they have sent violation letters to manufacturers. She noted that this is the source of a lot of litigation where their authority is being challenged. HRSA also sent a series of letters to covered entities as part of their ongoing compliance work with questions concerning their compliance with requirements. She said HRSA is working with the tools they have and would appreciate ore authority to enforce accountability. She said HRSA recognizes the critical role of 340B and the need for accountability. Rep. Carter asked how additional flexibilities around new access point funding will support mobile health units and the ability of CHCs to reach more underserved communities. Administrator Johnson said that feedback from CHCs shows that they could better reach populations with more startup resources.

Rep. Schrier (D-WA) expressed support for the reauthorization of the Special Diabetes Programs. She also highlighted the provider shortage. She said Health Point and other CHCs in her district were concerned with stable funding for their THCGME funding. She asked her why stable funding is so essential for CHCs and THCGME programs to continue bringing providers into rural areas. Administrator Johnson said that uncertain and variable funding is distressing and makes it more difficult to recruit staff and residents. Rep. Schrier highlighted the work being done in Washington in CHCs and Teaching Health Centers. She asked why rural residency programs are so important for maintaining the rural health workforce. Administrator Johnson said that these programs are hard to maintain in rural areas and need a lot of support.

Rep. Harshbarger (R-TN) said that only one-third of NHSC placements are in rural communities and these providers leave after their commitments are up. She asked how we can ensure that the NHSC better benefits the rural communities. Administrator Johnson said that the NHSC will further incentivize providers to stay past their commitment by paying down their debt even further. Rep. Harshbarger said the Administration announced a $1.1 billion program to continue providing COVID-19 vaccines and therapeutics to underserved populations. She asked if this money came from the Provider Relief Fund. Administrator Johnson said that funds are being used to support this program. Rep. Harshbarger asked how they got to this $1.1 billion. Administrator Johnson said she can consult with her colleagues and get back to her on that. Rep. Harshbarger turned to the Covered Countermeasures Injury Compensation Program. She asked how many reviewers are being used for the nearly 12,000 COVID-19 vaccine injury claims on file. Administrator Johnson said HRSA has done a series of hiring and is up to 38 individuals.

Rep. Miller Meeks (R-IA) said that provider shortages are complicated, because people do not just live where reimbursement rates are the highest. She noted that there has been a 30% reduction in privately-owned practices. She asked what the current service obligation is for the NHSC, the retention rate, and the costs of the program. Administrator Johnson said that the first obligation is two years for the first $50,000 of loan repayment. She said total FY 2023 appropriations for the program was $417 million. The retention rate beyond two years is 86%. Rep. Johnson asked how we can narrow the number of slots that are not filled. Administrator Johnson said that stable funding for resident training programs would enable stronger recruiting. Rep. Miller Meeks added that CHCs need to offer extended office hours.

Rep. Crenshaw (R-TX) said that inflation has impacted the ability to recruit and retain health workers. He said CHCs should increase access and reduce costs, but it is difficult to provide this care without the workforce. He asked what needs to be done to be able to hire more people. Administrator Johnson said HRSA has been linking grant dollars to apprenticeship programs that help people work up the career ladder. She also discussed the Healthcare Workforce Innovation Proposal to find innovative ways to reform training. She said that licensing flexibilities improved access to telehealth services during the pandemic. Rep. Crenshaw asked if there are better ways to incentivize practitioners to stay in underserved areas. Administrator Johnson said they are always looking for more ways to improve these programs.

CLOSING STATEMENTS

Rep. Carter acting as Chairman thanked the witnesses and adjourned the committee.