the American Association of Colleges of Osteopathic Medicine

This analysis was prepared by McDermott+ Consulting, on behalf of AACOM.

This hearing was held on Wednesday, April 26, 2023.

Purpose

The House Appropriations Subcommittee on Labor, Health and Human Services, and Education held this hearing to explore details of the Provider Relief Fund (PRF) and determine the causes and possible solutions for the health workforce shortages.

Members Present

Chairman Robert Aderholt, Ranking Member Rosa DeLauro, and Representatives Ciscomani, Clyde, Ellzey, Fleischmann, Frankel, Harder, Harris, Hoyer, Letlow, Moolenaar, Pocan, and Harder.

Witnesses

Ms. Carole Johnson

Administrator, Health Resources and Services Administration, Department of Health and Human Services

Key Takeaways

The hearing mainly focused on health workforce shortages and the grants provided by the Health Resources and Services Administration (HRSA) to recruit and retain a strong health care workforce.
Republican members raised questions about waste and improper use of funds in the Provider Relief Fund (PRF).
Democrats expressed concerns that budget cuts would lead to limit access to health care for many Americans.

Opening Statements

Chairman Aderholt (R-AL) discussed how the PRF was created to maintain a robust, high quality health care system in the face of the pandemic and ensure that providers could continue to offer care. In addition to improper payments and wasted funds, remaining PRF funds are being used for purposes other than its original intent, including $1.1 billion dollars being used to continue providing vaccines and treatments for uninsured adults through 2024, while other claims remain unpaid. Chairman Aderholt criticized the PRF for continuing to pay for things not authorized by Congressthat have been encouraged by the Biden Administration. He stated that the health workforce shortage has led to worsening access to quality healthcare, lack of specialty care, nursing shortages, lack of opioid treatment facilities, and has increased the burden of chronic diseases.

Ranking Member DeLauro (D-CT) stated that prior to the pandemic, health care workforce shortages were already a concern. Post-pandemic, these issues remain, and have been exacerbated in the nursing field. She discussed how this committee helped include a $100 million dollar increase in the Fiscal Year (FY) 2023 budget for HRSA’s workforce program, which included nurses, behavioral health specialists, and the Children’s Hospital Graduate Medical Education program. She detailed provisions of the Biden Administration’s proposed FY2024 budget, including increased funding for the nursing workforce and the National Health Service Corps. Ranking Member DeLauro expressed concerns over her Republican colleagues call for spending cuts, as it would impact children, families, seniors, and veterans. She mentioned that the Trump Administration did not appropriately allocate PRF funds approved by Congress, which included sending money to wealthier hospitals that did not need it, putting safety net hospitals at a severe disadvantage.

Testimony

Ms. Johnson discussed how the Health Resources and Services Administration (HRSA) administers over 50 programs aimed at strengthening the health care workforce. She noted that these programs train and deploy health care providers across a wide array of disciplines including primary care, nursing, behavioral health, and dentistry. She stated that the President’s budget prioritizes training more medical residents, alleviating bottlenecks in the nurse training pipeline, investing in growing the behavioral health workforce, prioritizing the health and well-being of the current workforce, and spurring innovation in health workforce training. Ms. Johnson mentioned that the budget also extends and increases funding for the Teaching Health Center Graduate Medical Education Program and the National Health Service Corps. These programs would expand access to care by supporting health care providers dedicated to working in underserved urban, rural and tribal areas by offering scholarships and loan repayment in return for service in these high-need communities. She discussed that since the PRF was established, HRSA has made over 800,000 payments to more than 440,000 providers across the country. HRSA has also distributed the dedicated rural fund appropriated by the American Rescue Plan Act of 2021.

Question & Answer

Chairman Aderholt asked about the unspent PRF balances and its relation to the shutdown of the COVID-19 program to provide testing and vaccines to the uninsured due to a lack of funding. Ms. Johnson said that when this occurred in early 2022, claims from the uninsured program were spurred by the Omicron surge, which required $2 billion dollars per month in funding at that time. The long processing timeline led to an unknown liability in claims, with 35 million claims occurring at one point. Now, HRSA is in a more stable place as many of these payments have been made, and less additional funding is required. Chairman Aderholt asked that if vaccines are being provided to the uninsured for free by Moderna and Pfizer, why does the government need additional funds to buy these free vaccines? Ms. Johnson said that the vaccine administration fee is an additional cost regardless of the vaccine purchasing arrangement.

Ranking Member DeLauro asked how proposed cuts by would impact community health centers, nursing programs, and mental health and substance use disorder counseling programs. Ms. Johnson mentioned how the committee has helped expand HRSA programs but said that these cuts would lead to a decrease in access to care for around 2 million community health center patients, including 600,000 rural patients. This would also lead to a cut in loan repayment programs, furthering the nursing and behavioral health workforce shortages.

Rep. Fleischmann (R-TN) expressed concerns of increased regulatory requirements and increased quality metrics without additional funding for long-term care programs. Ms. Johnson said that HRSA generally funds the advanced practice workforce with the Labor Department for early career ladder programs, including CNAs, to work them up through the medical provider ladder and create a robust nursing provider network. Rep. Fleischmann also asked about the opioid crisis and HRSA’s initiatives for this epidemic. Ms. Johnson stated that this is a whole-of-government response, but HRSA’s job is to support the workforce to increase access to services, especially in in underserved and rural communities, and to expand the rural community workforce. HRSA’s Rural Opioid Response program directly communicates with these communities to determine what they explicitly need in terms of funding.

Rep. Hoyer (D-MD) asked about increased health care costs due to emergency department visits. Ms. Johnson stated that data shows how community health centers that provide a regular source of care leads to decreased emergency department visits, saving a great amount in health care expenditures. Rep. Hoyer also asked about the dental provider shortage. Ms. Johnson mentioned HRSA’s Teaching Health Center Program, which trains dental residents in the community with the intention for these individuals to practice where they train.

