On Call for America: Strengthening Access Through Locum Tenens Providers

Good morning. The subcommittee on workforce protections will come to order. I will note that a quorum is present. Without objection, the chair is authorized to call a recess at any time. Today's hearing will cover an important issue affecting our health care workforce and ultimately patient access to care. Too often, patients struggle to obtain important medical services because of the long distance between their homes and providers. In rural Pennsylvania and many communities across the country, this can be especially challenging. Even after traveling long distances or utilizing telehealth appointments, some patients may still face challenges in seeing a specialist if hospitals and health clinics in rural rural areas don't currently have one on staff. Imagine a situation in which there is only one specialty provider with a hundred miles of your home. If that provider changes careers, takes leave to care for a family member, or simply goes on vacation, patients can find themselves without care. To address these gaps, many rural hospitals turn to locum tenens providers, which is a Latin phrase for placeholding. These health care providers usually operate as independent contractors rather than employees, and typically work in a role for no more than a year. They control their hours and practice. Like independent contractors in many other occupations, these providers provide a valuable uh flexibility and freedom that this me- uh model offers. The position these providers often fill can be difficult to staff on a permanent basis. It takes an average of a hundred and eighty-nine days to recruit a primary care uh position and two hundred and twenty-six days for a specialist. While locum tenens providers are critical in rural communities, their services are not limited to rural America. Some eighty-eight percent of health care organizations utilize these types of providers to help them meet their needs. Given the important role that these clinicians play in our health care system, they deserve clear rules regarding their employment status. Yet as we have seen in many occupations, uh i- in many other occupations, the law is not always clear on how locums tenants per clinicians should be classified. Moreover, states take different approaches to defining independent contractors. As a result, these providers and health care facilities that rely on them face needless uncertainty. To address this problem, Congressman Burgess Owens introduced H. R. eighty-three forty-seven, the Rural Health Care Act. This bill clarifies that qualified locums tenant providers our independent contractors under the Fair Labor Standards Act, and also the National Labor Relations Act. While no single policy will solve every challenge affecting our health care workforce this bill offers a step in the right direction toward bolstering patient health care access particularly in rural communities. At the end of the day, improving health care outcomes for all Americans begins with ensuring patients can access the right care at the right time. greater clarity in the law stands to benefit our patients, health facilities, and the communities they serve. I look forward to hearing from all of our witnesses today. We appreciate you being here. And with that, I will yield to the ranking member for her opening statement.

Thank you, Mister Chairman, and thank you to our witnesses for joining us today. Today's hearing is being presented as a discussion about expanding access to health care particularly in rural communities. I think it is fair to say that we all agree that rural America is facing serious and unique health care challenges. Too many communities struggle with provider shortage, has hospital closures, and limited access to care. Those problems deserve serious discussion and real solutions. However, misclassifying health care workers and stripping them of their worker protections and benefits will not solve any of these struggles. Across the country, hospitals, health care businesses are increasingly looking for ways to cut labor costs by shifting away from direct employer-employee relationships. Instead, they are relying more heavily on outsourcing subcontractors, temporary staffing arrangements, and worker misclassification as independent workers. The result is often the same. Employers reduce their responsibility and their bottom line, while workers lose critical rights and production protections. My colleagues might argue that automatically classifying some physicians and advanced practice providers as independent contractors will increase flexibility and help address workforce shortages. But flexibility should not come at the expense of fundamental workplace safety and security. When classified as independent contractors, workers can lose access to overtime pay, unemployment insurance, workers' compensation, and the right to collectively bargain for a better working condition. Those protections exist for a reason, even for highly educated professions, such as physicians and nurse practitioners. They help ensure that the people caring for our families can earn a living wage, work in safe environments, and have a voice on the job. And it is important to recognize that these temporary staffing arrangements often create challenges for patients' care. Despite temporary staffing arrangements becoming increasingly more common, many workers report receiving little or no orientation before beginning assignments. They may not know where supplies are located, how to navigate patient record systems, or who to contact when problems arise. The data shows that temporary nurses are assi assigned the most difficult units and are expected to perform without adequate support. Those conditions are difficult for workers and potentially hurt patients or reduce quality of care. For the sake of workers and the patients, Congress should not be promoting these types of temporary staffing arrangements in health care. Unfortunately, HR eighty-three forty-seven would do just that. It would create a special carve-out that allows employers to avoid responsibility that apply in virtually every other workplace. And it would replace long-standing legal standards with a blanketed rule that makes it easier to classify health care professionals as independent contractors regardless of the realities of their working relationship. We all agree that rural health care has unique needs. Rural hospitals often operate on thin margins and face persistent staffing shortages. And unfortunately, these challenges have been exacerbated by the cruel cuts of Medicaid and student loans included in H R one. The nearly one trillion cuts made to Medicare threatens the financial stability of rural hospitals and clinics that already operate on razor-thin margins, increasing the risk of service reductions, workforce shortages, and even facilities closing. As people lose access to health care coverage and federal funding declines, rural families might face longer travel time for care, fewer health care providers, and greater greater barriers to accessing essential services, such as emergency care, maternity care, and behavioral health treatment. Instead of weakening protections for health care workforce, Congress should explore targeted investment, workforce development programs, provide training opportunities, loan repayment assistance and other measures to help recruit and retain health care professionals in underserved communities. The dedicated workforce we are talking about today is the backbone of our health care system. They deserve policies that value their contribution, protect their rights, and support high quality patient care. Thank you and I yield back.

Thank you. Pursuant to committee rule eight C, all members who wish to insert written statements into the record may do so by submitting them to the committee clerk electronically in Microsoft Word format by five PM, fourteen days after this hearing. And without objection, the hearing record will remain open uh to allow such statements and other extraneous materials noted during the hearing to be submitted for the official hearing record. I note that some of my colleagues who are not present today uh or are not permanent members of the sub subcommittee may be present today and waving on for the purpose of today's hearing. Uh with that we'll go to the introduction of witnesses,

Yeah.

and I'd like to start our first witness, I'll introduce each of you and then uh you can bring begin with your testimony. Our first witness is Mister John Olsen-Wolfson, Visiting Fellow at the Institute for the American Worker in Washington DC. Our second witness is Miss Autumn Begay, Senior Corporate Counsel at CHG Healthcare in Midvale, Utah. Our third witness is Doctor Katie Wells, Senior Fellow in AI, and Healthcare at AI Now Institute in New York, New York. And our final witness is Doctor Leah Palagashvili, a Senior Research Fellow at Mercatus Center at George Mason University in Arlington, Virginia. Appreciate all of you being here, and uh we want to uh thank all of you again, and we look forward to your testimonies. I'll ask that each of you limit your oral testimony to a three minute summary of the written testimony which you provided

