Advancing the Next Generation of America’s Health Care Workforce

Good morning. We will call the sub- health subcommittee meeting to order here. Thank you uh to our witnesses uh for being here, sharing in in your perspective as we discuss advancing the next generation of America's healthcare workforce. I'm filling in today for subcommittee chairman, Mister Buchanan, who cannot be here this morning. He has a number of concerns about this issue, as do I. And I'm glad he called this hearing together. Our nation is facing a very real problem, a rapidly depleting health health care workforce. By two thousand thirty-seven, the US will see a shortage of one hundred eighty-seven thousand physicians. Nearly half of all practicing physicians will retire in the next decade. Eighty-three million Americans live in an area with too few primary care physicians. Rural communities are even more vulnerable to workforce shortages, with sixty percent fewer physicians for every ten thousand patients, when compared with urban areas. Medical school medical schools prepare uh, I'm sorry, medical school prepares students to help fill this shortfall, but residency programs after graduation deliver practical instruction and enable doctors to deliver the best patient care. This graduate medical education, or GME, is a critical component of physician training. Medicare is a major contributor to GME, supporting nearly eighty percent of residency training nationwide and paying more than twenty billion dollars annually to teaching hospitals. However, this funding is increasingly being directed to large coastal hospitals, while health care workforce shortages persist across the country. Rural and un- underserved communities in particular face unique barriers to establishing programs and training residents. Rural hospitals must overcome a lack of resources, staff and patient volume to establish new residency programs, while simultaneously getting reimbursed less than their urban counterparts. Congress recognized this gap and recently funded more than one thousand new GME slots, with ten percent specifically reserved for rural areas. But, concerningly, large urban hospitals have exploited a a Medicare loophole and have collected ninety-seven percent of the eight hundred slots distributed so far. This behavior perpetuates the already stark geographic disparities in GME, as research shows that doctors are five times more likely to stay in practice in a rural area if they train there, yet only two percent of residencies can be found in rural America. At the same time, we need to train new physicians to better address the chronic disease epidemic by focusing on prevention nutrition and incorporating modern technology. Six out of ten Americans have a chronic disease, and ninety percent of our health care dollars go toward managing these diseases. Unfortunately, most residents receive minimal training in prevention. In fact, only fourteen percent of residency programs have a required nutrition curriculum. If we are serious about strengthening our health care system, increasing our supply of physicians, and managing chronic disease, we must start with how and where we train our our physicians. I am encouraged by the success of some efforts, such as rural rural track programs and hospital residencies that are incorporating technology and lifestyle education. But I know there is more we can do. I look forward to discussing this important topic with my colleagues today, so this committee can lean on t- on targeted solutions to grow our healthcare workforce. I'm pleased to recognize a gentleman and my friend from California, Mister Thompson, for his opening statement.

Thank you, uh, Mister Chairman. Uh, as you know, the ranking member, uh, Mister Doggett had travel delays because of these storms, was unable to be here, so it's an honor for me to uh sit in for him but I would like to ask unanimous consent to enter his statement uh uh for the record.

Without objection.

Thank you. Uh, Mister Chairman, um well once again uh we're here to address n- without question a serious issue, and that's the next generation of healthcare workers, but at the same time uh just another uh effort on the part of my uh colleagues on the other side of the aisle uh to distract from talking about the eight hundred pound uh gorilla in the room, and that's the fact that they have eliminated health care coverage for millions of Americans. If Americans can't get coverage, they can't afford their health care. Um and and we as we know, people will still get sick, people will still get injured, and this is going to drive more Americans into debt, and it's going to be devastating for hospitals across our country. Hospitals will see their uncompensated care costs, increase. In H. R. one, the big ugly law, uh congressional Republicans cut one trillion dollars from Medicaid. They also failed to extend premium tax credits that helped millions of Americans afford their insurance coverage. They kicked fifteen million people off of their insurance so they could give their billionaire donors a tax break. And it should be noted they also added four trillion dollars to our national debt. Because these, because of these cuts, hospitals are being forced to reduce services or worse yet, close altogether. Every health care system will suffer because of Congressional Republicans' health care cuts, and rural and underserved areas will bur- bear the burden of these uh cuts at a greater uh level. We are supposedly here to talk about the future of health care workforce. Who's gonna train future rural physicians and health care providers with a trillion dollar hole in our health care system. My Republican colleagues are ignoring the warning of health care providers about the impact their policies will have on hospitals and health care systems, in their own district. They're also uh with this bill uh made it so future health care practitioners can't afford their education. They capped the amount at s- a student can borrow at two hundred thousand dollars. But the median cost for a public medical school, uh, in twenty twenty-four was nearly three hundred thousand dollars. And private medical schools in some instances cost even more. Students aren't gonna be able to pay for their education, so they either won't become doctors or they will have even greater debt. We know that doctors with less medical debt are more likely to practice in underserved areas in rural areas. We also know that doctors in with less debt contribute even more to our local economy. This borrowing cap hurts health care access for rural and underserved populations, some of which my Republican colleagues uh represent and claim to want to help. The Trump administration is also threatening the public service loan forgiveness program. Forty percent of physicians use this forgiveness program to help pay off their loans. Sadly, the Trump administration is targeting health care facilities whose care policies they disagree with by making their physicians ineligible for the program. We should make it easier for students to afford their medical education, so that they can grow our pool of talented doctors and provide a much needed health care to the people uh that we represent. We should grow the number of doctors training across our country, like the and we should do it with legislation such as the bill that our colleague, Congresswoman Sewell, introduced, the Resident Physician Shortage Reduction Act. And we should expand funding for training at children's hospitals. Instead, my friends on the other side are making it so only the wealthy can pay for medical school. I invite my Republican colleagues to join us in working to make health care accessible for all Americans not just wealthy Americans. And I yield back the balance of my time.

Again, thank you to our witnesses. I look forward to a thoughtful conversation here as we have an exchange of ideas, and hopefully a a focus on solutions. Uh, let me uh uh introduce our guests here today, our witnesses, Doctor Emily Hawes. She is a professor at the Department of Family Medicine at the University of North Carolina School of Medicine and is a rural clinical pharmacist by training. Next we have Mister Jace Jason Shennefield. He's the Chief Executive Officer of Phelps Health, a hospital in Rural Missouri, or as some locals would say, Missouri. But, but there's a variety of opinions on that, right? Uh, next we have Doctor Thomas Moore. He's Dean of Sam Houston State University College of Osteopathic Medicine. Then uh after uh Doctor Moore we have Doctor Jennifer Trilk, who is the Doc- is the Director of the Lifestyle Medicine Program at the University of South Carolina School of Medicine, Greenville, and Co-founder of the Lifestyle Medicine Education Curriculum. And finally we have Doctor Andrew Racine, who is President of the American Academy of Pediatrics. Again, I say thank you for sharing your time and certainly your expertise and, like I said, I look forward to a thoughtful exchange of ideas.

Mm-hmm.

Uh, be reminded that your written statements will be made a part of the hearing record, and you each will have five minutes to deliver your oral remarks. You'll see the uh the red uh well the green, then yellow, then red light in front of you. Once you see that uh yellow light uh uh you'll you can uh, as I like to say, bring the flight in for a landing. So we'll begin, uh Doctor Hawes. Uh, you are, you're recognized for five minutes.

Chairman Smith, Ranking Member Thompson, and members of the Health Subcommittee, thank you for the invitation. My name is Emily Haas and I practice as a rural clinical pharmacist in a small family medicine clinic in Boone, North Carolina. I serve as Director of the Rural Residency Planning and Development and Teaching Health Center Technical Assistance Centers, and I'm a professor at the UNC School of Medicine. My graduate medical education research conducted through the UNC C. Cel-G. Shep Center for Health Services Research. Living, practicing, and training clinicians in rural Western North Carolina gives me firsthand experience with both the access challenges facing rural communities and the tremendous opportunity for innovation in health policy. Today I'll focus on three points. One, training physicians in rural areas is an evidence-based strategy to address forced shortages and improve access to care. Two, federal and state rural GME policies are highly effective at increasing rural training. Three, Congress can take targeted steps to further develop, expand, and sustain rural training. Rural training uh we know that having fewer local physicians is a key driver of worse uh health outcomes in rural communities, but we also know a great way to address this. Training physicians in rural settings doubles the probability they will practice in rural communities. There are also these spillover effects from training. Through our national work supporting more than two hundred rural and underserved clinics and hospitals, we have seen that bringing residency training to a rural community can lead to additional benefits like reopening labor and delivery units expanding chronic disease management and fostering other clinical services compared to urban hospitals, many rural facilities face unique challenges. thin financial margins, limited subspecialty opportunities, and less educational infrastructure. Yet with targeted support, both start-up funding and Medicare funding for long-term sustainability, they can offer highly effective training. The HRSA-administered Rural Residency Planning and Development program which provides start-up funding and technical assistance has created sixty-three new rural residency programs representing eight hundred accredited resident positions. One in four rural residencies nationwide were initiated through this effort. In fact, several states are have created similar rural residency initiatives modeled on the successes from this federal program. While launching programs is necessary, so is a funding model that can continue to support the program. Recent congressional reforms like resetting historical low payments and streamlining accreditation have lowered barriers for rural hospital to establish training. Expanded flexibilities for critical access hospitals to serve as non-provider training sites has helped support GME participation. Increasing Medicare GME financing makes more sites viable. Taken together, rural residency programs have increased roughly four-fold since two thousand eight, a remarkable change in the GME landscape in less than two decades. Despite this progress, most GME remains concentrated in urban areas, and additional reforms are needed to ensure rural training can scale to meet workforce needs. Based on our on-the-ground technical assistance and research, I offer the following potential strategies that could increase rural training opportunities. Increase eligibility. Target Medicare rural track eligibility to rural census tracts rather than just rural counties to reach more rural sites for residency creation. Direct additional payment slots to geographically rural facilities. Enable other rural health facilities such as tribal sites to be treated as non-provider sites. Lower the fifty percent rural training threshold to thirty percent for procedurally intensive specialties like general surgery as rural hospitals struggle to achieve fifty percent of the training needed. Make rural training more feasible. Extend the Medicare cap building window five to ten years for rural hospitals to have more time to achieve their full training potential. Allow rural facilities to reset low per-resident amounts or FTE caps to unlock training capacity by extending the flexibility of section one thirty-one. Ensure rural hospitals, such as Seoul Community Hospitals, receive full Medicare GME re- reimbursement. Last, scale what works. Build on successful models like rural residency planning and development, which are developing rural training capacity. Training physicians in rural America is an evidence-based solution for addressing rural healthcare access. With continued bipartisan support and thoughtful policy refinement, rural training will continue to grow. Thank you, and I look forward to your questions.

Thank you, and uh, Mister Shenefield, you're recognized for five minutes.

