▶ 0:07:17button here. Turn on the light.
▶ 0:16:07Good morning. We will call the sub health subcommittee meeting to order here. Thank you uh to our witnesses for being here sharing in in your perspective as we discuss advancing the next generation of America's health care workforce. I'm filling in today for subcommittee chairman Mr. Mr. 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.
▶ 0:16:33Our nation is facing a very real problem, a rapidly depleting health health care workforce. By 2037, the US will see a shortage of 187,000 physicians. Nearly half of all practicing physicians will retire in the next decade. 83 million Americans live in an area with too few primary care physicians.
▶ 0:16:55Rural communities are even more vulnerable to workforce shortages with 60% fewer physicians for every 10,000 patients when compared with urban areas. Medical school medical schools prepare, 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.
▶ 0:17:25Medicare is a major contributor to GME, supporting nearly 80% of residency training nationwide and paying more than 20 billion annually to teaching hospitals. However, this funding is increasingly being directed to large coastal hospitals while healthcare workforce shortages persist across the country. Rural and underserved communities in particular face unique barriers to establishing programs and training residents.
▶ 0:17:51Rural hospitals must overcome a lack of resources, staff, and patient volume to establish new residency programs while simultaneously getting reimbursed less than their urban Congress recognized this gap and recently funded more than 1,000 new GME slots with 10% specifically reserved for rural areas.
▶ 0:18:11But concerningly, large urban hospitals have exploited a Medicare loophole and have collected 97% of the 800 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 and practice in a rural area if they train there. Yet only 2% of residencies can be found in rural America.
▶ 0:18:39At 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 10 Americans have a chronic disease, and 90% of our healthcare dollars go toward managing these diseases. Unfortunately, most residents receive minimal training in prevention. In fact, only 14% of residency programs have a required nutrition curriculum.
▶ 0:19:06If 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 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 lead on on targeted solutions to grow our healthcare workforce.
▶ 0:19:37I'm pleased to recognize the gentleman and my friend from California, Mr. Thompson for his opening statement.
▶ 0:19:42Thank you uh Mr. Chairman. As you know, the ranking member uh Mr. Dogget 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 for the record
▶ 0:19:58without objection.
▶ 0:19:59Thank you. Uh Mr. Chairman, um well, once again, uh we're here to address without question a serious issue, and that's the next generation of health care 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 800 pound, uh gorilla in the room, and that's the fact that they have eliminated healthc care coverage for millions of Americans.
▶ 0:20:29If 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 HR1, the big ugly law, uh, congressional Republicans cut $1 trillion from Medicaid.
▶ 0:20:59They also failed to extend premium tax credits that help millions of Americans afford their insurance coverage. They kicked 15 million people off of their insurance so they could give their billionaire donors a tax break. And it should be noted they also added $4 trillion to our national debt. Because these because of these cuts, hospitals are being forced to reduce services or worse yet close altogether.
▶ 0:21:28Every health care system will suffer because of congressional Republicans health care cuts and rural and underserved areas will b 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 going to train future rural physicians and health care providers with a trillion dollar hole in our health care system?
▶ 0:21:52My 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 cap the amount at a student can borrow at $200,000.
▶ 0:22:17But the median cost for a public medical school uh in 2024 was nearly $300,000. And private medical schools in some instances cost even more. Students aren't going to 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.
▶ 0:22:46We 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.
▶ 0:23:1140% 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.
▶ 0:23:30We should make it easier for students to afford their medical education so that they can grow our pool of talented doctors and provided 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 Su introduced, the Resident Physician Shortage Reduction Act.
▶ 0:23:59and 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.
▶ 0:24:24Again, thank you to our witnesses. I look forward to a thoughtful conversation here as we have an exchange of ideas and hopefully a focus on solutions. Let me uh introduce our guests here today, our witnesses, Dr. Emily Haw. She's 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 Mr. Jason Jason Schinnfield.
▶ 0:24:51He's the chief executive officer of Phelps Health, a hospital in rur rural Missouri, or as some locals would say, Missouri. But there's a variety of opinions on that. Right. Uh next we have Dr. Thomas Moore. He's dean of Sam Houston State University College of Osteopathic Medicine. Then uh after Dr. Moore, we have Dr.
▶ 0:25:14Jennifer 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 Dr. Andrew Rine, 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.
▶ 0:25:41Uh 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 yellow light uh uh you you can uh as I like to say bring the flight in for a landing. So we'll begin. Dr. Haw uh you you're recognized for five minutes. Chairman Smith, Ranking Member Thompson, and members of the health subcommittee.
▶ 0:26:11Thank you for the invitation. My name is Emily Haw, 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 is conducted through the UNCC Cecil G. Shep Center for Health Services Research.
▶ 0:26:37Living, 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 workforce shortages and improve access to care.
▶ 0:27:02Two, 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 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.
▶ 0:27:32There are also these spillover effects from training. Through our national work supporting more than 200 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.
▶ 0:27:58Thin financial margins, limited subsp specialty opportunities, and less educational infrastructure. Yet, with targeted support, both startup funding and Medicare funding for long-term sustainability, they can offer highly effective training. The HERSA administered rural residency planning and development program which provides startup funding and technical assistance has created 63 new rural residency programs representing nearly 800 accredited resident positions.
▶ 0:28:29One 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.
▶ 0:28:58Expanded 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 fourfold since 2008. A remarkable change in the GME landscape in less than two decades.
▶ 0:29:23Despite 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 tracks rather than just rural counties to reach more rural sites for residency creation.
▶ 0:29:53Direct 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 50% rural training threshold to 30% for procedurally intensive specialties like general surgery as rural hospitals struggle to achieve 50% of the training needed. Make rural training more feasible.
▶ 0:30:18Extend the Medicare cap building window from five to 10 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 131. Ensure rural hospitals such as soul community hospitals receive full Medicare GME Last, scale what works.
▶ 0:30:48build 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
▶ 0:31:12Thank you. And uh Mr. Centerfield, 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 Shennfield, and I serve as a president and CEO of Phelps Health in Raleigh, Missouri. I've worked in healthcare for more than 30 years, beginning as a Navy corman and spending my career on the front lines of care delivery, particularly in communities where access is fragile and every staffing vacancy is felt immediately.
▶ 0:31:43Rural residency development isn't 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 1951 as a small county hospital, Phelps Health has grown into a regional system serving more than 200,000 residents across six rural counties in South Central Missouri.
▶ 0:32:11Each 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 firstear residency slots for roughly twothirds 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.
▶ 0:32:41Residency 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.
▶ 0:33:05For these reasons, Phelps Health made the decision last year to establish a family medicine residency program with enhanced obsetric training. Our goal is straightforward. Strengthen recruitment and long-term retention of primary care physicians in our region. That decision became possible through two planning and development grants. One from HERSA and one from the state of Missouri. These grants help cover essential startup 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.
