Transcripts For CSPAN3 Health 20240706

Associations, and health care experts. The committee chaired by vermont independent senator bernie sanders. Not only is this unfair to working class and lower income americans, who cannot access a medical home when they need it, and we are losing over 60,000 people a year because they do not get to on time. But in addition to that, from a financial and costeffective perspective, what we have now is basically insane. We have a situation where people get sick, they do not go to the doctor, you know what happens when you dont go to the doctor and you are sick . You get sick or. Maybe you end up in an emergency room where the cost of primary care is ten times, or eight times more than it is if you walked into a Community Health center. If you cant afford prescription drugs, you get sticker, and you may end up in the hospital, and that will cost 100,000. So what we are talking about today is to, things my own personal view, and health care is a human right, and that we should emulate what goes on around the rest of the world with guaranteed health care for all people. I dont have the votes to do that. But i do hope that by the, way i think we are making progress, in a bipartisan way, at least whether you are rural indiana, or parole for moth or louisiana, or New Hampshire, that you do have the right to get into a doctors, office and save the Health Care System substantial sums of money. You know it is a funny thing we had a hearing a few weeks ago on the crisis in the Health Care Workforce. It turns out, there was strong bipartisan support. Nobody denied the fact that we need more doctors and nurses and dentist and Mental Health practitioners, and pharmacists. We all understood that. Ironically enough, you talk about nonfighters in ship, the witness i thought it was brilliant, talking about what was going on in louisiana, doing extraordinary work. Im sorry. Im sorry. Casey was good as well. But you are better. All the irish guys look alike. There you go. [laughter] but we witnessed the senator from louisiana was, i thought just, great it could have been hours. We brought dr. James herbert from new england university, it turns out i first met doctor herbert threw susan collins. Two years ago was her witness. Why is this, because i think we all understand the crisis, we have to work together. So our challenge right now is to do the right thing for the American People, and say that when you get sick, there will be a medical home for you to go to. And our other job right now, is to say in a Health Care System, which spends 13,000 per person, that is an insane amount of money. That is double what any other major country does, and we understand when we invest in primary health care, we are going to save the system money. So that is the struggle we have. I am determined to do everything i can in a bipartisan way, to make sure that we put together the kind of primary Health Care System of the American People want us to do. So with that, let me introduce senator what is the last name . Casey . Collins . Colins. [laughter] today we are discussing an important piece of infrastructure, Community Health centers. Im a doctor, i work in a Charity Hospital system for over 25 years, i know how Community Health centers provide primary care to low income, and uninsured patients. They also provide behavioral health, dental services, and other care essential to those folks. Our fellow americans. And, this is a topic we can agree upon. I hate to be a fly in the ointment of what should be a good hearing, but i am a little bit upset that the majority chose not to work with republicans in developing the hearing. Theres no reason we could not have gone through the basic Bipartisan Senate procedure to hold a bipartisan hearing. Republican support this issue. Now calling partisan hearings is a prerogative of the chair, but for issues like this, there is no reason our staff should not be working together from square one. I raise, this because last week the chair made a wonderful comment. He said that hearing should not be by themselves a hearing, they should be a gateway to bipartisan legislation. But it is difficult to have a bipartisan legislative agenda if the hearings that serve as a prelude are partisan. We can have fruitful hearings, produced meaningful legislation when the minority is engaged and able to contribute. But in this case, that the minority must be included in the planning of the hearing. With that said, we look forward to hearing and listening to our witnesses, and learning more about what we can do to address the needs of patients who end up in Health Care Community centers. In louisiana theres over 350 Health Center side serving over 400,000 patients per year. Over one third are in rural areas. Rural communities tend to be older, at a greater Disease Burden with fewer physicians, and other Health Care Personnel available. These factors make Community Health centers work all the more important. Now this committee must reauthorize the Community Health center front before september 30th. As Ranking Member, getting this and other reauthorizations done on time, and in a fiscally responsible way is my priority. To do this effectively we need an understanding of the full picture. The landscape of Community Health centers has changed significantly since the Affordable Care act was passed and the mandatory Community Health center fund was created. This is far from the Government Accountability office will give us color on the sum their most recent work from 2019. Here is my chart. The report shows, Health Centers revenue more than double from 2010 through 2017. Further, here is where we are, now this is where we were. Further g. A. O. Review raises the question, in fact points out, that Community Health centers have become less dependent upon grants, as revenue from has increased. And so, here is medicaid back, then heres medicaid. Now much greater growth. Grants have grown as well, you can see medicare has gone up, private has gone up, other, and it is unclear to me if other includes 3 40 b, because of kind of shaking her head no. And 340 b is an incredible source of revenue that i dont even think we know how much there is there. So, this is not to say that increased funding for Health Centers is not needed, that is what we discussed today. But to underscore the fiscal climate we are in, americans expect and deserve a full and thorough review of how their tax dollars are spent. Now mr. Farber is aware, this week i requested the g. A. O. Update its work on sources of funding for Community Health centers, and i ask unanimous consent to insert that request into the record. Thank, you sir. As policy makers, this information is critical to making informed decisions, especially when speaking about mandatory spending. So miss far, i think in advance for taking this project on. Last week, the center needs to be paid forward, and i protections maintained. ,. ,. Could account for savings based on prevention, but it happened in the past, and i do not think any of us think that that it from 2006 is the basis for picking amounts now. Health centers do great work, but as we, know the priorities, mandatory funding for Health Centers still needs to be paid for. And in closing, our thank our witness panel, i have centers use investment from the federal government to provide essential care, and particularly as we sit down and understand the reauthorization of Community Health centers we need your information. With that i yield. Thank you very much senator cassidy. I just want to briefly respond to senator cassidy opening thoughts about this being quote unquote, might part of this being a partisan hearing. I do not see it that way. I think you and i have a great disagreement, i think the minority has a right to invite any witness that you want. And i think the majority has a right to invite any witness you want. I dont want you to have to clear you witnesses with me, when i have to clear my witnesses with you. And i think so far, we have had wonderful witnesses on both sides, and i think that is the way we should proceed in a democratic society. All right, with that, let us hear from our panelists, and i think you all very much for being here. I have read your testimony. It is, i think, very strong. Lets begin with amanda pears kelly who is the ceo of advocates for Community Health, whose members include some leading 30 leading Health Centers around the country. Amanda is also the executive director of the association of clinic shuns for the underserved. She has many years of experience to expand access to high quality primary care for those who need it most. Thank you so much for being with us. Thank you so much chairman sanders. Thank you member cassidy. And distinguished members of the committee. My name is amanda pears kelly im the chief executive officer of advocates or Community Health, a c h as you heard is a Membership Organization of Community Health centers focused on advocacy to grow, integrated primary care, and cutting edge innovation in our field. I have worked with Community Health centers in some capacity my tire year, growing up in maine, there were times where federally qualified Health Center was actually my primary source of care. Im honored to testify today on behalf of the 30 million patients to Health Center serve, and on behalf of our incredible members to shed more light on how Community Health centers save lives, and save money. As other witnesses will testify, there has been consistent that over time that Community Health centers perform exceptionally well, and do so at a lower cost than other providers and other primary care settings. As noted in the testimony of doctor robert khan at the kaiser permanent day school of medicine, Community Health centers were estimated to solve a total of 25. 3 billion for the medicaid and medicare programs in 2021. Community Health Centers have a five decade history of success, but in the past few years, they have overperformed in five key areas that are detail in my written testimony. Today i want to highlight to. First, world health care, Community Health centers are responding to the Rural Health Care access crisis in rural areas. Between 2010 and 2021, 136 rural hospitals closed. Research has shown that in areas previously served by a rural hospital, there is a higher probability of new post closure. Overtime, most rural areas are seeing increased in an access to Community Health centers. Community Health Centers are not only part of the solution to preserving access to care in Rural Communities that might otherwise go inherently without, they are also an economic driver contributing to long term financial stability. Every Community Health centers workforce and governing board is built from the community that it serves. And, these facilities are often among the largest employers in the surrounding area. Second, building and retaining the Health Care Workforce. The foundation of Community Health centers quality care is their integrated interdisciplinary workforce and Community Health centers probably serve as the Training Ground for our countrys primary care workforce. To recruit, train, retain workers, Community Health centers leverage workforce scholarships and Education Loan programs, which help trinidad first workforce including the National Health service, and the teaching Health Center graduate medical education program. A critical factor i would like to call out is that Community Health centers extraordinary growth has dramatically outpaced funding. From fiscal year 2015 to 2021, total Community Health Center Funding increased by 11 , while the number of patients served increased by 24 . From 24. 1, million to more than 30 million today. Similarly, the number of Health Center visits reshare record 124 million in 2021. Unfortunately, Community Health centers are facing an unprecedented set of financial challenges, at immediate and long term funding is more vital than ever before. Medicare on winding will lead to an estimated 2. 5 billion dollars lost in funding for Health Centers. Expression of funding eliminates up to 11 of what underlines, and a vital source of workforce funding. 92 of Community Health centers surveyed said, they would have experienced additional turnover without funding or other benefits from the American Rescue plan. Contract pharmacy limitations, previous discrimination, and state law backs has also led to significant decline through 40 b l revenue for Health Centers. Indeed, the stakes are very high, but im here today to make a bold ask, a chp xin for Community Health care funding 30 billion by 2040 is not rooted in dollars and cents, it is rooted in a vision of what we can see for our patients, communities, and all those in need, and also savings across our Health Care System. We have seen what we can do with law funding, but we want to see if we can push ourselves further, specifically by 2040 when to serve 40 million patients, turn 25,000 additional providers increase the percentage of Community Health centers rushing National Clinical benchmarks by 25 increase the percentage of Community Health centers advocating in value by develop and bring skill at least 15 innovative social determinants of health, we are requesting a fiveyear extension of the Community Health center just on beginning at 6. 