Thank you, Mr. Chairman. Uh, Chairman McKenzie, Ranking Member Omar, Thank you. Uh, Chair McKenzie. Ranking Member Omar. Uh Chairman Wahlberg and Ranking Member Scott, thank you so much, and members of the committee, good morning. Thank you for having me here today. Uh before I start, I'd just like to thank my wife and my daughter Magnolia for being here today, joining me uh in the hearing, I'm glad that they're here with me. My name is Jonathan Wolfson, I am a senior fellow at the Niskanen Center and also a visiting fellow at the Institute for the American Worker. And my policy work at those organizations focuses on healthcare workforce, occupational licensing, and independent work. Today's hearing addresses two interrelated problems. America's healthcare workforce shortage and the legal uncertainty facing independent locum tenens workers. Locum tenens clinicians want to help, but they need clear laws to protect their independence. That's why my message today is really simple. Locum tenens clinicians are critical to patient access, and Congress should protect their ability to work as independent workers. First, locum tenens clin- clinicians can help to alleviate America's provider shortages. About a hundred and eight million Americans live in primary care health professional shortage areas, and we're pro- projected to be short about eighty-six thousand doctors across the United States by twenty-thirty-six. This is especially challenging in rural areas, but the reality is these shortages now are facing urban areas as well, and those shortages are projected to get even worse as our population ages. Patients experience those numbers as delays. They wait months for a primary care appointment, specialty care appointments, mental health treatments, and needed procedures. Hospitals experience them as the inability to provide the needed care that patients in their community need. Long-term reforms are necessary. We need to train more clinicians. We need to expand the scopes of practice where appropriate. We need to create better licensing pathways for qualified, internationally trained physicians and other providers. But those reforms take time. Locum tenens can deliver clinicians to patients right away. Locum Tenens is a permanent and growing part of the healthcare workforce. It supports roughly a hundred and eighteen million patient visits each year. It sees patients in emergency, primary care, psychiatry, obstetrics, anesthesia, pharmacy, and other critical roles. And in many communities, the choice is not between a permanent provider and a locum tenens provider. The choice is between a locum tenens provider and no provider at all. Second, locum tenens clinicians are independent contractors and they want to remain independent contractors. Locum tenens providers choose their assignments, they set their availability, they move among facilities, they maintain professional autonomy, they often build an independent practice across multiple states or multiple healthcare systems. The facility needs coverage. The clinician wants flexibility, additional income, professional variety, or the chance to serve different communities in need. Those interests best aligned through a contract for services, not a traditional ongoing employment relationship. But some policymakers want to convert independent contractors to employees. Here that instinct is badly misplaced because locum tennis professionals are highly trained licensed in-demand clinicians who are making deliberate choices about how to structure their work. So treating them like vulnerable workers who need government protection merely removes their freedom and reduces patient access. Reclassification would also impose costs on hospitals, clinics, staffing firms, and clinicians themselves. For small rural hospitals already operating on thin margins, added employment law uncertainty may mean fewer assignments or closed service lines. Health care presents a unique problem, finally, because health care factors that look like control in traditional employment law are often just patient safety. A hospital has to credential and provide privileging to clinicians. It has to follow HIPAA, Medicare, Medicaid, and local licensure rules. It may need physicians to work a particular shift because patients need care at particular times. The law shouldn't punish hospitals for doing what patient safety in the law requires. So Congress c- should create a s- durable safe harbor that allows these doctors to declare themselves independent workers and protects that status for the workers under the Labor Standards Act the National Labor Relations Act, and under the IRS code. A locum tenens safe harbor is not a loophole around employment law. It's the legal infrastructure that lets a licensed clinician, treat a patient who needs care now. Thank you so much and I look forward to your questions.

Thank you, appreciate that testimony, and welcome to your family, we appreciate you guys being here today. All right, next we're going to recognize Ms. Begay for your testimony.

Chairman McKenzie, Ranking Member Omar, honorable members of the subcommittee, thank you for the opportunity to testify on a critical issue facing rural healthcare. My name is Autumn Begay, I am Senior Corporate Counsel at CHG Healthcare. Our mission is to match medical providers with areas in need. Currently, there are tens of thousands of Americans who are hours away from the healthcare services that they need. In many cases, locum tendon providers cut these hours down to minutes. Locum tendon providers are physicians and advanced care practitioners who step in to provide short-term or temporary coverage. In practice, this may mean providing specialty services a few days a month at a clinic, covering call at a rural hospital, or caring for patients while a rural facility recruits to fill a permanent vacancy. In twenty twenty-five alone, CHG placed eleven thousand seven hundred and seventy locum tendon providers across the United States. These clinicians supported an estimated twenty-four million patient visits helping ensure care was available when, and where it was needed. The system works because of flexibility. Independent contractor status is central to the local attendance model because it allows providers to choose when, where, and how they practice. That autonomy makes it possible for them to step into rural, underserved areas to provide essential care without uprooting their lives or abandoning their primary practices. H R eighty-three forty-seven, the Rural Health Care Act protects this pipeline between qualified providers and temporary assignments, preserving access to care in areas that rely on locum tenens services. Unfortunately, the placement of these providers is being put at risk as we speak, impacting the patients who rely on them. Across the country, existing laws, proposed legislation, and regulated requirements designed for an entirely different workforce model are increasingly being applied to locum tenens providers. These rules were never intended to apply to these highly trained clinicians who accept temporary assignments to care for patients. Yet, they are already creating barriers to patient access. CHG and our industry colleagues fully support the Rural Health Care Act, because it protects locum tenem providers from unintended legislative and regulatory overreach. It is limiting placements at a time when rural health care facilities are already critically understaffed. I would like to thank Congressman Owens for his leadership on this issue and commitment to preserving access to care in rural communities across the country. We ask this subcommittee to advance H. R. eighty-three forty-seven, the Rural Health Care Act. I look forward to your questions.

Thank you. Next, I'll recognize Doctor Wells for your testimony.