Subcommittee Chairman Smith, Ranking Member Thompson, and members of the subcommittee, thank you for the opportunity to testify. My name is Jason Schenefeld and I serve as the President and CEO of Phelps Health in Rolla, Missouri. I've worked in healthcare for more than thirty years, beginning as a Navy corpsman and spending my career on the front lines of care delivery, particularly in communities where access is fragile and every staffing vacancy is filled immediately. Rural residency development is an academic for us, it's operational. It determines whether families can access prenatal care locally, whether seniors can get timely diabetes management, and whether patients with chest pain have a trusted physician who knows them before the ER is ever involved. At its core, this is about our mission, keeping high quality care close to home. Founded in nineteen fifty-one as a small county hospital, Phelps Health has grown into a regional system serving more than two hundred thousand residents across six rural counties in South Central Missouri. Each of these counties is designated as a health professional shortage area. for primary care and faces significant health disparities. One of the most persistent drivers of this shortage is a lack of rural residency programs. Missouri ranks among the top states in the number of medical schools, yet we only have enough first-year residency slots for roughly two-thirds of our graduates. As a result, Missouri exports a significant share of its newly trained physicians and once they leave the state for residency, they are far less likely to return, particularly to re- rural communities. Residency training shapes where physicians ultimately practice. When residents train in rural communities, they build relationships, understand the culture, and see firsthand the opportunity to make a difference. Family medicine physicians in particular play a vital role in improving population health through preventive care chronic disease management, and coordination with specialists. Their broad scope is especially critical in maternal health deserts where access to obstetric care continues to decline. For these reasons, Phelps Health made the decision last year to establish a family medicine residency program with enhanced obstetric training, Our goal is straightforward, strengthen recruitment and long-term retention of primary care physicians in our region. That decision became possible through two t- planning and development grants, one from HRSA and one from the state of Missouri. These grants help cover essential start-up costs such as accreditation, faculty development, and initial recruitment. They allowed us to move from years of discussion to meaningful action. However, these opportunities are limited. Only about fifteen federal wards are made each year and very few states offer comparable support. As we transition from planning to implementation, we are seeing firsthand the start-up grants are necessary but not sufficient. One immediate challenge is infrastructure. Accreditation standards require dedicated clinical and teaching space. Our early estimates for build-outs range from five to seven million dollars. For a rural health system operating on approximately a two percent margin, that level of capital investment is significant. Without additional flexibility, programs can stall before the first resident ever arrives. Sustainability presents another challenge. Medicare supports residency programs through direct graduate medical education and indirect medical education payments. However, rural hospitals often face structural disadvantages within this formula. For example, Seoul Community Hospital's reimbursed as a hospital-specific rate are excluded from IME payments a key funding stream from any programs Studies show that this can translate into nearly ninety-six thousand dollars less per resident per year compared to hospitals paid under the prospective payment system. That gap alone can determine whether a rural residency program breaks even. breaks even or operates at a loss. In addition, a hospital's per resident amount is frequently based on decades-old cost reports, in many cases dating back to nineteen eighty-four, to the first year a hospital ever trained residents. Our ra- rate reflects a very different era of health care delivery. While Congress has provided opportunities to reset resident caps, there's currently no pathway to modernize outdated per resident amounts. When thin margins, high need populations and outdated funding formulas intersect, rural hospitals are asked to shoulder disproportionate risk in building the very workforce pipelines our communities depend on. I would respectfully offer three practical bipartisan solutions. First, provide flexible bridge funding to cover the real world gaps between planning grants and full program launch especially for clinic infrastructure, teaching space, and start-up staffing. Second, create an option for rural hospitals to update their per resident amount when starting a new rural residency program. Third, ensure rural facilities are not disadvantaged in Medicare GME payments by allowing facilities access to payments if they cannot receive them. If we address these gaps, we will not simply create residency slots, we will create sustainable rural physician careers, expand access to care, and strengthen the long-term stability of rural communities. Thank you again for your leadership and the opportunity to share our perspective. Uh, we look forward to working with the community to develop sustainable policies that support rural residency programs across the country.

Thank you. Next, Doctor Moore for five minutes.

Subcommittee Chairman Smith, Ranking Member Thompson, and members of the subcommittee, thank you for the opportunity to testify on advancing the next generation of America's healthcare workforce. My name is Doctor Thomas Moore. I'm an osteopathic internal medicine physician and serve as the Vice President of Medical Affairs and Dean of the College of Osteopathic Medicine at Sam Houston State University in Conroe and Huntsville, Texas. Over the past twenty-five years, I've helped develop and launch twenty-five residency programs across five states, many in rural and underserved areas. Through that work, I have gained firsthand insight into how graduate medical education funding directly shapes the physician workforce. Osteopathic medicine is grounded in a whole person philosophy of care, recognizing the unity of body, mind, and spirit, and the interrelationship between structure and function. That philosophy combined with more than two hundred additional hours of hands-on training in osteopathic manipulative treatment prepares osteopathic physicians to deliver patient-centered care focused on prevention and community health. Osteopathic principles in practice are founded on lifestyle-based interventions and nutrition which are key to treatment of chronic disease. Community-based training is central to this approach. Osteopathic medical education utilizes a distributed model of clinical education that places medical students in community hospitals, rural clinics, health care centers, and physician practices. National workforce data consistently show that physicians practice where they train, making training location one of the strongest predictors of access to care. The community-based model works as medical students who train in underserved areas are almost three times more likely to practice in those areas and for DOs, more than seventy-three percent practice in the state where they complete residency. However, Medicare GME financing has historically been structured around inpatient hospital care. Direct and indirect GME payments are embedded in the hospital cost reporting system that were de- developed decades ago. While these mechanisms have supported the growth of strong academic medical centers, they can frustrate GME development in smaller hospitals and community-based institutions. Medicare per resident amounts, very geogra- var vary by geography based on historic cost structures. Residency caps limit expansion at hospitals that may now well be positioned to grow. In some cases, minimal training activities decades ago has a long-term implication for funding eligibility now. For rural hospitals with limited administrative capacity, these complexities can create real barriers to developing new programs. At the same time, many community are eager to participate in training. They see firsthand the connection between residency programs and long-term physician recruitment. Strengthening financial predictability for community-based programs, whether through clear per-resident support, thoughtful slot distribution, or policies that account for workforce need and demographic change, can help more of these institutions build sustainable pipelines. Increasing the number of Medicare-supported residency positions remains an important consideration. particularly in primary care and rural settings. Workforce shortages continue to affect many communities, and targeted growth in training capacity can help address those gaps. Transparency in residency selection also contributes to workforce strength. The bipartisan Fair Access in Residency Act promotes transparency in Medicare-funded programs by requiring reporting on DO and MD applicants and affirming consideration of the Comlex USA examination scores. Transparency enhances accountability and helps ensure that federally supported training opportunities facilitate physician distribution across both rural and urban areas. Innovation can further extend community-based training capacity as well. Technology-enabled education, including teleprecepting, remote specialty consultation, and physician-led artificial intelligence integration allows residents to train in smaller communities while maintaining access to broader expertise. At SHSU com, we recently launched a medical artificial intelligence institute dedicated to advancing ethical patient-centered innovation and strengthening training in underserved areas. Graduate medical education financing is ultimately a workforce investment, aligning funding structures with where care is delivered, supporting community-based training growth, and ensuring predictable and equitable support can strengthen physician supply in both urban and rural communities alike. I appreciate the subcommittee's attention to this issue and the thoughtful consideration being given to the future of graduate medical education. I look forward to answering your question and continuing this important conversation.

Thank you. Doctor Trilk, you're recognized for five minutes.

Good morning, subcommittee ch- Chairman Smith, Ranking Member Thompson, and members of the committee. Thank you for the opportunity to testify on how physician training directly impacts Medicare spending, chronic disease outcomes, and the long-term sustainability of our healthcare system. My name is Jennifer Trilk. I am the founding faculty member, tenured professor, and director of lifestyle medicine programs at the University of South Carolina School of Medicine, Greenville. I also founded Lifestyle Medicine Education, L Med, we call it, an open-source evidence-based curriculum that helps medical nationwide embed prevention, nutrition and lifestyle medicine into required training. As mentioned this morning, chronic disease now accounts for ninety percent of the nation's four point nine trillion dollars in annual health care spending, much of what is borne by Medicare and Medicaid. Conditions like type two diabetes, heart disease and hypertension are largely driven by modifiable behaviors, yet physician training remains predominantly reactive. focused on managing complications rather than preventing disease progression. For this subcommittee, which oversees Medicare's phys physician payment, graduate medical education and value-based care policy, this is not just an educational issue, this is a fiscal issue. If we want to bend Medicare cost curve, physician training must align with the realities of modern disease, starting on day one of medical education. At our medical school, we embed lifestyle, medicine, and prevention science into our required four-year curriculum. Students complete more than one hundred hours of required content in training and nutrition, physical activity, prescription, behavior change counseling, sleep health, stress management, and team-based care. These competencies are assessed and mapped to accreditation standards, just like pharmacology or pathology. The outcomes do matter. In most, in our most recent graduating class, eighty-seven percent of our students reported using lifestyle medicine prisi principles into their patient care. And eighty-six percent reported applying them personally. And the research shows physicians who practice healthy behaviors counsel more effectively, and patients are more likely to follow that guidance, improving outcomes tied directly to Medicare quality benchmarks. This training also strengthens residency placement and health system readiness. Residency directors increasingly seek physicians who understand population health quality metrics and value-based care. Our graduates enter residency prepared to contribute immediately to the chronic disease management and value-based reimbursement models. At the same time, the nation faces a growing primary care pipeline crisis. In twenty twenty four alone, nearly a thousand family medicine and pediatric residency positions went unfilled. Physicians are leaving primary care due to lower compensation and overwhelming patient loads, while patients wait months for access, allowing chronic disease to worsen and costs to escalate. In South Carolina, chronic disease costs fifty mi- fifty-nine billion dollars annually, and that's more than eleven thousand per person. To address this, our dean, Phyllis McGilvery, the first lifestyle medicine board-certified dean in the history of medical education, launched our primary care accelerated track. This three-year pathway offers full tuition scholarships, direct transition into family medicine residency within our Prisma Health partner, and a four-year in-state service commitment. We also are proud to report that forty-three percent of our twenty twenty-five graduating class matched into primary care across the nation. We emphasize community-based prevention. Through partnerships with more than forty organizations, including the YMCA and the United Way, our students gain firsthand experience with access gaps, and social drivers of health. Over Valentine's Day weekend alone, our remote area medical clinic served more than four hundred patients, delivering over two hundred and thirty-six thousand dollars in care at no cost to those patients. These experiences illuminate the real downstream costs of delayed and fragmented care to the students, costs Medicare ultimately absorbs. For the subcommittee's consideration, I respectfully offer three bipartisan policy priorities within your jurisdiction. First, for the subcommittee uh first align Medicare graduate medical education incentives with demonstrated competency in chronic disease prevention and whole person care second support CMS pilot pilot programs that evaluate long-term cost saving from prevention training physician cohorts. And third, incentivize training models that strengthen the primary care pipeline, particularly those tied to service in high need communities. The question before us is simple. Do we continue funding a workforce built uh for acute episodic illness? Or do we invest in one trained to prevent and reverse chronic disease driving Medicare costs? At the University of South Carolina School of Medicine Greenville, our mission is educate, innovate, and serve. Our lifestyle is medicine. If Medicare sustainability is the goal, workforce reform starting day one of medical school must be part of the solution. Thank you for holding this hearing, and thank you in advance for your questions.

Thank you. Doctor Racine, you're well uh you're recognized for five minutes.

Congressman Smith, Congressman Thompson, and members of the subcommittee. My name is Doctor Andrew Racine, and I'm President of the American Academy of Pediatrics, a non-profit organization of more than sixty-seven thousand pediatric physicians dedicated to the health, safety and well-being of all infants, children, adolescents and young adults. I'm also General Pediatrician and Health Economist with more than three decades in clinical practice and system leadership. I'm deeply grateful for the invitation to be here this morning, and my objective is to provide the committee with insights designed to help inform your important deliberations. Attaining optimal health and well-being of our children, of our country's children requires a pediatric workforce that's large enough and geographically available to all our nation's children and families. But today we face a significant imbalance between the demand for children's health care services and the supply of qualified pediatric practitioners available to meet that demand due to a systematic underinvestment in this nation's children dating back decades. What's driving the demand, the current prevalence of chronic conditions facing America's children, is our failure to invest in inputs that sustain and promote healthy children, good nutrition, parental supports, avoidance of exposures to environmental toxins, and optimal vaccination rates. This is coupled with a supply shortage of pediatricians and pediatric specialists. Today, children and families have to wait an average of ten weeks to see a child and adolescent psychiatrist, twelve weeks to see a pediatric palliative care doctor, and eighteen weeks to see a developmental behavioral pediatrician. Those waits are compounded for families in rural communities who most often travel long distances to see these specialists, forcing parents to miss work, interrupting school, and burdening families with travel costs. I'd like to focus on three critical elements that deserve our attention. Barriers to training enough pediatricians, the financial misalignment in the pediatric health care system, and threats to the retention of our highly trained workforce including burnout and moral injury. A strong pediatric workforce begins with substantive investments of time, effort, and resources. The federal government in medical training from federal loans to direct training support is essential in making this happen. At a time when the average medical school graduate leaves school with approximately two hundred and thirty-five thousand dollars in medical school debt caps on federal graduate loans and the elimination of the Grad Plus loan program will present significant new barriers for students pursuing medical school. Medicare is the largest single public program training for after medical school. Commerce can support more trainees and increase the number of Medicare-supported GME positions by advancing legislation like Representative S- Fitzpatrick and the Sewells' bipartisan Resident Physician Shortage Reduction Act. For pediatrics specifically, I'd like to extend my gratitude for Congress's recent support of the Children's Hospital graduate medical education program and the pediatric specialty loan repayment program. Investments such as these are essential, but they do not overcome the financial challenges pediatric physicians face once they complete their training. Close to half the children in the United States depend on Medicaid or CHIP for coverage. which is a boon because these programs improve long-term outcomes, including higher educational attainment, better health in adulthood, and greater workforce participation. However, pediatricians who disproportionately depend upon Medicaid to finance their practices suffer from untenably low Medicaid payment rates and are especially vulnerable to Medicaid program changes. We're very worried that as states confront looming budget gaps, children's access to care will suffer because of cuts in payment rates and coverage services. The future of pediatric workforce requires more, however, than just resources. It also demands preserving the integrity of the profession. When political interference and mis- and disinformation distort clinical decision-making, the long-term viability of the workforce is threatened, the physician-patient relationship is destabilized, and trust, the thing that's at the very core of the therapeutic alliance between pediatricians and families is undermined. I hear from pediatricians every day having to spend inordinate amounts of time counseling families who arrive at their practices confused and anxious about vaccines while other families are desperately afraid they won't be able to get the vaccines they know their children need. We have pediatricians triaging patients in their parking lots for fear of contaminating their waiting rooms with measles. Others whose patients are too afraid to come in at all, terrified of potential interference from immigration enforcement agents. These things have real consequences in burnout, early retirement, and questioning of professional career decisions. In closing, we have an opportunity to make a substantial down payment toward the health of America's children. When you look into the face of any child in this country, you are seeing the future in the process of becoming. Let's commit to the resources to c- recruit more promising individuals, to devote their professional careers to sustaining those children, and launching them into a lifetime of good health. Let's invest in Medicaid to allow those professionals to do their work effectively, and let's work to reduce the attrition within the pediatric workforce by eliminating the contributors to moral injury and burnout that are within our control. If we do that, children and families all across this country, from rural areas to urban centers, will be the grateful beneficiaries. Thank you and I look forward to your questions.