Rep. Harris (R-MD) asked if HRSA must balance their budget, to which Ms. Johnson said yes. Rep. Harris asked if medical inflation is harming medical practices because Medicare payments do not keep up with inflation. Ms. Johnson said she was not sure regarding Medicare payments but did say that anything that increases costs on medical providers puts more pressure on them.

Rep. Pocan (D-WI) questioned if HRSA has explored providers getting paid more by temporary hiring firms. Ms. Johnson said HRSA does not have regulatory or reimbursement authorities to investigate this. However, HRSA is focusing on the entire nursing shortage. Many providers have seen incredibly high turnover, leading to more of these nurses becoming temporary, short-time workers and shuffling through various hospital systems.

Rep. Moolenaar (R-MI) asked about the phase four reconsiderations that has 2,000 applications, many of which are coming from those who were previously rejected or denied. He asked what percent will be adjudicated differently. Ms. Johnson said she did not know because it is very application specific, but would follow up with further information. Rep. Moolenaar asked if the PRF should be used to address anything other than the COVID-19 pandemic. Ms. Johnson said the fund has previously been used for other emergent needs. These dollars will be needed to provide a smooth transition to the commercial market.

Rep. Frankel (D-FL) asked about cuts in maternal healthcare and related closures of hospital maternity wards. Ms. Johnson discussed how many patchwork solutions are attempting to improve the lack of provider availability but are contingent on funding availability.

Rep. Letlow (R-LA) discussed how the labor workforce is unreliable and unstable due to high wages in contract labor, which provides most care in her region. Ms. Johnson mentioned the need for recruiting health care professionals into teaching positions, which would bolster the entire medical field in these areas. She also mentioned the Nurse Corps Program for hospital faculty, which allows these professionals to directly apply for loan repayment.

Rep. Harder (D-CA) discussed the need for embedding research in medically underserved areas and increasing repayment for Medicare and Medicaid services, as much of the budget is not considering workforce shortages in other organizations outside of HRSA.

Rep. Clyde (R-GA) asked about the difference between addressing the nursing workforce shortage versus improving diversity in the nursing field. Ms. Johnson said it is important for those in each community to be represented by their providers in terms of racial diversity, and the same goals are applied to providers in rural areas. Rep. Clyde said it would probably be more effective to recruit those based on merit and drive for entering the workforce, regardless of their background, if looking to expand the workforce. Rep. Clyde also said the COVID-19 vaccine mandate contributes to the workforce shortage. Ms. Johnson said that policy is not in her jurisdiction but communications with physicians indicate that the real issue stems from a need for more training programs.

Rep. Ciscomani (R-AZ) asked about HRSA opportunities and grants for nursing programs. Ms. Johnson expressed the need for clear communication regarding eligibility between HRSA and entities that provide these training services. She said that HRSA is reaching out to eligible community colleges to help build these nursing career ladders. Rep. Ciscomani asked about the application process for these grants. Ms. Johnson said HRSA is attempting to simplify these applications, as many community programs do not have grant writers, limiting their ability to receive these grants.

Rep. Ellzey (R-TX) expressed his interest in rural healthcare, veterans, and maternal healthcare. He discussed one of HRSA’s Planning and Development Grants for expanding the residency program for one of the hospitals in his area. Ms. Johnson said that this Teaching Center Program is great for expanding the rural workforce. She also mentioned the need for funding for grants that can apply to rural health clinics.

Chairman Aderholt asked about the total amount of improper payments that HHS has identified in the COVID-19 uninsured program. Ms. Johnson said that HRSA viewed the fund according to the Integrity Information Act and included this in the 2022 report and are currently doing the same thing for this year. She stated that this is the first year HRSA will include reporting on the uninsured fund. Chairman Aderholt asked how to ensure this program will not lead to waste or fraud. Ms. Johnson said that the uninsured program was a way to encourage individuals to seek care, but this bridge program will run through more established mechanisms, including contract partnerships with pharmacies and traditional partnerships with health departments and community health centers. Chairman Aderholt asked about HRSA attempts to recover any funds. Ms. Johnson said that HRSA refers suspicious providers to the Office of the Inspector General, who then communicates with the Department of Justice.

Ranking Member DeLauro asked about peer support specialists and their response to those in a crisis. Ms. Johnson said that peer support specialists generally have lived experiences that can help those in a crisis feel connected to the community, especially for treatment of substance use disorder. The Behavioral Health Workforce Education and Training Program helps recruit individuals for these positions. Rep. DeLauro asked about HRSA’s funding request for the mental health workforce. Ms. Johnson discussed how these funds have been requested to help aid the workforce with their own mental health, including making the workplace more supporting and sustainable.

Rep. Ciscomani asked about nationwide labor shortages and how HRSA targets these program funds. Ms. Johnson said HRSA considers rural and underserved communities, which is documented in the applications, but they also factor in need of the community through an objective review process. Rep. Ciscomani asked about how these grants create sustainable programs without creating a reliance on the federal government. Ms. Johnson said that they use these funds to build a pathway and plan for sustainability, building capacity and infrastructure.

Rep. Hoyer discussed a great disconnect between resources and needs, the consequences of not investing in essential programs, and how many Representatives discussed direct needs from their communities that can be improved by HRSA.

Final Comments

Ranking Member DeLauro thanked Ms. Johnson for her testimony and responses. She expressed concerns with newly introduced bills that would require massive cuts to the healthcare workforce that will increase the shortage of nurses and physicians.

Chairman Aderholt concluded by thanking Ms. Johnson for her testimony.

Watch the full hearing here.