Chair McKenzie, ranking member Omar, and members of the subcommittee, Thank you for this invitation. My name is Katie Wells and I'm a senior fellow at the AI now institute. For the past fifteen years I have worked at the intersection of technology and labor, examining some of the largest gig economy companies in the US, from Uber and DoorDash to Instacart. Last year, nursing was the largest source of job creation in the US. Today, it is the surest ticket to the middle class. But new platform companies are threatening the growth of this profession and its stability by treating workers as independent contractors. Gig nursing platforms are reorganizing healthcare work in ways that create problems for workers and patients. For nurses, platforms generate financial instability. Gig nursing platforms rely on algorithmic management technologies that offer little transparency about how jobs are allocated, scheduled, or paid. On the same day, in the same facility, two different nurses can be paid different amounts for the very same shift. And they don't know why. Think surveillance wages. Some gig nursing platforms even encourage workers to bid against each other. Think wage auctions. To win a shift, a nurse must offer to work for lower rates than her peers. It is a race to the bottom. For patients, new platforms pose health and safety risks, too. Gig nursing platforms often drop strangers into unfamiliar and stressful situations with little to no support. There is often no orientation for nurses and no continuity of care for patients. One nurse described the situation. She said, quote, " You really have no one to talk to if you're needing help. It's really no communication with anybody but yourself." Worker after worker I've interviewed voiced similar concerns. One nurse even admitted that in these isolated workplaces, she has to be careful not to lower her own standards of care. What's more worrying? Gig nursing platforms are building a nationwide campaign to legitimize their version of health care, which leaves workers without basic labor rights. Since two thousand and twenty-two, lawmakers in seventeen states have introduced bills that do just this. An Ohio bill seeks to exempt gig platforms from minimum wage requirements. A Georgia bill seeks to exempt platforms from adhering to state unemployment insurance and workers' comp laws. Some bills specify that health care workers who use platforms are independent contractors. Other bills limit public oversight of these f- platforms by carving gig nursing platforms out of requirements to submit regular reports to the state. The workers implicated by these bills are not just nurses. These bills seek to exempt a whole range of health care professionals, those who are dentists, nurse practitioners, physical therapists, social workers, and the list goes on. These bills could upend decades of laws and norms in the health care industry, that guarantee public oversight, ensure worker protections, like paid sick leave, and safeguard patient care. Taking away the protections of health care professionals is not going to help us offer decent health care or build a strong economy. Thank you.

All right, and lastly, we will recognize Doctor Palagesh Velay for your testimony.

Good morning, Chairman McKenzie, Ranking Member Omar, and members of the subcommittee. It is an honor to testify before you. My name is Doctor Leah Palagosvili. I'm a labor economist at the Mercatus Center at George Mason University, where I study the independent workforce and worker classification laws. Let me start with the most fundamental point. Locum tenens clinicians help solve a labor supply problem in healthcare. When a rural hospital faces an unexpected departure, when a clinic has a re- recruiting gap, or when an emergency department needs call coverage, The choice is rarely between a locum tenens clinician and a permanent employee. The choice is often between temporary coverage and no coverage at all. You cannot train a licensed clinician overnight. When demand spikes or a staffing gap opens, flexible staffing is often the only lever that moves fast enough to matter. That is why locum locum tenens exist, to match clinician's supply with patient needs when permanent hiring cannot keep up. The data do not show independent clinical work replacing traditional employment. In two thousand twenty-five, roughly ninety percent of covered clinicians were traditionally employed. Self-employment is much smaller and has remained relatively stable. The data show coexistence, not replacement. Second, this workforce is very different from the workers at the center of typical misclassification debates and from the gig nursing platform debate we just heard about. These are physicians, nurse practitioners, physician assistants, and CRNAs, the four professions covered under the locum tenens bill. Nearly all hold a master's, professional, or doctoral degree. Nurse practitioners earn nearly three times the national median. CRNAs earn more than four times. Physicians earn at least five times. These are highly credentialed professionals making a making deliberate choices between how and where they practice. I also reviewed more than two dozen state and federal misclassification audits and reports. Not one identified these clinicians as the misclassified workforce. Third, one of the most striking findings in my analysis is the age profile. More than half of self-employed covered clinicians are age fifty-five or older. Among traditionally employed clinicians, that number is only twenty-two percent. When I testified before the Senate's special committing on aging this pattern came up directly. Older workers want flexibility, not a traditional job. They are willing to keep working, but on their own terms. In healthcare, a late career clinician may not want a full-time permanent role, but that same clinician may be willing to take a temporary assignment in a community that needs him. If independent work is restricted, the question is not whether these clinicians become W two employees. For most of these older workers, the question is whether they stay in the workforce at all. Fourth, restrictive classification laws can make healthcare staffing problems. Worker classification laws are often trying to solve a real prob problem, bad faith misclassification. But when written too broadly, they can block legitimate independent work, too. In California, AB five did not simply move independent workers into W two jobs. Self-employment fell, overall employment fell, with no offsetting increase in traditional jobs in those affected occupations. And when I looked specifically at the clinicians relevant here, the pattern was the same. Self-employment among advanced practice clinicians declined in California after eighty-five, while it grew in comparison states. If independent clinical work is restricted, these assignments may not become permanent jobs. They may just disappear. In health care, that can mean fewer clinical uh clinician hours, fewer field shifts, and less access to care. Fifth and finally, access to clinicians is already deeply uneven across geography. Non-metro areas have roughly half as many covered clinicians per capita,

Thank you. Next we'll move to member questioning of the witnesses and under committee rule nine we will ask uh our questions uh And it's a five minute rule. And the first person that I'd like to recognize is our esteemed Chairman of the full committee, Mister Wahlberg from Michigan.

Thank you, Mister Chair, and thanks to panel for being here and thanks for inserting uh in our state lives here a little bit of common sense reality of what's going on in the marketplace and um pushing a little truth in line with some of the big government approaches to trying to control what's g- what goes on a workplace. And in a time of need for employees to function in various ways, uh, some creativity is - is needed. And so thank you for being in the panel that we needed today. Mister Wolfson, your rest- your, uh, testimony states that using locum tenens, uh, providers is one of the most practical ways, uh, to fill cr- critical, uh, health care needs, uh, and the shortages in the workforce that are - are there. you also stated that healthcare facilities are often discouraged from turning to locum tenants providers can you speak more about the dis incentives uh that healthcare facilities may experience when considering whether to pursue a a locum tenants arrangement

thank you mister chairman yeah the i think the challenge for a facility is if they don't know that a worker is going to for sure be an independent contractor and they hire them as an independent contractor, they're taking a risk and their lawyers, and this is what I would have told my clients when I was in private practice, that on the back-end, maybe years down the road, those workers are the state or the federal government are to come in and they're going to fine and penalize the business for misclassifying that worker even though the worker may be perfectly content and knew everything that they were walking into and I think the challenge with locum tenens doctors and other advanced practitioners is these are advanced folks who understand the relationship they're walking into, and they know what they're getting into, they've chosen to be independent workers, and so them in the hospital or the clinic or the the pediatrics office that wants to bring them on while one of their practitioners is on maternity leave, they want this independent contractor relationship, but if they're worried that on the back-end they're gonna have the government come in and tell them they did it wrong, then those relationships are never gonna start in the first place.

How how wide-spread do you believe this problem is?

