Examining Existing Federal Programs to Build a Stronger Health Workforce and Improve Primary Care
American Hospital Association
Subcommittee on Health
Committee on Energy and Commerce
U.S. House of Representatives
Examining Existing Federal Programs
to Build a Stronger Health Workforce and Improve Primary Care
April 19, 2023
On behalf of our 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, the American Hospital Association (AHA) appreciates the opportunity to provide the subcommittee with information for its hearing on Examining Existing Federal Programs to Build a Stronger Health Workforce and Improve Primary Care.
SUSTAINING THE HEALTH CARE WORKFORCE
Health care careers are often a calling, and a qualified, engaged and diverse workforce is at the heart of America’s health care system. However, long building structural changes in the health care workforce, combined with the profound toll of the COVID-19 pandemic, have left hospitals and health systems, including post-acute and behavioral health care providers, facing a national staffing emergency that could jeopardize access to high-quality, equitable care for patients and the communities they serve.
Prior to the COVID-19 pandemic, hospitals were already facing significant challenges that were making it difficult to sustain, build and retain the health care workforce. In 2017, the majority of our nursing workforce was close to retirement, with more than half aged 50 and older, and almost 30% aged 60 and older. Yet, nursing schools had to turn away over 90,000 qualified applicants in 2021, according to the American Association of Colleges of Nursing, due to lack of faculty and training sites. Hospitals faced similar demographic trends for physicians, with data from the Association of American Medical Colleges indicating that one-third of practicing physicians will reach retirement age over the next decade. Hospitals also were reporting significant shortages of allied health and behavioral health professionals. Congress should consider the following policies to help sustain the nation’s workforce:
- Address nursing shortages by investing in nursing education and faculty. Schools of nursing continue to need more faculty, preceptors and clinical training sites to support students, new graduates and prospective students. The Future Advancement of Academic Nursing Act would provide those vital resources to support the needs of nursing students, help retain and hire diverse faculty, modernize nursing education infrastructure, and create and expand clinical education opportunities.
- Provide scholarships and loan repayment. Title VIII Nursing Workforce Development programs such as Nurse Corps help bolster the advanced practice and nursing workforce by addressing the shortage of nursing faculty and clinical sites, as well as funding nursing schools located in rural and underserved communities. The CARES Act reauthorized these critical programs through 2024. Reauthorizing and funding these programs remain a necessity. Congress should ensure nursing students are eligible to receive such benefits to attend high-quality nursing schools regardless of the educational institution’s tax status and ensure parity of treatment for hospitals and their workers regardless of tax status in federal health programs, including those enumerated in the Public Health Service Act.
- Reauthorize and increase funding for the National Health Service Corps. This program awards scholarships and assists graduates of health professions programs with loan repayment in return for an obligation to provide health care services in underserved rural and urban areas. The AHA supports the Strengthening Community Care Act of 2023 (H.R. 2559) to extend funding for community health centers and the NHSC. The NHSC is a critically important program for both giving clinicians support to offset the substantial cost of their education, while also incentivizing practice in underserved rural and urban health professional shortage areas across the country
- Increase GME slots. Address physician shortages, including shortages of behavioral health providers, by increasing the number of residency slots eligible for Medicare funding.
- Support foreign-trained health care workers. Support expedition of visas for foreign-trained nurses and continuation of visa waivers for physicians in medically underserved areas.
- The National Nursing Workforce Center Act of 2023 (H.R. 2411). The AHA supports this legislation to provide grants to state and regional nursing workforce centers to support research to bolster the evidence base for what types of nursing workforce programs are most effective in attracting and retaining the nursing workforce.
- Investigate travel nurse agency practices. We urge Congress to direct the Government Accountability Office to study the business practices of travel nurse staffing agencies during the pandemic, including potential price gouging and excessive profits, increased margins that agencies retain for themselves, impact of increased reliance on travel nurses in rural areas, and how these practices contribute to workforce shortages across the country.
- Allow for innovative staffing models to develop. Severe workforce constraints prompted hospitals and health systems to develop innovative new staffing models that better enable clinicians to practice at the top of their licenses. Hospitals need flexibility to test, evaluate and — when the evidence supports it — implement new models. That is why we urge policymakers to avoid the use of restrictive staffing rules that limit innovation and threaten to exacerbate health care access challenges, such as nurse staffing ratios or levels. The AHA believes staffing ratios are a static and ineffective tool that does not guarantee a safe health care environment or quality level to achieve optimum patient outcomes. They also usually are informed by older care models that do not consider advanced capabilities in technology or inter-professional team-care models.
SUPPORTING THE WELL-BEING OF THE HEALTH CARE WORKFORCE
The traumatic impact of COVID-19 has amplified the need for support and efforts to improve clinician well-being, destigmatize mental health and address overall wellness. Addressing well-being cannot be entirely isolated from the other efforts to improve the work lives and well-being of the health care workforce, including mitigating workplace violence and expanding access to behavioral health care.