▶ 0:33:36Only about 15 federal awards are made each year, and very few states offer comparable support. As we transition from planning to implementation, we are seeing firsthand the startup grants are necessary, but not sufficient. One immediate challenge is infrastructure. Accreditation standards require dedicated clinical and teaching space. Our early estimates for buildouts range from 5 to7 million. For a rural health system operating on approximately a 2% margin, that level of capital investment is significant.
▶ 0:34:03Without 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, soul community hospitals reimburseed as a hospital specific rate are excluded from IME payments, a key funding stream for many programs.
▶ 0:34:28Studies show that this can translate into nearly $96,000 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 1984 to the first year hospital ever trained residents. Our rate reflects a very different era of healthcare delivery.
▶ 0:34:55While 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.
▶ 0:35:17First, provide flexible bridge funding to cover the real world gaps between planning grants and full program launch, especially for clinic infrastructure, teaching space, and startup 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 rural facil facilities access to payments if they cannot receive them. If we address these gaps, we will not simply create residency slots.
▶ 0:35:45We 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.
▶ 0:36:06Thank you. Next, Dr. Moore for 5
▶ 0:36:10Subcommittee 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 Dr. 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.
▶ 0:36:33Over the past 25 years, I've helped develop and launch 25 residency programs across five states, many in rural and underserved areas. Through that work, I've 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 interreationship between structure and function.
▶ 0:37:00That philosophy combined with more than 200 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 lifestylebased interventions and nutrition which are key to treatment of chronic disease. Community-based training is central to this approach.
▶ 0:37:26Osteopathic 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.
▶ 0:37:54And for DOS, more than 73% 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 developed decades ago.
▶ 0:38:14While these mechanisms have supported the growth of strong academic medical centers, they can frustrate GME development in smaller hospitals and community-based Medicare per resident amounts vary geograph vary by geography based on historic cost structures. Residency caps limit expansion at hospitals that may now well be positioned to grow.
▶ 0:38:38In 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 hospitals are eager to participate in training. They see firsthand the connection between residency programs and long-term physician recruitment.
▶ 0:39:04Strengthening financial predictability for community-based programs, whether through clearer per resident support, thoughtful slot distribution, or policies that account for workforce need and demographic change can help more of these institutions build sustainable Increasing the number of Medicare supported residency positions remains an important consideration, particularly in primary care and rural settings.
▶ 0:39:29Workforce 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 and residency act promotes transparency in Medicare funded programs by requiring reporting on DO and MD applicants and affirming consideration of the complex USA examination scores.
▶ 0:39:56Transparency enhances accountability and helps ensure that federally supported training opportunities facilitate physician distribution across both rural and urban Innovation can further extend community-based training capacity as well. Technology enabled education, including telerrecepting, remote specialty consultation, and physician-led artificial intelligence integration, allows residents to train in smaller communities while maintaining access to broader expertise.
▶ 0:40:26At SHSUM, 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.
▶ 0:40:44Aligning funding structures with where care is delivered, supporting community-based training growth, and ensuring predictable and equitable 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.
▶ 0:41:11Thank you, Dr. Tril. You're recognized for five minutes.
▶ 0:41:15Good morning, subcommittee 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 health care system. My name is Jennifer Trilk. I am the founding faculty member, tenure professor, and director of lifestyle medicine programs at the University of South Carolina School of Medicine, Greenville.
▶ 0:41:42I also founded Lifestyle Medicine Education, Elmed, we call it, an open-source evidence-based curriculum that helps medical schools nationwide embed prevention, nutrition, and lifestyle medicine into required training. As mentioned this morning, chronic disease now accounts for 90% of the nation's $4.9 trillion in annual health care spending, much of what is borne by Medicare and Medicaid.
▶ 0:42:07Conditions 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 P physician payment, graduate medical education and valuebased care policy. This is not just an educational issue. This is a fiscal issue.
▶ 0:42:34If 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 4-year curriculum.
▶ 0:42:52Students complete more than 100 hours of required content in training in 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 pharmarmacology or pathology. The outcomes do matter.
▶ 0:43:15In most in our most recent graduating class, 87% of our students reported using lifestyle medicine pres principles into their patient care and 86% 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.
▶ 0:43:42This 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 2024 alone, nearly a thousand family medicine and pediatric residency positions went unfilled.
▶ 0:44:11Physicians 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 cost 59 59 billion annually, and that's more than 11,000 per person. To address this, our dean, Phyllis McGelry, the first lifestyle medicine board-certified dean in the history of medical education, launched our primary care accelerated track.
▶ 0:44:40This three-year pathway offers full tuition scholarships, direct transition into family medicine residency within our Prisma Health partner, and a 4-year instate service commitment. We also are proud to report that 43% of our 2025 graduating class matched into primary care across the nation. We emphasize community-based prevention.
▶ 0:45:01Through partnerships with more than 40 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 400 patients, delivering over in care at no cost to those patients. These experiences illuminate the real downstream costs of delayed and fragmented care to the students cost Medicare ultimately absorbs.
▶ 0:45:31For the subcommittee's consideration, I respectfully offer three bipartisan policy priorities within your jurisdiction. First, for the subcommittee, 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 costs saving from prevention training physician cohorts.
▶ 0:45:55And 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 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, where lifestyle is medicine.
▶ 0:46:22If 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.
▶ 0:46:34Thank you, Dr. Reine. You're well, you're recognized for five minutes. Congressman Smith, Congressman Thompson, and members of the subcommittee. My name is Dr. Andrew Rsine, and I'm president of the American Academy of Pediatrics, a nonprofit organization of more than 67,000 pediatric physicians dedicated to the health, safety, and well-being of all infants, children, adolescence, and young adults.
▶ 0:47:00I'm also a general pediatrician and health economist with more than three decades of experience 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.
▶ 0:47:27But 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.
▶ 0:47:51good 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 10 weeks to see a child and adolescent psychiatrist, 12 weeks to see a pediatric palative care doctor, and 18 weeks to see a developmental behavioral pediatrician.
▶ 0:48:16Those weights are compounded for families in rural communities who must 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.
▶ 0:48:44A 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 $235,000 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.
▶ 0:49:12Medicare is the largest single public program training for after medical school. Congress can support more trainees and increase the number of Medicare supported GME positions by advancing legislation like Representatives Fitzpatrick and SU's bipartisan resident physician shortage reduction act. For pediatrics specifically, I'd like to extend my gratitude for Congress's recent support of the children hospital graduate medical education program and the pediatric specialty loan repayment program.
▶ 0:49:40Investments 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.
▶ 0:50:03However, 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.
▶ 0:50:32When 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.
▶ 0:50:49I 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.
▶ 0:51:19These 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 recruit more promising individuals to devote their professional careers to sustaining those children and launching them into a lifetime of good health.