Thank you again to our panel for uh your thoughtful approach here. We'll now move into the question and answer session. I'll uh kick it off here with a few questions. Doctor Hawes, you mentioned in your written testimony the successes of the Rural Residency Planning and Development Program, RRPD, which has helped establish some sixty-six new rural residency programs since it began in two thousand nineteen. Can you tell me uh in a bit more detail how challenging it is

Thank you. Establishing an educational infrastructure, especially in a setting where they've never had training before, requires substantial upfront costs. Programs must recruit a program director, faculty, obtain accreditation, hire administrative staff, develop curriculum, form clinical partnerships, which Interestingly, in a lot of these rural programs they have many, many partnerships versus being in one or two uh clinical settings. Negotiate funding agreements, establish budgets, recruit residents, execute employment contracts, and often complete construction or renovation of clinical and office space. The RRPD program provides essential seed funding to provi- to support program development over a three to five year period and help them navigate that complex process. The sustainable Medicare GME reimbursement is the hinge that ultimately determines whether these programs can survive and grow, which is why your authority over Medicare GME policy is one of the most powerful levers for addressing rural workforce shortages.

Thank you. And now, uh, we know that RRP RRPD is not even fully codified in law, and I'm proud to say that I've been working with my colleague Carol Miller colleague, to Carol Miller, formally authorize RRPD. I'm wondering if you could reflect a little bit how that uh formal codification would further encourage the development in additional residency programs.

Thank you for that question, Representative. There are many rural hospitals across this nation and rural health facilities that are primed for launching residency programs. There's, in my written testimony, I think there's over seventeen hundred rural facilities that have never engaged in GME yet, um there's a lot of untapped potential. And so, um you know, i- it's and - and there's a lot of opportunity to grow graduate medical education. One thing about RRPD that many people don't know is that it actually funds technical assistance and a lot of the research that you read in the um written statement that are really driving these policy solutions that I'm giving you today, Um the other thing that RRPD provides is that um it shows that rural training is possible and it provides that critical piece of start-up and and technical assistance that Medicare GME does not so there's a lot of potential um growth possibilities recent reform with Medicare has been helping increase training, and we've been learning through a lot of the research with RRPD that that there are some refinements that can increase eligibility feasibility and long-term viability for other rural health facilities that wanna engage in this work.

Okay, thank you. Uh, Mister Sh- uh, Shana Field, I'm wondering, certainly appreciate your perspective and uh, operating a facility in in rural America. What would you describe as the single greatest challenge in recruiting a physician to your facility?

Uh, uh, it's hard to narrow it down to just one single challenge. I think that, you know, what I, what I can say is, um, having been in healthcare for thirty years now, uh early in my career doing physician recruiting uh for probably about eight years of that and just seeing how much harder it has become to recruit physicians. I think it's just uh the need has gotten greater um and the availability of physicians has gotten fewer. And so uh I think it's just it's a supply and demand issue. Uh I think in in rural America it is uh getting people to come to your community, to to see the community um and and somehow connect to it. I think since most the residents uh that go through training train in urban areas, uh there's amenities, there's things that they get attracted to, uh oftentimes they may meet their spouse who's from that area, and it's hard to pull them away to uh a rural part of America. Uh so I think it's hard to narrow it down to one thing, but I can definitely tell you it has gotten harder and harder over the years, uh really from a supply and demand standpoint.

Mm.

Jesus.

Uh, thank you. I'll, I have a lot more questions, but I want to uh save time for my colleagues as well. So, uh, uh, on the whole GME thing and the, uh, match day and the fact that, uh, a, a medical student would not only get into medical school and out, the fact that five percent of, um, graduates would not match on match day I think should concern all of us.

Mm-hmm.

And so, uh, lot, lots, uh, lots going on there, but, uh, I now recognize Mister Thompson for questions he asked.

Thank you, Mister Chairman, I wanna thank all the witnesses for being here, I appreciate, uh, your, um, your your work that you're doing. I have a question for all of you, and if you could just give me a yes or no, we'll start with uh Doctor Haas and go down the line. Did the trillion dollar cut to Medicaid uh help or hurt delivery of health care in rural areas? Yes or no? Did it h- did it did it help?

Sorry. Um, I'm here discussing rural disease.

J- just yes or no, did did thi- did this help?

GME is funded through multiple sources. Um, a change in one will af- will have effects on the system,

Uh, doctors.

and rural and underserved programs are receiving Medicaid G.

Mister Shanfield.

I've been in healthcare for thirty years and payment source has been a a challenge every every year of my career almost so it's no different than any other time.

Doctor Moore.

Resident physicians do take up a greater percentage of the uh of the care uh for those folks who don't have uh insurance or are under uh insured, um uh it certainly makes it more difficult.

Doctor Trilk?

This is outside of my scope as an undergraduate medical educator.

It's outside your scope to know if a trillion dollars taken away from healthcare uh helps?

Yes, sir.

The uh Doctor Racine?

It hurts.

Thank you. Um Secretary Kennedy is, I believe, undermining health care in America. His anti-vaccine views are increasing the burden on our physicians and in some cases, uh, truly harming, uh, children. Let's be absolutely clear. Vaccines are safe and effective. Vaccines save lives. Before Secretary Kennedy, we had nearly eradicated measles, now it's infecting kids across our country. from my home state of California to South Carolina. Secretary Kennedy, uh, I believe, is harming that, uh, our kids and he is doing a terrible job in this position. I would like to ask unanimous consent to enter into the record this Washington Post story says as measles headlined, as measles spreads, these nine vaccine preventable diseases could be next. They're sounding the alarm in need for vaccines.

Not objection.

So, um, Doctor, uh, Rasim, do vaccines save lives?

Unequivocally.

The Secretary of Health and Human Services is charged with improving uh the health of our country. Can you talk about the struggles your pediatrician members are dealing with in combating Secretary Kennedy's vaccine disinformation?

I think the extent to which there has been uncertainty that's injected into this area has caused a great deal of difficulty for practicing pediatricians. We're spending a lot more time counseling folks who are coming in with misinformation or disinformation about the benefits of vaccines, and that takes away from time that we could be doing other things. At the same time, there are lots of anxious parents calling up our practices morning to make sure that they'll be able to get the vaccines, and they're worried that that's not gonna be available to them. I think also, um, there are a lot of, uh, pediatricians who are concerned about the liability of prescribing and delivering vaccines that are no longer routinely recommended, although we're being reassured by the CDC that that liability has not changed, but they're worried about that. And they're also worried about where this is leading. That is, the current, the current confusion with regard to vaccines is part of a longer term um initiative and the concern is that what's going to happen next is going to be changes to the vaccine injury compensation program and that this is just going to snowball further and further, so there's lots of concerns in the pediatric community about this.

And um I I greatly appreciate the work that your members and all pediatricians do in protecting our kids um and as pediatricians treat disease outbreaks, could uh be prevented by vaccines. Can you explain how this impacts all kids and their access to care?

Uh, sure. We um, we've been talking a little bit about what changes pediatricians are having to make in their practices to accommodate the fact that they now have to worry about things like measles. There is a um pediatrician in South Carolina who recently has been speaking about having to triage her patients in the parking lot. And the reason for that is you don't want to introduce a child potentially with measles into your practice. Because if you do, the entire practice has to shut down, because you have - you have obligations with regard to uh cleaning that entire area. The measles virus will stay - stay in the air for some time. So you have to not only take everybody out, you're then gonna have to find all the people who were there and trace them, particularly for children who are too young to have received a measles vaccine, and therefore - or therefore um susceptible to catching the disease, children who are immunocompromised. There's a huge amount of work that has to happen should a child potentially with measles come into the practice. That's in a private practice. If you're in a hospital and you're in a busy emergency department and a child with measles comes in, that entire that entire emergency department has to shut down. You have to essentially re-institute um procedures that are going to cleanse that whole area and every person every family member every child that's currently in that busy emergency department, has to be notified, has to be tracked, all of that. There is a tendency right now in the United States to be closing pediatrics beds, and that has been going on for some years, to the extent that some of these children, either with measles or with influenza or something else, get admitted to the hospital. They're taking up a bed that someone else might need, and if this is in a rural area, that may mean that some other child is gonna have to travel very long distances.

The gentleman's time has expired.

I apologize. Sorry.

Thank you very much.

Thank you. Chair would like to remind both members and witnesses to please limit their remarks to the five minutes allotted. Pursuant to committee practice, we will now proceed with two-to-one questioning. I now recognize the gentleman in the, uh, chairman of the full committee, Chairman Smith from Missouri.

Thank you, Chairman. Before I go to my questions, um, let me first say thank you to each and every one of you for taking time out of your busy schedules to be here and to help, um, bring forth productive conversation to actually solve issues within healthcare instead of trying to get political points by random questions. So I appreciate um for each of you that are willing to actually actually get to the meat of the problem of issues and to address them. Um so thank you first off. Also um I'm pleased to have A gentleman from my neck of the woods, from Rolla, Missouri, it's great to have you here Jason. Um, uh, by the way you have a great first name. Um, but, uh, the, the Rolla, Rolla community, the Phelps County Hospital, um, serves the people of Rolla in a, in a great way, serves my family, serves my friends, serves my neighbors. Um, so, appreciate, um, you being here. When it comes to this committee's work on making healthcare um affordable and accessible, um for all Americans, not just a select group, but for all Americans, my number one priority remains expanding access to care in rural America. Um those are the communities I'm from and who I represent. I I see firsthand um, the need for better access to even the most basic health care services. Last week, I traveled throughout our congressional districts, um, district, went to two different hospitals, rural hospitals, every hospital in my congressional district is a rural hospital. We went to, even went to a primary care facility, um, in Fredericktown, Missouri. Um, these are all things that's so important to rural health care. So I'm excited to have someone here today that can speak not just to this issue generally, um, but to the specific health care needs of the people of Missouri. Um, so, um, Mister Shenefield, could you please share how Phelps Health is developing its family medicine residency program, the hurdles, the f- uh, financial and otherwise you have faced in that process, and how how the Medicare program can make it

Thank you, Chairman Smith. Uh, happy to answer that question. Uh, you know, we we've talked about doing a residency program for a few years, um, you know, prior to knowing that this funding was out there and, uh, the challenge was just how how do we pay for getting it going? And so I think that, uh, you know, the need really comes from, as you said, creating more access. Uh, there there are not enough primary care providers in our community uh and and we really felt that that was the best way to to create more access is developing a residency program uh specifically family practice with obstetrics um it just seems to fit a few of our different needs in our community um as you know um a obstetrical care is is a a great need as well and so we're trying to fill a few few gaps and uh throughout that i think as far as funding you know uh again the the grants that we've received have really helped with um identifying um a program director getting some of the the administrative staff in place but I think really um you know what we're where we're at right now is is we we understand that we need a designated clinic space and you know that's uh from our initial estimates is is about a five to seven million dollar need um to build that space and we need to be doing it soon uh because we plan to have residents um really ready to match in uh July of of twenty twenty eight, and so we need to have that space done and and everything. Um, you know, I think, you know, looking at our being able to update our per resident amounts, uh, when starting a new residency program, I think that that is a concern as, uh, we estimate that it'll be close to, um, about a hundred thousand dollar loss per resident, um, you know, based off of our current estimates. Um, and so I think those are those are some of the big things that we see is just that Um, we are unique that we're just big enough that we can take this on. I think, you know, smaller hospitals would struggle, um, but I think if some of these issues are fixed, I think that they could overcome that as well.