2 billion in fy 24 and getting up to ten billion in fy 28. We realized these are large amounts of funding in a difficult fiscal time for our country, but i want to call out a few staving stats for my testimony in general. For every dollar invested in primary care, 13 is saved in downstream costs. We know that Health Center specifically save 24 billion dollars to the system a year. We also know that for every dollar invested in Health Centers, 3 are returned. Investing in Health Centers did not just save lives, it saves money. I hope my testimony today may because that Community Health centers are the best place to invest federal resources, not only do Community Health centers have a proven track record of savings, accountability, and positive Economic Impact, they are the breeding ground for an invaluable innovation to drive further savings and Better Health outcomes, all while responding to localize needs of their community. Congress has the opportunity to set this vital Health Care System on the right path for the future. Whether measured in lives or dollars, there is no Better Health Care Investment than the Health Center program. We look forward to working with the committee and your colleagues on a bipartisan basis, i thank you so much for the opportunity to testify and welcome questions. Thank you very much miss amanda pears kelly. Our next witness will be ben harvey. Mr. Harvey is the ceo of indiana primary health care association, he will be introduced by senator of indiana. Thank you chairman sanders, and ranking cassidy, pleasure to introduce ben harvey, fellow hush, or graduate of Taylor University back in indiana. Our indiana primary health care association, great job at heading it, previously served in a senior role at the Missouri Department of health and senior services. His work has helped increase the number of Community Health centers throughout indiana, and modernize States Telehealth laws which has become increasingly important. Down the road in health care. Resulting in greater access to quality care for many greatly appreciate your willingness to come, and share your hoosier practicality and look forward to hearing what you have to say. Thank you senator for the introduction, it is an honor to be, here it is an honor to be in this room, and by a like yourself. Chairman sanders, Ranking Member cassidy, members of the committee, thank you for the invitation to be here and discuss Community Health centers. I would like to specifically thank you mister chairman, to expand the National Health service, Core Community centers, and your leadership is appreciated by Health Centers in my, state and across the country. Thank you for that. I would also like to thank senator braun, senator, young senators from indiana for the longstanding support of indianas Community Health centers. Before begin, i want to know to have a very personal connection to Health Centers and the work they do, i grew up in a rural medically underserved part of indiana, greg county, and i have seen firsthand the impacts of a lack of medical services on individual lives. So the concept deaths despair, that idea that the all americans are dying earlier, it is a very real thing to me. Ive seen friends and family die of Substance Use, disorders suicide, crime, diseases, these are very real. So i stand as a witness, not only on the impact that Health Centers have on the Health Care System, but also on the impact they have on individual americans, and the people that they serve. So, Health Centers like amanda mentions our nonprofit patient governed organizations that provide high quality comprehensive primary health care to People Living in medically underserved areas. In 2021 houston tours nationally reached a historic milestone of 30 million americans, in a single, year in indiana, we have 350 clinical sites that serve a little over 600,000 hoosier 90 of whom are below the federal poverty level, and 65 of whom are below the poverty level. Health centers in indiana have established themselves of the safety net for indiana communities, a recent example of this is the response to Health Centers of indiana Community Health centers and indiana Health Centers had to a hospital in bedford. Both as i see h c and i h c stepped into that situation, which you are all aware of when a rule hospital closes, it can have detrimental impacts to health, also have detrimental impacts to the economy. Both of those Health Center stepped into that void, to provide continuity of services, to work with the other existing critical access hospitals, and to support the local community. In addition to that, we know c h c positively impact the economies of the community, which are oftentimes distressed in a mission to be medically underserved. In indiana the total Economic Impact is over a billion dollars annually, and that number is certainly much near larger than the national level. Hunters additionally impact their local economies by providing employment and Workforce Development opportunities in areas that are impacted by higher rates of unemployment, for example Health Center on Central Indiana has created their own medical System Training program which allows the training of also allows Health Center gives them the ability to work with local Community Groups like the goodwill of central and Southern Indiana to identify potential candidates from the community for training. It is well established, and will noted that integrated primary Care Services improve health care quality, and cost outcomes. Decades of Research Like those done by dr. Have consistently shown Health Centers create savings despite serving populations that are at risk of overall poor health and crime conditions. Health centers they valleys 24 billion dollars a year. It is a wellestablished. Numbers hospitalizations, also blood, missions lower rates of specialty care, visits and lower numbers of inpatient bad days. Researching has shown that Health Center patients of about 24 lower overall cost than patients receiving primary care settings. Access to primary care like those Health Centers can be improved, and sustained through strategic investments. We know that the poorest of americans with identified source of primary care is decreasing, and in indiana, the cdc and federal agencies estimate there are more than 2 million hoosier professionals and Health Shortage areas, and those who report lacking a place to go for usual medical care. Additional investments will extend the reach into the underserved communities of indiana, and deep in the existing Service Lines greeting greater access to health, mental behavioral health, care and oral health care. Federal funding, senator cassidy just showed an image on this which is generally less than 20 of a Health Centers overall budget, provides critical funding to stabilize operations and provide start of funding for new services or new Service Sites in underserved areas. So again, in conclusion, the Community Health Center Programs is a cornerstone of the u. S. Health care system, and indianas Health Care System. They are costeffective, high quality, idlyefficient form of primary care, which save billions of dollars every year and improve the lives and health of millions of americans, many of whom i know. Health centers need continued sustained funding, and are bound to meet the ongoing and expanded needs of the patients in the communities they serve. Again, thank you for the invitation to testify, and i look for to your questions. Mr. Harvey, thank you very much for your testimony. Our next witness is doctor robert s. Nocon who is an assistant professor at kaiser permanent Bernard Tyson school of medicine, before that a researcher at the university of chicago. Doctor robert s. Nocon thank you so much for being with us. Chairman sanders, Ranking Member cassidy, and distinguished members of the committee, thank you for the opportunity to testify on the topic of Community Health centers today. As was mentioned, i work as an assistant professor at the assistant professor at Kaiser Permanente bernard j. Tyson school of medicine and i am in Health Services researcher who studied the financing and organization of care in the safety net. I say for the record that my views today are my own as a researcher, i did not necessarily represent the views of the the robert s. Nocon Kaiser Permanente bernard j. Tyson school of Medicine School of medicine. Providing access to comprehensive high quality primary care across the United States. There is also a long history of Academic Research on Community Health centers, and the care they provide. I will be focusing my comments on research that assesses the cost and utilization of care for Community Health center patients, while specifically highlighting ongoing series of studies that conduct along with my collaborators that the university of chicago. In these studies, our group uses National Medicaid and medicare administrative claims that a drawing from data from 2012 to 2016. We use the claims data to identify patients who receive most of their primary care in Community Health centers, and compare some patients to mainly get their primary care in other settings. We conduct separate studies for general populations of adults, children, and individuals duly eligible for medicaid and medicare, as well as more focused studies on individuals with opioid use disorder, and diabetes. By using these National Claims that a sets, we are able to study a range of different types of Health Care Utilization and costs. Not only the types of services that Community Health centers provide, but also the services that occur downstream of primary care, such as emergency department, use of hospitalization. Across these studies, we find that Health Center patients have greater use and cost for primary Care Services. But, generally less use and cost of other services. When we add up those costs across all services, we find that helpful interviews is associated with a lower total cost of care, on average, 15 lower for adults, and 22 lower for children. In terms of quality of care, specific results vary by disease area, we mostly find that Health Centers have similar or better levels of performance on quality measures such as prevention of unnecessary hospitalizations, and completion of recommended child visits. Applying our estimates the cost savings to the National Population of Health Center patients in 2021, we estimate that Health Centers resulted in a cost savings of over 25 billion dollars from reduced payments from medicaid and medicare over a oneyear period. Beyond our own Research Group studies, our findings are consistent with multiple studies overtime, that have found Community Health centers to be associated with lower total costs. Dr. Layton coup of George Washington university shared his own estimates in literature that upended to my testimony. Notably, much of doctors whose work is used a completely data set of National Service of patients, and observe similar levels associated with Health Centers. Across different populations, data sets, years, and Research Groups, several studies have described this pattern of Health Center care being associated with lower total costs, and comparable or better quality. Overall, these studies provide a large body of evidence that supports the case for Health Center. Given the committees consideration a few troll federal house under route funding, i will close by highlighting one additional thing from our work, which is the particular importance of this Grant Funding to Health Center operations. Recently published studies from our group have shown that Health Center staffing and Service Volume are particularly sensitive to changes in federal Health Center grant levels. These grants are associated with stronger Overall Financial Health as an organization. Other Witnesses Today have and will continue to speak eloquently about the support of services in advance care model that Health Centers provide. Our Research Suggests this model of care contributes to value through lower medicaid and medicare costs for other types of utilization. And, the Community Health center Grant Funding under consideration by this committee is particularly important, to maintaining this program, and the benefits and provides to our most medically underserved communities. Thank you for the opportunity to testify today, i look forward to your questions. Thank you doctor robert s. Nocon for your testimony. Our next witnesses sue veer, president and ceo of carolina Health Centers in South Carolina, and served since 2006. Miss sue veer has over 35 years of supporting development in Health Centers and primary care associations, she also serves on the board of directors of the National Association of Community Health centers. Miss sue veer thank you so much for being with us. Thank you chairman sanders. Chairman sanders, Ranking Member cassidy, and members of the community, i want to thank you for this opportunity to testify about the important work of Community Health centers. As the senator said, my name is sue vera, im the president of carolina Health Centers which is a qualified Health Center that serves as the primary care medical health for over 25,000 patients in rural South Carolina. My career has spent 25 years, and several different settings of care. One constant have been a commitment to ensure that everyone, regardless of demographic or social economic barriers have access to appropriate and Effective Health care that has been delivered with respect, dignity, and compassion. There is no better fit for that commitment and Community Health centers. Health centers manage their patients across, not just the continuum of care, but oftentimes the entire spectrum of their lives. We provide access to comprehensive comprehensive primary care and a list of social Health Issues by tackling really Health Issues bike homelessness, joblessness, domestic violence. Parenting skills, food insecurity, transportation, the list goes on. And access to these programs and services derives more appropriate and effective use of health Care Services and improved outcomes resulting in savings across the entire Health Care Delivery systems. While cost prevention may not count in the scoring of congressional funding, it matters in real life. It matters in reality Health Centers also have a significant Financial Impact or Economic Impact i know you hear a lot of that. You have a lot of that in writing. A study in carolina how scanners that was completed by capitol link in 2020 indicated 24 million in savings to the overall Health Care System. 