▶ 0:51:49Let'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 Thank you and I look forward to your
▶ 0:52:14Thank you again to our panel for uh your thoughtful approach here. We'll now move into the question and answer session. I'll kick it off here with a few questions. Dr. pause. You mentioned in your written testimony the successes of the Rural Residency Planning and Development Program, RRPD, which has helped establish some 66 new rural residency program since it began in 2019.
▶ 0:52:37Can you tell me uh in a bit more detail how challenging it is to start up a rural residency program and how this funding can help push a new program onto a sustainable path for success?
▶ 0:52:49Thank 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.
▶ 0:53:18negotiate funding agreements, establish budgets, recruit residents, execute employment contracts, and often complete construction or renovation of clinical and office space. The RPD program provides essential seed funding to prov to support program development over a 3 to fiveyear period and help them navigate that complex The sustainable Medicare GME reimbursement is the hinge that ultimately determines whether these programs can survive and
▶ 0:53:49grow, which is why your authority over Medicare GME policy is one of the most powerful levers for addressing rural workforce
▶ 0:53:58Thank you. And now uh we know that RR RPD is not even fully codified in law. and I'm proud to say that I've been working with my colleague Carol Miller to formally authorize RPD. I'm wondering if you could reflect a little bit how that formal codification would further encourage the development and additional residency programs.
▶ 0:54:21Thank you for that question, There are many rural hospitals across this nation and rural health facilities that are prime for launching residency programs. There's in my written testimony, I think there's over 1,700 rural facilities that have never engaged in GME yet. Um there's a lot of untapped potential and so um you know it's and and there's a lot of opportunity to grow graduate medical education.
▶ 0:54:51One 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 RPD provides is that um it shows that rural training is possible and it provides that critical piece of startup and and technical assistance that Medicare GME does not.
▶ 0:55:18So, 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 RPD that that there are some refinements that can increase eligibility, feasibility, and long-term viability for other rural health facilities that want to engage in this work.
▶ 0:55:38Okay. Thank you. Mr. Uh Shennfield, 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?
▶ 0:55:57It'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 30 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.
▶ 0:56:23Uh 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 of 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 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.
▶ 0:56:53uh really from a supply and demand standpoint.
▶ 0:56:57Thank you. I'll I have a lot more questions, but I want to uh save time for my colleagues as well. So, uh on the whole GME thing and the uh match day and the fact that a medical student would not only get into medical school and out, the fact that 5% of graduates would not match on match day, I think should concern all of us.
▶ 0:57:18And so, uh lot lots lots going on there. But I now recognize Mr. Thompson for questions he has.
▶ 0:57:26Thank you, Mr. Chairman. I want to thank all the witnesses for being here. I appreciate uh your um your your work that you're doing. I I have a question for all of you. And if you could just give me a yes or no, we'll start with uh Dr. Haw and go down the line. Did the trillion dollar cut to Medicaid uh help or hurt delivery of health care in rural
▶ 0:57:46Yes or no? Did it Did it Did it help? Sorry. Um I'm here discussing
▶ 0:57:55just yes or no. Did did this did this
▶ 0:57:58GME is funded through multiple sources. Um a change in one will will have effects on the system and rural and underserved programs are receiving
▶ 0:58:08Mr. Shenfield,
▶ 0:58:12I've been in healthcare for 30 years and payment source has been a challenge every every year of my career almost. So it's no different than any other time. 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 under insured, um it certainly makes it more difficult.
▶ 0:58:36This is outside of my scope as an undergraduate medical educator.
▶ 0:58:40It's outside your scope to know if a trillion dollars taken away from healthcare uh helps.
▶ 0:58:48Yes, sir. Uh, Dr. Rousan,
▶ 0:58:52it hurts.
▶ 0:58:54Thank you. Um, Secretary Kennedy is, I believe, undermining health care in America. His antivaccine 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.
▶ 0:59:23Now 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.
▶ 0:59:40I would like to ask unanimous consent to enter into the record this Washington Post story says as measles headlined as measles spreads these nine vaccinereventable diseases could be next. They're sounding the alarm the need for vaccines. So um Dr. uh Rine, do vaccines save lives?
▶ 1:00:08The 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
▶ 1:00:27I 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.
▶ 1:00:47At the same time, there are lots of anxious parents calling up our practices wanting to make sure that they'll be able to get the vaccines that they want and they're worried that that's not going to be available to them. I think also um there are a lot of 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.
▶ 1:01:17That 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
▶ 1:01:41and 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 that could uh be prevented by vaccines. Can you explain how this impacts all kids and their access to care?
▶ 1:02:01Uh 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.
▶ 1:02:19And 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 going to have to find all the people who are there and trace them.
▶ 1:02:42Particularly for children who are too young to have received a measles vaccine and therefore are therefore um susceptible to catching the disease, children who are imunocmpromised, 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.
▶ 1:03:07You have to essentially 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.
▶ 1:03:30To 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 going to have to travel very time has expired.
▶ 1:03:45I apologize.
▶ 1:03:46Thank you very much.
▶ 1:03:47Thank 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. Now recognize the gentleman and the uh chairman of the full committee, Chairman Smith from
▶ 1:04:02Thank 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.
▶ 1:04:26So, 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. I also um I'm pleased to have a gentleman from my neck of the woods from Raleigh, Missouri. It's great to have you here, Jason. Um uh by the way, you have a great first name.
▶ 1:04:52Um but, uh the the Rala Rala community, the Phelps County Hospital, um serves the people of Rala in a in a great way. Serves my family, serves my friends, serves my neighbors. Um so appreciate um you being here.
▶ 1:05:11when it comes to this committee's work on making health care 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.
▶ 1:05:36I 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 enter even went to a primary care facility um in Fredericktown, Missouri. Um these are all things that's so important to rural healthcare.
▶ 1:06:05So, 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 Mr.
▶ 1:06:20Shinfield, could you please share how Phelps Health is developing its family medicine residency program, the hurdles, the uh financial and otherwise you have faced in that process and how how the Medicare program can make it easier for hospitals in rural communities to innovate in the manner that you have.
▶ 1:06:44Thank you, Chairman Smith. Uh happy to answer that question. And 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
▶ 1:07:14program 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 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.
▶ 1:07:43But 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 uh from our initial estimates is is about a 5 to7 million 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 2028 and so we need to have that space done and and everything.
▶ 1:08:10Um, you know, I think, you know, looking at our being able to update our per resident amount, uh, when starting a new residency program, I think that that is a concern is, uh, we estimate that it'll be close to, um, about $100,000 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.
▶ 1:08:41Um, but I think if some of these issues are fixed, I think that they could overcome that as well.
▶ 1:08:46Missouri has a longstanding 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 10 states that export their medical graduates.
▶ 1:09:14While 107 of 114 counties in Missouri have a shortage of primary care doctors, we lose onethird of needed physicians to residency programs in other states. Dr. more. 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.
▶ 1:09:44Thank you, Chairman Smith. Uh, and that's a great question. Um, it is one of those things that uh um that unfortunately suffers from the the legacy of funding within the current CMSGME structure. um because everything was kind of frozen in time in 1997 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.
