NCUIH Joins Partnership for Medicaid in Letter to Senate on Addressing Healthcare Shortages

On March 20, 2023, the National Council of Urban Indian Health (NCUIH) signed on to a Partnership for Medicaid letter to Chair Bernard Sanders and Ranking Member Bill Cassidy of the Senate Committee on Health, Education, Labor, and Pensions (HELP). This letter is in response to the Senate HELP request for information (RFI) following its February hearing on understanding the root causes of our current health care shortages and exploring potential legislative solutions.

The Letter Identifies Drivers of Workforce Shortages:

• State provider payment rates are insufficient to achieve the goal of being able to recruit and retain enough providers to serve Medicaid beneficiaries.
• Insufficient supply/Increased demand of providers for populations served by the Medicaid program.

The Letter Recommends:

• Grants administered by relevant federal agencies such as the Department of Labor (DOL) and the Department of Health and Human Services (HHS) to strengthen the healthcare workforce, including the direct care workforce.
• Expand loan repayment programs to include more health workers, especially those who come from disadvantaged backgrounds and/or racial or ethnic minorities.
• Ensure broad eligibility for federal programs intended to increase providers in underserved areas.
• Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 7961), legislation that would protect caregivers from workplace violence.

Full Letter Text

Dear Chairman Sanders and Ranking Member Cassidy:

The following are part of a nonpartisan, nationwide coalition comprised of organizations representing clinicians, health care providers, safety net plans, and counties dedicated to preserving and improving the Medicaid program. The undersigned organizations appreciate the opportunity to provide comments in response to your request for input from stakeholders to best understand views on the drivers of health care workforce shortages and ideas on potential solutions. In our view, workforce shortages, especially those seen in providers and professionals struggling to care for the Medicaid population, stem from insufficient payment rates, insufficient supply of providers, and increased demand for particular services most acutely in urban and rural underserved areas. These challenges impact the ability of health care providers and plans to provide needed services to our nation’s most vulnerable: low-income children, pregnant individuals, parents, individuals with disabilities, seniors, and other adult Medicaid beneficiaries across the country. Below, we provide recommendations for specific policy solutions within your Committee’s jurisdiction that would start to address some of these issues. We hope to continue working with the HELP Committee as you begin to shape these policy solutions into actionable legislation.

Drivers of Workforce Shortages

• State provider payment rates are insufficient to achieve the goal of being able to recruit and retain enough providers to serve Medicaid beneficiaries. While Federal law mandates that state Medicaid payments be “sufficient to enlist enough providers so that care and services are available under the [state] plan,”existing Federal regulations fail to adequately measure and enforce adequate payment rates. As such, Medicaid has notably low reimbursement rates, that are often much lower than Medicare payment rates, and at times lower than the actual cost of providing care to Medicaid patients. This makes it more difficult for the program to enlist a sufficient number of providers who can meet patient demand, and thus negatively impacts access to care for Medicaid beneficiaries, who are disproportionately people of color.
• Insufficient supply of providers for populations served by the Medicaid program. Even before the pandemic, many types of providers and clinicians, including the longterm care community, behavioral health providers, and primary care providers as well as clinicians, increasingly experienced worsening workforce issues, and the COVID-19 pandemic only accelerated this decline. For a variety of reasons, including cost of education, not enough people are pursuing careers in these important fields.

Increased demand for provider types serving the Medicaid program. Due to COVID-19 and other factors, certain types of providers are experiencing ongoing surges in demand, likely to continue for the foreseeable future. For example, our aging population will continue to significantly increase demand for long-term care services, for which Medicaid is the primary payer.More than two-thirds of older adults will need some personal assistance in their daily lives, and nearly half will have a high enough level of need that they will be eligible for private long-term care insurance or Medicaid at some point in their lives. Further, the COVID-19 pandemic has exacerbated an already significant mental health crisis in this country, increasing demand for mental health services and further stretching the existing capacity of mental health providers serving the Medicaid population.