456 jobs generated. 53 million in direct and indirect spending in our communities. A primary Health Care Service area covers 370,000 square miles in seven rural counties. We were established in 1977. We now operate 12 medical practice sites, three of which are pediatrics, to community pharmacies, and we provide agricultural Farmworkers Services during the growing season. Behavioral health and Substance Use Disorder Services are particularly important. They are provided through integrated, inhouse behavioral Health Services and collaboration with the local Mental Health and Substance Use agencies. It is a particular challenge, however, due to the lack of thirdparty reimbursement, or any other source of funding. In a medicaid non expansion state, futile to have coverage. Consequently, we estimate that 80 of those needing services have no source of thirdparty reimbursement. This challenge extends to our ability to provide Substance Abuse disorders because Behavior Health is incredibly important component of medication assisted treatment. Our pharmacy includes to entity own pharmacies, which are both open retail and 3 40 b. We also provide prescriptions through several contract pharmacy arrangements necessary due to both geographic barriers andlimited payer networks. Our Critical Care pharmacy is also part of the critical treatment team. Or health is provided through a network of contract on to. We subsidize that care for our low income, uninsured, and underinjured patients. And the time i have remaining out early like to introduce our three initiatives that contribute to our ability to effectively manage the pair of our placement first is the integrated models of care. First i would like to focus on child services, as it is a bit unique to Carolina Health Care Services. We operate Early Childhood services that include for evidence based programs. Three of which are home visitation programs. They also provide a range of care coordination to ensure the needs of all families are met. You have an outline of the criteria for all of those programs. What is important is the impact for families. As well as across the house care delivery system. On more than one occasion, the Home Visiting nurses have identified pre term labor preventing possible death of either mother or baby. Or preventing premature delivery which wouldve resulted in a costly nicu visit. Weve seen countless stories of parents who ended abusive relationships, i finished high school, and gone back to college. Also our pediatricians attest to the fact that these parents are often the most adherent to treatment protocols, wealth checks, and not using the emergency room for sensitive conditions. The Success Stories really speak to the impact on the health and wellbeing of our families. Behind the scenes, it is really about the resources they have saved, not to mention the fact that these families can now make meaningful contributions to their communities. I have very little time left. A day want to mention, as you have in writing, a outline of a Quality Management department, which really works to close gaps in care. Making sure people use care effectively. Secondly, manage the medical lost we show. Which is a measure of how much of the companys capitation ray is spent on direct patient care. We operate right around an 80 range, which is extremely costeffective. We are also a member of the urgent Health Center controlled network in collaborative. 200 Health Centers are in a learning collaborative that optimizes the use of technology to manage care. The last thing, in closing, but i will mention is we have one site that is quite unique. It is located within the halls of a hospital continuous turn emergency room. Over all the years that its been open, i think 12 years, it has shown a dramatic reduction in use of vr. Thank you very much. I look forward to your questions and the continuing discussion. This veer, thank you very much. Our final witness will be jessica farb. The managing director of the Health Care Team at the u. S. Government Accountability Office misses far but is responsible for leading the team in comprehensive work in the full spectrum of the house care center. Mrs. Farb affair thank you so much for being with us. Members of the committee, thanks for the opportunity to be here today to discuss geos work on the Health Counter program for over 50 years how centers have been working with low income individuals to access care in medically underserved areas, which was previously. Notice primary and Preventative Health care is provided over 30 Million People by 1400 Health Canada today organs of their ability to pay. In order to provide this care, health senator right on revenue from a number of private sources. There are four types of Health Centers under the house in the program which is amiss to bring the Health Services administration over three quarters of them are Community Health centers that serve the general population. The remainder of Health Centers that survey specify population, including houstons for the homeless, residents of public housing, and migrant workers. The scope of health care provided a house senator brought, as my colleagues of said today. It must include primary care, such as internal medicine in pediatric care, Preventative Care such as immunizations and prenatal care, Emergency Care which may provide about a range of provided me on the house center, and enabling services that facilitate access to care, such as translation and transportation services. How centers are not provided by behavioral sources. Although many do so to meet the needs of the populations they serve. In addition to the services they provide, health on adele required to document the unmet health needs of president s in their service area. And to periodically review the service area to determine whether the Services Provided are available and accessible to area residents promptly, and as appropriate. Health centers must also have a sliding fees gambling patients ability to pay. They generally must be governed by Community Board of at least 51 of the members or house senate or members. Houston or determine whether grantees meet these other requirements when making war determinations. Over the past two decades in response to Program Changes and funding increases, gao has been fundamentally asked to a best again fundamental areas in the house program. For example in 2008 we looked at the number of Health Care Center sites in underserved areas as well as the type of health Care Services the areas were provided. In 2011 we described strategies to reduce unnecessary emergency use. In 2012, we examined the oversight process and the extent to which the noncompliance of key program requirements. I most recent resort on the houston are described in 2019 describe has done a revenue from 2010 to 2017. During this timeframe houston a revenue more than doubled from 12. 7 billion in 2010 to 26. 3 billion in 2017, as senator cassidy pointed out. This increase occurred at the same time that the number of senate groove, growing from 1120 centers to 1423. The number of patients served also grew by 7. 7 million individuals. Our 2019 report also describe trends in the sources of health care revenue. According to our analysis, about 60 of houston a 2017 revenue came from medicare, medicaid, in private insurance payments for the care that was provided. 30 of Health Center revenue in 2017 came from federal state grants. Comparing those proportions to those in 2010 we found that revenue from public and private insurance and grown over time. Accordingly, the proportion for federal state grants had decreased. These federal grants include those funded by the sikh unity Health Center fund. As we reported for fiscal use 2011 through 2017, intercede to possibly 70 18 billion from this fund. Of this amount, the vast majority, 12. 6 billion, was awarded to maintain operations that existing Health Centers. We were target by officials in the course of a prior work that these grants from chrc f field fill the gap between what costs to operate the center and the revenue received. As such, grants help to cover care that would otherwise be and compensated. The remaining portion of the 50. 8 billion in chp grants from 2011 to 2017 remain to increase the amount of Services Provided existing Health Centers, to increase the number of Health Centers, and to support specialness it is such as Health Information technology. While the most recent reporting predates the pandemic, houston revenue since 2020 has included funding made available to the covid19 some appropriations. How centers have led access to covid19 tests, vaccines, and treatment. Providing essential primary care and providing health care to patients in their communities. As senator cassidy mentioned in the coming months we will be starting in examination of Health Center funston lets review, including assessment of how the supplemental funding provided response to covid19 has been used. In addition, we anticipate analyzing the characteristics of the patient Health Centers served, among other issues. Chairman sanders, Ranking Member cassidy, members of the committee. This completes my prepared statement. I would be happy to answer any questions you may have. Thank you, very much. Now we will begin with questioning. I will star. Senator cassidy will follow. We will go around the table. Panelists, let me read a quote which i think speaks to the bipartisan support that Community Centers have always had. This is what george w. Bush, president bush said in 2004. I quote. I think it is a wise use of taxpayer money to expand and increase the number of Community Health centers all across america. As a matter of fact, the goal ive set every poor county in america has a Community Health center. It is much better if folks who need help get help at the Community Health center then in a merge unseat room, or local hospitals. Not only do taxpayers save money, it is a more compassionate way to help people. And of quote. That is george w. Bush, 2004. Bush talked about expanding Health Centers to every low Income Community in america. Today we have medical deserts for almost 100 million americans. Was bush right in his desire to expand Community Health centers all across this country . Amanda, you want to take a shot at that . Certainly. I appreciate you calling out the long history of bipartisan support for Health Centers. I think that he is right. I think how centers are poised to step up and do everything that they can to care for as many people that are in need. Our proposal focuses on reaching 40 million patients. Certainly, i think Health Centers are up to the task. To be honest, senator, and members of the committee, it really will come down to the investment that is made enabling to do so. If we are talking about caring for about 100 million americans, which i think Health Centers could certainly scale to do with the appropriate investment, we would need to scale our proposal up. It would be considerably more year to year but there has never been a time when i have seen Health Centers not me to task. Where we are today i think it has everything to do with the investment that is made to enable them. Thanks very much. Let me ask miss veer, in your testimony, you talk about keeping people out of the expensive emergency room care by getting them to a Community Health center. We are doing a little bit of that in four months as well. Is it your understanding that all across this country, people who do not have a medical home and up in Emergency Rooms, and much more expensive care than would otherwise be provided through a Community Health center . Say a word about saving money in that regard. Absolutely, senator, i believe the lack of primary care medical health has that impact, and i believe it is a multi generational behavior that we see over generations. That is what people have done. As a result of that, not only are the hospitals saddled with incredible bad debt, i mentioned that one of our Health Center site is located next to an emergency room. And, we originally hoped that we would get direct referrals from that emergency department, what happened was really people got referred to us after the emergency room visit, but once they established care with, us 76 of them ceased using the emergency room within the next at great savings to the system . At gradings to the system, because 43 of them are uninsured. Mr. Harvey, you talked about diseases of despair, something that i studied for quite a while. Tell us a little bit about what happens in Rural America when people have no hope, no access to health care they need . Yes, it is a great question. It is what it describes. You see worse crime diseases, Substance Use disorder skipping, and particularly the county i grew up in. As manufacturing jobs left, and without access to care, Mental Health, care Substance Use Disorder Treatment, those things get worse, they get worse quickly. I think you see that as well with suicide, right, increased rates of depression, increased rates of hopelessness, in Rural America is really in this is maybe