Missouri has a, uh, long-standing challenge with recruiting and keeping doctors. Um, we have six medical schools, um, and rank ninth in the nation in producing talented medical students that go on to become great doctors. Um, unfortunately, Missouri also falls under the highest ten states that export their medical graduates. While a hundred and seven of a hundred and fourteen counties in Missouri have a shortage of primary care doctors, we lose one third of needed physicians to residency programs in other states. Doctor Moore Tell me about barriers in the Medicare program that perpetuate this problem, and why recent attempts to expand medical GME slots to rural hospitals have fallen greatly short.

Thank you, Chairman Smith. Uh, and that's a great question. Um, it is one of those things that, uh, um, that un- unfortunately suffers from the - the legacy of funding within the current CMS GME structure. Um, because everything was kind of frozen in time in nineteen ninety-seven with the caps, uh those that uh that had funding continued to um uh to - to have funding for GME, and it made it more and more difficult for us to create new programs. If we're going to get people to stay in your state and my state, uh we need to train them in the areas where we're uh - where we want them to stay. Um, and that means to - that we need to pay attention to the - the differences, the changes in population growth. the changes in uh in migration patterns and and understanding that the way that uh that medical education looked in nineteen ninety seven nineteen ninety eight is different than it does right than it looks right now um and so by making sure that we have appropriate funding for being able to run operate and start those new programs uh especially in rural and community based areas and not just in the legacy academic medical uh medical centers which are great, and we need them But it's not filling in those gaps that you need in Missouri and that I need in Texas. Um, some of the, uh, some of the attempts, uh, have been made and we appreciate all attempts made to try to fill in some of those gaps. Um, some of the, uh, the changes in cap reset and cap redistribution, whether you're talking about section one thirty-one, which I'm currently doing right now, uh, for a hospital, section, uh, one twenty-six, which I've tried to do in the past, um, or a rural, um, uh, uh, reclassification, which, um, unfortunately doesn't always help the rural sites, it helps the urban site. Um, those have fallen short, uh, to be able to actually, uh, change, uh, the conversation when it comes to keeping people in, training people where we want them to stay. And so I think that there are some real opportunities, um, for us to be able to continue to evolve the system that we're in, um, and be able to prioritize, uh, some of the areas that, uh, um, that we're hoping to keep, uh, our, our resident, uh, physicians, uh, to stay.

Simply put, rural areas need more doctors.

Absolutely.

That's just pretty simple. Um, one third of Americans who live in areas with primary care shortages live in rural areas. Americans in rural communities often must travel farther for appointments and and work harder to get the care that they need. Um, if you look at the average life span of folks who live in rural areas, it is that much less than those that live in the cities. And that's because they don't have access to basic care. That has to change. This is the United States of America. That has to change. And so we also know that there's a higher likelihood of doctors staying with practices in areas where they complete their residencies. Um, yet only two percent, two percent of residencies take place in rural America. Two percent. Why do we not have doctors in rural areas? That might, might be a reason. Um, Doctor Hawes, why do residents tend to stay in areas where they train? And can you underscore the importance of geographic location of training residents to encourage them? to stay in communities that they're in.

Thank you. GME is inherently a place-based and sticky is the word that I like to think about. Physicians most often practice within a hundred miles of where they do residency, so it really matters where they do that training. During training, residents, and you alluded to some of this, become embedded in their communities, their family members find employment, they purchase houses, develop professional networks, establish roots within the local healthcare infrastructure. And one thing that we're seeing with these new programs is that these residents are helping shape the clinical services of these r- rural areas. They're filling workforce gaps, they're growing into leadership roles that really strengthen that draw to their community. So I live in a community where one of these new family medicine residencies started. And nine of our thirteen res graduates have stayed within our rural region. Um Jason County that has worse primary care access. So it's really sticky and effective, and when we're looking at kind of how to distribute and grow GME, we need to be thinking about the places that we're locating residencies and the access to care that exists in those communities.

Thank you, Mr. Chairman.

Thank you. Mr. Kelly, you are recognized for five minutes.

Thank you, Mr. Chairman. Thank you all for being here today. Um, I just wanna relate this for a couple minutes and then I wanna my my good friend Dr. Murphy to take over. Um, I'm a Chevrolet dealer. Uh, and, and this is one of the things that people say, why the heck would you be talking about cars, Kelly, when the, we're talking about how will we take care of people? Well, you know what, taking care of cars is pretty important too. And in nineteen seventy, there were four thousand eight hundred Chevrolet dealers. Today there's two thousand eight hundred and seventy eight. Now people say, so what does it have to do with anything? Well, all the rural dealers are gone. There just wasn't big enough market for them to participate in. And at the end of the day, it's always gonna be about the money. And I'm not dismissing the cost of whatever it is that we do and say, well you gotta stop it, don't talk about money because these people need care. I get that. I get that. The hardest part of our business right now is recruiting technicians. First of all, they're no longer grease monkeys. These guys are electronics experts. So it takes a lot more education, a lot more talent. But today what we're talking about again is what are we gonna do about this, and how do we fix this, and what in the world can we do? And I just think it's not so much about the money, it's where the money's spent and what's the return on taxpayer dollars, because every single penny that comes out of a federal, government, a state government comes out of a taxpayer pocket. So we have a grave responsibility to return to taxpayers a return on their investment. Oh, Miss DelBene and I have a piece called the Improving Senators' uh Seniors' uh Timely Access to Care Act, and that's Not only Mr. Albany, but Doctor Murphy's on it, Doctor Baer's on it, Doctor Joyce is on it, we got a lot of doctors on the, on these bills. Uh, we have over two hundred fifty people, we can't get the bill to move forward. And that's the problem when we talk about why can't we get things done. Well, we can't get things done because we're not all on the same page at the same time, with the same amount of effort as where it is that we're trying to get there. What's the end goal? If it's not the American people, then what the hell are you doing here? If you're here for a singular purpose, please go home. Find some other capital that you can stand on the steps and crow about what your party's not doing. Let's make sure we're all pulling in the same direction at the same time for the same reasons. And, and uh you Thank you all. You've given up a day of your life to come here. I don't wanna go on about Chevrolet dealerships, because I'll get a call from Chevrolet saying, hey, you know what, Kelly, shut the hell up or we're gonna come after your dealership. I'll say, we're, we're way over what we're supposed to produce, so stay away from me. Uh, I do wanna give my time to Doctor Murphy. He does this every single day of his life. He's very passionate about it. Doctor Murphy, please take over. Doctor Murphy.

Thank you, sir. I just I I appreciate it. I I I do wanna talk about GME, but I also wanna respond a little bit to one of my democratic colleagues' issues and just ask Doctor Racine a couple questions. Tell me, has the CDC recommended against the measles vaccine?

No, they have not.

No, no, they have not. So it is an abject lie or an insin or any otherwise insinuation to say the CDC is not saying anything, is saying anything against measles vaccine. Let me ask you this. Do you believe it's the purpose of vaccination to treat at-risk populations to decrease severity of illness?

I think it's the purpose of vaccinations to treat everybody.

No, that didn't answer my question. You don't look,

I'm sorry.

you you n- m- m- No, you don't, everybody doesn't need a vaccine for everything. You treat at-risk populations to decrease the severity of illness. That has been the historical scientific dogma of what vaccines, regardless of COVID or regardless anything else, that is always what has been a vaccine for. That's why elderly people get the shingle shot and fourteen year olds don't get that. That's been the purpose of vaccines. Have you ever heard of or seen of or seen reported a vaccine injury?

Sure.

OK, so it is not scientifically unreasonable to have some reluctance to jump in, and we've seen over twenty-five years the number of vaccines offered to children or recommended to children go from forty-five into the seventies. Is it okay for the scientific community to every so often question themselves, are we doing the right thing? I will give you an example in pediatrics. Recently seen how the peanut allergy issue dogma was pushed and pushed and pushed, and we created a generation of people allergic to peanuts because of false data. That's the perfect example. It is okay. for the scientific community to step back and say, are we doing things right? Example, in nineteen ninety-four, false literature came out about a physician surplus. Hence, we are in the position we are today that we don't have enough physicians. So is it OK for the scientific community to question itself every so often?

Absolutely.

Uh, I think it is, and so I think we, we need to restore objectivity back to the world of science, This is what we always have done, and not be polluted with the, with the politics, which is what's come over the last several years, and get back to really being scientifically objective. Thank you, Mr. Chairman, I'll actually talk about what we're supposed to talk about next.

And thank you, Dr. Murphy. I recognize Ms. Chu for five minutes.

Dr. Racine, I have to say there's a glaring disconnect between today's discussion and the policies that my Republican colleagues have put in place. Because of the big ugly bill Republicans passed last year, more than four hundred rural hospitals are now at risk of closure. Plus, those that remain open are projected to lose nearly ten percent of their Medicaid revenue. What's more, uncompensated care is expected to rise by more than one-third. And we know that when hospitals are forced to cut critical services like oncology or maternity care, physicians leave and the training pipeline shrinks with them. And if that wasn't bad enough, their bill caps federal student loan borrowing at two hundred thousand dollars, which doesn't even cover the full cost of medical school in most cases. And the Trump administration's new H one B policies now require hospitals to pay one hundred thousand dollars per visa, even though international physicians are twice as likely to practice in rural areas and four times as likely to serve in high-poverty communities. So, Doctor Racine, let's connect the dots. Taken together, are Republican policies moving us closer to or further away from solving the physician shortage in rural and underserved communities?

Well, I I believe that policies that make it more difficult for people either to afford medical school or um to locate in rural communities, have a detrimental impact on the supply of physicians. I don't think there's any question about that. I also think it's true that we have an imbalance between the demand for care, particularly in pediatrics, and the supply of those physicians, particularly in rural areas. I um, I practiced many years in the Bronx. If I had come across a child who had particular difficulty with a behavioral or developmental issue and I needed to get them care, I'd call and across the borough I could get somebody to see them. My colleague in New Mexico, if she has that exact same patient, there is not a behavioral or pediatric or behavioral or developmental pediatrician in the entire state of New Mexico. That family has to travel to Arizona to get care. If you are a child on dialysis and you need a pediatric nephrologist and you are in the state of Montana, There's not a single pediatric nephrologist in the entire state.

And that brings me to my next question, which is about reproductive and maternity care. Uh, so, Doctor Racine, I'd like you to focus specifically on the physician shortage there, which is that since the Supreme Court overturned Roe versus Wade, state abortion bans have decimated the OBGYN workforce in this country. Residency applications are plummeting. in states with abortion restrictions. And many physicians are now actively avoiding training or practicing in those states altogether. For example, Idaho has lost more than one-third of its OBGYNs since its abortion ban took effect. What's more, for the past four years, more than two rural labor and delivery units have closed every single month. We have even seen pregnant women having to be airlifted across state lines just to receive the care they need to save their lives. So, Doctor Racine, how significant are post-dobs abortion bans combined with big li- ugly bill cuts to health care, driving OBGYNs out of affected states, weakening the training pipeline, and increasing risk for women in rural and underserved communities?

Well, thank you, Representative Chu. You're speaking to the president of the American Academy of Pediatrics. It's a great set of questions, I think, to address to my colleagues at the American College of Obstetricians and Gynecologists. Having said that, a large percentage of children in this country at delivery are not attended to by pediatricians. They're attended to by OBGYNs. And to the extent that there are fewer of those folks around, those children, those newborn babies are at risk. And I just wanted to return to some of the discussion I was having with Doctor Murphy a moment ago, because a lot of the uncertainty that's been injected into this whole issue of vaccines, which is not necessarily because of changes in the science, but it's changes in the messaging that's coming from the Department of Health and Human Services, is having knock-on effects in the newborn nursery. We are seeing more and more children whose mothers and fathers are refusing to give them vitamin K at birth. And those children are at risk for bleeding into their brains. We're seeing more and more children whose parents are refusing ophthalmologic um treatment to prevent gynecology, gynecologic sorry, uh GC um infection in in their eyes. There are people that are refusing hearing tests as newborns. all of these things are simply compounding the risks that newborns are facing because of some of these messages.

The gentleman's time has expired, the gentlelady's expired, uh time has expired, I'm sorry. I now recognize Doctor Murphy for five minutes.