Recommendations

• Grants administered by relevant federal agencies such as the Department of Labor (DOL) and the Department of Health and Human Services (HHS) to strengthen the healthcare workforce, including the direct care workforce.
  • The Committee should consider legislation that would authorize increased funding to relevant federal agencies within its jurisdiction to increase investments that support the recruitment, training, retention, and professional development of a diverse clinical and non-clinical workforce.
  • For example, the legislation can authorize funding to DOL to award grants to health care entities in health professional shortage areas to support the hiring, training, and retention of healthcare workers, including direct care workers.
  • The legislation could also authorize funding to HRSA to carry out grants for health care entities for pilot demonstrations to enhance the skills of healthcare workers including direct care workers mental health professionals and promote retention.
  • Last, the legislation could also increase funding for HRSA Title VII workforce development programs.
• Expand loan repayment programs to include more health workers, especially those who come from disadvantaged backgrounds and/or racial or ethnic minorities.
  • The Committee should consider legislation that would expand loan repayment programs that provide for student loan repayment in exchange for service commitments for a range of different types of health care providers.
    • The Committee could look to S. 462 (The Mental Health Professionals Workforce Shortage Loan Repayment Act of 202313) as a guiding example. This bipartisan legislation would address the current lack of incentives for mental health providers working in the Substance Abuse treatment to serve in areas that struggle to recruit and retain physicians. It would also create new incentives to attract providers to serve in underserved areas. This legislation would repay up to $250,000 in eligible student loan repayment for mental health professionals who work in mental health professional shortage areas.
    • The Committee should consider these policy ideas and extend them to additional provider types experiencing severe shortage issues.
  • The Committee should also consider legislation that would incentivize current and former National Health Service Corps (NHSC) participants (physicians, nurses, and dentists) to enroll in demonstration programs to support entities, including long-term care facilities and hospitals at risk of losing obstetric services, experiencing severe staffing shortages.
    • The variety of settings experiencing severe staffing shortages also warrants consideration for expanding the NHSC to other qualified health specialties, including certain mental health professionals and direct care workers.
• Ensure broad eligibility for federal programs intended to increase providers in underserved areas.
  • The Committee should consider utilizing expansive eligibility language in legislation intended to increase providers in underserved areas.
    • For example, Section 403 of the MISSION Act of 201814 directs the VA to expand its existing medical residency program to underserved non-VA facilities. The Act provides an expansive definition of “covered facility” for the purpose of the program by listing specific provider types and including “[s]uch other health care facility as the Secretary considers appropriate for purposes of this section” as a catch-all.

• Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 7961), legislation that would protect caregivers from workplace violence.
  • The bill, introduced by Reps. Madeleine Dean (D-Pa.) and Larry Bucshon, MD, (R-Ind.), would provide legal penalties, similar to federal protections that exist for flight crews, for individuals who knowingly and intentionally assault or intimidate hospital employees. Increasing threats and acts of violence against health care workers have further burdened a workforce already under immense strain from shortages, burnout, and trauma related to the COVID-19 pandemic. While Congress and the Department of Justice have addressed violence against airline workers, they have not done the same for the health care workforce.

The Coalition appreciates the opportunity to provide these comments and looks forward to working with the HELP Committee to identify bipartisan solutions to remedy our nation’s health care workforce shortages and develop these ideas into legislation. If you have questions or seek any additional information, please contact Elizabeth Cullen at the Jewish Federations of North America at Elizabeth.Cullen@jewishfederations.org.

Sincerely,
American Academy of Family Physicians
American Dental Association American Dental Education Association
American Health Care Association
America’s Essential Hospitals
ANCOR
Associations for Clinicians for the Underserved
National Association of Counties (NACO)
National Council of Urban Indian Health
National Health Care for the Homeless Council
The Jewish Federations of North America

About the Partnership for Medicaid

NCUIH is a member of the Partnership for Medicaid, which is a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety-net health plans, and counties. The goal of the coalition is to preserve and improve the Medicaid program. Members of this coalition include:

• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Obstetricians and Gynecologists
• American Dental Association
• American Dental Education Association
• American Health Care Association
• American Network of Community Options and Resources
• America’s Essential Hospitals
• Association for Community Affiliated Plans
• Association of Clinicians for the Underserved
• Catholic Health Association of the United States
• Children’s Hospital Association
• Easterseals
• The Jewish Federations of North America
• Medicaid Health Plans of America
• National Association of Community Health Centers
• National Association of Counties
• National Association of Pediatric Nurse Practitioners
• National Association of Rural Health Clinics
• National Council for Mental Wellbeing
• National Council of Urban Indian Health
• National Health Care for the Homeless Council
• National Hispanic Medical Association
• National Rural Health Association