too broad of a statement, but it is in dire straits. You see hospital closures, Health Centers can be in fact, they are, they are that limit or. They have stepped into a lot of those areas, and certainly in indiana. Especially from Substance Use disorder, crime disease treatment, to provide that opportunity to hold back the tide, and reverse it. Let me ask anybody on the panel, we are the richest country in the history of the world, we now spend twice as much per capita on health care as any other people. In your opinion, is in fact too much to ask that every american leads to have access to quality primary health care . Senator cassidy mentioned that includes dental, care of Mental Health counseling, lower cost prescription drugs, is that too much to ask in the United States . As i said in my testimony, that has been my lifes commitment, to ensure that we remove those barriers that prevent everyone from having access to that kind of care, that also drives healthy behaviors, that keeps chronic disease controlled. Anybody else want to is this dystopian . I dont think. So i think you are right. I think access to care, right, taking policy piece out of, this it obviously has pelosi implications, the access to care is one of the core that is a core piece of the foundation to a healthy life. I have a son that has down syndrome, without access to care, my life looks different for him. Right . Life looks different for hoosier who dont have 14 sources of primary care, we dont have routine sources of treatment. That really does matter. Okay, thank you all very much. Senator cassidy. Thank you. All eyes will have devoted much of my professional life to make sure that those who do not have care have care, and i thank you for that commonality of interest. What i hear here today, is how to make sure that you have the Adequate Funding . Is it otherwise adequate, or is more needed . Miss farb, when i was speaking about 340b by the way, looking, it is clearly important 340b, because both miss amanda pears kelly both speak about the importance of. It i think as much as 18 million out of your total 44 Million Dollar budget seems to come from in revenue seems to come from 340b. It comes from our pharmacy services. A portion of which is 340b. What portion of that would be 340b . I apologize, i dont have those numbers. It is a substantial portion . It will be at least 60 . Miss farb, when i was mentioning and askings 340b revenue included, here and you are nodding your head no, do you have any comments on that . Yes, senator, so, the 340b program, given the way it works, so the entities are able to get discounted drugs, and they are able to submit claim for those drugs at the price that a player would pay. The funding shows up in medicare, medicaid, and private insurance. That is where those numbers will show up, and i will look to my colleagues to confirm that is what they would report, not reported as part of other revenue. Got it, let me ask you this, it is my understanding that when it comes to medicare and medicaid, that that Community Health centers get a extra rate relative to the guy who is just practicing next door. Right, they have an enhanced p. S. So what is the degree of that enhancement . Off the top of my head, i cant answer that question. But i will look to my colleagues, because they might actually. No yes i think they would. Miss amanda pears kelly . I cant give you the specifics on what it looks, like but i can tell you that it doesnt actually cover the total cost. And suit may be able to speak to that. I accept that. I accept that. Im just trying to figure, as we put together a business plan, if somebody told me that it is the lesser of 80 of what you charge, and you can kind of pick the charge are the ppss, the lesser of those, to mr. Harvey look like you are now, i think it is a bit of a complicated picture and pps rates vary by state, so medicare has a set pps rate with a geographic adjustment factor, but it varies by state and medicaid program. Like amanda mentioned, sometimes, in certain places, it will cover the total cost. But because of the Global Nature of what Health Center provide, you are asked to do more i get. That again, we are just talking about a Business Model, and how much is needed relative to that from what you receive another sources. Mr. Robert s. Nocon, i noted that there is actually a bunch of lookalike Community Health centers, lookalikes being they do not get the grant money that we are speaking of today, but nonetheless they have grown, they have doubled since 2017, theres over 100 now. Yes. When you did your study, did you compare the lookalikes, there not getting grants, versus those receiving grants in terms of the array of Services Provided, the stability of the organization, the effectiveness of the organization et cetera . We have not done, that but the looks like our extended to the sample for our studies. And, okay, miss far did you look at any of that, and compare the difference between the two . Because clearly there is a Business Model out there that is working without the grant money without the grant dollars. That is why im interested in understanding. No, we did not look at. That mr. . Harvey specifically, indiana has the second most lookalikes of any state in the country, which is kind of hard to believe in comparison to california and new york are the large states. But qualitatively, the lookalike i have seen because of the unique nature of what Health Centers are required to provide, they do not receive that Grant Funding, they do not receive funding, that is an economic strain, it is an economic pressure that they face because they do not have that sustained funding. Again, we have a dozen lookalikes in the state of indiana, and two organizations would say that well, that is not my question whether or not there is a strain. It is whether or not they have the ability to provide the services effectively . Limited capacity compared to those that receipt grant resources. Got you. By the way, let me compliment sue veer, it seems like you are all using the 340b program the way the 340b program is supposed to be used. There are a lot of abuses of that program. But it does seem that if you are using it correctly, so tell me, if you want to elaborate on that, are you open to reforms to the program to make sure that patients that your facility got them, and they are not going to build a chandelier at a hospital et cetera . Please be brief. I will be as brief again. It is a complex problem, but i do think there are abuses, but unfortunately the abuses get highlighted much more than the many, many thousands of organizations that do this right, and that is patient centered. Certainly, we operate both at a retail and 340b pharmacy. 340b is use only for patients of the Health Center, and only four prescriptions that emanate from our Health Center site. That revenue is managed very carefully to ensure that it is all located to our operating margin, and i use operating margin specifically, because it is not a profit margin. It is a margin that allows us to operate muchneeded services. And, it is a simple allocation of services that operate at a deficit or made hole by the contribution of our pharmacy margin. In terms of let me stop you, there im already a minute over, and i have to be great to my colleague. Certainly. Thank you very, much senator cassidy. Well, thank you very much mister chair, Ranking Member cassidy for this hearing. Thanks to the witnesses for being here, but for the work that you do. Mr. Harvey, i want to start with a question for you. Community Health Centers play a vital role in addressing the ongoing Opioid Crisis by serving as major providers of medication assisted treatment, which is widely accepted as the Gold Standard of care for individuals with opioid use disorder. However, many centers are facing difficulties in meeting the increase demand for treatment. To help address these challenges, i worked with senator murkowski to pass a law without mainstream Addiction Treatment act, which eliminated an unnecessary hurdle to providing treatment. Mr. Harvey, what else can congress do to make sure that Community Health centers can provide care for those with Substance Use disorders . Yes, thank you for the question. I appreciate that very much. Let me give a hoosier response to this, a couple things right around the opioid use disorder, one is the Mental Health workforce, finding a psychiatrist in particular in rural indiana is honestly nearly impossible, but very difficult. I just want to focus a little bit on medication. Because the purpose of this is to allow primary care physicians to prescribe we know that along with counseling that is exactly. That is exactly. So extending the opportunity outside of the psychiatrist office, extending the capacity of the Mental Health workforce, that is really a critical aspect of this. It is a workforce in general would be a big piece, in the Administrative Burdens as, well overtime, the administrative hurdles have gone down significantly, and that has boosted access to treatment but you are also telling, me and im sorry to cut you, off more Mental Health workforce, more psychiatry, it would be another critical thing we could do grooving forward. Okay, thank you. Let me follow up another question to mr. Harvey, about our Mental Health crisis in New Hampshire patients seeking Psychiatric Care being forced to wait in Emergency Rooms for days, or weeks, hoping that an inpatient psychiatric bed will open up. According to the states latest reporting, 26 granted status including three children are being awarded in emergency departments. This morning can last for weeks, last week a federal Court Ordered the state to devise a plan to address this emergency room board crisis. So how can Community Health centers helped provide regular Mental Health care to patients, and adjust Mental Health concerns before inpatient Psychiatric Care is needed . Yes, that is a great question. I think you see that in indiana, a number of the fqhcs will work with local court systems, or a number of local Community Providers to create a network of support for patients with mental illness. So, you do not end up in that situation where someone ends up in the emergency room with nowhere else to go, right, and you have a hole in a spiral. So certainly supporting them with funding, resources, workforce to provide continuity of care would be a big piece for health thunders to address, an unfortunate situation, that is like you said, occurring in your state, but also occurring nationwide. So from a capacity standpoint, we really have a ways to go to address that. Well, thank you. Missive ear, i want to turn to you for a moment, New Hampshire Community Health centers are grappling with an unprecedented workforce shortage, something i know we have already talked about this morning. To overcome this challenge, we have to prioritize the training and development of more doctors, nurses, and other Community Health care professionals. What role do Community Health centers play in training the Health Care Workforce . And how can we support those efforts . Thank you very much, it truly is a challenge. I think certainly, we serve as rotation sites, many of us serve as rotation sites for both medical professionals, as well as we train nursing staff, and one of the things we have recently done is begun to provide stipends, living stipends in second year of residency. With a commitment for a fouryear service agreement. So in addition to loan repayment, that helps us. Now, that is an otherwise unfunded program, but it has enabled us to recruit, and really get people into the Health Center model early. We are getting the same thing with our technical colleges. And i know that in rural areas, the country sometimes if we can get trainees into the rural areas, they learn that they like not only the Community Health center model, but living in some really beautiful wonderful rural areas in our country, but we have to get them there so they can experience it. Yes, until you experience, it may not be where you think you want to go. I will yield the rest of my time mister chair, thank you very, much thanks again to all the witnesses. Thank you senator hassan, senator collins . Thank you mister chairman. As miss peters kelly mentioned, having grown up in maine, our Community Health centers in maine play an absolutely indispensable role it cheer the 20 health Community Centers provide Critical Health Care Services to nearly 210,000 patients, that is about 16 of the population of the state of maine. And, more than 60 of the patients are low income, and about 20 are over the age of 70. But, what im hearing now, from our main Health Centers, is that they fear that a perfect storm is brewing. They are experiencing unprecedented turnover, and staff shortages, they feel they are facing threats to the critical 340b drug pricing program, and they are having difficulty in recovering from the pandemic. Because, patients are being slow to return, so, my question for mr. Harvey and mrs. Sue veer, is given the current workforce crisis, and the issues that i have mentioned, are our Community Health Care Services centers able to meet the workforce needs, if we were to dramatically expand funding for them, and skill that up rapidly . Are we going to end up with clinics that have more money, but simply do not have the staff to serve . Mr. Harvey, we will start with you, and then miss speier. It is a fair question. I appreciate that question. Health centers, like you said, they are facing an array of difficulties coming up. Medicaid, on wanting, certainly in the state. The expansion of medicaid liken in