Thank you, I'll try to get back onto the topic at hand. Um, I think we have to look also uh objectively and say why do we not have physicians in rural areas. And I think it's not, let's go, uh let's step away from the supply problem, let's actually look at a a demographic problem. We've had uh a huge shift away from our rural areas of population, of manufacturing, of education, et cetera, et cetera. People live where they want to live. I mean, you that's just that's basic human nature and the same thing goes with physicians, cuz actually physicians are humans too. W- w- people live where they want to live. Now, everyth- I think everybody agrees, I don't need to keep saying it over and over again about physicians training in rural areas staying in rural areas. It's w- it's a wonderful thing. But we also, incumbent on other policies that are outside the purview of this committee, need to understand that we need to get manufacturing back in America, get it out in our rural areas so that it is a nice place to live, therefore physicians will go there. And fortunately, that's one policy of this administration, is to restore American manufacturing, which I think will have downstream effects of being able to do these type of things. There's some other things that go on, other than people going, living where they want to live. We have a huge, you have to look at the, we added twelve hundred slots to GME, um, two years ago, three years ago, four years ago. There, the, I personally don't believe it is the issue that n- there are not enough slots, I think is number one, misallocation, and two, the fact that there are a large number of people who are graduating from medical school now, who don't practice medicine. If you look at three years out, you look at five years out, so many in certain demographics have popped off to do other things. So I think this is incumbent upon those who control medical education to get control of that again, and make sure that the people who are going medical school actually plan to make it for a career. I think that's one salient issue that is being missing from every conversation. We also have a decrease in the amount of efficiency workload. Uh, there's a lot more talk about work-life balance, which I have no problem with. But we have to look and see that's an, also a driving cause of decreased efficiency. We have to look and see why these things are happening. Doctor Moore, let me, let me ask you this. Um, actually, Dr. Hawes, I'm sorry. Let me get you, Dr. Halls, real quick. Um, we added additional slots, but despite congressional intent, a lot of these did not reach rural areas. They went to places where they were not supposed to go. How do, how do we make that, moving forward, that that does not happen?

Thank you. And it, it, the section one thir- one twenty-six that you're referring to, uh, points to the fact that rural hospitals who want to expand their training should be able to. and ten percent of them were supposed to go to geographic rural areas. Um there were relatively no low number of eligible rural hospitals, which is something to consider. The prioritization of the slot distribution by health profession shortage areas actually disincentivized some of the rural hospitals with low or no HPSA scores from even applying so that's one way that it could be per- improved next time so in the next slots I would recommend disassociating that HPSA allocation, if they're training in rural areas, they need slots, um, and be, to be able to expand. A couple of key points about, um, programs that were helped, ECU had, has two, three FQHC tracts in rural areas that were helped, um, and there are, you know, rural programs and partners of urban's that did get the, did get the slots.

Yeah, i- it's a chicken egg kind of thing, because, you know, in my area, uh, eastern North Carolina, twenty-nine counties, if you put it into a single state, we'd be one of the poorest states in the country. We do a hub and spoke approach with a lot of our specialty uh medicines. I've gone out and operated and and take care of rural areas. That has to be. Truth be told, also, our foreign medical grads. If we didn't have those populations, we would have no doctors in some areas. So it's critical that all these populations are dealt are are dealt with. Let me ask Doctor Moore, um, do you feel there's any reluctance on the part of medical school executives to give up their residency slots that are in the big medical center, which are busy as can be because people have moved there, to give them up, to push them out in rural areas.

Hmm.

Well, I can't speak for the leadership at, at other institutions, um,

Yeah, but

but I think,

I mean, you talk to other people.

but I, I think for certain they're, um, you know, every, nobody wants to, to give up what they have, um, a- and, and yet to, to your point earlier, Doctor Murphy, um, uh, you know, we want, we wanna make sure that that we incentivize people to go to rural areas. And, and there is a chicken and an egg. Uh, medical care is infrastructure for rural areas.

Yes.

Um, and so how do you, how do you pull industry, uh, and manufacturing into an area that doesn't have the healthcare to be able to support it, uh, and then how do you convince those physicians to come in an area that's not supported, um, by, uh, by industry and manufacturing? And I think that those are two of the things that we're gonna have to, uh, to see, but I think that that uh just doing what we're doing is is not gonna get us to where we wanna go. Um I think there's gonna have to be additional incentives uh to to be able to uh prioritize healthcare infrastructure in those sites and I think that that's

Yep.

something that we can do from the medical schools in prioritizing folks that do wanna practice medicine and are interested in primary care and do have a heart for service in rural areas and I think we can do that.

Thank you. Thank you. Uh again I I will submit that I think if you go back and look historically, the primary driver, the reason we don't have things happening in our rural areas is because we killed American manufacturing. I think historically speaking that's the reason. Thank you. I'll yield back.

Thank you. Mister Hern is recognized for five minutes.

Thank you, Mister Chairman, for holding this hearing, I think it's very important, uh being from the great state of Oklahoma, I'd I'd I wish my colleague was still here because I'd like to get a point of clarity. Uh she made reference that there, and I'm not a physician, but uh she made reference that there are fewer OBGYN doctors today because they can't commit abortions I thought that was a very interesting statement that would Like to see that validated. The second thing is, is she referenced hospitals closing, I didn't see any a member of the other party uh talking about hospitals closing under Obamacare and from reimbursement rates and other things that went on, but that's for another hearing. Uh, you know, being from Oklahoma, I'm very familiar with the topics that uh have been brought up today. Physician shortages in rural areas, lack of accessible care, and poor health outcomes. I grew up my younger life in Arkansas and the Ozawa mountains. miles to go see the one doc, so I'm very familiar how important it is and how special it is to have rural doctors. Oklahoma's physician to patient ratio is thirty-nine percent worse than the national average. Currently one third, thirty-three percent of Oklahoma's physicians are within retirement age, so physician access will only decline unless changes are made. We are not keeping up with demand, so I'm glad we're discussing meaningful solutions to these problems. I frequently hear from physicians back home about burnout and the massive administrative and clinical burdens they face. It is my hope that the new technology will help ease these burdens they feel when practicing medicine. As a matter of fact, I just talked to the OSU medical president, uh, just, uh, two days ago, actually on a Sunday, and he said that in rural health care that the physicians are dealing with about thirty percent administrative burden, where in the urban areas it's ten percent. So we have to keep working to mitigate these, these burdens that are not, uh, patient forward. That being said, we have all seen in our lifetimes just how our lifetime just how fast technology changes and improves. But in rural states like mine, access to advanced medical training can be limited by geography. Doctor Moore, how are residency training programs keeping pace with the technology sector and making sure both residents and the physicians' trainings, training them, know how to use these newest health technologies? And can you confirm residents in both rural and urban settings are receiving equal training in these advanced systems?

Thank you for the question, Mister Hern, and uh you have an

Mm.

incredible schools in uh in Oklahoma and uh my colleagues, Dean Blankenship and Dean Bray and uh in the in Tulsa and Tahlequah doing an excellent job and that's one of those places where you have put a medical school campus in a very rural area especially in the Tahlequah nation um where you can actually train people where you want them to be, and I think that that's um uh that that's admirable. But back to your question, um uh are we keeping up with technology, um we're trying um but I wouldn't say that we're keeping up. It's moving too fast right now. It's moving too fast for all of us. Um, but that's something that, uh, we need to put energy and effort into. At Sam Houston State University we've created a, a medical AI, um, institute to help us to do, um, to, to do research but also to figure out how best to utilize medical technology, AI, um, uh, large l- uh, learning modules and, uh, and, and independent wearable technology into, uh, the, the health care of, uh, that are out there. Now, this could be the great equalizer for rural areas, cuz this actually could be a way that we can bring that um uh those types of technologies out to support rural areas to decrease some of that terrible administrative burden which absolutely leads to burnout and moral injury um but we have to be able to lead the process um and and

I'm

that

gonna

I'm gonna I'm gonna get to one other question if you don't mind. Thank you for that response. Um, The James Mountain-Inhofe VA Medical Center, named for our dear friend, the late Senator Inhofe, Uh, it's scheduled to open this year in my district. This is nearly two hundred and seventy-five thousand square foot, fifty-eight bed hospital that will serve veterans from all over the state of Oklahoma. It's attached across the street from the OSU Medical Center. I'm extremely proud of this project which was made possible by partnerships with the VA, Oklahoma State Medical Center, the state, and other entities. Veterans are a unique pa- patient population and it is important, so important, that they can access and receive state-of-the-art care. An exciting part of this partnership is that medical residents will complete training rotations in the VA hospital gaining useful experience caring for our nation's heroes. Doctor Haas, can you explain the importance of residents to receive training in different settings of care such as VA VA hospitals tribal health facilities and the value in learning to treat these patient populations and how can we continue to support these partnerships that will generate considerable benefits to our residents and their communities.

How and where you train impacts how and where you practice. And when I think about Oklahoma, I think about the OMICA partnership that uh started this family medicine residency and within six months of their residency, wait times for a new primary care physician reduced from nine months to three months. And then their graduates are serving the Cherokee Nation and they're establishing new services. So they have physicians who are bringing wound care that was not available um outside of the care of a surgeon. They're providing obstetric services. So thinking about caring for different populations and different sites is gonna just increase the richness of their learning and ultimately increase access to care.

Thank you. I yield back.

Thank you. And now recognize Mister Horsford from Nevada.

Thank you to the chair and to the ranking members. So my home state of Nevada and my district, I cover fifty thousand square miles, uh, and this issue of health care uh workforce shortage is true whether it's in the urban areas of Las Vegas and North Las Vegas uh to Pahrump out to Carson City and Reno. All seventeen counties in my home state carry some form of healthcare shortage designation. Nevada ranks near the bottom nationally in several key workforce categories, forty-fifth for active physicians, forty-eighth for primary care physicians, and forty-ninth for general surgeons. But during the COVID-19 pandemic, we made a deliberate choice to confront this crisis head-on. Utilizing funding from the Coronavirus State Fiscal Recovery Funds, we launched the Nurse Apprentice Program, an initiative specifically designed to address severe nursing shortages, particularly in rural and underserved communities. From March, twenty twenty-two through February of twenty twenty-five, more than seven hundred nursing students trained across thirty-six non-profit hospitals, critical access hospitals, s- skilled nursing facilities statewide. Importantly, more than two hundred and twenty of those students were hired directly into permanent positions upon graduation. That means that two hundred and twenty health care professionals, Nevadans, are now caring for our population in communities that desperately need them. They're earning a paycheck, they're building a career, and most importantly, they're strengthening our health care system. This is about solutions. This is how you build a workforce. This is how you strengthen rural health care, and this is how you invest in the future of patient care. In rural Nevada, where a single nurse vacancy can mean the difference between access and no access, programs like this are lifelines. Now the Nurse Apprentice program also demonstrates what's possible when federal lawmakers choose to invest in communities rather than overlook them. But you cannot claim to care about the future of the healthcare workforce while supporting policies that re- will result in the largest cuts to rural healthcare in our nation's history. You cannot claim to support innovation while pulling the foundation out from underneath rural hospitals. And you cannot point to the Rural Health Transformation Program so-called as a good faith effort when it was created to secure a single senator's vote. That is not improving health care access or the workforce shortages that we're talking about today. Doctor Racine, can you explain to the people throughout my district why the Rural Health Transformation program will not deliver the promises and come short uh of the promises that have been made by my Republican counterparts uh that they're trying to sell?

Thank you, Representative. Um, I think that the Rural, uh, Health Transformation Program, um, can make important inroads for certain kinds of care. There are a lot of states that are using it, for example, to expand telemedicine, and these are good things, because it does expand access. What it will not do, it - it will not replace, um, the funding for individual children who are losing coverage because Medicaid is being cut. it will not change essentially the infrastructure that is going to suffer when people who are paying the bills for those hospitals can no longer pay those bills because Medic- they're no longer on the Medicaid program. So these are sort of separate in my mind. I think that we need to restore the cuts that have been um that have been proposed and have been implemented to the Medicaid program in order to make

I agree, but the biggest challenge that I see is it's temporary, it's not permanent funding. Just like the tax cuts for billionaires are permanent, and the relief for working families is temporary and capped. So how are rural communities supposed to even sustain programs like the one I talked about, if it isn't funded beyond a program period.

Um, I'm not the legislator here, so I think that's a good question for the folks who are making the laws. But I agree with you, you would want that funding to be permanent.

