>> i'm not certain -- and ogle conversations >> the doctors believe >> is only physicians. >> serving underserved areas, okay. >> mr. chairman? >> briefly i want to respond to senator coburn. i don't think there's a lot of debate and that is one of the key reasons we are not attracting people and to primary health care. no question about that but not to ignore the fact people are graduating medical school at vermont at $150,000 in debt you have a family, that's a real impediment to go out to do primary health care when you do a specialty and make three or four times that. so i think providing every way we can come educational opportunity in helping people with debt which i don't think it is one or another, i think it is both factors.

both factors. .. that we acknowledge the reimbursement system is to spartan in primary care. we acknowledge that. when we deal with the finance committee we look forward to working on a bipartisan basis to include it, but my meeting with primary care physicians, they tell me there are three things in their life that really is -- they feel a deterrent to coming into primary care. number one, reimbursement. i would acknowledge that. number two, dealing with the hassle factor and they would like to be able to practice primary care rather than a lot and number three they do have stood alone as particularly the younger practitioners so the scope of this committee deals with one. mr. chairman a couple of months ago i was checking in a grocery

line checkout counter and one of the young lady is to undo tony when she want to do to the to be a doctor but she found out that by going to your interests in maryland would cost anywhere from 100 to $120,000 even living at home. the daughter of a single mother. she founded breathtaking, she found a stunning. she cannot comprehend or in that family that family income is under $30,000 that she was going to go and incur a $100,000 of debt so just the thought of it at times precludes people of embracing a pursuits which obviously could be a wonderful and rewarding career. so let's meet the needs to where we can and work on the reimbursement system but i support every approached. >> and i acquire -- >> certainly.

>> we are creating a lot of programs and commissions with this. we're up in the spending by 400%, i think that is close to accurate, i don't it is right on. the question we have to ask is up until now why have the program's been working? why we have a primary care shortage? is a because of lack of student loans? known. i am not denying that we should have a student loan program and not fighting to eliminate. what i am saying is the solution that we have is not the solution to the problem and there is no question -- knightley there are four things. the fourth reason people don't want to go into primary care is lifestyle and what we have found in oklahoma is if you recruiting young college student from a rural community and then you get them stew in loans that are much more likely to go back to a rural community so people who are raised in this city don't

want to go -- so there are all sorts of factors of the number one factor in the outlays 100 to one over the other two is into economic and an ambitious to see what you're going to do on that and the other parts of this bill because if you do that right you don't need to do this and i think senator enzi is right. and that we adjust the payment schedule of medicare which will adjust of medicate in every other interest company in this industry, you will see not 2 percent of medical students coming will see 10 or 15% of that medical students go into primary care and that is our goal. many of those will do without the aid of a student loan. >> let me just say, in fact, i suspect if we had to have a vote on pressurizing what are the major reasons that people aren't going to primary-care i suspect all of us would agree that the

number one reason is that the reimbursement rate so there is no debate about that. there is a jurisdictional question in terms of our ability to deal with the rates in this committee and what we can have a deal with here is the student loan area. this is a chicken and egg test -- case and that you have a, if you are even inclined to move into this area and the costs of their medical education is in the range i think everyone and acknowledged the 150,000 that bernie mentioned it is not unique to vermont and maybe a local lumber then your ability to actually make that choice is the primary care for the very reasons you have identified are so low that your ability to pay off that 150 is daunting is so even if whether it was out to wisdom or lifestyle questions the decision has been made for

you whether you like it or not you are going to have to move into an area that gives it a greater income capacity to meet those finish obligations to have incurred. if you can begin that process by saying we hang it to a medical education for less than the 150 provided you are willing to really spend time in this primary care area which we all acknowledge where the gaps are then i think it's easier for a person to make the choice. the reimbursements still has to be addressed but if you settle yourself with a huge debt to begin with and, of course, if we do or don't deal collectively reimbursement will have a huge impact. i don't think there is any debate about the point you're making and we are working now encourage other involvement with the finance committee on how we get those reimbursement rates up. i think tom harkin has told the story several times over the last two weeks we have been together about that part to position. cardiologists and iowa where it sank while our people lawyers to