I think they, you know, and I think Miss Begay probably has better data on the specific companies, I think that most businesses sit down with their attorneys and when they are worried about a misclassification, the decision tends to be that they don't hire at all, rather than trying to navigate the system.

OK. I appreciate that. Miss Begay, uh your written testimony cites that um studies show that patients really don't notice a difference, whether it's a local pen uh uh tenants provider or the traditional provider. Uh in addition, the majority of of local tenants providers report that they uh likely would not continue working as you presented if - if they didn't have that opportunity and had to work as a W-two employee. Uh why does the ten ninety-nine status of these health care providers seem to cause so much uncertainty about employment law?

I think where the uncertainty derives from is from overly broad workforce classification laws that are never intended for this unique workforce model. and yet our increasingly there are concerns that they're being applied to it. Uh an example that comes up of where there is clearly not an intention to uh direct these laws towards our advanced practice providers would be in Illinois, where there was a temporary staffing agency law that required registration as part of it. It was interesting to note that when registering you have to identify a nurse who is going to supervise your advanced practice provider. And it's interesting to note that in the community and in the industry, advanced practice providers are actually those who provide direction to nurses. And so this is clearly not intended to capture these highly trained clinicians. But what happens then is that providers decide that they don't know whether or not they're gonna be classified correctly if they practice in Illinois. And so some agencies and providers have chosen now not to go to Illinois to fill those important positions. So that uncertainty is coming from laws that aren't intended for this unique model,

Mm-hmm.

but then the practitioners are wondering how they're gonna be treated. And to, Mister Wolfson's example is exactly the same of concern about what happens later on if after the care is provided does something come back to create risk for them, and the model.

Yeah.

Thank you. Uh, Dr. Palagashvili, um, your written testimony states that independent clinical work exists alongside traditional W-two workforce. Can you explain why this is largely true across uh the independent workforce?

Thank you for your question, Mr. Chairman. So traditional employment is usually the right model for ongoing full-time institution-specific work. Independent work is often used for temporary, short-term, supplemental, or specialized work. The two arrangements can exist side by side because they meet different needs for workers and organizations. And according to the data that I analyzed on uh using the current population survey we don't see that there's a substitute between the two. We see that they are growing mostly actually independ- uh self- traditionally employed clinicians are growing and uh since two thousand fifteen and self-employed clinicians uh have been relatively stable. So there's been no we haven't seen at least in the data yet uh that there's been any sort of replacement. They they grow together and coexist together.

Seems to be working, so well thank you, my time has expired, so I yield back.

Thank you, next I'll recognize our ranking member for five minutes of questioning.

Thank you, um Doctor Rils I I share some of the concerns that you um expressed about the gigafying of healthcare um professions as So often happens with the in with innovative staffing solutions, a lack of transparency on the back-end operations can cheat workers out of what they are owed um or it can leave them with no options for recourse if they're treated unfairly and your testimony you outlined how some gig platforms require nurses to bid on shifts with the work being awarded to the lowest bidder can you explain how this practice and other job allocation schemes that the platforms use can impact workers' job quality um and even the quality of care that they perform to patients.

Thank you for that question. I'm also deeply concerned about this job bidding process. So what happens on these gig nursing platforms, many of them, not all, is that a shift will come up on a worker's phone. and a different shift or that same one may come up on another worker's phone, the initial app message will say bid on this shift, bid to win, lowest bid wins, and so a five minute clock will begin and two workers will be given that notification and essentially bid against each other to secure work. Now, in some cases, these shifts that show up on workers' phones don't have a bid option. In those cases, there is still deep concern about algorithmic wage discrimination or what we could call surveillance wages because two workers or sometimes seven workers see the exact same shift at the exact same facility and they see the offer rate for different amounts. Even yesterday, two nurses sent me screen shots of a shift in Pittsburgh with a ten dollar differential per hour. Um, wage discrimination and the algorithmic management technologies that we believe is at the foot of these gig nursing platforms also impacts how workers um are ranked. And that ranking affects their access to future shifts um and it's a black box where workers who want to do care work and believe in the importance of their work, are fighting against a system with very little transparency. And I believe that this system affects care work and the ev- uh, the quality of care that's provided because what it means is that workers are walking into facilities with very little information about who their peers are, who their supervisor might be, how a patient portal works, whether a patient needs help with feeding. Um, and so this algorithmic management software really interrupts the relationships between the worker and the facility. And as a result, the facility and the patient.

Mm-hmm. And in in in the example that you used earlier um in your testimony about two nurses working in the same facility um with different pay, um we oftentimes hear from nurses who are dealing with travelling nurses that are getting paid more than what they are being paid at a facility and how that impacts the morale. Uh can you speak to that a little bit as well?

Yeah, we have definitely heard from workers at facilities that there is all kinds of increased tensions in facilities that use either traditional agency or travel nurses, and use gig nursing. Because this model often ends up with workers who might walk in that are unfamiliar, need extra help, it puts extra burdens on the existing regular pool of nurses. And so there have been some studies that show that initially we are seeing decreased staff morale and even staff care in facilities that integrate gig nurses. Because it does take a lot of work to help orient someone who shows up at your facility never having worked there before.

Yeah. And you talked a lot about um the different pieces of legislation that are popping up in in different uh states and and even here in in Congress. Um lots of lobbying effort um it it seems like happening from venture capital and equity um fund to launch the these campaigns. How big is the financial interest that's involved in creating this effort?

We believe it is quite big. Of the top ten gig nursing platforms, two of them already are unicorns. Um the speed and the amount of money with which these companies um are sort of growing, initially reminded me of Uber, um but now it seems to surpass that. And so I'm worried.

Yeah. I share that worry with you as well. Every time we hear common sense from the other side, seems like there is moneyed interest involved in it. So appreciate that. Thank you and I yield back.

Thank you. Next we'll go to Mister Grothman from Wisconsin.

First of all, I kinda like Uber. I mean, it's not a bad thing. I use it all the time. I bet people in this room here use it all the time. So I I just want to defend the Uber people. Think they're great people and They do a great job. Um Okay, first of all we'll stop uh we're starting this baguette baguette. Um could you I know we've kinda gone over already, but could you rattle off why a nurse out there would choose to be an independent contractor?

Thank you for that question. What we see and this bill specifically addresses are these highly qualified physicians and advanced care practitioners. So these are for advanced practice practitioners, these are folks who have had significant education and independent practice, clinical making decision ability. And the reasons why they would do it, I have a great story I'd love to share around a doctor, Leigh Marlana, or Marlana Lee. She experienced, uh, in her practice that she did private practice as a family medicine physician. Then when she went on to, uh, go to a job in faculty at the University of Utah. Thereafter, she, her father, her stepfather was experiencing signi- significant health issues and went into hospice and so she took a sabbatical. When she came back from that sabbatical, she was wondering, what do I do? I still have commitments to my mother, to my children, and what is the flexibility that I need? So, what she did from there is she found that locum tenens was the perfect fit for her to continue to practice.

