What Should Be Done About the Health Workforce Shortage?

WASHINGTON — Members of the Senate Health, Education, Labor, and Pensions (HELP) Committee each had a different issue to raise with witnesses Thursday at a hearing on healthcare workforce shortages.

Sen. Tim Kaine (D-Va.) wanted to know how the U.S. could increase the number of immigrants joining the healthcare workforce. “According to the Migration Policy Institute, as of 2018, the foreign-born comprise almost 18% of the 14.7 million people in the U.S. who work in healthcare — nearly one in five — and the foreign-born make up a disproportionate share of certain high- and low-skilled healthcare workforces: 28% of our physicians and surgeons are foreign-born, and 38% of our home health aides were born outside the United States.”

“What could we do with an immigration reform that’s focused on healthcare … that would make all of your jobs easier?” he asked witnesses.

James Herbert, PhD, president of the University of New England in Biddeford, Maine, said he would like to see some restrictions lifted. “There’s no question that immigrants disproportionately go into healthcare at various levels,” he noted. “They’re very hard workers. They want to work. And I can tell you from personal experience, at least locally, what I see is a lot of folks who want to work, they’re here legally, but they’re not able to work because of arcane regulations that really should be changed.”

Untapped U.S. Talent

James Hildreth Sr., MD, PhD, president and CEO of Meharry Medical College in Nashville, Tennessee, had another idea. “We have lots of talent that we have not tapped into in our country here,” he said. “For example, it used to be that 26% of all the Black students who went to medical school came from HBCUs [historically Black college and universities]; it is now less than 10%. Why is that? Because we’ve under-invested, under-resourced those schools … By properly resourcing the schools we have, we can fill a lot of that gap with native-born talent right here in the United States.”

Kaine responded that he “completely agreed” this was also an issue, and said he had sponsored a bill in the last session of Congress focused on HBCUs. The measure calls for the Health Resources and Services Administration (HRSA) to award grants to educational institutions to establish or expand medical schools, with a priority on minority-serving institutions or those that want to expand or establish schools in medically underserved areas.

Sen. Tammy Baldwin (D-Wisc.) expressed concern about the effect that violence against healthcare workers was having on the workforce. “A recent study found that more than two-thirds of nurses reported experiencing verbal abuse, and 44% reported being subjected to physical violence,” she said, noting that she introduced a bill last year that would require healthcare and social service employers to write and implement workplace violence prevention plans. “Violence against healthcare workers is totally unacceptable.”

Sarah Szanton, RN, PhD, dean of the Johns Hopkins University School of Nursing in Baltimore, agreed. “I’ve talked to nurses who say, ‘I used to be the hero walking into their room, and I used to have respect just based on being a nurse, and now I don’t always get that.'” She added, however, that as more and more care that used to be provided in the hospital begins to be delivered in people’s homes, in their communities, and in more family-centered settings, “some of that will dissipate.”

Alleviating the Nursing Shortage

 Committee chair Bernie Sanders (I-Vt.) raised the nursing shortage issue. “In my state, in our largest hospital, we have seen a huge expenditure of $125 million for traveling nurses at a time when we have more young people who want to become nurses, but can’t accommodate them in our nursing schools,” Sanders said. He asked whether this problem was specific to Vermont or if it was happening nationwide.

“It’s very much a national problem … We’re seeing the exact same thing in Maine,” said Herbert. “Clinical training sites like hospitals need support to be able to accommodate more trainees, which will help with the problem.”

Szanton said increasing support for programs like HRSA’s Nurse Corps — which provides scholarships and loan repayment to nurses, nursing students, and nursing faculty — also would be helpful.

Sen. Mike Braun (R-Ind.) said increasing competition — rather than getting the federal government involved — was the solution. “We had a startup recently in Indiana where a bunch of anesthesiologists and surgeons wanted to start their own practice,” he said. “They were able to take a gallbladder removal that cost $21,000 in Indiana” for those covered by insurance, and $32,000 for those paying out of pocket, “and they’re doing it for $8,000, and they’re going to pay themselves twice as much in terms of fees” compared to when they worked for a hospital.

“Until you fix the industry itself with competition, transparency, removing the barriers to entry, making it entrepreneurial, the whole idea of getting people to work within it is almost going to be a secondary consideration,” he added.

Addressing Burnout

Sen. Roger Marshall, MD (R-Kan.), asked about burnout among doctors and nurses. “A lot of our physicians are leaving the market right now because of burnout,” he said. “Issues like prior authorization, surprise billing — our ER doctors have just been overworked and underpaid, if you will, but mostly they’re burned out. They’re getting burned out with the surprise billing issues, and the COVID epidemic just overwhelmed the system and those folks are leaving like we’ve never seen them before.”

Leonardo Seoane, MD, chief academic officer at Ochsner Health in New Orleans, said that while other types of workers can turn off their TVs and get away from the pandemic, “for those frontline nurses and those frontline physicians, they can never get away from the pandemic. It’s day-in and day-out … It’s been a marathon for them, not a sprint, and that marathon continues. I think we’ve got to work on ways that we can improve the working environment.” He added that his institution has opened a wellness office and is providing wellness programs for nurses and doctors.

Sen. Bill Cassidy, MD (R-La.), the committee’s ranking member, said he had read that “we have an absence of medication-assisted therapy (MAT) clinics,” which may be contributing to a crush of overdose cases in emergency rooms. “If we had effective MAT, in which we were keeping people from coming to the ER, because they were less likely to be an overdose or withdrawal, that could be something that could be relatively quickly implemented to have a relatively rapid response.”

Cassidy also asked witnesses about whether reducing the burden of chronic illness would help healthcare workers, to which Hildreth responded, “Our healthcare system is actually a sick care system. We need to be focused on the social determinants of health — where you live, where you work, how much money you make, your educational attainment. All of those things contribute much more to your health than going to see a doctor. My job is the business of training doctors, dentists, researchers, but the reality is that what we need more of is investment in public health, and I would argue that reintegrating public health and primary care is the best way forward.”