indiana. Youre gonna lose hundreds of thousands of patients from medicaid, that coverage, trying to transfer them. To Health Centers have the capacity . I have spoken to all 39 of our Health Centers. Individually, each one of them has expressed the desire to go further, to do more. To look for resources to do more. That continued federal funding. It has a long history here if federal funding is increased, you willing increased work in these help the nerves that they do, but patients a, cnn service of the payoff. Or no, i dont think the funding will be lost. I think as i said in my testimony, it is a very wise investment on behalf of the federal government. Continue to support and expand the support of the aisle senate receive. Miss veer. Yes, thank you very much, we are actively basing those challenges. Two things come to mind. I hear of many Health Centers that are, in fact, in the process of reducing services because of a loss of contribution from the 340b program. With the impact of the challenges that we have had there. Yes, you asked about being open to reform, senator cassidy, i think we are. There we really need to look at that. However, i agree that if we have the Adequate Funding to continue expanding the services that we provide, we have always stepped up to the plate. Stood in the gas. We have always done it. I have a real commitment from the schools in the educational system in it is a pipeline. If people enter the pipeline now, it may be months, if not years, before we have them in place. As we develop we will get there. I would like to associate myself with the remarks of senator hassan about training opportunities and Community Health centers. I think that is absolutely essential, as we heard from the president of the university of new england. The more we do those connections and the more likely the Health Care Professional is to stay in a rural area and practice there i think that is something we need to consider expanding. Encouraging and incentivizing. A quick, final question for you my largest Community Health center, has seen a real dropoff in patients coming back after the pandemic. Is that you need to my state. Have you experienced that . No, i dont think so. I think peoples patterns of engaging with the Health Care System exchanged off of covid. Health centers in indiana have seen some recovery from that. And thats the real intentional, intensive works. You have to develop new Service Lines. Things like telemedicine, to reach patients from home to provide care more convenient ways. I do not think that is unique. I think it is an additional burden on Health Centers now to try to continue to reach those patients who may have just change behaviors because of the impacts of the pandemic. Thank you. Thank you, mister chairman. Senator smith . I thank you, mister chair. Thank you to all of our panelists. I really appreciate this conversation. I just want to pick up on what senator collins and what senator hassan or talking about. Creating opportunities for people to get training in rural opportunities are so important. Im reminded of the minnesota duluth precept a program which puts folks in medical school in communities with rural doctors so they can understand what that means and how to do that kind of practice. It is different you dont have a huge hospital around you or a big network around you. I think that is something we could find good partisan agreement on. I am so blessed in minnesota. We have a Strong Network of Community Health centers. Ive had an opportunity to visit many of them. I have been so impressed by the work that they do. Both in rural, suburban areas. Especially in Rural Communities, there is such a challenge to getting access to health care. Here is one example, cook, minnesota, which is in the northern part of minnesota, up by lake 4 million. Nearly 100 mayan big city, which is duluth. The scenic river is the only primary Health Care Provider around four miles, hours i want to just ask, i think im gonna ask the question of mr. Harvey in maybe miss veer first. If we were going to think of one or two things we have to do in order to support those rural Community Health centers we talked about training. I fully appreciate that. What would be the wanted to think we would want to have for most of our minds as we evaluate this rule centers . No pulling at my heart, Rural Health Care. A couple different things. Rule huskers different. You talked about the work for. Grow your own. Its a big piece of it. Sustained predictable funding for Health Centers is really a critical piece of. That work for sunday. We talked about 340b. Doing those things will go a long way to supporting rural Health Centers and in particular leaning into Health Centers. Programs that help those ruaha centers growing your own. Where you live predicts where youre gonna work oftentimes. Where you train predicts where gonna work. Doing all of the things will go along lance pointing Rural Health Care. This question of sustained funding is something on a followup on. Mister chair, i remember so well visiting Health Care Centers some of these Health Care Centers in years past. They were faced with this fiscal cliff. Theyre trying to figure out how to plan. How do economically provide health care to their communities. Yet, the funding streams are uncertain. They are on the one hand trying to figure out how to lay off people, because theyre not sure that funding is gonna be in place. At the same time as they are trying to figure to meet growing demand on the other hand. He reminds me of what of important responsibility we have to the work that we reauthorize this legislation to not put clinics in the position of wasting time, energy, in resources trying to plan for a fiscal cliff that they hopefully wont have to face. So, i appreciate it. Im bringing it up. Let me, also, ask a question related to, sort of, i dont know, Wraparound Services i dont know if most people around washington even knows what that means but what im trying to get at is how in minnesota you often have Additional Services, Additional Needs that people have when they come to Community Health centers. If you cant meet those needs than the health care you are trying to provide to them is not going to work. A great example of that is and fqhc center in minnesota which have been around for 50 years. Many of the folks that they are serving our folks who dont speak english. Immigrant workers, migrant workers. They make our farm economy work. It is essential that they have access to health care. That means that we need interpretive services. Interpretive services are paid for. They have to figure out how to raise the money for that. Would anybody like to comment on the value, the importance, of having those kinds of Additional Services in order to make the whole thing work . I would say that they are absolutely essential. And our Spanish Speaking population in three over centers has increased, probably, tenfold over the last five years. Without Translation Services we cannot deliver appropriate care. We really cant use the Family Member that is standing there that doesnt have a medical training. There is a Real Investment that needs to be made in that. Keeping in mind, i love the fact that you use sustainable and predictable. Flap funding in these days is not flat funding, because of inflationary pressures that have really increased our costs. I appreciate that, i suspected almost everybody on this committee would agree that, while we certainly have a moral obligation to make sure people can get the health care that they need, if we are not able to provide health care to those folks, that doesnt mean that they arent going to get sick. It just means that they are not going to get the health care that they need at the time that they need it. That is why this is so important. Mister chair, i have another question which i will submit for the record around the importance of integrated care. Mental health care, dental health care, which we do a good job of providing in committee Health Centers but we need to do a better job. Thank you thank you. Senator paul . Thank you mister chairman, i will start off with a simple statement. No one should go broke in this country because they get sick or have a bad accident. Everyone in a country like ours should have access to health care on the entire spectrum. Here is where it gets complicated, how do you do it . When i mention going broke what is really broke as a Health Care System in general. I think you are a manifestation of when its not working where it should be, i dont even like to call in the private sector. It is not a market delivery. Something is going to happen. You are the manifestation of it. Eventually i will get to a question and see how you are doing such a good job of being the cost leader in it. We are in a place here where we borrow about 30 about what we spend. It would be a tricky long term Business Partner hooking up with the federal government as we now operate. The other side is even worse. You have a system that has evolved over time wrestling with it like i did as a Small Business owner you cant imagine how frustrating it is to hear how lucky it was to only have my Health Insurance going up five to 10 each year. It didnt feel very lucky. 15 years ago i took it on at the grassroots level. That would be for another time and conversation. You may want to come work for my company when i tell you this. And no longer run. We made it consumer driven every tool to avoid the broken system but putting every wellness tool out there created a health care consumer. Cut costs by 50 then. Weve not had a premium increase and 15 years. Somehow we ought to be talking about the entrepreneurialism that needs to go along with the entrepreneurialism that you are doing financed by the federal government. Your long term Business Partner, i dont think, is healthy. The system is broken. We need to find out how working together we can deliver a better product to the american public. What entry to me is you are doing primary health care. First of all, insurance was probably never intended for that. That begs the question how to people who cant afford any health care, let alone insurance, how do they get Proper Health care . Here you go, youre there. I think primary Health Care Needs to be where it starts. If it is not what you are doing, maybe youre gonna have individuals dealing on a direct pay basis with providers that can afford it. Something other than what weve got. Until that system is fully transparent, competitive, and it run like a real market, we shouldnt be defending it here because its broken. Lets start with you, mr. Harvey, out of deference to being a hoosier. We will go to miss kelly after. What are you doing, taking the entry point of health care and you are doing it at a better value than the other way that you get primary health care . What is the secret sauce . Thats a great question. I appreciate the question. You know, i think there are three things i was thinking of as you made the point. Health centers provide integrated whole person care, right . It is Community Based. You cant overlook that. The community really runs and owns these organizations on the board. They are patient driven Health Centers. They also provide those enabling services. Right . They provide comprehensive services to support as was brought up earlier. Translation services, transportation services. There are really systems of primary care. Going deeper with individuals to produce those costs savings. Again, i agree with you. What you mentioned, senator braun, i have been a longer proponent of this is the Administrative Burden that Health Centers face. We are not outside of that. We do it in the face of that. You are dealing with very complex billing arrangements. All the prior authorization pieces. All of the credentialing pieces that you have to deal with from a insurance perspective. There is a huge beast of administrative costs are you transparent . Do you post the prices of the things that you do . Yes. Yes. Hala lu yeah the other side of provision doesnt do it. Now even practitioners, doctors and nurses, are getting tired of now having to be employed by huge corporations. Its not like it was before. They dont embrace transparency at all. Before we run out of time, miss kelly . Thank you. It is a great question. I think been hit on several of the things that i would call out. You mentioned a couple things. The consumer component. The beauty of Health Centers is a 51 consumer majority board. The services are actually driven by the People Living in the community. They see what is needed. They are able to address that, immediately. The other thing is it is competitive. All of the house senate have to go through a competitive grant process to make sure that theyre actually in a position to you underestimate needs and community concerns. The savings is there. The model has proven itself. Integration of care, all of it. I think the stats, im happy to repeat them. We have the stats around the savings, for sure. Alert to the people who provide our health care. Hospitals now that i think control the bigger share of it than anyone used to be more evenly balanced with practitioners. Health insurance. We have to get to where people except their own responsibility for their own wellbeing. Given the tools to do it. They need to take a note from what youre doing. They asked for so many benefits from government. The way you pay for health care, whether it is the government, or on the private side, the delivery of it has got to get more competitive, more transparent, more operation like markets. Kudos to what youre doing. Keep doing. It thank you. Senator