It gives you flexibility, right?

Yes.

Absolutely. And do sometimes these gig nurses make more money than their counterparts who are, you know, kind of stuck on one employer?

I can't speak to the gig economy around nurses, but I can say that our physicians and advanced practitioners when they're looking into this, they are primarily looking around the ability to have flexibility and control. Of course financial decisions are always something that they take into consideration, but they say that they're looking to be able to control what they do.

Yeah. The reason I I pointed out is Doctor Wells implied that different nurses are making different amounts of money and that this was for some reason a bad thing. I would think that if you're, you know, told that we're gonna call you to work forty hours away or call you on short notice, you should be compensated for that, and I'm just assuming Therefore, maybe I'm wrong that these gig nurses sometimes make more money. Is that true?

Uh, I can't speak to the gig nurse economy as that's a very different uh group than what this bill is covering today, but I can say that our that our folks who do this do it because it works for their lifestyles and their goals.

Right, right, it it if you have to maybe work twenty hours one week and if you want to, f say you're an

Yes, exactly. And it's what allows providers to continue to provide practice long after they're ready to retire.

OK. Uh, Doctor Wells, you can see how there are certainly individuals out here who have taken advantage of this opportunity because of their life circumstances. and I'm sure it'd be very upsetting to them if this option was not open to them. Would you feel guilty if we if we got rid of these sort of positions and and the people who maybe wanna work less hours or maybe work more hours one month and another month uh they no longer have that option?

Thank you for that question. My expertise is about the rise of the gig nursing platforms and the dangers and conditions they create for patients and workers.

OK, well, um, I guess the answer should be obvious, but we'll ask, uh, well, as Doctor Pella, I don't mean then you cannot get questions because we

Polygestaly.

Right, right, right. Do you feel, um, that anybody is being forced to do this or, uh, in any way are being taken advantage of? Are the people opting for this type of work go in with their eyes open and want to do this in other words you're taking away something that they have decided would be their career

thank you for the question so the occupations that i analyze for this testimony um these are highly compensated highly skilled professionals um who are taking on these work arrangements, either um

In in other words, these people are not dummies. They know what they what they want, they know what they're getting involved in, and they don't need a bunch of congressmen telling them how they should run their life, right?

So, I I think that the data is showing um that one, they're highly compensated, they're highly educated, and they're making likely a deliberate choice to be in these work positions because it's what suits them especially the older worker profile. and I've highlighted that in my written testimony. These are the type of workers who as they near towards retirement, they don't want a W two job. Um, they actually ease into retirement looking for flexible jobs. So you might think about it in other industries like they typically can be substitute teachers. In this case, these are late uh older workers who are clinical clinicians who take on these work opportunities precisely because they don't want part-time or full-time W two jobs.

They seem very happy. I hope we don't screw up their lives.

Thank you. Next we'll go to Mister Fein from Florida.

Thank you, thank you, Mister Chairman. Uh, Doctor Wells, how many open positions are there in the country for nurses? How many openings are there available today? You study the market gig versus non-gig. How many jobs are available for nurses today?

Thank you for that question. I do not study the gig versus the non-gig.

Well, you did a g- how many how many gig nursing positions are being advertised right now.

I am so glad you asked that question. As an empiricist, it makes me crazy that I cannot find the answer and that no independent researcher or regulator has access to that information.

OK, so, so there are two hundred and sixty thousand open nursing positions nationwide, full-time nurses. So if you're a nurse and you wanna get a job as a nurse working full-time, wherever, is it difficult today or is it hard? Are you forced to go work for these gig people because none of these other two hundred and sixty thousand positions are available to you?

Thank you for that question. My expertise here is about the rise of gig nursing platforms and understanding the labor market that has contributed to it.

Well, I'm asking about the labor market. So there's two hundred and sixty thousand nursing positions. My question to you is this. If you are a nurse and you wanna get a traditional nursing job, you spoke at the beginning of your testimony, you said we have a shortage of nurses. So is it

I didn't.

Well, somebody did. I mean,

I did not say that for the record.

is it is it diffi- do you believe do you believe it's difficult to get a job today?

I it's not my understanding that there is a shortage of able, trained nurses in the US. It is my understanding that there is a shortage of jobs that nurses are willing to take in the US.

There are two hundred and sixty thousand there are two hundred and sixty

There's quite a difference between those two.

thousand open nursing positions in this country and and it is dishonest to imply, there there may be positions out there where there aren't lots of options. But we have massive nursing shortages in this country. As someone said it up here, it's the greatest way to the middle class is to go become a nurse, because it's easy to get a job if, if you get a nursing degree. It's why people wanna do it. So, it's dishonest to imply that people are forced into these gig economy jobs because they can't get a traditional nursing position. And by the way, here would be my next question, since you study this so much, these gig um nursing positions, where are they, where are they looking for people? Are they Are they working in Palatka, Florida? Are they working in rural America or are they working in our big cities? Are they trying to get gig folks to work in the boonies or are they working in our large cities you talked about Pittsburgh where do they tend to be looking for people to do these gig jobs?

I disagree with some of the statements you've made about dishonesty. I do wanna say that many gig nursing platforms focus on rural areas and they are present in the state of Florida.

OK, well, great. We have a lot of rural too. Do you think we have we have nursing shortages in our rural areas.

My expertise.

You don't study that, I got it. So, so not super useful testimony. The fact of the matter is, there are massive health care shortages out there, massive. Two hundred and fifty thousand open nursing positions in this country right now. And so we ought to be exploring all of the platforms to do it. And the fact that you can say that you study one part of the industry without studying the whole thing I think puts into into question the value of all of this testimony at all. Uh, Miss Begay, your testimony says that almost two hundred rural hospitals have closed since two thousand five in part due to staffing challenges. How would increasing certainty for locum tenens providers, as the Rural Health Care Act does, help some rural hospitals remain operational?

Thank you for the question. By creating certainty, we're gonna continue to protect a workforce that has been working for the health care system today. This workforce has started since the seventies and has been around for decades, and we rely on it. These rural health care facilities rely upon the opportunity to take on short-term providers to meet the needs that they have. If we remove that certainty, rural facilities in particular will be harmed because it's harder to recruit there. Those are the first jobs that folks will not take because they aren't as uh enticing. They'd like to stay close to home if it's easier to do it that way and they don't have to worry about uncertainty.