▶ 1:10:14If 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 1997, 1998 is different than it does right than it looks right now.
▶ 1:10:39Um, 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 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.
▶ 1:11:08um some of the uh the changes in cap reset and cap redistribution, whether you're talking about section 131, which I'm currently doing right now for a hospital, section 126, 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.
▶ 1:11:30um 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 physicians to stay.
▶ 1:11:54Simply put, rural areas need more doctors. Absolutely. That's just pretty simple. Um, onethird 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.
▶ 1:12:15Um, if you look at the average lifespan 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.
▶ 1:12:39And 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 2% of residencies take place in rural America. 2%. Why do we not have doctors in rural areas? That might might be a reason. Um Dr.
▶ 1:13:05Haw, 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?
▶ 1:13:22Thank you. GME is inherently place-based and sticky is the word that I like to think about. Physicians most often practice within a 100 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 health care infrastructure.
▶ 1:13:51And one thing that we're seeing with these new programs is that these residents are helping shape the clinical services of these 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 13 residents have stayed within our rural region adjacent county that has worse primary care access.
▶ 1:14:18So 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
▶ 1:14:38Thank you, Mr. Chairman. Thank you all for being here today. Um, I just want to relate this for a couple minutes and then I want my my good friend Dr. Murphy to take over. Um, I'm a Chevrolet dealer. Uh, and and this is one of the things people say, why the heck would you be talking about cars, Kelly, when 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 1970, there were 4,800 Chevrolet dealers. Today, there's 2,878.
▶ 1:15:08Now, people say, "So, what does that have to do with anything?" Well, all the rural dealers are gone. There just wasn't a big enough market for them to participate in. And at the end of the day, it's always going to be about the money. And I'm not dismissing the cost of whatever it is we do and saying, "Well, you got to 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.
▶ 1:15:36These 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 going to 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 is 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.
▶ 1:16:05Now Miss Delaney and I have a piece called the improving senator uh seniors timely access to care act and that's not only Mr. Delbaney but Dr. Murphy's on it, Dr. Bar is on it, Dr. Joyce is on it. We got a lot of doctors on on these bills. Uh we have over 250 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 we trying to get to. What's the end goal?
▶ 1:16:35And if it's not the American people, then what the hell are you doing here? If you're here for a singular purses, 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 I you Thank you all. You've given up a day of your life to come here.
▶ 1:16:54I don't want to 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 going to 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 want to give my time to Dr. Murphy. He does this every single day of his life. He is very passionate about it. Dr. Murphy, please take over.
▶ 1:17:13Dr. Murphy,
▶ 1:17:14thank you, sir. I just I I appreciate it. I I I do want to talk about GME, but I also want to respond a little bit to one of my Democratic colleagues issues and just ask Dr. Racine a couple Tell me, has the CDC recommended against the measles vaccine?
▶ 1:17:30No, they have not.
▶ 1:17:31No, no, they have not. So, it is an abject lie or an in or any otherwise insinuation to say the CDC is not saying anything is saying anything against me's 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?
▶ 1:17:49I think it's the purpose of vaccinations to treat everybody.
▶ 1:17:52No, that didn't answer my question. You don't look you 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 of anything else, that is always what has been a vaccine for. That's why elderly people get the shingle shot and 14y 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?
▶ 1:18:23Okay. So, it is not scientifically unreasonable to have some reluctance to jump in and we've seen over 25 years the number of vaccines offered to children or recommended to children go from 45 into the 70s. Is it okay for the scientific community to every so often question themselves, are we doing the right thing?
▶ 1:18:46I 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?
▶ 1:19:12Example in 1994 false literature came out about a physician surplus. Hence we are in the position we are that we don't have enough physicians. So is it okay for the scientific community to question itself every so often?
▶ 1:19:28Absolutely. I 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
▶ 1:19:49And thank you, Dr. Murphy. I recognize Miss Chu for five minutes.
▶ 1:19:53Dr. racing. 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 400 rural hospitals are now at risk of closure. Plus, those that remain open are projected to lose nearly 10% of their Medicaid revenue.
▶ 1:20:20What's more, uncompensated care is expected to rise by more than onethird. 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 which doesn't even cover the full cost of medical school in most cases.
▶ 1:20:49and the Trump administration's new H1B policies now require hospitals to pay $100,000 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, Dr. Rsine, let's connect the dots.
▶ 1:21:13Taken together, are Republican policies moving us closer to or further away from solving the physician shortage in rural and underserved communities?
▶ 1:21:26Well, 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 practice for many years in the Bronx.
▶ 1:21:56If I had come across a child who had a particular difficulty with a behavioral or developmental issue and I needed to get them care, I'd call and across the burrow, 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 behavioral or developmental pediatrician in the entire state of New Mexico. That family has to travel to Arizona to get care.
▶ 1:22:21If you are a child on dialysis and you need a pediatric nefologist and you are in the state of Montana, there's not a single pediatric nefologist in the entire state. And that brings me to my next question which is about reproductive and maternity care. Uh so Dr.
▶ 1:22:39Aine, I'd like you to focus specifically on the physician shortage there which is that since the Supreme Court overturned Row 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.
▶ 1:23:04For example, Idaho has lost more than onethird 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, Dr.
▶ 1:23:32Rine, how significant are post jobs abortion bans combined with big 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.
▶ 1:23:59It's a great set of questions, I think, to address to my colleagues at the American College of Obstitricians and Having said that, a large percentage of children in this country at delivery are not attended to by pediatricians. They're attended to by 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 Dr.
▶ 1:24:28Murphy 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.
▶ 1:24:57We're seeing more and more children whose parents are refusing opthalmologic um treatment to prevent gynecology 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.
▶ 1:25:22Gentleman's time is expired. The gentle lady's expired. Time is expired. I'm sorry. I now recognize Dr. Murphy for 5
▶ 1:25:31Thank you. I'll try to get back on to the topic at hand. Um I I think we have to look also objectively and say why do we not have physicians in rural areas? And I think it's not let's go 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, etc., etc. People live where they want to live. I mean, that's just that's basic human nature.
▶ 1:25:58And the same thing goes with physicians because actually physicians are humans too. People live where they want to live. Now, every I think everybody agrees. I don't need to keep saying it over and over again about physicians training in rural areas, staying rural. It's 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 a rural area so that it is a nice place to live.
▶ 1:26:23Therefore, 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.
▶ 1:26:38We have a huge you have to look at the we added 1,200 slots to GME um two years ago, three years ago, four years ago there I personally don't believe it is the issue that there 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.
▶ 1:27:07So 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 decrease efficiency. We have to look and see why these things are happening. Dr.
▶ 1:27:38Moore, let me let me ask you this. Um, actually Dr. Hos, 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?
▶ 1:27:58Thank you. And it it the section 13 126 that you're referring to points to the fact that rural hospitals who want to expand their training should be able to and 10% 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.