hickenlooper. Thank you, mister chair. Ranking member. I tried to have a long history supporting Community Health and theres. I dont to date myself but 50 years ago i helped mark missile yesterday Community Health Center Incorporated in middletown connecticut, back when i was a college student. Community Health Center incorporated is one of the nations largest and most innovative. I would argue, most innovative primary care centers for the poor, the underserved, just as youve all been saying. Making sure we help provide theyve been making sure we help provide safety net providers in all 50 states with workforce training. Research education. They branched out even beyond connecticut. I do you have that experience where and i first saw telemedicine they were starting it back in 1998, 1999. Certain applications. They clearly blossomed during covid in a way that we didnt really understand. Doctor nocon, you probably have some more data on how possible deleterious effects, negative effects, of too much telemedicine. I havent seen any. The cost savings ive seen have been dramatic. Thank you for that question. We have not specifically like that question in terms of telemedicine use in the context of q agencies we have seen it. Significant use of telehealth medicine and the underlying cost of that the more efficient model of patient interaction. I will look forward to some measurements. I think that is the next step there. As an industry we begin to look at telemedicine and make sure we are being careful to maintain quality. Look at those savings. I mention the Community Health center in connecticut now has over 200 locations. I thought, miss kelly, i would ask you since you are in a parallel universe, what are some of the ways that you look to mobilize Getting Health Care into every community . We think a couple of things. I hate to bring it back to it but i have to do with investment and funding. That is one of the most key factors that enables the expansion of that growth. I think because all these Health Centers are community governed, they look at where there is increasing need. They do market assessments. They look at where do we need to go to meet people where they are . There are Health Centers that are extremely creative and trying to find ways, additional funding, to call together what they can. At the end of the day that expansion does, and a lot of ways, depend on the federal investment in order to have that stability. They came up earlier today. It is very difficult to stand something up without the continuity. Without the guarantee of continuity. Though, i think that ca ink is a fantastic example of what can happen and what can be when there is investment and Health Centers, appropriately. He has a book that has come out now on the first 50 years he humourously refers to his Health Center career. It recounts, in that first decade, how many forces were aligned against him getting that funding and the continuity of funding. All kinds of competitive Health Services saw this as an imminent threat i remember vividly back in the late 70s some of the transportation funding was getting waylaid by the Community Health Center Movement which was just beginning to pick up speed. To be able to move and expand into the smaller towns get that House Service provided closer to where people live that depends on getting the funding to get started. We have a wonderful Community Health center in colorado bilingual. We want you guys discussing that before. I do think the language barrier, writ large, are still a challenge. There is software now we can get that actually dramatically helps us deal with the division of different languages. Do any of you guys use out of the solution . We used technology across all 12 over centers around translation. It is not always the perfect solution. Oftentimes, particularly in rural areas where we may have connectivity problems another problem were gonna address. A different committee. Yes it is very useful when you cant find the translation staff to be doing in person. Great. Thank you very much. I do have another question. I wont ask it i will submit it. I know you guys are all involved and how we get more workforce training into the process. You discussed it a little bit as i watched from my office. Thank you senator hickenlooper. Senator marshall . Thank you mister chairman. You know im a huge fan of Community Health centers. I have volunteered in the before. Practicing in rural kansas as an obstetrician had certain interaction with our Community Health centers. And trying to visit most of the Community Health centers that we have across the great state. Another program i think that has been successful is the 340b program. Profit centers for rural hospitals, as well as Community Health centers. My first question will be for miss veer. Im asking you how to explain how the pharmacy benefit managers steal money from the 3 40 b program from the Community Health centers as i understand it and this is based upon the Community Health centers and Community Pharmacist telling me that pbms have found a way to make money off the 3 40 b program by requiring contract pharmacies to disclose which 3 40 b drugs a dispense by requiring disclosure pharmacy benefit managers shave off a portion of the savings savings which congress intended to go to the safety meant providers that support vulnerable populations. That is very true i can give you a specific example of the naming specific pbms. Please do. There are two major assault on the program the first is manufacturers refusing to submit to honor 340b pricing without a submitting data. When we submit data, that becomes transparent to the pbms who then, in turn, in order to recoup the rebates they lost, reimbursed for less than what they would for a retail pharmacy. I will use one example. We operate both retail and 340b. It gives us a lens into both. The for the retail pharmacy, the reimbursement rate might be a w p minus 4 . You turn it over to 340b and it is awp minus 32. 5 . When you add dir fees on top of that the dramatic reduction is below cost. Mister chairman i hope that the staff is taking note of this conversation. This is an issue for separate hearing. Ranking member, i certainly think we need to dive deeper into that want. Next, a question for miss farb. Im trying to put my numbers together here. For as the payer mix, we saw the dollars and cents. A patient volume is probably 60 medicaid, 20 25 medicare . Does that sound about right to you . I think that is right, senator, based on our analysis. Based on, currently, what we see in terms of the patients who are covered. Even going up to current numbers, i think, it is probably a little bit less. Closer to 50 medicaid, 11 medicare. Okay. There is a certain number that would have private insurance. Right. About 20 . How many of this are literally self pay. No insurance, no medicare, maduro medicaid. Uninsured is about 20 . Self pay is included in that. Youre gonna break those apart for us, if you can. I do not have those numbers broken up by uninsured persons versus self payers. Anyone have a quick guess he runs a clinic . Of those 20 who ourself harry actually have private insurance . How many have private insurance . Commercial insurance the number of patients you see in your clinics. What percentage of them might have private insurance, as opposed to medicaid or medicare. Generally less than 10 in the state of indiana. It sounds like maybe 5 dont have either medicare, medicaid, or insurance. I want to make that point to you, as. Well miss farb do you deny any access to clinic of a inability to pay mr. Harvey to you . Doctor are you aware of any clinics who refuse payment based on their inability to pay . No that is built into the that is what im trying to indicate to the chairman. Financial is not the problem with access to care. If the ability to pay is not the access to care. Who is with cooper who arent getting care . You mentioned a desert. We have 32 clinics in kansas. I would guess that 95 of the patients that dont get health care but within 30 minutes of them. Why do patients not get the health care that they need when they show up in my emergency room instead . Miss veer, what are we missing here . Its more than just throwing money at it. It is more than just throwing money at it but the investment is really important. I have one Family Medicine practice that is in high demand. It is a three month wait to see a provider there. Another thing that we are seeing largely as a result of the pandemic that we are coming out of is more need for walk in the same day services. Particularly for Community Members who may not already be established for us. As we see covid continue to be part of our lives, they need testing, vaccines, treatment. They are looking to us to provide that. Many of us cant. We dont have the resources to do a same day walkin clinic. I would love to have more answers but i am pastime. Thank you very much, gentlemen. Thank you. Mister chairman thank you very much. Massachusetts is the birthplace of the Community Health Center Movement in the United States. From north adams to provincetown, our Community Health centers proudly Bring Health Care to every corner of the state. Our Community Health centers are leading the way in providing health care to trans people, treating Substance Use disorders, and battling Health Impacts of food insecurity. They are at the forefront and front lines are responding to intensifying storms and stronger heat waves. They care for people before they need to go to overcrowded Emergency Rooms and provide a welcoming environment to communities too often ignored or maltreated by our Health Care System. Justice is not just about affording health care. Health justice means they can get health care when and where they need it. Community Health Centers provide the accessible, holistic, and Compassionate Care that empower the people who they serve. There is no question that we need Community Health centers that serve every single city in town in our country. Community Health Centers proved how vital they were in the early stages of the covid pandemic. They provide a Gold Standard of care when treating people and getting people vaccinated. Covid is not the only crisis that we are facing. Climate change is bringing intensifying floods, fires and pandemics. With it, people are experiencing worsening Health Impacts. Miss spears kelly, what would deeper investment mean for the Health Care System to adequately respond to the ever increasing threat from Climate Change to our country . Thank you, very much. That is a very important question. This is a matter of Public Health. Further investment would enable Health Centers to enable plans in operations to be responsive to Natural Disaster emergencies. You name it Climate Change is very much a high priority in the space. Many Health Centers, weather in areas where there have been severe flooding, wildfires, hurricanes. Health centers are on the front line at the. This continued investment enables them to be responsive to those needs. Frankly, to continue to play the role that they often do. Which is to coordinate the response in these communities that are already underserved which, frankly, cant afford to be battered any further. Thank. You thank you mr. Harvey for your attention to the Substance Use disorder and the opioid pandemic. As my colleague, senator hassan, mentioned. Treatment is a key resource for people with opioid use disorder. That includes methadone medication, which is locked behind outdated restrictions in regulations. Treatment barriers can have deadly consequences. How our Community Health centers helping patients overcome the structural barriers in our country . That is a great question. I appreciate you bringing that back up. A big piece of this is enabling the patients to get the treatment they need by being accessible, right . By supporting their payment methodology, as we just talked about. As well, trying to navigate the system. We spend a lot of time trying to navigate the system. I would say Health Centers are really good about integrating services, right . Recognizing when someone has a Substance Use disorder and trying to get them into available treatment. As well, building their Treatment Options around the existing constraints. There has been a long evolution of policy around Mental Health. Mental health is looked at now, differently than it was when it was being legislated 15 or 20 years ago. That is a really good thing. Health centers have been around in that evolution. Theyre certainly seeing more and more patients come into them with Mental Health needs, seeking to address those. Follow up, talk about what can be done to ensure that there is better coordination between Community Health centers and hospitals . So that there is a minimum of care for these people, too many as we know are black, brown, immigrant, poor. Their understanding of the system is very low. What can be done . At the local level and think the relationships matter a lot, you know . Sometimes it can be onesided. Sometimes they are twoway street. I think the requirements that Health Centers have certainly assist them in the way that they are oriented to trying to develop those relationships oftentimes the treatment of the Hospital Systems to players in the Hospital System it can be a limiting factor for Community Health centers. Like you said payment mechanisms, they really can be limiting factors for patients getting in there. By requiring that integration. By recording that those two guys talk to each other. That goes a long way into creating services. Thank you. Thank you senator markey, senator budd . Thank you