Thank you. Look, we have massive worker shortages in health care over overall. They're exacerbated in our rural areas because given the same job, the same pay, many people would choose to live in a bigger city or a more suburban area than many of our rural options we ought to be maximizing the chances to fill these jobs. If this was a a um a market where we had more workers than we had jobs, I think some of these concerns would be legitimate. But, you know, I find it highly suspect that I think if w- instead of talking about, you know, these things, if we were talking about nearing centers, like we've talked about leering centers, I think if people were getting paid to do nothing, I suspect that my colleagues on the other side of the aisle would be much more comfortable with the discussion. So, Mr. Chairman, I yield back.

Thank you. Next I'll turn to myself for five minutes of questioning and uh just uh uh I would like to start by saying that there is a shortage of nurses in healthcare professionals in this country and I think we should be able to agree on basic facts like that. Whether you're in a rural area or even a suburban community, uh like myself where our two health networks are are located primarily, uh they often face these kinds of shortages and so they've been turning to different staffing options for years to try to figure out how to fill these positions and provide the best care for their patients and On the flip side, there are providers, uh individuals, uh in the health care space who enjoy the flexibility and these different innovative options that are out there as has been said, many of these uh temporary positions provide exceedingly uh high wages actually, and that's why people choose to go into them, not just the flexibility but also the fact that they can make additional money. So uh I think we need to uh understand uh the whole situation in the health care system and and be honest about that uh so that we can actually try to figure out what what uh possible legislative approaches or solutions we want to advance going forward. Uh, Mr. Wolfson, I'd like to start with you. You talked about uh the the ninety thousand physician shortage that you see in the next ten years alone, and uh some numbers have that even higher. Uh, can we talk about ways to increase, you you mentioned, increasing the pipeline, of physicians in full-time positions, uh, but also, uh, for these temporary placeholder, uh, individuals, how do we expand their options as well and, and grow those things simultaneously?

Thank you for your question, Mr. Chairman. I th- I think the doctor shortage, the shortage across a lot of advanced practitioners is one of those challenges that we have to train more people. That's absolutely part of the challenge. We need to figure out ways to find trained people who aren't practicing. You've got people who are, have come to the United States from other countries, who are licensed who need to get licensed in the United States we need to fix how deal with those challenges what locum tenens does is it says we have doctors who are practicing in the United States today who might be practicing in one place but they have extra time that they're willing to practice or maybe they are someone who's decided to take some time off of practice after having children and they would like to work twenty hours a week instead of forty fifty or sixty hours and so locum tenens is a great way to identify shortages and identify people who are willing to fill those shortages These are not people who the labor laws seek to protect. This is a different kind of worker. This is the type of worker who has five, ten, fifteen years of graduate experience after they've completed undergrad. These are people who are making significant money. And if we allow them to make independent choices to say, " Yes, I would like to go to this place." Maybe they wanna travel with their family to that location in practice. The biggest place this is most helpful is when a

Thank you for that. So,

Mm.

recognizing that there is a shortage and there are some

Thank you for your question, Mr. Chairman. So traditional employment and independent work fill two completely different roles for the US economy. Traditional employment uh work is often um is a is for ongoing, full-time or part-time positions that tend to be more permanent. Independent work is often used for temporary, short-term, supplementar or specialized roles, exactly like locum tenens would, right? Like you need a temporary staffing position for one week, three months, in a different location, and so forth. Now, that's kind of the theoretical backdrop of it. What we see in the data, um, according to the Bureau of Labor Statistics and Census Bureau data using current population survey, is that um uh there's about ninety percent of these clinicians, the four occupations covered in the bill, are all traditional traditionally employed, so that's the vast majority of the of the US labor market for these workers. They're traditionally employed W two workers, so there's you know it it's not like it's the other way around where they're ten percent, and we're talking about mostly self-employed. Um and that number by the way since twenty fifteen has been growing, that share. Uh, self-employed workers, clinicians, excuse me, self-employed clinicians in these four occupations is about ten percent of the workforce. Um, and they've been relatively stable since at least twenty fifteen. And what that is, what that is telling us is that they tend to coexist rather than one replacing the other. So we don't see growth in self-employment of these clinicians while traditional um uh employment is falling for these clinicians. So over time since at least twenty fifteen, we see them, again, self-employment clinicians relatively stable, hovering around ten percent with a little bit of growth from traditional employed clinicians. So to - to - to - to us that's - that looks like relatively stable, uh, employment coexisting, traditional employment coexisting, with self-employed clinician all work coexisting.

Well, thank you, uh, appreciate that, and I - I'll just, uh, wrap up here by saying if we have the shortage and we find ways that we can increase or be additive to uh getting individuals into these positions to me that seems like a good thing that we wanna figure out how to manage in advance going forward um and so appreciate uh you both answering my questions today thank you and with that I'll turn to uh ranking member of the full committee Mister Scott from Virginia

thank you thank you Mister Chairman um Mister Wolfsen you know that um if a worker is designated as a independent contractor the employer is no longer responsible for minimum wage overtime unemployment compensation workers' compensation and the uh independent contractor is not allowed to organize and form a union you know how much money the employer saves in labor costs by designating someone as an independent contractor as opposed to an employee

thank you uh mister uh ranking member uh i think that that varies because it depends on how much they're actually paying the worker in that job so in these particular circumstances if you hired a locum tenens anesthesiologist you're probably paying them on an hourly basis significantly more than you would be paying a full-time

well generally speaking the employer saves a lot of money uh by designating someone as an independent contractor does it matter whether the worker agreed to it or not

i think i think that the worker agreeing to it is a critical part of an independent contractor relationship and i think that a lot of the

so so a person can waive his right to be an employee by signing on with the with the employer i agree to be an independent contractor and not eligible for minimum wage overtime unemployment compensation and everything else i can just agree to it

i think that in certain context an individual can choose to be they can say i would like to be a locum tenens doctor i would like to fill this role and that they would they understand that they are waiving those right those that is something that absolutely can happen it doesn't get to happen in if you were to try to work at the shipyard and do that, down in your district, mister ranking member, that's obviously a very different conversation.

Uh I I think you're right.

But if you're a highly skilled individual, if you were the person who comes in to fix the crane at the shipyard and you're an

Yeah.

outside contractor that person could absolutely do that even down at the shipyard,

Well

and these are folks who are highly

Does the length does the length of time a person works somewhere um uh is that a factor? I mean, you know, department stores hire employees on the holidays. all the time just for a few weeks are they independent are those people independent contractors are they employees

i think that most of my understanding of the market is most of those folks who are getting hired are being brought on as employees but i'm not i'm not i do not work in retail management i'm not positive about that

um doctor wells um if uh people are brought on uh you you talk about these wage auctions one defense the workers would have against that would be to form a union collectively bargain and prohibit wage auctions. Uh, what is the problem if uh most of them are independent contractors?