Nurses, physicians and other staff on the front lines of care in U.S. hospitals, emergency departments (EDs) and health care systems experience high rates of violence. A survey of registered nurses working in hospitals showed that, during the pandemic, 44% reported experiencing physical violence and 68% reported experiencing verbal abuse.1 Despite the near-daily occurrence of abuse directed toward health care workers, there is no federal law that protects them by specifying consequences for acts of violence or intimidation.1
The AHA urges Congress to consider the following policies to support the well-being of the health care workforce:
- Protect health care workers from violence. Congress should enact H.R. 2584, the Safety from Violence for Healthcare Employees (SAVE) Act. This legislation would provide federal protections for health care workers against violence and intimidation, as well as provide grant funding to hospitals for violence prevention programs, coordination with state and local law enforcement and physical plant improvements.
- Continue to provide grant funding support to well-being focused initiatives. Thanks to the Dr. Lorna Breen Health Care Provider Protection Act of 2022, the health care field received important funding for projects that help support well-being in their workplaces. We encourage Congress to provide additional support for projects and collaborative efforts to scale successful practices on well-being across the health care field, especially those efforts that link well-being with hospital efforts to improve quality and the patient experience.
- Consider funding projects to identify and evaluate successful practices on how behavioral health issues are considered in licensure and application processes. Many clinicians fear losing their license or ability to practice based on questions relating to their mental health that may be overly broad or invasive. These questions may inadvertently serve to stigmatize mental health issues and can create barriers for clinicians to seeking appropriate treatment and decrease clinician well-being. We urge Congress to remove barriers for certain types of licensed practitioners to provide remote services (e.g., licensed addiction counselors, family therapists) to expand access to needed care.
OTHER PRIORITY PROGRAMS
Children’s Hospitals Graduate Medical Education (CHGME) Program Reauthorization
The CHGME program supports graduate medical education programs at children’s hospitals that train resident physicians. Freestanding children’s hospitals typically treat very few Medicare patients and, therefore, do not receive Medicare funding to support medical training of residents; the CHGME program helps offset this inequity in funding. In addition to teaching the next generation of physicians and conducting research on childhood diseases, these hospitals provide lifesaving care to many medically underserved children in rural and inner-city areas as well as for those with complex medical needs. Currently, CHGME hospitals train 56% of the nation’s pediatricians and 54% of the pediatric subspecialists who care for children living in all 50 states. Unlike Medicare’s GME program, CHGME is funded through annual appropriations. The program has enjoyed bipartisan congressional support since its inception in 1999. Maintaining a strong CHGME program for another five years is critical for both the children’s hospitals’ patients and the future health of all children. The AHA supports reauthorizing the CHMGE program with at least $385 million in annual funding.
340B Drug Pricing Program
For more than 30 years, the 340B Drug Pricing Program has allowed hospitals to stretch limited federal resources to directly improve patients’ access to care by expanding health services to the patients and communities they serve as well as reducing the price of outpatient pharmaceuticals. 340B hospitals achieve savings by purchasing drugs at a discount. The amount of that discount depends on drug companies’ pricing decisions, with the discount increasing the more drug companies decide to raise the prices of their drugs.
Hospitals use 340B savings in many ways to meet the unique needs of the patients and communities they serve. This includes the provision of a range of vital programs and services, such as the provision of free or discounted drugs to low-income patients, free care for uninsured patients and support for behavioral health clinics and community health programs. In fact, in the most recent year for which information is available, 340B hospitals provided nearly $68 billion in total benefits to their communities.2 340B hospitals also are responsible for a majority of hospital care (77%) to the nation’s Medicaid patients.3 The AHA urges Congress to continue to protect this critical program and oppose efforts to cut its benefits, which would result in reduced access to quality care for the patients and communities served by 340B hospitals.
The AHA is alarmed by the actions of several drug companies to unlawfully restrict access to 340B discounted drugs for 340B hospitals that have established arrangements with community and specialty pharmacies. These actions have resulted in significant financial impact to 340B hospitals at a time when hospitals are already facing a number of financial challenges and threatened the ability of 340B hospitals to maintain patient programs and services that are supported by 340B savings.
The AHA has strongly supported the Health Resources and Services Administration (HRSA) in its efforts to enforce the requirements for drug companies set forth in the 340B statute and encourages HRSA to strengthen its own oversight of drug companies’ behavior through an invigorated Administrative Dispute Resolution (ADR) process. This would allow 340B providers to bring claims for relief where they have been overcharged including cases where 340B pricing has been unlawfully denied by drug companies through contract pharmacies. In addition, it could permit providers to address certain behaviors on the part of some drug companies that force hospitals to report burdensome data to the drug companies’ own third-party vendor in exchange for some limited relief on their unlawful efforts to deny 340B pricing through contract pharmacies. Finalizing the ADR proposed rule is a priority for the AHA and our 340B members as we believe it will improve HRSA’s oversight of the 340B program and bring much needed accountability that can help protect 340B providers.
The Securing the U.S. Organ Procurement and Transplantation Network (OPTN) Act (H.R. 2544). The AHA supports this legislation to increase the budget and make programmatic improvements to the OPTN. At the same time, we urge Congress to direct HRSA to provide needed oversight to those organizations with which it chooses to contract to ensure the coordination, timeliness and smooth functioning of the system.
The AHA appreciates your recognition of the challenges ahead and the need to examine America’s health care workforce issues. We must work together to solve these issues so our nation’s hospitals and health systems, post-acute and behavioral health care providers can continue to care for the patients and communities they serve.