Ranking Member. I think even the panels for being here today. Just a few moments ago that agricultural meeting one for blow and a couple offices away. While we were talking agricultural policy, the number one concern that came up with a rural access to health care. Not even related to this committee. Again, i appreciate you being here. I hear all over north carolina. And all 100 counties i would constantly hear about the access concerns for patients in rural north carolina. At the Community Health centers, they really help close the gap in our state. It is a half Million People. I appreciate what you do. It is an important safety net its important to providers have the flexibility in tools they need to treat patients including in rural and underserved areas. Community Health Centers also provide the Critical Resources to mothers and at risk families while making sure taxpayer dollars do not fund abortions. The Community Health center fund is one of several for these centers of course as you know. Before considering its reauthorization we have to understand that Program Funds have been used to make sure we are staying accountable to the taxpayers. Miss veer, again, thank you for being here. The funding for Community Health centers comes a mix of federal, state, and private sources. In your role as ceo of Carolina House and its, can you provide specific examples within the federal funding programs were congress can provide more flexibility to meet the needs of their patients. That is an excellent question. The first thing i think about when you say more flexibility to innovate it goes to workforce. The ability to use Resources Team create those incentives for people to come on board with us. Innovation certainly fa like we were really innovative with Early Childhood Services Program. We are, something, of a unique model within the Community Health centers. I applaud mrsa. They just recently released a notice of funding opportunities for Health Centers to compete for funding to place an integrated Early Childhood Services Program in pediatric medical homes. That is critical. We have saved lives. We send people back to college. Looking beyond the walls of a traditional medical practice, what can we invest in that affects peoples lives as it relates to their health . The first grant to the office of Economic Opportunity back in 1965 had a quote that said, the need is not for passive recipients. But for the active involvement of the community in ways that will change their knowledge, their attitude, and their behavior, as it relates to health care. We need to be able to be flexible in using our resources to go out into the community and affect people where they live. Thank you for that. Further can you go into more detail on how managed care in value based arrangements improve Health Care Outcomes for underserved areas, while also generating savings for the Health Care System . Absolutely. That i did put in my written testimony, some examples of this. Our Health Center is part of 14 Health Care Centers in South Carolina partners and what is called an independent practice association. Ipa for short. Our ipa is financially in clinic integrated to enable us to develop shared protocols and how we manage care and then work with our medicare managed Care Organizations to develop value based arrangements. I can tell you that, to date, those value based arrangements have resulted in millions of dollars over the last ten years for the 14 partnering Health Care Centers we are provided those incentives based on our collective performance. The ipa distribute them based on individual performance. Our Health Center for the last few years have been in the top three performing of those partnering Health Care Centers. And the time we have remaining thank you again for being here, as this committee the Health Care Center fun are you aware the ngo that study duplication in funding to ghg. Looking for duplication or throughout federal programs. The only area that we have looked at in the past and related to overlap is whether or not the Community Based Health Clinics that provide care through the medicaid program, if there is to push and pay through medicaid. Looking at how cms oversees that. We have not looked at the cmc fund in particular. Thank you. And thank you to the other panelists. Are you back. Thank you senator budd, senator casey . What a group of a great panel. I really meant a lot from sitting in listening to you. There are Sorority Community have candidates and virginia. Two are in West Virginia right on the board of virginia and appalachia, virginia. To one of the Rural Health Clinic they serve about 370,000 virginians. The ftc eased in our virginia Health Care Center is about 2800 of ts. The work that they do, i see it every day is truly. Tremendous i want to start with you on the fourth question hours in treat in your testimony you talked about indiana. The fqhcs that arent doing their own grow your own program to train medical assistance. Medical assistance work in a variety of health care settings, providing both clinical administrative tasks. They are critical members of the medical team. When i support the delivery of high quality care. From 2011 to 2021 the number of medical assistance employed in the u. S. Grew from nearly 540,000 to over 75,000. Reflecting the growth of this occupation is part of primary care teams. Like other frontline workers, medical systems reported a lot of burnout and stressed. During covid, about 29 of them intended to leave their jobs within the last two years, by their own reporting. When a provider leaves an organization usually incurs a tone over cost of about 40 of that individual salary. To figure out how to backfill and make it up. Those are one of the intangible costs like Patient Satisfaction the lower levels of productivity. The one way we can bring more medical assistance in is by reducing training costs. Giving people more incentives. Every city reintroduced, with senator braun of indiana, the job site. With many of my fellow colleagues. The bill would make high quality shortterm education and workforce Training Programs eligible for pell grants. We dont allow pell grants to be used for high quality career technical to cajun. We need to do more. I would like to ask mr. Harvey how would Something Like the jobs act, which would allow pell grants to be used for high quality cte, help us bring people into entry Level Health Care professions . What other strategies do yall have to suggest to us to revenue retention . I think that would be a big catalyst, quite honestly. We have a program in indiana that is similar. The number of health care a indiana worth course development. Although it has no limitations in terms of funding. The governors nextlevel job for graham. It provides opportunities for credits towards training in those high priority positions. I demand occupations. Medical assistance are part of it. A number of health Care Services have relied on that it is a critical source of funding to both support the cost of the training. Growing your own is a really great model but it requires resources, right . Also for a maze, people who are in the community to be interested in being medical assistance they often time to have college education. They will need support themselves to be able to bear the cost of whatever that Educational Opportunity is. It is a huge catalyst. You are growing your own in the community and if you have the resources to enable people who otherwise couldnt get that training you get someone that is bought in more to the house. Enter brought in more retained more in houston it oftentimes will double down by creating career ladders for a maze. I think the Ranking Member made this point in the last hearing about a nurse that he knows. You can go up from ma and really scale up in your career. You can do that in a Health Center with some other supports around that. I think that is a really important idea. To support people in those areas. I hope it is an idea whose time has come. The Pell Grant Program is known for its flexibility. We have pell for to college students. Parttime college students. We recently restored something that was part of pell originally pell can be used by incarcerated folks to get the skills so when they finish their time they will be able to get productive jobs we have never allowed pell to be used for a high quality Technical Education a finley that is income qualified for pell and that one child that wants to go to college than great another child that wants to go to college in if they want another child wants to go to ct than they dont really care about that in an economy where there is so many credential programs we want to make sure their high quality to be offered or entry Level Medical positions or infrastructure who is gonna build everything . I hope that we can take our tradition of using pell in a flexible way in finally say high quality Technical Education is every bit as good as gold in college that something i look forward to working with my colleagues with i think you can have benefits thank you mister chairman thank you Ranking Member to the witnesses here for all that youre doing we had a Community Health Center Annual fly in two juneau last week i was with many of them as they were there talking about many of the issues that you have presented here today the concern over 3 40. Certainly the workforce issue all over the place. Began hours are of the value that comes from Community Health centers. The fact that it really is patient driven care. Understanding what the real issues are in the community and then being able to respond the folks at the sunshine clinic there real challenge is a lot of the people in their service area do not have running water. Youre thinking about Health Concerns and considerations and you dont have good water that you can count on, that hands a whole additional layer of complication and complexity to what you are dealing with. Those people know what to do with it. They are advocates and other areas. I am a huge fan for Community Health centers. I wanted to follow up just a little bit with senator kaine and talking about workforce. Where are we going to get these great people from . One of the programs that has been helpful for us in alaska has been the National Health Service Corps. I havent heard any of you mention that this morning. I would be curious to know if you feel we can be doing more with the National Health Service Corps to help bolster our work for us . Thank you so much for your understanding and your long history of support. The National Health Service Corps could not be more important when we talk about investing in the Community Health center program, we have to think about the program like the National Center core, which enables them to staff up. If you are making the investment and Health Centers you have to think about part of the access equation is that workforces. The National Health Service Force has a decadeslong record of success, boats in diversity and in retention in areas where they are doing the training. There is a request for significant funding to at least keep intact what has been invested over the past couple of years through the rescue plan. It has been a huge enabling factor to make sure that Health Care Centers have been able to bring in and retain the staff that they have. I cannot echo emphasize enough the importance to the National Health corps specifically. As well, that is really what enables House Centers to train up. Just getting at what you also mentioned, senator, around, where are these people coming from . There are so many individuals in the community who are poised, who want to pursue a pathway within the Health Center. It doesnt just need to be Clinical Operations technical unity boot. Health care centers have a bit of all of it. The teaching house on a program. Frankly, giving Health Centers added investment to be able to innovate, create these programs, to create homegrown opportunities for developing workforces is not just needed but it is absolutely critical. Well be working on that reauthorization one of the other issues that folks were talking about back home, one of the other facilities that had been open to medicare eligible individuals had just close. We have a real challenge in alaska with access for those who are medicare eligible. Our reimbursement rates are so out of whack in alaska. It is a real challenge for us. Those medicare eligible folks are just not able to find care. We are seeing more shifting over to our Community Health centers. We also have this situation coming up in the beginning of april with medicaid. The disenrollment. The redetermination of the medicaid population that is going to be required when the urgency Public Health emergency is taken down. We are concerned. We are hearing there is going to be concerns individuals who are not really able to navigate how they dont gain access to near insurance plans. It may be looking at plans and potentially higher deductibles the question is, is anyone doing anything to anticipate . This was their navigation assistance who might be made available . What are we doing to deal with this population that we may see coming to your doorstep . That is an incredibly important question. The under ones gonna have a ripple effect. We are trying to invest right now in working with the population to ensure the correct addresses are in the system, et cetera said iran. One of the problems were facing in South Carolina is the enrollment process is paper only. There is no electronic reenroll meant. Just a new years day . Just enough day but looking at it across the nation in terms of if there were