Thank you for that question. The problem when they're independent contractors is they do not have a right, I believe, to collectively bargain.

Um, if uh someone is placed as an independent contractor for a few weeks and they keep working just like everyone else, just like all the other nurses on staff, do they ever get to become an employee?

That's a great question. One thing we do know about how these platforms work is that even workers who are, quote, regulars, and I use the word regular because one of these apps called Clipboard Health, it actually only allows nurses who are, quote, regulars to bid on particular shifts. So there is some indication that long-term work at a particular facility does not immediately convert to employee status.

So so if you work there for a year or more than a year, that doesn't come in?

Correct.

That's not a factor? Uh,

As far as I know.

what what happened if a hospital just put off its human resources department as a separate business, and the separate business placed independent contractors at the hospital? Would that um uh immunize the hospital from having to pay minimum wage overtime, be subject to unemployment compensation, workers' compensation, and none of those persons could join a union?

It is my understanding that many facilities are shifting to that model, to reduce the amount of union workers on staff. We are seeing admin nurses being remote or s- contracted out. We are seeing that within traditional uh facilities as well as these gig nursing models.

Uh Doctor uh Gisvely, you indicated that you had um some research that you referred to. You'd referred to that research in prior testimony. Has that research been published?

Thank you uh for your for your question. Are you talking about the California AB five research? That one has been published since two years ago.

the one that you referred to

it's available on our website um with the

the one you referred to in in the january twenty twenty five post is about a forthcoming paper you referred to that forthcoming paper in testimony last year and you referred to that on page two of your prepared statement

we let's look at that so our our study on california ab five has been published uh and it's available online on the marcata's website with the full data uh appendix and everything on there um we've actually had an ergonomist reach out and ask to replicate the data that's the california eighty five study

thank you

thank you next we'll go to mister owens who is waving on to the subcommittee today

uh thank you uh uh uh mr. chairman and remember uh for this uh very very important topic uh almost weekly i meet with hospitals small families uh clinics uh physicians in advance for practitioners who are working hard to keep the doors open. A constant concern in these conversations is that the s- the system is is stretched thin from recruiting providers to s- to staff uh rural health systems, to freeing up operating rooms in major hospitals, our health care workforce is fragmented and our constituents are paying the price. There are delayed appointments, long drives, and worsening outcomes. This growing need is why I introduced the Rural Health Care Act. In Utah and rural and underserved communities across the country, there are shortages to get worse in the coming decade, especially in primary care and uh and key specialties. In many of these places local tenants are professionals are providing a real lifeline. At at a time when it takes nearly half a year on average to fill a primary care position these independent cl- clinicians are step in so patients don't lose access while facilities search for what m- what might be the only doctor within fifty fifty miles. We absolutely need long-term reforms for training, recruiting and retaining health care workers, we also need to address a system struggling to stay afloat due to vague and restrictive rules. Countifying what is already common s- common practice and practicing and protecting a workforce model that is often the only lifeline for rural and underserved communities is common sense. It is a model that provides immediate re- relief and continues to deliver care where it's needed most. Let's remove the bureaucratic barriers that hinder delivery of this very very important health care service. With that, I'll move on to my questions. Um, this may uh be a uh H CHC HealthCare uh is headquartered in Utah and has deep roots supporting rural and underserved communities there, which also plays local tenders providers in rural and tribal hospitals and clinics across all fifty states can you speak to your nationwide footprint, helping to maintain access to care?

Yes, thank you, Congressman Owens, so much for your support. we place providers across the entire nation, and to give an example, there is a provider who goes to the very most northern city in Alaska, uh I'll probably pronounce it incorrectly, but I believe it's Utkiyavik, and provides care all the way to that far north. And then we have folks who provide care at the Hibbous Hibbous Supai tribe, uh at Hibbous Supai Falls. And so we see that this care is necessary all across the nation and remote communities. and that they are willing to do it and provide that care.

Thank you. Uh from HCG's uh perspective on the ground, what is the greatest staffing pressure right now, and which states or communities do you find the hardest place, hardest to place advanced practitioners practitioners when uh when facilities ask for help?

The places that we find uh hard to place are uh I think I'll have to get back to you on with that question specifically, Of course, we know that in general rural facilities are more challenging because you have to make sure you have the right fit between the provider who has the right care, and the willingness to provide it at the time that it's needed.

OK. And, Mister Wilson, uh, you studied independent con- uh, independent work across the economy. From a legal and economic perspe perspective, what are the specific features of local tenant tenants' work, and what make it clear fit for independent contractor status rather than traditional employment and why does this does this essentially matter for patients' access to care?

Thank you, representative. I think that the key thing about locum tenens is that those doctors understand going into the relationship that they are not going to be employees. And they go in willingly with their eyes wide open to that scenario because they want to serve patients in that community or at that facility. And so because they go in with their eyes wide open, then we have to look at the factors that we traditionally use to decide whether or not someone is an employee or an independent contractor, with that framework, cuz I think one of the challenges that we often look at this as, we assume people are employees unless they prove otherwise, but if these highly trained individuals have told us they want to be independent workers, we need to evaluate the criteria. And I think the thing that I highlighted in my verbal testimony this morning was that often one of the categories that we look at is the control factor. Even in the proposal from the US Department of Labor right now, the control factor matters, but here a lot of the vestiges of control in the

I ap- appreciate that summary. Um, I was in corporate sales for thirty years. The entire time I was also an independent contractor. I was there, I was an independent contractor for that reason. I wanted exactly to have goals and dreams of my own. I did not want to be an impl- another, to be employed by someone else. I think it's time for, for bureaucrats in DC to realize that we have a choice also to be independent contractors and we provide a service in place like uh uh Alaska that other people not wanna go to and we do it with our eyes wide open. Let us do what we do best. Let us follow our dreams and stop trying to to craft us into something that you think is beneficial to you and your your whatever, as opposed to those of us who want to make things happen and and provide the services very well needed so thank you so much for that and uh with that I'll go back.

Thank you, next we'll go to Representative Mester Mesmer from Indiana.

Uh thank you Mister Chairman and thank you for our witnesses for being here today. Uh Mister Wol- Wol- Wilson in your testimony you indicate that in many cases the choice is not between a locum tenens provider or a full-time physician, or rather a locum tenens provider or no health care provided at all. Can you discuss whether we we could expect positive outcomes for patients if more local tenants providers can practice in underserved areas?