▶ 1:28:19The prioritization of the slot distribution by health profession shortage areas actually disincentivized some of the rural hospitals with low or no HIPSA scores from even applying. So that's one way that it could be improved next time. So in the next slots I would recommend disassociating that HIPSA 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.
▶ 1:28:47ECU had has two three FQC tracks in rural areas that were helped. Um and there are, you know, rural programs and partners of urbans that did get the did get the slots.
▶ 1:28:57Yeah. It's a chicken egg kind of thing because, you know, in my area of eastern North Carolina, 29 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 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 deal are dealt with let me ask Dr. more.
▶ 1:29:27Um, 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.
▶ 1:29:44Well, I can't speak for the leadership at at other institutions. Um, but I think but I I think for certain there um you know, every nobody wants to to give up what they have. Um and and yet to to your point earlier, Dr. Murphy, um you know, we want we want to make sure that that we incentivize people to go to rural areas and and there is a chicken and an egg. Medical care is infrastructure for rural areas.
▶ 1:30:11Um and so how do you how do you pull industry uh and manufacturing into an area that doesn't have the health care 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 going to have to uh to see. But I think that that uh just doing what we're doing is is not going to get us to where we want to go.
▶ 1:30:35Um I think there's going to have to be additional incentives uh to to be able to uh prioritize health care infrastructure in those sites. And I think that that's something that we can do from the medical schools in prioritizing folks that do want to 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.
▶ 1:30:56Thank you. Again, 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.
▶ 1:31:09Thank you, Mr. Hearn is recognized for five minutes.
▶ 1:31:11Thank you, Mr. Chairman, for holding this hearing. I think it's very important being from the great state of Oklahoma. I I 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.
▶ 1:31:34I didn't see any 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 have been brought up today. Physician shortages in rural areas, lack of accessible care, poor health outcomes. I grew up my younger life in Arkansas in the Ozar Mountains. We drove 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.
▶ 1:32:03Oklahoma's physician to patient ratio is 39% worse than the national average. Currently one-third 33% 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.
▶ 1:32:32As a matter of fact, I just talked to OSU medical president uh just uh two days ago, actually on a Sunday, and he said that in rural healthc care that the physicians are dealing with about 30% administrative burden where in the urban areas it's 10%. So we have to keep working to mitigate these these burdens that are not patient forward. That being said, we have all seen in our lifetimes just how fast technology changes and improves. But in rural states like mine, access to advanced medical training can be limited by geography. Dr.
▶ 1:33:02Moore, 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?
▶ 1:33:20Thank you for the question, Mr. Hearn. And uh you have in incredible schools in uh in Oklahoma and my colleagues Dean Blankenship and Dean Bray and uh in in Tulsa and Taloqua 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 Taloqua nation um where you can actually train people where you want them to be and I think that that's um that's admirable. But back to your question um are we keeping up with technology? Um, we're trying.
▶ 1:33:49Um, 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 large learning modules and uh and and independent wearable technology into uh the the health care
▶ 1:34:19of uh of folks that are out there. Now, this could be the great equalizer for rural areas because this actually could be a way that we can bring that um 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
▶ 1:34:41I'm I'm going to get one other question if you don't mind. Thank you for that response. Um, the James Mountain Inhof VA Medical Center, named for our dear friend, the late Senator Inhof, uh, is scheduled to open this year in my district. This is nearly 275,000t, 58 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.
▶ 1:35:08Veterans are a unique p patient population and 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. Dr. Dr.
▶ 1:35:26Hos, 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.
▶ 1:35:45How and where you train impacts how and where you practice. And when I think about Oklahoma, I think about the OMA 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 9 months to three months. And then their graduates are serving the Cherokee Nation and they're establishing new services.
▶ 1:36:10So 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 going to just increase the richness of their learning and ultimately increase access to care.
▶ 1:36:30Thank you. I yield back.
▶ 1:36:32Thank you. And now recognize Mr. Horsford from Nevada.
▶ 1:36:35Thank you to the chair and to the ranking member. So, my home state of Nevada and my district, I cover 50,000 square miles. Uh and this issue of healthc care uh workforce shortage is true whether it's in the urban areas of Las Vegas and North Las Vegas uh to perump out to Carson City and Reno. All 17 counties in my home state carry some form of health care shortage designation.
▶ 1:37:03Nevada ranks near the bottom nationally and several key workforce categories. 45th for active physicians, 48th for primary care physicians, and 49th for general surgeons. But during the CO 19 pandemic, we made a deliberate choice to confront this crisis headon, utilizing funding from the coronavirus state fiscal recovery funds.
▶ 1:37:26We launched the Nurse Apprentice Program, an initiative specifically designed to address severe nursing shortages, particularly in rural and underserved communities. From March 2022 through February of 2025, more than 700 nursing students trained across 36 nonprofit hospitals, critical access hospitals, skilled nursing facilities statewide.
▶ 1:37:54Importantly, more than 220 of those students were hired directly into permanent positions upon graduation. That means that 220 health care professionals, Neadans, 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.
▶ 1:38:24This 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.
▶ 1:38:49But you cannot claim to care about the future of the health care 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 goodfaith effort when it was created to secure a single senator's vote.
▶ 1:39:18that is not improving health care access or the workforce shortages that we're talking about today. Dr. Rine, 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.
▶ 1:39:43Thank 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 tele medicine 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.
▶ 1:40:09It 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.
▶ 1:40:26I 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 sure that people are uh can avail themselves of that care. But I also think that the rural health transformation program has some good utility to it.
▶ 1:40:45I 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?
▶ 1:41:13Um, 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.
▶ 1:41:22Yeah. So, let's make healthc 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 hospitals. 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.
▶ 1:41:53Miller for five minutes.
▶ 1:41:55Thank you, Chairman Smith, and thank you all for being here today. It's so I grew up in Columbus, Ohio. When I left it, I think there were 600,000 people, the Ohio State, lots and lots of physicians, wonderful education. I moved to West Virginia. I loved my home state of West Virginia. I've been there over 50 years.
▶ 1:42:19I moved to a town of approximately 85,000 that is now approximately 47,000 people because bad policies can have bad results. And I've seen a huge turnaround 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.
▶ 1:42:46When 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 2% of residency programs in rural communities and more than 90% of the residents today have never even practiced in a rural setting. Dr. Haw, thank you for highlighting the rural residency planning and development program, also known as RRPD, in your testimony.
▶ 1:43:15This 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 costs of developing new residency programs because without rural training pipelines, we can't solve the rural physician shortages. My question is for you, Dr. Haw. it.
▶ 1:43:43Given 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.
▶ 1:44:03Thank you, Representative Miller. And I want to thank you and your team for the wonderful data requests and emails that you've sent over the years. We want to be helpful with information and so I offer that to all of you too as you're evaluating policies.
▶ 1:44:16Um 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.