away. If there was some central way for these people to be reenrolled or to go through the rian roman process it would be helpful. We expect to lose tens of thousands of beneficiaries. Do you have any handle of what is coming just a followup on the it is a massive issue think South Carolina is not alone in terms of the barriers. It really varies from Health Centers across states. Making sure independently there is enough region evocations possible. There is an enormous Administrative Burden. The issue also is churning. Something that has been an issue with medicaid for years. What happens is, to your point about eligibility, we do have folks who will continue to meet eligibility requirements. Getting them into the system is both costly to the state and the Health Care Center. Thank you mister chairman, i went over my time. Thank you senator murkowski. Senator baldwin . Thank you chairman. I have been really amazed with the Community Health care centers in my home state. They really led the way when it comes to expanding services to meet the needs of their patients. It is especially true when it comes to behavioral Health Substance use Disorder Treatment as well as dental services. There have, however, been some frustration, or challenge, with the lack of funding for service line expansions. Those grants. I support additional funding for a brandnew Community Health care centers. I also want to make sure that we also explore ways to make funding go farther by investing in our existing Health Care Centers. Allowing them to expand their services ray to me local needs. Mr. Harvey, can you talk about the importance, for Health Centers, to have the resources to expand Service Lines . Thats a great question, thank you for pointing that out particularly Services Like dental services, for example. Historically very expensive. Historically white needed in areas that are served by Health Care Centers. That sustained investment is really going to be important for existing Health Care Centers to expand their service online. Areas like oral health, dental Care Services. Substance use disorder, Mental Health. That is really critical enabling them to support the additional operational expenses, additional personnel expense, the general expense that comes into the Health Care Service model going deep incomprehensible with individuals that treat the issues. Thank you. Several of our Witnesses Today a notice that Health Centers are also supported by the medicaid grant i will say that again. Medicaid, which help support those with disabilities. Those who need nursing home care. New moms and babies. They also support Health Centers cuts to medicaid would be devastating to wisconsin. It would put the more than 1 million vulnerable wisconsinites who rely on medicaid for their health care at risk. It would also hurt our Community Health care centers. Miss hares kelly, can you describe what you describe what you expect to happen if there are significant cuts to medicaid . With this fourth Community Health care centers to cut staff, reduce hours, ce less vulnerable patients . Or, possibly, for some clinics to shutter altogether. Unfortunately, yes. Health centers will be very challenged with the reduction in basically reimbursement that comes through medicaid. They are required to treat everyone who walks through their, doors and they will continue to do that. Im proud of my colleagues that we can say that. With full commitment. But the reality is, that loss in revenue, that loss in funding will mean additional strains to workforce, which is already extremely burdened and burnt out. It will mean making difficult decisions around services. To your point, how can you continue to fully operate when you are facing a multi Million Dollar loss in revenue, it will absolutely have an impact on future predictions, or future ability to care for all of the real needs in the community, and so again, the needs are not going to go away just because they happen to fall off medicaid. These are patients who will need someplace to go, and unfortunately, the alternative is they end up in an emergency room. The Health Centers will do everything they can to ensure that doesnt happen, but the loss of revenue is going to have sharp impact on that. I think it does go across services, across sites, across workforce, and across other areas as well. Thank you. I want to stay with you, we talked a lot today about how Health Care Centers describing wish themselves from other providers because of the populations they serve, and the value they add to the entire system. With that in mind, i wanted to get back to the program. I have been a long supporter of 340b and have serious concerns about how the actions of Drug Companies have jeopardized this program which helps low income, and other vulnerable patients access more for double medications. What is unique about the Community Health centers participation in the program . Well, for starters, they invest every dollar back into Patient Access and community, and we can verify that. That is over and over, again and every single data point that we can get with centers. It is also one of the issues we have been talking about, today whether it is workforce expanded services, longer hours, transportation, enabling services unit, but all of these things can be documented and every single dollar that comes from the program is verifiable to be used in that way. Now i can speak to other entities but i can say that the that exist, and there have been many hearings over years and years to verify that. And, so i think it does distinguish Health Centers that the intention of the 3 40 b program as it was designed is being used, and executed by Health Centers extremely accurately and properly. If you do not mind my interrupting, but i have to also add one other distinguishing characteristic, is we are as a 3 40 b covered l entity, we are required to provide all services regardless of availability to pay, which means we are required to provide a formidable medication and a discount. So that is one of the distinguishing factors as well. Thank you. Mister chairman, i yield back. Thank you, senator baldwin. Senator cassidy wanted to ask some initial questions. Yes, thank you. Great panel. Thank you very much. Michael coming in here was to attempt to understand the Business Model, how do we in congress ensure that we have a viable path forward for the good work you do . Dr. That robert s. Nocon i looked at an article you had factors for performance, and it kind of goes with this growth in medicaid funding. In your study, did a varied analysis, and you found a higher percent of patients the medicare covered patients was associated with better margins, and many other better things. Yes. Now, miss sue veer has talked about the struggles in South Carolina, in which she probably has a higher percent of patients who are uninsured. Im guessing. Because, you are not a Medicaid Expansion state. That is my point. So, and it is my understanding that the Grant Funding is given irrespective of whether or not a state has done a Medicaid Expansion or not. So, as we look at that, did you find that is their difference between kind of inherent in your paper, is that if you separate it out between those states that have done Medicaid Expansions, those not, that the federal qualified centers are probably doing a bit better financially, therefore in the other means as well. In those, stated that the expansion versus those that did not. Is that a Fair Assessment . Yes. And, the dollars spent for patient, we did the math, and based on your work, it is about 650 in 2011, and 970 in 2017. With inflation, that is probably about flat funding. But im guessing that in those states which did the Medicaid Expansion, that theyre funding for patient probably grew more significantly, and has boiled down a little bit when you average it across those states that did not do the expansion. Is that again a fair statement . Likely. Yes. Likely. And so, as i look at the Business Model, and we want to make sure that you have an adequate Business Model, and those states that did the expansion, im thinking im hearing, because even in South Carolina without, congratulations, you are all managing to keep it together. And in the states that didnt do it, theyre just going to be better off financially with all that entails in terms of the availability in your paper, better margins means better services. Again, is that a fair characterization . Could you repeat that senator cassidy . Im just trying to understand if in the Business Model, those states in which there is the Medicaid Expansion which also federally qualified Health Centers, if they if you are able to see that those failed to qualify Health Centers have better margins than in those states that those appear to be doing better financially. And so therefore, they had other positive things associated with those margins . Presumably, yes. Okay, thank you. Let me just ask can i ask one more thing . Sure. My overall point, it does seem like a diversified income stream, it is also associated with clinics doing better. You are not dependent upon one thing, rather you have multiple things feeding into the overall financial i think that would be reasonable statement in particular because we also find Community Health Center Funding is associated with more stable and stronger financial performance. Yes. Thank you. Thank you senator cassidy, let me ask a few more questions and we will wrap it up. We spend over 18 of our gdp on health care, that is almost double what any other country spends. And, it is broken as our general Health Care System is, it seems to me that our primary Health Care System is even more broken. With tens of millions of people not able to get to a doctor when they get sick, and i have talked to physicians and vermont, and around the country who tell me that people walk into their offices very, very sick, and sometimes with incurable illnesses that could have been dealt with if they walked in the door on time. They didnt, because they didnt have insurance, or were embarrassed not to have any money to pay. In your judgment, number one, would at a time when we spend so much more than other countries on health, care if we provided at least primary health care, that we primary Health Care Accessible to everybody in the long run, would it save our Health Care System substantial sums of money . Miss vera, you are jumping to answer that . I, am senator. Thank you so much for the question, i would, say yes, maybe. But, because the maybe is you also need to make sure that they not only have access, but the work is being done to connect them to the appropriate services. Because just having the access, it does not connect people to the appropriate services. Quality and Population Health management but another issue, again having to do with the fact that we are the only major country not have a National Health care program, so somebody walks, in a diagnosis, you say we are, sorry you have breast cancer. Oh, but i cant afford other treatment that i need, or im going to go medically bankrupt as a result. All right, who else wants to jump into the issue of either the morality of providing health care to all people at a time when we lose we dont talk about it very much, but studies that i have seen suggest that we lose over 60,000 people a year who dont get to a doctor on time. And if we do not treat you said it, an ounce of prevention is better than a pound of cure. Are we spending on the cure, for sure area health, care 100,000 dollar surgeries, rather than making sure people have the medicine for premier health care they need . So i appreciate you putting in that context, and i would just call out some of the comments that senator cassidy made earlier, that this is the wise investment, and your, point it is about keeping people healthy. So, if you keep them healthy on the front, and if you keep them out of the emergency, room if you keep their chronic diseases, managed if you keep them from getting severely ill, which you can do in Health Centers, yes, it is going to serve, and it is meaningful for the hundred Million People we called out today, but really for everyone. Primary care is the path to success in health care. Period. Yes. I would just, add a long history of research on primary care generally, specifically looking at comparative performance of Health Systems across countries, has reinforced that a strong high functioning primary care system is associated with a broad range of Health System outcomes that we look for. Is it fair to say that specifically in terms of primary care, we invest far less than other major countries . Absolutely. And that is perhaps one of the contributing factors why we end up spending so much per person on health care . Is that a fair . That would be fair. Yeah, okay, listen, let me thank the panel for being here. You were great. We are talking about a major issue of concern for the american, people and it is my determination to do everything we can to come up with legislation, that will improve and expand Community Health centers in this country, and move us towards the goal of making sure that every person no matter where they maybe, have access to premier health care. So, that is the end of our hearing today, i want to thank all of our witnesses for the participation, for any senators that wish to ask additional questions for the record, they will be due in ten business days, on the 17th of 10 pm, finally i ask consent to enter into the record statement from senator casey, and statements from stakeholder groups outlining their priorities to the Community Health centers, the Community Stands adjourned