Yeah, so let's make health care funding. Let's restore the trillion dollars of cuts from the one big betrayal of a bill. Let's put the money back into Medicaid. Let's shore up our community health Let's make sure that people continue to have access and that we actually build a health care workforce for all communities including those in Nevada that I represent thank you and I yield back.

Gentleman yields back and I recognize Mrs. Miller for five minutes.

Thank you, Chairman Smith, and thank you all for being here today, it's so important. I grew up in Columbus, Ohio. When I left it, I think there were six hundred thousand people, the Ohio State, lots and lots of physicians, wonderful education. I moved to West Virginia. I love my home state of West Virginia. I've been there over fifty years. I moved to a town of approximately eighty-five thousand that is now approximately forty-seven thousand people because bad policies can have bad results. And I've seen a huge turn around in the last couple of years to our state. But it's rural health care, I can't scream it loudly enough how important rural health care is to my state and many states when you look at the number of people that have spoken from Missouri and Oklahoma and except for my partner over here who is from a big city. So we have less than two percent of residency programs in rural communities. and more than ninety percent of the residents today have never even practiced in a rural setting. Doctor Hawes, thank you for highlighting the Rural Residency Planning and Development program, also known as RRPD, in your testimony. This program is essential to hospitals in West Virginia, and I'm proud to have introduced the Rural Residency Planning and Development Act. My bill formally authorizes the RRPD program which helps Rural hospitals cover the upfront cost of developing new residency programs, because without rural training pipelines, we can't solve the rural physician shortages. My question is for you, Dr. Haas. It Given that rural hospitals face unique barriers, what additional policy changes beyond what we're doing are needed to ensure rural communities can not only start a residency program but enable Medicare to better sustain them long-term and successfully retain physicians after their training.

Thank you, Representative Miller, and I wanna thank you and your team for the wonderful data requests and emails that you've sent over the years we wanna be helpful with information and so, I offer that to all of you too as you're evaluating policies. Um, I also want to highlight um just a story that that has impacted me from your districts in um Marshall started a Point Pleasant uh psychiatry program, and and it just it speaks to the impact of these programs. So they noticed that the the psychiatry patients were coming from Point Pleasant, and so they said, let's go out to Point Pleasant and start a residency in a county with no psychiatrists. And um what they're doing is they're using telemedicine and a partnership with Marshall that is enabling them they they up-fitted an emergency room that has two telemedicine like triage sections and then also they created a new rural health clinic as a result of that psychiatry residency and their residents are starting a cancer support group from just one of the the benefits and spillover effects so one of the things that just specifically about your district and a policy that would that would help is just tele- supporting telemedicine and tele-precepting especially for psychiatry

Thank you so much. I'm pleased to see that the osteopathic s- medical schools are represented here today. Um, as our country grapples with worsening physician shortages, we've got to eliminate the unnecessary barriers that prevent highly qualified osteopathic medical students from accessing residency opportunities for a rural state like my own. We cannot afford artificial barriers to physician distribution, particularly when doctors of osteopathic medicine play such a vital role in primary care, which is why I introduced the Fair Access to Residency Act. Doctor Moore, from your perspective, what role do doctors of osteopathic medicine play in helping close the nation's physician shortage particularly in communities that are rural?

Thank you for that question and thank you for su- your support of the Fair Act. My my job as dean is not just to educate and train medical students so that they can graduate pass the board examinations but also to assist in their residency placement. Um, osteopathic physicians uh are essential to meeting rural and underserved workforce needs, uh and by percentage uh our students do uh tend to go more into rural and underserved programs. Um, however, according to national the national residency match program data, twenty-nine percent of residency program directors currently uh state that they never or seldom interview DO candidates, while nearly three quarters, seventy-three percent of GME programs that do consider DOs mandate that they take the MD licensure exam uh where we take the Comlex USA licensure exam. Um there this this causes our students to have to take two examinations uh which are costly and expensive and stressful and unnecessary because every state every medical board in the nation re- uh recognizes the Comlex USA And so I think we need to understand that, uh, to be fair, um, and to help to support osteopathic physicians who are more likely to go into rural community based and underserved areas, uh, that we have to have a little bit more transparency when it comes to, um, uh, to, to acceptance. And that's what the Fair Act, as you know, does. Uh, it, uh, uh, it suggests that there be a reporting of, uh, of both DO and our MD colleague applicants,

Channel eight, this time is expired.

uh. Thank you.

I'm sorry. Thank you so much.

Thank you.

Mister Fitzpatrick is recognized for five minutes.

Thank you. Thank you all for being here. Um, our physicians are facing increasingly challenging environments, as you all know very well. Um, and with that comes higher rates of burnout. Uh, approximately forty-five percent of physicians report that burned-out feeling, um, in twenty twenty-three, coupled with an aging workforce and reduced medical school entrance. There is a projected shortage of up to eighty-six thousand physicians by the year twenty thirty six. Communities across America, including in my hometown communities of Bucks and Montgomery County and Pennsylvania are certainly feeling the strain of this growing shortage. Longer wait times for care has become the expectation for patients, limiting critical access to health related needs. To address this shortage of physicians, as was referenced earlier, uh I partnered with my friend and colleague on this committee, Representative Sewell, uh to introduce H. R. forty thirty-one, the Resident Physician Shortage Reduction Act. Uh, this bipartisan bill would expand Medicare-supported uh, medical residency positions, delivering a targeted common sense solution for what has become a growing crisis. Specifically, this bill would add fourteen thousand residency slots over the next seven years, prioritizing distribution in rural and underserved areas, health professional shortage areas, states with new or expanding medical schools, and hospitals currently training over their resident caps. This legislation builds on past congressional investments in the Medicare supported graduate medical education, especially in strengthening training in other serve areas. Uh, Doctor Moore, given your experience uh in administrating uh a GME program, can you expand on how the Resident Physician Shortage Reduction Act, uh this bipartisan bill would impact your program uh at hospitals you work with, and specifically Um, what would the result be in addressing uh the increased support for underserved areas and areas with health professional shortages?

Ultimately, the number one bottleneck when it comes to starting new programs is start-up costs, uh and clarity about um uh uh about sustainable uh operational costs once the program gets started. And I would say that many of the uh smaller hospitals and rural hospitals that I've discussed starting residency programs with that uncertainty is really key. Um, a- a- and so I think that, uh, that the hope here is, is that we're going to be able to have more clarity and certainty in the funding sources, um, that will allow, um, uh, programs and hospitals like Phelps that have a very low margin to be able to say, yeah, I'm willing to take the risk, um, because I have a little bit more certainty as far as where that goes. And, uh, and we appreciate your support on that bill.

You bet. I wanna move, uh, quickly. to uh the need to modernize aspects of GME uh to insure our future physicians can best serve their patients uh in the evolving healthcare landscape. Digital tools like telehealth and remote patient monitoring are incredibly valuable for doctors to address care disparities in underserved areas with high rates of chronic disease because of this, many residency programs are required to have available telehealth capabilities uh for their accreditation. Um, Doctor Haas, if I could ask you to speak to this, can you uh address the role telehealth plays in your program? Uh, and what should be uh taken into consideration uh for best preparing our future doctors to meet uh the ever-evolving and changing needs of patients?

Thank you for that question, and piggybacking on what I was sharing with Representative Miller too, is that telemedicine and tele-mentoring, which is that virtual precepting piece, is really, really important for psychiatry residency programs. And so, um, we support that and need that and we need more psychiatry residencies.

Thank you. I yield back, Mr. Chairman.

Gentleman yields back, and I'll recognize Miss Sanchez for five minutes.

Thank you, and I thank the witnesses for their testimony today. Um, as has been said over and over, the US is facing a critical physician shortage. We're projected to need between thirteen thousand five hundred to eighty-six thousand additional physicians to keep up with the demand in just the next ten years. And in California, ninety-five million people live in health professional shortage areas, lacking adequate health services like primary care, dentistry, or mental health providers. So that means that almost forty percent of Californians live without access to routine primary care. Uh, Doctor Racine, almost three and a half million Californians are losing their medical coverage after Republicans slashed health coverage last July. And by the way, these cuts to America's health coverage paid in part for the salaries and bonuses of the ICE agents we are see gunning people down in the streets. Um, I don't consider asking about cuts to Americans' health care a political trick. I think it's important to ask how these Republican Medicaid cuts are gonna impact patients' in medically underserved areas. Can you speak to that?

Uh, sure. I think, um, the function that Medicaid serves is sometimes underappreciated. It is the underpinning of all pediatrics care in the United States. Fifty percent of the children in this country are covered by Medicaid or CHIP. Half of all the children admitted to the hospital are covered by Medicaid. To the extent that that funding is threatened, that doesn't threaten the access simply for the children on the program. If you are looking at trying to get a child taken care of in a NICU in this country, and half the revenue of that NICU comes from the Medicaid program, cuts to the Medicaid program will impact not just the i- uh the access of the children in the program, it will impact the ability of that hospital to offer a NICU at all. And no matter how much money you have, and how rich you are, without a NICU your child can't get the care that they need if they have, sorry, not a congenital heart disease. It also happens to be a human capital investment

They

so children who are exposed to Medicaid as children end up earning more when they get to be adults, they are healthier as adults, they pay more taxes as adults, they use transfer payments less.

More more productive as adults. Thank you, Doctor Racine. You also sa- stated in your testimony that international medical graduates account for nearly twenty-five percent of the total physician workforce in the US. On top of that, sixty-four percent of international medical graduates serve in medically underserved areas. September of last year, President Trump imposed a new one hundred thousand dollar supplemental fee for new H one B visas. Previously, employers typically paid between two thousand and five thousand dollars in fees for visas for these highly skilled workers. Um, Doctor Haas, can a rural hospital afford to pay a hundred thousand dollars fee each for new H H one B visas for physicians?

Um

Simple yes or no will do.

I

I'm have limited time.

yeah. Um, I'm not sure. I haven't studied that yet. Um, there are I do wanna point to something you said, where there is a higher percentage of rural and underserved programs that place international medical graduates, and it certainly will have implications for these residencies.

Thank you, Doctor. Could Phil could Phelps Health afford to pay a hundred thousand dollars each for new H one B visas?

Um, we have not had to experience that yet, so Can I not answer that question?

But if it went from five thousand, let's say, at the top to a hundred thousand dollars, would that fiscally impact

It's a decision we would have to make.

the ability to provide care?

It's, it is obviously a difference in fiscal amounts, so we'd have to evaluate that and can it's

It's a pretty big differential, wouldn't you say?

Mm-hmm.

Yes or no?

Yes.

Yes, thank you. Um, health care is the industry where we are seeing some of the most significant labor shortages in this country, and it's also not entirely surprising that this administration is further undermining our physician And that's why the state of California filed a lawsuit against the Trump administration on these fees as well as the Chamber of Commerce. Even the Paragon Institute discusses the important role that foreign trained doctors play in play in the US physician workforce, citing concerns over visa caps and large fees in their response letter to a Senate RFI on health care workforce shortages. Doctor Racine, what sort of impact does President Trump's new one hundred thousand dollar supplemental fee have on hospitals in underserved communities.

I think that the running theme in today's discussion is an imbalance between supply and demand. Anything that's going to decrease the supply is going to have an impact on our ability to serve the needs of children in this country. If it's a impact, a supply impact that has a disproportionate impact on the rural communities, you can expect that's what will happen. Anything that increases the supply It'll have the opposite effect.

And how is that policy of increasing the visa fees more than tenfold, coupled with the Medicaid cuts that Republicans um passed, how is that gonna impact underserved communities?

I think it's likely to make it more difficult to find physicians to practice in these areas.

Do you think that people will die as a result of not having the care that they need, or having to travel uh very long distances to get the care they need?

It's more likely that people are going to have to travel long distances. It's more likely to limit access to care. Whether or not people will die from it is not something that I can sit here and predict one way or another but it's not gonna help.

Does delayed care typically make, uh, conditions worse or better?

Delayed care typically makes people sicker. It also makes it more likely that people are going to access emergency departments,

Delayed care is a fire.

as opposed to primary care for their care.

Thank you, and I yield back.

I'll recognize Mister Moore for five minutes.

Thank you, Chairman. Appreciate it. Thank you all for being here. Doctor Haas, as you know, Utah has a robust population centers. Um, not much of that, uh, very, very sparse communities outside the I-fifteen, Wasatch Front corridor. Um, so it's a real issue with access to care as people have to travel far to get treatment. Um, we have great hospitals and training programs in Utah that customize their programs to include rotations in rural areas or use a kind of hub and spoke care model, if you will. Can you describe to me some of the different forms rural training can take and how this fill, k how this helps fill community gaps?