▶ 1:44:47And um what they're doing is they're using tele medicine and a partnership with Marshall that is enabling them they they upfitted an emergency room that has two tele medicine 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.
▶ 1:45:13So one of the things that just specifically about your district and a policy that would that would help is just tele supporting tele medicine and telea precepting especially for psychiatry programs.
▶ 1:45:23Thank you so much. I'm pleased to see that the osteopathic 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.
▶ 1:45:43For 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. Dr. more from your perspective, what role do doctors of osteopathic medicine play in helping close the nation's physician shortage, particularly in communities that are
▶ 1:46:11Thank you for that question and thank you for 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 and pass the board examinations, but also to assist in their residency placement. Um osteopathic physicians 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.
▶ 1:46:37Um, however, according to national the national residency match program data, 29% of residency program directors currently uh state that they never or seldom interview DO candidates while nearly 3/4 73% of GME programs that do consider DOS mandate that they take the MD lensure exam uh where we take the complex USA lensure exam.
▶ 1:47:02Um 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 reh recognizes the complex USA.
▶ 1:47:18And 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 it suggests that there be reporting of uh both do and our MD colleague applicants.
▶ 1:47:45Gentlemen's time is expired.
▶ 1:47:46Thank you.
▶ 1:47:47I'm sorry. Thank you so much.
▶ 1:47:48Thank you.
▶ 1:47:49Mr. Fitzpatrick is recognized for 5
▶ 1:47:51Thank 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. Approximately 45% of physicians report that burned out feeling um, in 2023. coupled with an aging workforce and reduced medical school entrance. There is a projected shortage of up to 86,000 physicians by the year 2036.
▶ 1:48:19Communities 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 Su, uh to introduce HR 4731, the Resident Physician Shortage Reduction Act.
▶ 1:48:48Uh 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 14,000 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.
▶ 1:49:17This legislation builds on past congressional investments in Medicare supported graduate medical education, especially in strengthening training in nervas. Uh Dr. more. 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 and hospitals you work with?
▶ 1:49:42And 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 startup costs uh and clarity about um uh about sustainable uh operational costs once the program gets started.
▶ 1:50:04And I would say that many of the smaller hospitals and rural hospitals that I've discussed starting residency programs with that uncertainty um is really key. Um, 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
▶ 1:50:34as far as where that goes." And uh and we appreciate your support on that bill.
▶ 1:50:38You bet. I want to move uh quickly to uh the need to modernize aspects of GME uh to ensure our future physicians can best serve their patients uh in the evolving healthcare landscape. Digital tools like teleaalth 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 teleaalth capabilities uh for their accreditation.
▶ 1:51:08Um Dr. Hos if I could ask you to speak to this can you uh address the role tellah health 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.
▶ 1:51:26Thank you for that question and piggybacking on what I was sharing with Representative Miller too is that telea medicine and telementoring 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.
▶ 1:51:47Thank you. I yield back Mr. Chairman.
▶ 1:51:50Gentleman yields back and now I recognize Miss Sanchez for five minutes. Thank you. I want to 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 13,500 to 86,000 additional physicians to keep up with the demand in just the next 10 years.
▶ 1:52:11And in California, 95 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 40% of Californians live without access to routine primary care. Uh Dr. Rine, almost three and a half million Californians are losing their medical coverage after Republicans slashed health coverage last July.
▶ 1:52:39And 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 healthcare a political trick. I think it's important to ask how these Republican Medicaid cuts are going to impact patients in medically underserved areas. Can you speak to that?
▶ 1:53:05Uh, sure. I think um the function that Medicaid serves is sometimes underappreciated. It is the underpinning of all pediatrics care in the United States. 50% 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.
▶ 1:53:29If 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 uh the access of the children on 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 sign out of congenital heart disease.
▶ 1:53:55It also happens to be a human capital investment vehicle. 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,
▶ 1:54:09more more productive as adults. Thank you, Dr. You also stated in your testimony that international medical graduates account for nearly 25% of the total physician workforce in the US. On top of that, 64% of international medical graduates serve in medically underserved areas. September of last year, President Trump imposed a new $100,000 supplemental fee for new H1B visas.
▶ 1:54:36Previously, employers typically paid between $2,000 and $5,000 in fees for visas for these highly skilled workers. Um, Dr. Haw, can a rural hospital afford to pay $100,000 fee each for new H1B visas for physicians?
▶ 1:54:55Um, simple yes or no will do. I'm have limited time.
▶ 1:54:59Um, I'm not sure. I haven't studied that yet. Um there are I do want to 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.
▶ 1:55:12Thank you Dr. Shenfield. Could Phil could Phelps Health afford to pay $100,000 each for new H1B visas?
▶ 1:55:20Um we have not had to experience that yet. So can I answer that?
▶ 1:55:25But if it went from 5,000 let's say at the top to $100,000 would that fiscally impact the ability to provide care.
▶ 1:55:33It's it is obviously a difference in fiscal amounts. So, we'd have to
▶ 1:55:36It's a pretty big differential, wouldn't you say? Yes or no?
▶ 1:55:40Yes. Thank you. Um, healthcare 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 workforce with this policy. 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.
▶ 1:56:01Even the Paragon Institute discusses the important role that foreign trained doctors 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. Dr. Dr.
▶ 1:56:17Rine, what sort of impact does President Trump's new $100,000 supplemental fee have on hospitals in underserved 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.
▶ 1:56:42If it's a impact supply impact that has a disproportionate impact on the rural communities, you can expect that's what will happen. Anything that increases the supply will have the opposite effect.
▶ 1:56:53And how is that policy of increasing the visa fees more than 10fold coupled with the Medicaid cuts that Republicans um passed, how is that going to impact underserved communities? I think it's likely to make it more difficult to find physicians to practice in these areas.
▶ 1:57:13Do you think that people will die as a result of not having the care that they need or having to travel very long distances to get the care they need?
▶ 1:57:20It'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 going to help.
▶ 1:57:31Does 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 as opposed to primary care for their care.
▶ 1:57:44Thank you and I yield back.
▶ 1:57:46Now recognize Mr. Moore for 5 minutes.
▶ 1:57:48Thank you, Chairman. Appreciate it. Thank you all for being here. Dr. Haw, as you know, Utah has a robust population centers. Um not much of that. Uh very very sparse communities outside the I-15 Wasach 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.
▶ 1:58:17Can you describe to me some of the different forms rural training can take and how this fill how this helps fill community gaps?
▶ 1:58:25Thank 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 of stetric 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.
▶ 1:58:51And this is something that I think is similar to the community health center of Utah where um and and I want to illustrate with this with another grantee that we support that's similar to to them is that we uh in Kahaba 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.
▶ 1:59:19And 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
▶ 1:59:34Thank 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 a it's excellent. It's excellent work. Dr. 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?
▶ 2:00:05Thank you, Representative. We opened our doors in two 2012 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, Aoney County and our existing counties.
