The Honorable Charles Schumer The Honorable Nancy Pelosi
Majority Leader Speaker
United State Senate United States House of Representatives
Washington, DC 20510 Washington, DC 20515
The Honorable Mitch McConnell The Honorable Kevin McCarthy
Republican Leader Republican Leader
United States Senate United States House of Representatives
Washington, DC 20510 Washington, DC 20515
Dear Leader Schumer, Speaker Pelosi, Leader McConnell and Leader McCarthy:
On behalf of the American Hospital Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, we ask that as Congress considers an infrastructure proposal that you prioritize hospital and health system needs to ensure our nation’s health care system is well positioned to meet the opportunities and challenges that lie ahead.
We rely on our critical infrastructure to protect and advance the physical, economic and environmental wellbeing of our nation. Hospitals are one of the basic physical and organizational facilities needed for the operation of a society, and thus, by definition, are part of our nation’s infrastructure. Indeed, health care is one of the 16 critical infrastructure sectors designated by the Department of Homeland Security (DHS).
Hospitals and health systems meet the daily medical needs of patients, as well as serve on the front lines protecting the lives and wellbeing of individuals in emergencies. These emergencies can range from an outbreak of communicable disease, such as COVID-19, to natural disasters, such as unprecedented storms or wildfires, to manmade emergencies, such as bombings, mass shootings or transportation disasters. In normal times and in times of crisis, Americans look to their hospitals and health systems as a place of care, comfort and refuge.
Yet, the reality is that just as other critical infrastructure, including our nation’s roads, bridges and transit systems, have aged, so too have many of our nation’s hospitals. Many hospitals faced financial challenges prior to the pandemic, but COVID-19 has brought unprecedented financial losses. The AHA last June estimated that hospitals and health systems would lose more than $320 billion in 2020 alone. In addition, a study released last month estimated that hospitals and health systems would lose between $50 billion and $120 billion in 2021. These compounding financial pressures have resulted in delays in necessary capital spending, including for needed maintenance and physical plant upgrades. In addition, some hospitals that are in the greatest need of repair have the greatest barriers to accessing capital.
Now, more than ever, federal investment is needed to ensure hospitals are able to meet the health care needs of patients and continue to be a source of jobs and economic stability in their communities, and often their largest employer. As Congress develops policies aimed at rebuilding our nation’s critical infrastructure, we urge you to prioritize support for health care and its vital role in addressing critical challenges including health equity, emergency preparedness, workforce, access to care and more.
This letter addresses our recommendations for infrastructure investments that will ensure our hospitals and health systems are fully equipped to respond to any future public health emergency and deliver equitable, environmentally sustainable care to their communities.
Investing in Hospital and Health System Physical Infrastructure
To deliver the safe, timely and effective care that Americans depend upon, hospitals, health systems, post-acute care, and other providers continually maintain thousands of facilities comprising physical infrastructure that relies on extensive, complex and costly mechanical systems, information technology, medical equipment, and other supplies. America’s hospital infrastructure faces a number of challenges, including the need for physical plant upgrades amidst severely compromised hospital finances. In addition, hospitals face the added challenge of needing to reconfigure care delivery and “right-size” so that they can continue to transform to meet the needs of the health care system for the future in an effort to make care more accessible and convenient for patients.
We urge your support for funding for hospital infrastructure as these investments will be critical to ensuring the long-term viability of hospitals; maintaining access to high quality, safe and equitable health care; and sustaining the millions of health care jobs that hospitals and health systems provide.
In particular, the availability of tax-exempt financing, a long-standing and important source of capital financing for hospitals and health systems, should be expanded and enhanced. Tax-exempt advance refunding of hospital bonds should be reinstated. Advance refunding can lower health care costs by reducing hospital financing costs. Bank qualified bond rules, set in 1986, should be modernized to encourage banks to invest in tax-exempt bonds from smaller, less-frequent hospital bond issuers. Any legislation to establish new tax credit or direct pay bonds, which offer an investor a federal tax credit or the issuer a direct payment, should include tax-exempt hospitals and health systems as eligible for that financing option.
Building Capacity for Emergency Preparedness and Response Capacity
Caring for patients during the COVID-19 pandemic required hospitals to rapidly rethink and often “reinvent” their physical infrastructure to mitigate the spread of the virus, increase critical care capacity, and adjust to complex medication handling requirements to support treatments and vaccines, among other needs. While the needs related to internal facility reconfiguration were immense, hospitals also have worked to develop and implement solutions to reduce systemic barriers in access to care that further complicate emergency response, including access to reliable transportation and digital devices. The COVID-19 experience reinforces the need for sustained federal investment to support increased capacity for emergency preparedness and response.
For nearly 20 years, the Hospital Preparedness Program (HPP) has provided funding and other resources to states and other jurisdictions intended to assist hospitals in responding to a variety of emergencies. However, despite the significant need for this type of support, the program has been historically under-funded, and more recently, hospitals have received only a fraction of HPP funds that have been appropriated. We urge Congress to ensure an adequate annual funding allocation for the HPP and to consider structural improvements to the program to ensure the funding ultimately reaches hospitals to support their emergency preparedness and response activities.
