March 12,2009

Grassley Hearing Statement on Health Care Workforce

Opening Statement of Sen. Chuck Grassley
Hearing: Workforce Issues in Health Care Reform:
Assessing the Present and Preparing for the Future
March 12, 2009

Any discussion of health reform must include an examination of our health care workforce. As
we embark on this important effort to address the shortcomings and problems in our health care
system, we have to understand these important workforce issues. And one obvious area of focus
is what impact expanding coverage to all Americans will have on the health care workforce in
the future. It is easy to see that increased health coverage is useless without a workforce to
provide care.

The experience in Massachusetts provides a useful example of how important these workforce
issues have to be. In Massachusetts, health reform efforts have increased the number of people
covered, but there are reports that many people are now finding it difficult to find and get
appointments with primary care providers. The challenge of finding primary care providers has
put tremendous pressure on the emergency rooms and will almost certainly increase health care
costs in Massachusetts. Future health care reform efforts ought to proceed with the health care
workforce in mind in order to avoid unintended consequences such as those in Massachusetts.
These workforce issues are driven by a multitude of factors as we will hear today. And they have
multiple effects on the system. These issues and how we respond to them affect not only the
basic access to health care but they also impact the quality of health care and the cost. There are
many projections of the workforce challenges we face. The Association of American Medical
Colleges has estimated an overall physician shortfall of 124,000 by the year 2025. The Health
Resources and Services Administration (HRSA) projects that the nation’s nursing shortage will
grow to more than one million by the year 2020. According to a study last year in the Archives
of Surgery, the number of general surgeons per 100,000 people fell 26% during the past 25

As our population ages, health care workforce shortages are predicted for nursing staff,
technicians, general surgeons, and other allied health professions. Rural areas, such as those in
Iowa, are at greatest risk for health care workforce shortages. According to the Health Resources
and Services Administration (HRSA), approximately 20% of the United States population lives
in rural areas, but only 9% of physicians practice there. And we have a shortage of primary care
providers within our existing workforce. Disturbing reports continue to show the dwindling
percentage of medical students who plan to become primary care physicians. It is as low as two
percent of current medical students, according to a study in the Journal of the American Medical
Association. And our country is becoming increasingly reliant on foreign medical graduates to
fill gaps in primary care residency positions and in underserved areas.

The increased cost of education and a lack of sufficient financial incentives for primary care are
a significant factor in this decline. These workforce challenges don't just affect the availability
of health care. They also have a significant impact on how the health care delivery system
performs. The Dartmouth Atlas Project and others have shown that regions with greater primary
care presence have lower costs, higher quality, and reduced socioeconomic and geographic

So we need to change incentives to promote emphasis on primary care. Patients would then have
better access to a provider who can coordinate their care. We are very interested in delivery
system reform as part of the larger health care reform effort. The fragmented incentives in place
for the education of medical professionals only reinforce the fragmented silos of care that we are
trying so hard to change. We shouldn’t expect changes in the delivery system if we don’t pay
more attention to the education of medical professionals. The socket has to match the plug. So in
addition to reimbursement, we need to look at how Federal programs promote workforce
development. Over the years, the Federal government has developed several programs that seek
to influence the education, training, and retention of the health care workforce. We should
consider reforming Medicare and Medicaid Graduate Medical Education to more effectively
foster broader workforce goals. With that, I’ll yield and look forward to the testimony of our