▶ 2:00:24It 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 Deuke, 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.
▶ 2:00:52We in rural areas, we want to be able to access health care, but we also can use our community organizations like the senior centers to help save, I'm sorry, to help have um uh the physicians working with the patients in their care.
▶ 2:01:13Thank you. Um appreciate it. Dr. Moore, sounds great. spelled wrong. In your testimony, you mentioned the importance of embracing technology and medical education. This has already helped deliver better care for patients through teleahalth 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. Um uh reducing administrative burden on physicians.
▶ 2:01:40You 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 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?
▶ 2:02:05Thank you for that question. Um and and I think that this is a rapidly evolving field that we have right now. And you know 20 some years ago uh there was a rapid evolution of electronic health records into that really changed the landscape of 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.
▶ 2:02:30How do we ensure that these new technologies 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 find ways to maybe reduce that uh that burnout 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 patients needs are front and center along the way.
▶ 2:02:59And 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.
▶ 2:03:11Excellent. Thank you all so much. Good Go back chairman.
▶ 2:03:18Thank you, Mr. Moore. How do you spell your name is irrelevant to the committee's hearings. Next, I'll uh represent uh or recognize Representative
▶ 2:03:28Thank you, Mr. Chairman, Medicare spends roughly 22 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.
▶ 2:03:52I'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-1B.
▶ 2:04:10Our priority should be training and retaining American physicians and clinicians and removing barriers that keep qualified non-fysician providers like pharmacists, advanced nurses, and chiropractors from practicing at the top their license to expand access. Because our time is short, I'm going to just ask a series of kind of rapidfire 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.
▶ 2:04:37So, by a 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 no right or wrong answers. I'm just trying to get a feel of where you guys are at. Do you agree that visa policy should not become a substitute for fixing broken domestic training Okay, I got three, four.
▶ 2:05:04Do you agree that if we make it easier to hire noncitizen clinicians, some systems may have less incentive to invest in training and retaining US physicians? Yes or no? Do you agree the first obligation of federal workforce policy should be training and employing US citizens and law for workers? Two out of four. Oh, four. Okay.
▶ 2:05:28Do you agree that if federal policies created a training bottleneck like CAPGME, 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 in shortage specialties in rural markets?
▶ 2:06:00Yes or no? No. Okay. U Mr. Shinnenfield, in the time I have left, when CMS allocates rural slots or rural track 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?
▶ 2:06:19Sure. I quite understand your question. Can you restate that?
▶ 2:06:22If Congress tightened or ended H-1B 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
▶ 2:06:38I think other than policy, I think it's time because right now there are so many um uh foreign trained medical students in residency programs and so I think we're recruiting for what our needs are now. And so I think it's going to 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.
▶ 2:07:03Um I think it it would take time because um last time I looked I think you know over 50% of of people in residency fellowships are are foreign trained medical students. Um so I think it's just going to take time if that's the direction policy makers want to go.
▶ 2:07:19Okay. Miss Haw, 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
▶ 2:07:37Thank you for that. Um, I think there needs to be transparency in looking at where slots are distributed. And one thing I want to highlight that happened um based on congressional request is the GA GAO did a wonderful report on where section 126 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
▶ 2:08:08So 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 good policy.
▶ 2:08:39Um, 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
▶ 2:08:56Gentleman from Illinois is recognized, Mr. Davis.
▶ 2:09:01Thank you, Mr. Chairman, and I want to thank all of the witnesses, and I'm delighted that I got an opportunity to be here. chairman, let me ask if uh I would have unanimous consent to submit for the record a statement from the National
▶ 2:09:23That objection so ordered.
▶ 2:09:25Thank 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 healthc care was director of training at one of the early community health centers. Of course, things have changed because that was a long time ago.
▶ 2:09:55Long, 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 lowcost, high quality interdisiplinary model.
▶ 2:10:11Yet this year, Congress provided only 225 million for the community-based teaching health center program while spending $22 billion on hospitalbased training that many specialists who primarily practice in big cities.
▶ 2:10:34Miss Hayes, what steps should Congress consider to shift health care workforce training dollars away from producing specialists in large hospitals and toward more community-based settings in a rural or
▶ 2:10:57Thank 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 and really this evidence this body of evidence comes from the teaching health center program.
▶ 2:11:22And so I want to 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 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.
▶ 2:11:50Thank 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.
▶ 2:12:15I'm concerned that Medicare funded programs are not sufficiently prioritizing community-based training. Um, how can we assure that Medicare invest more in training primary care and dentists in primary care forward settings like community health centers?
▶ 2:12:47thank 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 FQC as well as a critical access hospital and an FQC and they are partnering with Medicare funding to be able to expand in community health centers.
▶ 2:13:16Um, 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 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.
▶ 2:13:45Matter of fact, rural Arkansas to be exact. And we recognize what has been and continues to be a scarcity of welltrained physicians and other health personnel.
▶ 2:14:05How do we change this this scenario so that individuals in rural America can feel safe with their resources? The gentleman's time is expired.
▶ 2:14:25Gentleman from Florida, Mr. Bean, is recognized for five minutes.
▶ 2:14:28Mr. Chairman, thank you very much. Good afternoon to you. Good afternoon, 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 Congress. I want you to imagine an America where congressional representation was based on the 1990 census and we never made changes. What would our country look like? Uh we would see half our country over represented, half our country under represented.
▶ 2:14:59Uh 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 1990s uh numbers. How about that? And just like the music in 1990s, uh it's a jagged little pill for states like Florida to have to swallow things like that. So, there's got to be a better way.
▶ 2:15:28Florida 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 shortchanged. 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 reshuffled the deck every 10 years along with the census that we shuffled uh GME slots? How about that?
▶ 2:15:58Uh we've got states like Massachusetts and New York, tiny states that uh have 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? The bean plan, reshuffle the deck with the census. Uh the dean, you start uh you say, is that a good idea, a bad idea? And would you vote for something like that? I you know I think that we're first of all thank you for that question. Um
▶ 2:16:28the correct answer is uh Dean yes. You would say yes. I'm going to vote for something like that.
▶ 2:16:32Hey I'm I'm in Texas much like Florida. We are growing our numbers and there has not been any type of redistribution. So yes there there is some uh there is 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.
▶ 2:16:5910 for No, thank you very much. Uh Dr. Haw, 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, Dr. Hos? 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.
▶ 2:17:28And so I I like the idea
▶ 2:17:30every 10 years. That's not too much to
▶ 2:17:33True. True. Um, so yeah, I think I would just want to explore more of the unintended consequences and implications. Um, and haven't really explored that yet.
▶ 2:17:41I got you. You must not be in a state that's struggling for uh for GMEs like we are.
▶ 2:17:46We are we have 25 counties without general surgeons.
▶ 2:17:48So that's that's it. Uh Dr. Shfield or Mr. Shifffield, what's the downside of the bean plan of reshuffleling the deck every 10 years? Can you think of anything uh why you wouldn't go along with it?