prepare in the answer said if you pay primary-care physicians what you pay me you have a lot more in primary care -- a pretty honest answer why we're not giving people for the reimbursement rates are what the profession pays. so my inclination and another will be a lot of amendments in the area we are talking about for the of our consideration to including senator mikulski is but i am supporting what senator murray is doing now because it will solve the problem. senator coburn is right, it's not good to solve the problem but it is still a major piece of this at least a significant piece of what the financial burdens of like that have influence on decisions he met alan brinkley said, i think it is a very good thing that we all seem to be on the same page. nco lot of disagreement in understanding there is a crisis and we have to move toward in a number of the runways. i mentioned for the record the best of my understanding in

terms of debt forgiveness for example of for every four applicants for a national health service program and that is a federal program that reduce debt fort those that go into primary care, only one is accepted in. so i think we are in agreement that we have to approach this problem in a number of different ways and i hope we all agree we are not one to solve the crisis until we address primary health care. it is a huge issue. >> mr. chairman, i agree that the burkowski of and it takes care of of 5% fixed rate and i said that at the outset that numbers one and four have been taking care of it. my amendment does not change how they have been taken care of, is still goes back to where they were, but i am really concentrating on that 18 percent fixed interest rates for those who deal called and i know we get into the credit-card debate on this thing. it has nothing to do as a credit-card defaults.

this has to do the default, printing of the contract that says i will go to an underserved area and look of some loan interest rates and repayment and then i decide i go to a place that pays me much better and so i am willing to default on this agreement i have of going into an underserved area and ought to be a penalty that they pay when they do that, not a reduction in their interest rates or mayor increase of six tenths of a percent if they do that. there ought to be a phantom -- penalty to pay for that so this is in the raw the defaulting on the payments on their loan, it is for defaulting on the agreement they paid, they would do in exchange for giving villone. i think it is important to keep that up at 18% not to make -- it doesn't make it tough on those because they're getting adequately paid, they're probably getting all paid off by going to another area and what i

always encourage them to do is in the fine printing when going into the contract not try to get out of a contract is so it is this default rates, not a fixed interest rate when they get the loan and of the parts we have taken care of that would keep six of the three people in kenya because that money of those have to pay for not reading the fine. of the contract and accepting a much more lucrative job goes back into this fund and this is what funds people so and we reduce that from 18% to 5.6% not nearly as much money will go into this fund invests the money doesn't and there is no money to go ahead and load to other people. so i just know that we can keep the policy of their where it has been and so i am trying to maintain the program as it has been because i think this part of it has worked. we don't have emphasis to get

people into primary care but it has been working. >> is an interesting observation as well. >> mr. chairman, as we have been working on this amendment we realize as we make it no one will choose to go in which eliminates the goal of this program to make sure people chose to go into primary care. >> i think my colleague and. >> does that mean the assumption we have a 18% interest rates discouraging people from going into primary care? >> no, i let the chairman now we have been working with senator burkowski and have an alternative amendment working with hrsa and others who will reverse a graduate of rates both as incentive for a loan recipients but not so great to deter applicants. that is the real goal of this and hopefully we can get to our amendment shortly. >> is adding guess that the 18% rate discourages people from going into primary care?

>> i'm sorry? >> is it your belief or hrsa believe that because we have 18 percent rate based on noncompliance because when they see that -- connected does discourage them he max hrsa agrees? >> hrsa agrees. >> i think my colleagues. the clerk will vote on the the murray amendment. i am sorry, the enzi amendment. [roll call]

[roll call] >> the amendment is not agreed to and let me say to senator enzi, is an interesting observation and the pride that hrsa thinks it has been discouraging to people to go and was persuasive to maim. it is one of the issues another is a debate about it but i think we have certainly had a eighth straight pal empty for a long while and we're not getting the results. >> mr. chairman, the senator

rakowski will be offering an amendment we can all agree on that is graduated rate we have been working on it a really good alternative. >> i think for the contribution. >> mr. chairman, i do have an amendment agreed upon, senator burkowski and i ask unanimous consent it be accepted? >> yes, burkowski never 40. >> i think it has been cleared on both sides. >> member 40. >> not the one i referred to. >> i think it is clear that on both sides -- tom, do you want to see it? i am going to recognize senator miracle for an amendment. just a second, we're looking at a burkowski amendment is there objection to the senator burkowski amendment? without objection the amendment is adopted. senator miracle. >> thank you mr. chairman, i want to take this opportunity to