Thank you, Representative. I think that that's absolutely right. When we are looking at the locum tenants population and often the places they fill, they fill these rural roles, they fill roles that it's hard to find, or they fill roles for an individual who's going to take that temporary leave. I think the best example are these situations where a female doctor is on maternity leave and she's a pediatrician and she has patients who need to see her, but obviously we want her to be able to take that maternity leave. So how do you do that? Well, you find someone to come in for six, twelve, however many months that practice provides her with maternity leave, and you let someone fill that role. Locum tendens doctors can fill that role, and that means that the small children in that community don't have to miss out on care because their pediatrician decided to have her own family. And so I think

OK, thank you. Um, in my district in Indiana, it it's heavily rural and we struggle to keep up with basic health care needs of our area,

Mm.

let alone specialty practice needs of patients. Uh Miss Begay, how do these uh local local tenements assignments allow advanced practice providers to reach these areas that would normally be healthcare deserts?

Can you ask that question one more time?

Yeah, how do th- how do uh the locum tenem tenens allow advanced practice providers to reach areas that would normally be healthcare deserts in r- in rural in uh parts of America, like my district?

Thank you f- so much for that question. What this allows is for them to be able to choose where they can go to provide care. And we know that in those rural areas, that these local maintenance providers are a significant contributor to a reduction in burnout both for the provider themselves and for those that are there locally so we know facilities will hire local tenants specifically to reduce the burnout amongst their own staff we found that uh advanced practice providers will also report that they have reduced uh symptoms of over of burnout after they perform one of these assignments.

Great. Thank you. And why is it important for these providers to have the flexibility to work these assignments?

It's integral. It's why they do it. Uh, I have multiple stories of physicians who are at different stages of their life, whether they're first coming out of residency while they're currently have a full-time practice, or maybe while they're looking into residency and they w- are looking into retirement. And they say specifically that that ability to control their schedules is what allows them and makes them choose to do this work. So much so that nearly three out of four would choose not to do the work, if they were unable to do it in this model.

Okay, thank you. Uh, there's many misconceptions surrounding the independent contracting and how it affects the tr- traditional W- two workforce. Uh, Dolla uh, Doctor uh, Paula Gashvili, can you expand on the worker misclassification debate and how locum tenens uh provider providers fit that in fit into that conversation?

Thank you for that question. um, worker classification debate is usually centered around more vulnerable, um, economically dependent workers. Um, the occupations as a part of this bill are highly specialized, highly professional, highly educated, um, and vast majority are insured, both self-employed collations, the local tenants, and the traditionally employed collations. So from the American Community Survey, um, there are I'm gonna tell you the exact number that I looked at. Ninety-six point one percent of self-employed covered clinicians report having health insurance. So, this is fundamentally a different market, a different type of workforce than what we typically focus on in um, the kind of the misclassification uh ish and concerns and issues. So, um, that's kind of the, that's a key thing uh we think we should try to understand is, when we talk about misclassification or worker classification, we're typically thinking about a different workforce. these four occupational categories um in the as part of the bill, um who are local tenants, don't fit that profile. Um they're highly educated, high income, mostly insured. Thank you.

Thank you. Thank you for your answers and I yield back.

Thank you and with that we'll uh close out questioning. Uh appreciate everybody's answers today. And now we will go to closing remarks and for that I'll recognize the ranking member for her closing statement.

Thank you, Mister Chairman, and thank you to our witnesses for their testimony today. Today's discussion should reinforce an important point. Rural communities face real health care workforce challenges, but weakening worker protection is not the solution. H R eighty-three forty-seven asks us to believe that the path to expanding access to care is making it easier to classify health care professionals as independent contractors. But when workers lose access to basic protections such as unemployment insurance, workers' compensation, overtime protection, and the ability to organize, the burden did not does not just disappear, it's simply shifted onto workers and their families. We also hear today that recruiting and retaining healthcare professionals in rural communities remains a significant challenge. Yet, instead of pursuing policies that strengthen the this legislation creates incentives for staffing models that can increase turnover, reduce stability, and weaken accountability. This is not a long-term solution for patients, providers, or rural hospitals. If we are serious about addressing rural health health care shortage, we should focus on proven strategies. We should invest in workforce development, support loan repayment programs, and ensure that hospitals and clinics have the resources they need to recruit and retain qualified professionals. We must also recognize that the recent cuts to Medicaid and student aid will only make these challenges worse moving forward. America's health care workers deserve fair treatment and strong workplace protections. And patients deserve a stable, well-supported workforce providing high quality care, and we can and must insure both. Mr. Chairman, I request unanimous consent to enter into the record the statement from the National Nurses United regarding the healthcare staffing crisis.

Without objection.

And with that, I yield back.

Well, thank you. And uh thank you again to all of our testifiers. I thought it was a very interesting and informative discussion that we had here today and that's the purpose of subcommittee hearings like this is to gather new information hear different perspectives on the different topics. and uh als- also get feedback on uh potential legislation. And so uh I think it was a very productive hearing that we had here today, and I would just like to close by talking a little bit about some of the things that I heard and how we are facing a health care shortage of uh trained individuals all across this country and that ability to see your doctor and receive care should not be a luxury uh but for many people it's a necessity. that they get this type of care. Today's unfortunate reality, though, is that it takes on average two hundred and twenty-six days to fill a specialty care fi uh position and workforce shortages in rural communities are expected to reach as high as sixty percent over the next decade. So it's clear, uh, from today's hearing that we have heard that both full-time employees and independent contractors can o- o- operate side-by-side and actually be additive, to the uh ability to provide care for patients all across this country, and it makes it easier for hospitals and health systems uh to continue to serve those patients during workforce interruptions. Unfortunately, we have also heard about state laws uh such as AB five in California that have forced independent providers into uh employee arrangements that many of them don't even want uh and that is further complicated and and and matters are made worse, uh because of this distinction sometimes that is made in state laws, uh where physicians are exempted from the law but other providers such as nurse practitioners and physician's assistants are not. And so to ensure that independent providers can continue to care for patients, we need to meet these workers where they are and support their work choices, uh which are often multifaceted decisions, whether it's uh pay, benefits, full-time employment versus independent contractor work, workplace safety, and - and uh their situations uh that they would like to - to be in. Uh all of those things come together to allow them to make a decision, and - but we should allow workers to make that decision on their own. And so we should also take a close look at solutions such as HR eighty-three forty-seven, which has been talked about here today, uh the Rural Health Care Act which was introduced by Representative Burgess Owens. Uh this could at least uh the - the - be the least that we could do here at the federal level. to give some level of predictability and clear up decades of uh worker misclassification uncertainty uh that has has riled so many different industries including healthcare so I I think it was a very helpful uh and informative discussion that we had here today appreciate all of you being here again and uh with that we will go to wrapping up uh without objection and there being no further business before this subcommittee, we now stand adjourned. Thank you.