▶ 2:18:00Um I I think again just the unintended consequences. I think it you know
▶ 2:18:04reshuffleling 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 30 years goes by and it never changes. Um, because that's where I think we find a lot of problem.
▶ 2:18:22That's where we are right now. So, uh, we've got to make changes. Uh, panelist, I gave y'all a chance out there to jump in to say we got to do better. We just have limited authority. 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. He'll continue with that. Let's go to Dr. Trilk. Dr. Trilk, it seems like, speaking of the ' 90s, Jerry Seinfeld in the 90s says that uh there's state laws that when you turn 70 in New York and other states, you're required to retire in Florida.
▶ 2:18:51Uh 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?
▶ 2:19:04Absolutely. So having lifestyle interventions such as physical activity programs, nutrition programs where people live, work and gather through community health workers, faith-based organizations, schools, cooperative extensions, YMCA's, 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.
▶ 2:19:34They 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 in needs with limited care. So um it also family lifestyle medicine is a team-based sport.
▶ 2:20:01Uh when we look at teleaalth models that we've talked about before allowing physicians to work together with new with nurses allowing dieticians, community partners to extend way beyond the clinic and in that rule setting as I mentioned in Iowa. This approach can really strengthen the trust. Thank you very much. Thank you. It's a winner. That's what you're saying. The bottom line, Mr. Chairman, I winner yield back. Thank you so much.
▶ 2:20:23Thank you.
▶ 2:20:24Gentle lady from Alabama, Mr. tools recognized for five minutes.
▶ 2:20:28Uh thank you so much, Mr. Chairman. Um I want to thank our witnesses for being here today. Preparing the next uh generation of health care workforce as 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.
▶ 2:20:55I'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 let alone a specialty or someone uh you know with a uh with expertise in mental health and the and the like.
▶ 2:21:20Uh many of my constitu 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.
▶ 2:21:39Uh, 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 going to put it in my my district in the rural part of my district in Demopoulos. And its sole focus will be on creating health care professionals starting at 9th grade going forward, which is a huge plus for our state. Now, it won't it won't actually begin until 2027.
▶ 2:22:09Uh, 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 the number of of uh residents all throughout. Um we want 14,000, but we'll take whatever we can get. And over the years, we've been able to get a thousand here, 200 there. Um all of which make a difference. Um, I want to specifically talk about the need in rural parts of my district.
▶ 2:22:40Uh, last week I had an opportunity to visit uh my uh hospital in my hometown of Selma, Alabama, the Vaughn Regional uh medical center. Uh, there they operate for the last 30 years um the University of Alabama Birmingham Federal um uh sorry, family medicine residency program that has graduated hundreds of residents and currently we have 15 residents. I'm concerned because UAB is thinking about shrinking the number of residents uh that will be at that hospital.
▶ 2:23:09Uh Vaughn Regional Medical Center uh has 175 beds. It services not only Selma and Dallas County, but 40 I mean sorry four other counties that surround it uh for a total of about 90,000 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.
▶ 2:23:30Uh in fact if we did not have residents we would have no doctors actually doing rounds uh at nighttime in my in my in in this particular hospital. And in fact during co 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.
▶ 2:23:54And 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.
▶ 2:24:20Now I know I have to battle with UAB about restructuring this program and I plan on doing that but Dr. How 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.
▶ 2:24:43And 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
▶ 2:24:54in Bib County, which is not in my district, but I mean it's adjacent.
▶ 2:24:58Yeah. And so it's it's transformative, right? It improves access to care. It brings workforce. It increases services. And then one of the things that I think we've seen with GABA is that training leads to more training. And so it's absolutely transformative
▶ 2:25:12and many of them choose to stay in those communities and raise families 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 Mr. Mr.
▶ 2:25:33Chairman, 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 Dr. How I have an opportunity to talk to you about the rule um uh track the the rule track program uh for residency because I I'm going to make that as a an alternative 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.
▶ 2:26:01Thank you. Uh Mr. for the gentleman from Virginia, Mr. Byer, is recognized for five minutes.
▶ 2:26:06Mr. Chairman, thank you very much and thank all of you for being with us today. Uh, last year, my Republican friends passed a law to cut 900 billion dollars from Medicaid. And the nonpartisan Congressional Budget Office figure that's 7.8 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.
▶ 2:26:29And most of them are not going to be able to find other So my concern is what they create massive amounts of uncompensated care for the rural clinics, the rural hospitals that are already stressed. Dr. Rsine, with these massively increasing cost rural hospitals, did it make sense to send the US Mercy Hospital ship to Greenland where they already have free health care and free medicines?
▶ 2:26:54I'm going to pass on that.
▶ 2:26:56Okay. How about a politer question? Is it going to make it harder for the rural hospital to focus on training the next generation of physicians?
▶ 2:27:03Right? 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 reortioned.
▶ 2:27:19That that's perfectly appropriate answer. Dr. Rine, Dr. Murphy was asking you a lot of questions about vaccines. Would you like time to respond?
▶ 2:27:30Um, well, Dr. 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.
▶ 2:27:52And 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 acrue when children are protected against vaccinereventable
▶ 2:28:19Thank you very much, Dr. Haw. I came late, but I appreciated reading your comprehensive written testimony. And you mentioned that HR's rural residency planning and development program was a successful model. And last year sent $186 million to Virginia and 12 million just to develop the rural healthcare workforce. Again, though, it's in real trouble. The first half of last year, the new administration fired or forced out more than 700 employees from HERSA.
▶ 2:28:46and last the year before they planned on eliminating the agency entirely. What would a disruption in staffing and funding to the RRPD due to rural residency programs? The rural residency planning and development program has created 66 new residencies. 40 more are in development and this is a collaborative partnership with HERSA who are administering it.
▶ 2:29:11And 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 startup funding to help them kind of initiate the program and so it you know it is critical I think to growing rural training opportunities.
▶ 2:29:34Departing a little bit, my friend Congressman Sty talked about um how difficult it was to get Americans into the rural programs, but one of 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.
▶ 2:29:52Um, I served in Switzerland for four years where in most of Europe physicians have a four or fiveyear 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 22 or 23 rather than 28 or 30? Dr. Sure.
▶ 2:30:22There'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 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.
▶ 2:30:49And 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.
▶ 2:31:19So I appreciate both sides of that.
▶ 2:31:21I was just thinking we have a doctor chair in the committee that 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 and what with that Mr. Chair I yield back.
▶ 2:31:34Thank you. I I'll just submit I think we need to actually look at that a little bit more of shortening undergrad when kids are graduating with so much debt and moving things forward. I think there needs to be a much better a much greater look at trying to mold undergraduate education. But to your point, Dr. Rine, I think a well-rounded physician is a better physician. To that point, I I want to thank our witnesses for coming today. I will say, Dr. Rine, 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.
▶ 2:32:04Uh 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.