note that sma share with the appointed senator enzi to making a one folks approach. they break their agreement needs to be addressed in a way and that both let's them enter the program and discourages them from violating the terms of the deal and i'm glad to hear those a continuing conversation under way to work out that strategy and thank you for raising that point. the amendments i am pervez presenting is miracle number to end this addresses the evolution in the situation with nursing. the general accounting office reports increased use of caris settings has increased the demand for higher skill musks are registered nurses. many of our nurses however come from to your programs that have a relatively low level of technology training and in this amendment is about working to provide grants that provide a

primarily community colleges with the ability to enhance their technology training in the two-year program which either would better prepare for the workforce or for a transition to a four year program. the amendment would allow this flexibility to address the systemic nurse pipeline in a variety of ways by per carry stimulation mannequins, developing additional teaching faculty, create a uniform standard find an exit of the art technologies of the community colleges and in the same time the program and raise the bar in technical literacy as a whole. i will continue to go into additional details because it is my intention after offering this any comments anyone would like to make to withdraw. at the recommendation of staff to continue working with the nursing community on issues related to this.

and i think we can either end to or improve the strategy laid out in this amendment and perhaps bring it back on the floor so that is my intention. so and to think that in short technology is playing a much larger role. we have very large number, about 700 community college programs, 15 in oregon which ledbetter be able to prepare their students with assistance in preparing and nurses for the high technology based nursing care and thank you mr. chairman kim mr. chairman, i want to just commend senator mark lee on this amendment. as a former community college teacher as well as chairman of implement and workplace safety i agree community colleges are extremely valuable in finding in how a skilled workforce so i share your concern that they be adequately addressed in this and will work with you as we move to the floor he met with me and my

voice to that as well. the community colleges are in a fabulous job and tremendous source of education opportunity for people and i am not sure we celebrated in an upper supportive enough and i suspect in the years to come given the rising cost of our education you'll see a greater role played by the community college system across the country and provide a quality education of substantially reduce costs from the others are charging. whenever we can do to expand those opportunities and to imagine up with the ever growing demand for people in the health-care professions make all the sense of the world so i commend my colleague for his thoughts. >> mr. chairman, i would note that pokes coming to a two-year program have a very good a living wage job, very high demand job was starting wages and are often 40,000 of -- 40,000 or higher.

there's a huge challenge is to know from all the discussions taken place in this committee and i commend the senator murray for her work in leading this discussion that these work-force challenges just don't have enough slots, there are so many cable will soon as one in to be in these programs and this type of effort will enable those from to your programs to enter the workforce more easily and also supporting some of the technology demands will enable american easier for these to expand and bring more students into the system can't great, i keep on noting there was then the average age of a nurse in new devastates is 55, and the average age of 80 tinners is 62. then again because of the salaries of teaching purse is what we should pay of lenders is harder to get people into teaching professions that can train people. we have a vote of people of our

service men and women coming back from service and iraq and afghanistan that we learned from vietnam i think it was the ceo of the cleveland clinic who is a physician india nominee talk about what he was able to do with a handful of physicians the tremendous number of medics in the algoma and the number of our servicemen and women who are injured. the utilization of those talented people to come back into the health-care profession and a number of colleagues around this table as well as others are deeply interested in ways we can open up the access to the health-care professions serving the military to provide that service as well and expanding opportunity is the. >> we had an interesting experiment because they do have problems getting instructors for the health care and in their main program and there is nursing and when they did was

increase the tuition which was practically nothing before. a couple of thousand dollars in all of that money went to teacher pay which created a bit of a rift in the organization because typically all of the professors to the same pain but they weren't able to entice the cannon people they needed sold it has worked. they have a tremendous program so i appreciate anybody who is thinking of ways and these areas and i do hope that consolidate and modernize programs as we go. i can't imagine anybody in the health-care profession that doesn't have a high-tech background, is going to be absolutely essential. given senator enzi is our next amendment. >> i do. i called the amendment number 53. >> enzi number 53.