Thank you for that question, Representative Moore, and Community Health Center of Utah are one of the grantees that we've been supporting doing amazing work with full spectrum obstetric care reaching into underserved areas all throughout Utah um and you know what we're what we're seeing with these programs that are unique is um that they're being designed for community needs. And this is something that I think is similar to the Community Health Center of Utah where um and and I wanna illustrate with us with uh another grantee that we support that's similar to to them is that we uh in Cahaba Medical Center in Bib uh County, Alabama realized that they had high infant mortality rates. And so they designed a program that opened a labor and delivery unit and expanded prenatal, postnatal care. And now, several years after their residency, they've seen a reduction in infant mortality. And so that's one example of the way residency can impact, uh, access to care. And these are stories that are happening all throughout um our country and even in Utah.

Thank you so much. Appreciate it. I've been to many of the community health centers from the northern part of the state through other more urban centers, and they they really do find a way to make it happen. And uh it's it's it's a it's excellent, it's excellent work. Doctor Tilk, or Trilk, um how I I know much of the actual treatment for chronic disease happens outside a doctor's office and actually in community settings can you discuss the ways that lifestyle medicine meets patients where they are and and how this improves their health outcomes?

Thank you, representative. We opened our doors into two thousand twelve to be able to serve community where they live, work, pray and play. The idea of bringing lifestyle medicine into our primary care and then also into Greenville County, Oconee County and our existing counties, it is a way that we can serve patients' needs and then also have providers and residents who graduate from our program and go into uh rural areas. To Representative Kelly's point, I'm from Dubuque, Iowa, where the largest John Deere manufacturing company is in the United States, and understanding, you know, and I'm also, you know, from a rural area. We, in rural areas, we want to be able to access health care. But we also can use our community organizations like the YMCAs, senior centers, to help save, uh I'm sorry, to help have um uh the physicians working with the patients in their care.

Thank you. Um, appreciate it. Doctor Moore, sounds great, spelled wrong. In your testimony you mentioned the importance of embracing technology in medical education. Uh, this has already helped deliver better care for patients through telehealth or remote monitoring. Um, things that we've learned over, you know, the last, I'd say, five years to say, hey, we can, we can deliver some of this better. uh, reducing administrative burden on physicians. You may have seen that Utah recently became the first state to allow an AI health platform to prescribe refills for patients with chronic conditions. This is a big step for the future of care delivery that certainly has raised some eye eyebrows. We know technology can and should never replace doctors or in-person care. Can you tell us more about the Medical Artificial Intelligence Institute at your school and how you are teaching future doctors to integrate AI while considering medical ethics and patient safety?

Thank you for that question. Um, a- a- and, and I think that this is a rapidly evolving field that we have right now. And, you know, twenty some years ago, uh, there was a rapid evolution of electronic health records into that really changed the landscape of uh uh of medical practice. Um, and some of that was good, some of that was bad. And I think unfortunately it wasn't always led by the medical community in the process of making that happen. And I think that that's what we really need to focus on here. How do we ensure that these new that are revolutionizing what we do are actually going to uh cause benefit for the patients improve what we're doing for the patients and there are ways that we can limit the administrative burden um and uh and and find ways to maybe reduce that uh that burn out that uh that we have but somewhere we have to figure out what the the most ethical way of still having a human in the loop uh to make sure that uh that the patient's needs are front and center along the way and that's really what we're looking at studying within our institute. both how we can roll that out, um, uh, for clinical care, uh, for research, and also for improving how we teach our health care professionals of the future.

Excellent. Thank you all so much. You're back. Go back, Chairman.

Thank you, Mr. Moore. How you spell your name is irrelevant to the committee's hearings. Uh, next I'll, uh, represent our our recognized representative, Steube.

Thank you, Mr. Chairman.

Medicare spends roughly twenty-two billion a year on graduate medical education, yet patients in Florida and across the country still struggle to find a primary care doctor, a general surgeon, or an OB provider, especially in rural or underserved communities. Today's hearing should be about accountability, whether federal GME dollars are actually producing doctors where we need them, in the specialties we need them, and with the skills to treat chronic disease instead of just managing it. I'm interested in practical reforms that put rural hospitals first, close loopholes, that well reassured urban systems gain rural benefits and ensure taxpayers get measurable results for every dollar spent. As we talk about the workforce, we should be honest about the temptation to paper over shortages with immigration programs like H one B. Our priority should be training and retaining American physicians and clinicians and removing barriers that keep qualified non-physician providers like pharmacists advanced nurses and chiropractors from practicing at the top of their license to expand access. Because our time is short, I'm gonna just ask a series of kind of rapid-fire questions. And if you agree with it, if you would just raise your hand, if not, just keep your hand down, uh, instead of asking each one of you individually, and I'd run through three minutes really quickly. So by show of hands, do you agree that any physician visa exemption should be narrow, conditional, and targeted to underserved areas, not just a blanket exemption? Raise your hand if you say yes. None of you agree with that? Okay. There's no r- no right or wrong answers, I'm just trying to get a feel where you guys are at. Do you agree that visa policy should not become a substitute for fixing broken domestic training pipelines? Okay, I got three, four. Do you agree that if we make it easier to hire non-citizen clinicians, some systems may have less incentive to invest in training and retaining US physicians? Yes or no? Okay. Do you agree the first obligation of federal force policy should be training and employing US citizens and lawful workers. Two out of four. Oh, four, okay. Do you agree that if federal policies created a training bottleneck, like Cap GME, the fix should be domestic capacity, not importing workers to patch the hole. Nope, okay. Do you agree Congress should require data reporting on how many residency slots residency slots and jobs are filled by non-citizens? Okay. Do you agree that using immigration as the release valve can depress wages or bargaining power and shortage specialties in rural markets? Yes or no? No. Okay. Uh, Mister Shenefield, in the time I have left, when CMS allocates rural slots or rural tract flexibilities, what documentation should be required to show where residents actually train and where the rural site is truly benefiting, rather than the urban sponsor capturing the dollars?

Sure, I not quite understand your question. Can you restate that?

If Congress tightened or ended H one B in certain health occupations, what would rural hospitals need? Loan repayment, residency expansion, scope of practice modernization to avoid workforce gaps while prioritizing American trained clinicians.

Well, I think, um, other than policy, I think it's time, cuz right now there are so many, um, uh, foreign trained medical students in residency programs, and so I think we're for what our needs are now. And so I think it's gonna take time if if the intent is to refill that pipeline with American trained um medical students. So I I see that as that it's not just an easy policy change and it's fixed. Um I think it it would take time because um last time I looked I think, you know, over fifty percent of of people in residency fellowships are are foreign trained medical students. Um so I think it it's just gonna take time if that's the direction policymakers wanna go.

Okay, Miss Hawes, your testimony says rural training is one of the strongest predictors of rural practice, often two to five times more likely. What specific measure indicators should Congress use to ensure new rural GME dollars translate into physicians actually practicing in rural communities after graduation?

Thank you for that. Um, I think there needs to be transparency in looking at where slots are distributed. And one thing I wanna highlight that happened um, based on congressional request is the GA GAO did a wonderful report on where section one twenty-six slots went. And so looking at kind of where slots are going, where the need is, um, how that translates to the specific, uh, physician supply within populations are all measures that um I think we need to be aware of in making decisions.

So I was in the state house before I was in the state senate, so I spent eight years in the state legislature and I'll just end with this. I have had numerous medical groups, Florida Medical Association, time after time again, every single year, every single session, and then when I got up here saying that we have a shortage in residency slots. Um, and American workers, American doctors, Americans graduating from medical school are not getting those slots because there are foreign workers and foreign doctors coming in and taking those residency slots. I do not believe that is a good policy. Um, I am going to be filing legislation as it relates to that. whether you guys agree with that or not, but time and time again I have had doctor medical groups in Florida come to me and say that American doctors are losing slots to foreign doctors, and I don't think that that's right. I yield back.

Gentleman from Illinois recognized, Mr. Davis.

Thank you, Mr. Chairman, and I want to thank all of the witnesses. And I'm delighted that I got an opportunity to be here. Um Mr. Chairman, let me ask if uh I would have unanimous consent to submit for the record a statement from the National Association of

That objection is so ordered.

Thank you, thank you very much. You know, um, investing in community health-based training, I was just reflecting the very first job that I ever got working in health care was director of training at one of the early community health centers. Course, things have changed because that was a long time ago, long, long time ago. But I'm proud that a health center in my district is training the next generation of primary care providers and dentists in a low-cost, high-quality interdisciplinary model. Yet this year Congress provided only two hundred and twenty-five million for the community-based teaching health center program while spending twenty-two billion dollars on hospital-based training that produces many specialists who primarily practice in big cities. Ms. Hawes, what steps should Congress consider to shift healthcare workforce training dollars away from producing specialists in large hospitals and toward more community-based settings in a rural or underserved area.

Thank you, Representative. Um, those physicians who complete training in community health centers are more likely to practice in rural locations, prescribe medication treatment for opioid use disorder, and deliver babies. So it makes a difference to train in community health centers. Regarding t- and really this evidence, this body of evidence comes from the Teaching Health Center program, and so I wanna acknowledge that this program is based, is outside of the jurisdiction of this, this committee, but it really informs how we think about where we need to distribute training. And so I think we need to expand more opportunities for community health centers as well as rural he- health facilities. to be part of training programs. They are happening, but we need to broaden that even more. Um, and with respect to the teaching health center program, stable funding is needed for residency training.

Thank you, thank you very much. Um, primary care providers and dentists who train in community health centers are more likely to continue practicing in rural and underserved areas. uh, communities that provided training in other settings, I'm concerned that Medicare funded programs are not sufficiently prioritizing community-based training. Um, how can we assure that Medicare invests more in training primary care providers and dentists in primary care forward settings like community health centers. Yes.

Um, thank you for that question. Um, there are some wonderful partnerships happening with community health centers now through um them playing a role in through Medicare GME as non-provider sites. So one example that I think of is Oregon Health science university has partnered with a tribal FQHC as well as a critical access hospital and an FQHC. And they are partnering with Medicare funding to be able to expand in community health centers. Um, and, you know, I think we need to expand rotations, expand opportunities within, um, both these urban and and urban hospital and community health center partnerships.

And I'd like to ask any witness who would take it while I live in in Chicago, Illinois, large urban area. But I grew up in rural America. Matter of fact, rural Arkansas, to be exact. And we recognize what has been and continues to be a scarcity of well-trained physicians and other health personnel. How do we change this - this scenario so that individuals in rural America can feel safe with their resources?

Thank you.

The gentleman's time's expired. Gentleman from Florida, Mister Bean, is recognized for five minutes.

Mister Chairman, thank you very much. Good afternoon to you. Good afternoon. in Ways and Means and to our panelists, welcome to uh the Ways and Means hearing room. You'll always get to say, that time I testified before uh Congress. I want you to imagine an America where congressional representation was based on the nineteen ninety census, and we never made changes. What would our country look like? Uh, we would see half our country overrepresented, half our country underrepresented. Uh, that's a scary thought. It seems like half our country would say this isn't working for us. But yet, that's exactly what we do with graduate medical education slots. We're basing right now the way they're distributed across our nation, we're based on nineteen nineties uh numbers. How about that? And just like the music in nineteen nineties, uh it's a jagged little pill for states like Florida to have to swallow, things like that. So there's gotta be a better way. Florida got so frustrated, I was in the state legislature, I was in charge of spending money. We spent our own money. Florida spends its own money because we are just drastically short-changed. So my question, it's a toss-up panel question, I guess, if the bean plan, what if we did this? What if we just re-shuffled the deck every ten years along with the census? That we shuffled uh GME slots. How about that? Uh, we've got states like Massachusetts and New York. Tiny states that uh have uh a drastically smaller population. But Florida is struggling right now, struggling. We're struggling in rural areas. We're struggling in metropolitan areas. We're struggling all across the board. So is that a good idea that being planned, reshuffle the deck with the census. Uh, the dean, you start uh you say, " Is that a good idea or bad idea?" And would you vote for something like that?

I, you know, I think that we're uh, first of all, thank you for that question. Um, and and certainly

Yeah, the correct answer is uh, Dean, yes. You would say, yes, I'm gonna vote for something like that.

eh, so Hey, I'm I'm in Texas, much like Florida,

Yeah.

we are growing our numbers and there has not been any type of redistribution. So, yes, there w- there is some uh, uh, there is uh absolutely a benefit to that, but we're also at a place of abundance. We have a huge need. And so, I think the question is, can we continue with the caps that are currently there, the funding that's currently there, and expand even further to meet the needs of Florida and Texas and other fast growing states.