Expanding Health Care Digital and Data Infrastructure
The COVID-19 emergency highlights the importance of a strong digital health infrastructure. This includes access to adequate, affordable broadband connectivity, which is essential to enabling telehealth and increasing access to care, as well as support for telehealth infrastructure to ensure all Americans, and particularly those in underserved communities, can realize the promise of digital health. Additionally, we must prioritize strong cyber defenses to protect the privacy and safety of patients and their health information. Finally, we must continually modernize the key data systems that support the ability of government and health care organizations to identify, track and respond to issues that affect health equity, racial and ethnic disparities, the quality of health care delivery, and public health responses.
Specifically, we ask Congress to consider policies to support:
- Completing the nation’s broadband infrastructure. Significant new funding should be provided to the Federal Communications Commission’s (FCC) Rural Health Care Program to support broadband access and make other program improvements as needed.
- Expanding telehealth capacity. Congress should establish new funding programs to offset the high upfront and ongoing maintenance costs of telehealth professionals and hospitals providing telehealth services.
- Strengthening cybersecurity defenses. We should strengthen our cybersecurity defenses by advancing efforts, including development of coordinated national defensive measures; expansion of the cybersecurity workforce; disruption of bad actors that target U.S. critical infrastructure; and utilization of a “whole of government” approach to increasing consequences for those who commit attacks.
- Modernizing the nation’s data infrastructure. We should do this through dedicated funding for upgrades and maintenance of the systems hospitals and other health care providers use to report vital quality data, as well as investing in public health data system modernization and workforce development to support expanded surveillance and response capabilities.
Strengthening the Health Care Workforce
A qualified, engaged, diverse workforce is the core infrastructure of our health care system. Yet COVID-19 has taken a heavy toll on our health care heroes who have been on the front lines of the pandemic with many suffering from trauma, burnout and increased behavioral health challenges. A number of hospitals have experienced critical staffing issues due to the demands of surges of very ill COVID-19 patients, as well as assistance in helping control the pandemic through testing, contact tracing and vaccine deployment. We urge your support for efforts to ensure an adequate, sustainable health care workforce including:
- Increasing the number of residency slots eligible for Medicare funding;
- Funding educational loan pay-downs and vouchers for clinicians and other front-line workers;
- Bolstering the capacity of schools of nursing and allied health professionals, and increasing the number of faculty;
- Creating pathways for new American jobs by funding clinical apprenticeship demonstration programs, such as those for medical and nursing assistants;
- Providing visa relief during emergency response;
- Funding research and demonstration programs related to clinician wellbeing;
- Establishing grants for cultural competency training in medical residency programs and in-service training for health care professionals;
- Providing grants to expand, modernize and support schools of medicine and schools of nursing in rural, underserved areas or minority-serving organizations; and
- Rejecting reductions to Medicare funding for direct and indirect graduate medical education.
Securing the Supply Chain
A strong and reliable medical supply chain is critical to delivering safe and effective high-quality care to patients; however, it has become increasingly clear that the level of fragility across our national medical supply chain is unsustainable. A disruption anywhere in the supply chain process has the potential to create a series of prolonged difficulties in supply acquisition for providers, which ultimately can directly affect the patients they treat or even their ability to offer treatment. The traditional “just in time” or “lean” supply chain approach has resulted in unintended, yet severe, consequences, such as delayed supply delivery, fraudulent or counterfeit products entering the market, and price gouging, all of which impact the ability to deliver patient care. To mitigate these challenges, we urge your support for investment in strengthening the supply chain by:
- Increasing domestic production capacity and manufacturing redundancy; and
- Reinforcing the strategic national stockpile through continuous investment so that the equipment is available in adequate amounts and is managed in an appropriate manner so as to be useable and useful when emergencies require health care providers to seek help from it.
Supporting Behavioral Health Access
Behavioral health needs have long gone under-addressed in the U.S., and the COVID-19 pandemic has and will continue to exacerbate this issue; for example, the Centers for Disease Control and Prevention reported that overdose deaths spiked after the start of the pandemic, driven by synthetic opioids like fentanyl. It is essential that hospitals and health systems are able to serve patients experiencing mental illness and/or substance use disorders both in-person and remotely and that capacity to respond to the unique behavioral health needs of children and adolescents is expanded. Inpatient psychiatric facilities, as well as general acute care hospitals that offer inpatient and outpatient behavioral health programs like partial hospitalization and opioid treatment programs, face unique infrastructure challenges that are critical to address now before the increasing surge of behavioral health needs stemming from the pandemic becomes insurmountable. We urge Congress’ support for:
- Funding the construction of new sites of care to improve access to behavioral health services;
- Funding physical renovations to improve safety and help offset the costs to refurbish psychiatric facilities to align with the most up-to-date safety standards and meet the unique needs of children and adolescents;
- Funding end-user devices to upgrade audio-video technology to support telehealth in the location where patients are receiving behavioral health care, which may include the patient’s home for certain psychotherapy and addiction recovery services;
- Funding local crisis intervention teams and overdose response programs to support community partnerships between law enforcement and mental health/addiction professionals;
- Investing in technologically driven therapeutics developed specifically for children and adolescents, including mobile applications, text messaging, and remote biometrics that can assist in screenings and treatment for behavioral health conditions; and
- Creating opportunities for behavioral health providers to acquire interoperable electronic health records that enable improved information sharing among providers and with public health and other government agencies.
On behalf of America’s hospitals and health systems, we look forward to working with Congress to address the infrastructure needs of our health care system to ensure that patients, families and communities have access to the care they need to reach their highest potential for health today and into the future.
Executive Vice President-Designate
Government Relations and Public Policy