>> thanks and this is a build as of a plea to require funds for primary care training to ensure that the funds for training health professionals is targeted to primary-care and a specialty care, it is a branch remember the house committee pass higher education bill that provided the loan forgiveness to professionals, dentists and more. this bill greatly expands health professions programs to include public health workers and researchers and they will cover those individuals, but this eminent insurer is that health professional programs will fun at education and training for a primary care providers not specialists. it provides financial support for training and educating researchers. we need to be targeting practitioners.

in the amendment states and this comes from a the hrsa web site on the definition, states in only health-care professionals the practice in family medicine, general pediatrics, preventive medicine, osteopathic general medicine, obstetrics and gynecology or general dentistry will receive funds and of the program and the authorization level in this program represents a 400% increase and that is five and for tens of billion compared to one and three tens of billion in the crenshaw and that is an annual increase so over all there are 20 new programs of the rise in every existing program increase from 30 to 730 percent over current law. again and to place the emphasis on primary care. >> senator murray. >> what this does is essentially limit the funding in this entire title of programs the only train

primary care workers and i think all of us recognize there is a need for primary care and that as of the only place where we need to create a strong workforce in health care. we have shortages and a lot of other areas. the patients entered, the senator precursory has talked about and nurses, social workers, mental health professionals probably an important parts of our health-care system. it and a person is someone very well who was hurt very badly in in a bike automobile accident in a couple months ago and the only reason she is home and hospital is because of physical therapist and occupational therapist can come to her home. as opposed to stay in a hospital, in the words of the cost of care for everyone but without those professionals available and many of our areas. it has a real impact both on the cost and quality of health care so and this title we have worked

for hard to make sure that we address a number of shortages. and as senator brown has worked hard on this and i'm sure he will comment but if we want to obtain our objective of ensuring high-quality affordable health care we have to make sure that we provide support for increasing health care professionals at a variety of levels. >> mr. chairman. >> senator brown. >> thank you. senator murray for your leadership on this. this sets us into ways the enzi amendment and i appreciate his genuine concern for primary-care physicians, but we had a hearing three or four weeks ago in a row position representing academy of pediatrics and to talk about how the of all that was not just for finding specialists and rural areas but simply an of specialists generally pediatrics specialist for all kinds of

various iran diseases are relatively rare disease as she was already looking in a long way from a children's hospital and she also could i get patients in because of a long wait here and there is example, a 3% of children's hospitals report a gain over nine went to schedule their relative is a it's and i can give a six examples of gastroenterology and a whole host of a sub specialists that we find in short supply in pediatrics, so that would be a help eliminated and also as some said the issue of community health workers and others, not md is, who are so important providing less expensive for direct and more important care in some sense of this bill in part is how the remaining cost one of the ways is two have people like community health workers instead of alaska which has been a

trailblazer, and nationally been on a program that provides services to rural and native american countries and a group called the committee held access program is higher 11 or $12 and our community health workers who don't have huge amounts of training but have some training to cut down on the rate of low birthweight babies and think of the money that saves for our health care system and the local hospital and the state's medicaid and federal tax dollars other are some reasons this is to remain a broader if you will for a specialist in pediatrics from there to community health workers and training of physical therapist and a whole host of non and the health care workers also. >> the purpose of this certainly would not be to reduce the number of health-care workers, we know that there are older and retiring as it had about the teacher problem. what we have done is create a

bunch of silos and the silo is it a little bit one for health care. in we have a workforce grants and loan forgiveness programs and other areas that are the main source of health professions spending in medicare in 2007 it spent 6 billion in indirect medical education and two in four tense billion in direct education. the title seven program receive less than $200 billion so i am asking this to consolidate and to put our money where our mouth is on a meeting primary-care and if we eliminate the silos we can get the money into this area. there isn't an area of health care providers that there isn't a shortage and, in fact, my favorites report on wyoming says there is a shortage in every single kind of provider including a veterinarian's which usually draws a question to veteran there is sort of people in the answer is, yes, as they

are far enough from other kind of dr.. sought and sustanon been called for health professionals. of all times. >> as a raid, there is a lot of agreement normally in the race to have fundamental disagreements. there is no fundamental disagreement and i think the point and bob casey has a great interest in the subject matter and i have had over the years. the one area that, in fact, there hasn't been in a race to specialization is in the pediatric area and esso anomaly in a way that has been obviously an the other is a plan from the area of pediatrics has been the opposite case paramount so the sweeping statements we made which have a lot of accuracy is about correct. we have all made the point on some occasions over the last nu