Ten four. No, thank you very much. You're welcome. Uh, Doctor Hawes, is that a good idea, and wouldn't it be better to let the state legislators then uh argue or at least debate where they should put those slots in rural areas or in metro areas? Is that a good idea? You'd vote for it, right? Doctor Haas?

It's complicated. Um, you know, I think To build a GME program and to train physicians is a long, a long run, right, and so that takes years of infrastructure and so I, I like the idea of having

But every, every ten years? That's not too much to ask.

Yeah, true, true, true. Um, so yeah, I think I would just wanna explore more the unintended

OK.

consequences and implications um and haven't really explored that yet.

I got you. You must not be in a state that's struggling for uh for GMEs like we are in Florida.

We are, we have twenty-five counties without general surgeons.

So that's uh, that's it.

So we are actively

Uh, Doctor Shenefield, or Mister Shenefield, what's the downside of the bean plan of reshuffling the deck ev- every ten years? Can you think of anything uh, why you wouldn't go along with it?

Um, I, I think again just the unintended consequences. I think it, you know

Reshuffling the deck? Putting doctors, trainees where the people are? What could be wrong with that?

Well, on the surface it sounds good, but that's how a lot of things go, I think. And so I think it's, it's just understanding more of the details. Um, I think it's better than we put something in place and thirty years goes by and it never changes um because that's where I think we find a lot of problems.

Okay. That's where we are right now, so uh we've gotta make changes.

Right.

Uh panelists, I gave you all a a chance out there to jump in to say we gotta do better. We just have limited author- I mean I know we live in a world where we want just more money for everything, but we are we're struggling, we're struggling to build continue with that. Let's go to Doctor Trilk. Doctor Trilk, it seems like, speaking of the nineties, Jerry Seinfeld of the nineties says that uh They're state laws that when you turn seventy in New York and other states, you're required to retire in Florida. Uh, whether that's true or not, people are coming to Florida. What can uh, and we've got the, I tell you what, they're all over the place, but how would an emphasis on nutrition, diet, and exercise save Medicaid uh and Medicare money?

Absolutely. So, having lifestyle interventions such as physical activity programs, nutrition programs, where people live, work, and gather through community health workers face-based organizations schools cooperative extensions YMCAs teaching kitchens local food systems working together to save money together that can help make if we scale that in rural settings that would be a way that we could save money if we're looking at um also the fact that this is empowering patients where they live work pray and play they learn how to manage their own nutrition they learn how to get better sleep sleep hygiene who all in here is suffering from poor sleep quality and quantity, uh gaining tools that control their health and and their visits. So this could lead to better blood pressure, it can lead to diabetes control, fewer complications, fewer emergency department visits, outcomes that greatly matter, and needs with limited care. So um it also, family, lifestyle medicine is a team-based sport, uh when we look at telehealth models that we've talked about before, allowing physicians to work together with nu- with nurses, allowing dietitians, community partners, to extend way beyond the clinic and in that rural setting, as I mentioned in Iowa. This approach can really strengthen the trust and the group appearance.

Gentlelady, this time's expired, yeah, Dr. Sewell, thank you very much. Thank you. It's a winner. That's what you're saying in the bottom line,

It's a it's a winner.

Mr. Chairman, I yield yield back.

It's a winner.

Thank you so much.

Thank you.

Gentlelady from Alabama, Mrs. Sewell is recognized for five minutes.

Uh, thank you so much, Mr. Chairman. Um, I wanna thank our witnesses for being here today. Preparing the next uh generation of health care workforce is is essential to reducing the health care professional shortage that we see all across America and in improving health care outcomes. As a member of Congress representing the historic rural black belt counties of Alabama, I experience high rates of chronic illness in my district. I'm very sensitive to the health care needs of rural Americans, and my citizens uh in my district have historically experienced disproportional rates of chronic diseases often due to the fact that they lack access. Some have to drive many, many miles to be able to see a general practitioner,

Mm-hmm.

let alone a specialty or someone uh who, you know, with uh uh with expertise in mental health and the and the like. Uh many of my consti constituents are really forced uh to go without health care altogether in some areas some droughts that I have. Um we have baby deserts in my district all throughout uh because um the first thing that goes in a rural hospital is the obstetric, the labor and delivery unit. Uh, in an effort to train and prepare the next generation of health care professionals in Alabama, I have to say that my state has put a major investment in creating a residential public high school. They're gonna put it in my my district, in the rural part of my district, Demopolis, and its sole focus will be on creating health care professionals starting at ninth grade going forward. which is a huge plus for our state. Now it won't it won't actually begin until twenty twenty seven. Uh in the meantime we are facing huge shortages like everyone um across this nation. I'm proud uh to join with my Republican colleague uh Brian Fitzpatrick in supporting our GMA GME bill um that will increase a number of of uh residents all throughout um we want fourteen thousand but we'll take whatever we can get, and over the years we've been able to get a thousand here, two hundred there, um all of which make a difference. Um I wanna specifically talk about the need in rural parts of my district. Uh last week I had an opportunity to visit uh my uh hospital in my hometown of Selma, Alabama, the Vaughan Regional uh Medical Center. Uh there they operate for the last thirty years um the University of Alabama, Birmingham's federal um uh sorry, family medicine residency program that has graduated hundreds of residents and currently, I'm concerned because UAB is thinking about shrinking the number of residents, uh, that will be at that hospital. Uh, Vaughn Regional Medical Center, uh, has a hundred and seventy-five beds. It services not only Selma and Dallas County, but forty, I mean, sorry, four other counties that surround it, uh, for a total of about ninety thousand people in that service area. And literally it is the lifeline. Those residents are the lifeline of providing health care services to the people of my district. Uh, in fact, if we did not have residents, we would have no doctors actually doing rounds uh at at nighttime in my, in my, in, in this particular hospital. And in fact, during COVID they were instrumental. And I went there to talk uh to the residents specifically about how we can go about increasing the number of residents that choose to come to rural and underserved communities. And what I found is a group of very compassionate young people who felt that their experience in family in family medicine couldn't have been better served than in a rural community where they see everything. Uh, they talked about how there was a continuity of care, that they got to know one-on-one the the folks in that small community, the mother, the grandmother, and really was able to, um, make a difference in that area. Now, I know I have to battle with UAB about restructuring this program, and I plan on doing that, But, Doctor Howe, I wanted you to talk a little bit about uh or elaborate more on the uh the benefits of having more residents in say family medicine in rural America, and how it really does address the access issue.

Thank you for that question, Representative, and specifically in your state, the reopening of a labor and delivery unit because of a family medicine residency, increased or decreased the infant mortality rate. That is actuals and outcomes for Bibb County.

in Bibb County, which is not in my district, but I mean it's it's adjacent,

But, yeah, and so it's it's transformative, right?

exactly.

It improves access to care, it brings workforce, it increases services, and then one of the things that I think we've seen with Gahaba is that it training leads to more training, and so it's absolutely transformative.

Absolutely. And many of them choose to stay in those communities and raise families,

Yeah.

and and so I I I'm quite concerned. I mean I I wanted to be on Ways and Means because of the health care crisis in my district. I represent the poorest district in the state of Alabama, but I grew up in this district. I know what's possible in this district with resources and opportunities. And so, um, Mister Chairman, I look forward to this committee continuing to grow our, uh, graduate medical education program and increasing the number of slots that we have uh for residents. And I would love to, Doctor Hawes, have an opportunity to talk to you about the Rural, um, uh, Track, the, the Rural Track program, uh, for residency, cuz I, I'm gonna make that as a an alternative to the restructuring that they're currently thinking about at UAB's, uh, family medicine residency.

Wonderful.

So thank you so much for all that you all do.

Thank you. Uh, mister, the gentleman from Virginia, mister Beyer, is recognized for five minutes.

Mister Chairman, thank you very much, and thank all of you for being with us today. Uh, last year my Republican friends passed a lot of cut, nine hundred billion dollars from Medicaid. And the nonpartisan congressional budget, all of us figure that's seven point eight million Americans will be kicked off of Medicaid. And as we know, these are people who are disproportionately more rural, they're older, they're sicker, and most of them are not gonna be able to find other insurance. So my concern is what they create massive amounts of uncompensated care for the rural clinics or rural hospitals that are already stressed. Doctor Racine, with these massively increasing costs to rural hospitals, should it make sense to send the US Mercy hospital shipped to Greenland? where they already have free health care and free medicines?

I'm gonna pass on that.

OK. Well, how about a politerer question? Is it gonna make it harder for the rural hospital to focus on training the next generation of physicians?

Right, that mercy ship can't make it to most rural areas in this country, so it's probably not the issue. But I do think that any money that's spent sending any resources to areas other than the rural areas of this country that could use it, I think could be probably better reapportioned.

Uh, that that's a per- perfectly appropriate answer. Doctor Racine, Doctor Murphy was asking you a lot of questions about vaccines. Would you like time to respond?

Um, well, Doctor Murphy and I may have some disagreement about that. I think there are things that we do agree on. But most importantly, what I would say about vaccines is that the science of vaccines is established, their safety and their efficacy is established, vaccination is probably the greatest single public health triumph in the past hundred years and the children of this country actually deserve access to, not only the vaccines themselves, but correct information about the benefits of having them. And that's what the American Academy of Pediatrics has been doing when we issued our own vaccine recommendations at the end of January, trying to keep the country focused on what benefits can accrue when children are protected against vaccine preventable diseases.

Thank you very much. Doctor Hawes, uh I came late, but I appreciated reading your comprehensive written testimony. And you mentioned that HRSA's Rural Residency Planning and Development Program was a successful model. And last year, it sent a hundred eighty-six million dollars to Virginia, and twelve million just to develop the rural health care workforce. Again though, it's in real trouble, the first half of last year, The new administration fired or forced out more than seven hundred employees from HRSA. And last, the year before, they planned on eliminating the agency entirely. What would a disruption in staffing and funding to the RRPD do to rural residency programs?

The Rural Residency Planning and Development program has created sixty-six new residencies, forty more are in development, and this is a collaborative partnership with HRSA who are administering it, and um it has the potential to um significantly increase rural training across uh the nation, because these rural health facilities, as we heard from our colleagues at Phelps, um need that start-up funding to help them kind of initiate the program, and so it, you know, it is critical I think to growing rural training opportunities.

Departing a little bit, my friend Congressman Stubbe talked about um uh difficult it was to get Americans into the rural programs but one of the things I've heard again and again is there's a shortage of residencies everywhere, uh rural and urban, and that there's also a shortage of doctors. Um I s- served in Switzerland for four years where in most of Europe, physicians have a four or five year undergraduate full education rather than a four year degree from University of Virginia or Virginia Tech and then four years later. The physicians on the panel, is there any chance of moving to a more European model, of getting wonderful physicians at age twenty-two or twenty-three, rather than twenty-eight or thirty? But Doctor Racine.

Sure, there's been discussions um with regard to graduate training as to whether or not that timing can be uh shortened. I will say I'm of two minds about this, having been someone who studied not biology or medicine during my undergraduate degree. and then went on to do the medical school and economics. Um, there is an enormous luxury in this country of going to an undergraduate program, where you can study almost anything and become an educated person. And I do think that there are elements of philosophy or literature or other kinds of humanities that inform people and make them better physicians. So, I appreciate, I mean, I have colleagues in Europe and that's how they were trained, I have colleagues who came from England, that's how they were trained. But I think there are pluses and minuses to each of those systems. I will say that my wife is an immigrant. She comes from Norway. And I will tell you around our dinner table, this is a constant source of conversation. So, I appreciate both sides of that.

I was just thinking, we have a doctor chairing the committee that the the whole notion of if we have a real scarcity this may be a way to address it. Uh, and certainly my experience was the doctors were pretty good in Zwitser. With that, Mr. Chair, I yield back.

Thank you. I'll I'll just submit I think we need to actually look at that a little bit more, shortening undergrad when kids are graduating with so much debt and moving things forward I think there needs to be a a much greater uh uh a much greater look at trying to mold undergraduate education but to your point, Doctor Racine, I think that a well-rounded physician is a better physician to that point. I I wanna thank our witnesses for coming today. I will say, Doctor Rosin, I'm sure you and I agree with things much more than we disagree, uh but that's okay, that's what healthy debate in science is. Not everybody agrees. Uh, please be advised that members have two weeks to submit written questions to be answered later in writing. Those questions and your answers may part will be made part of the formal hearing record. With that, the subcommittee stands adjourned.