House Ways & Means Subcommittee Issues Testimony From University of Washington School of Medicine Professor Frogne

WASHINGTON, March 12 -- The House Ways and Means Subcommittee on Worker and Family Support issued the following testimony by Bianca K. Frogner, associate professor in health economics and director of the Center for Health Workforce Studies in the Department of Family Medicine at the University of Washington's School of Medicine, as part of a virtual hearing entitled "Worker and Family Support Subcommittee Hearing on Health Profession Opportunity Grants; Past Successes and Future Uses" on March 10, 2021:

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My name is Bianca Frogner. I am an Associate Professor in health economics and Director of the Center for Health Workforce Studies (CHWS) housed in the Department of Family Medicine at the University of Washington's School of Medicine. I am honored to have this opportunity to discuss with the committee the importance of investing in the career pathways of health care workers through the Health Profession Opportunity Grants (HPOG) program.

I bring to this testimony extensive health workforce research conducted over 20 years by my Center. Within my Center, I am currently the Principal Investigator of two large federal funded center grants, one of which focuses on allied health professionals and the other which focuses on health equity. Among the relevant topics about which my team has published include defining career pathways into and within the health care industry, identifying barriers to achieving a diverse health workforce, and examining policies and programs that support our health care workers in providing high quality and culturally competent care.

I have followed the HPOG program with great interest since its inception in 2010. My early research experience was examining the transitions of participants in the Temporary Assistance for Needy Families (TANF) program and their employment outcomes based on a large-scale NIH funded study on welfare reform called the Three-Cities Study.1 Among the key findings was the importance of TANF recipients, particularly Black and Hispanic recipients, gaining employment soon after transitioning out of TANF to prevent long-term earnings loss and further decline into poverty.2,3 HPOG is an excellent example of the type of supportive service we should be investing in to help TANF participants find gainful employment.

Health care has been a constant source of jobs in the economy, providing relatively low barriers to entry and opportunities for career growth for former TANF recipients and other low-income populations. Between 2009 and 2019, health care added approximately 2.6 million jobs to the economy4 and is projected to add another 2.4 million jobs by 2029./5 During tough economic times, health care has served as a job engine, most often drawing workers who have been unemployed or out of the labor force as well as those working in the hospitality and retail sectors.6

Given that hospitality has a 13.5% unemployment rate as of February 2021 compared to only 5.1% at the same time last year, an expanded HPOG program could provide a much needed opportunity for these workers to be retrained and employed in health care.7 Health care jobs are in high demand, with health care representing 8 out of the 20 fastest growing jobs over the next decade according to the U.S. Bureau of Labor Statistics.8 Among the fastest growing jobs are home health and personal care aides--common entry-level health care occupations for HPOG 1.0 participants9--which requires only a high school diploma or equivalent with short on-the-job training.10

Career progression to higher skilled jobs in high demand, such as a nurse practitioner or physician assistant, is possible with employer supported on-the-job training such as found in Registered Apprenticeship models, which is an integral component of the HPOG program.11 A pressure facing health care is high turnover rates among entry-level positions,12 as well as in specific settings such as skilled nursing facilities where the average turnover rates were estimated to be above 100% across skill levels before the pandemic and may remain high well after the pandemic.13,14 While low wages play a role in turnover, other contributing factors include burnout, lack of promotion opportunities, lack of employee assistance programs such as child care.15,16,17,18

We also know that many workers in entry-level health care positions are left without health insurance, rely on the Supplemental Nutrition Assistance Program (SNAP), and face long commutes on public transportation.19,20 The support services offered through HPOG are critical elements to retain health care workers and could be especially important for rural communities who may otherwise not have the resources to recruit for high demand occupations such as home health aides.21

These services are also important to retain a diverse pipeline of health care workers given that minority populations are more heavily represented in entry-level positions rather than in higher skilled positions.22 These support services are likely to be contributing to the success of HPOG based on Abt Associates' evaluation, which found significantly higher levels of employment in health care with signs of career progress among HPOG participants versus a control group.23 While the evaluation report did not necessarily find higher wages among the HPOG participants, it is important to note that the program is operating within a complex reimbursement model that affects wages and the program has little, if any, role in influencing reimbursement.

In summary, to provide high-quality care to patients, we need a high-quality health workforce. To produce that workforce, we need to provide opportunities for career advancement through on-the-job trainings combined with support services to allow workers to focus on their careers. The HPOG program has a proven track record that is built on evidence, and with expanded investments, has the potential to strengthen our pipeline of health care workers in areas of greatest need.

Thank you again for the opportunity to testify today. I look forward to answering your questions.

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Footnotes:

1 Angel R, Burton L, Chase-Lansdale PL, Cherlin A, Moffitt R. Welfare, children, and families: a three-city study. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-10-04. https://doi.org/10.3886/ICPSR04701.v7

2 Frogner B, Moffit R, Ribar D. Working paper 09-03: income, employment, and welfare receipt after welfare reform: 1999-2005 evidence from the Three-City Study. 2009. Available at: http://web.jhu.edu/threecitystudy/Workshops/WP09_03IncomeEmployment.pdf

3 Cherlin A, Frogner B, Ribar D, Moffit R. Welfare reform in the mid-2000s: how African American and Hispanic families in three cities are faring. Annals AAPSS 2009; 621:178-201.

4 Calculation based on 2009 and 2019 data for NAICS codes 621, 622 and 632 extracted from Bureau of Labor Statistics occupational Employment Statistics. Available at: https://www.bls.gov/oes/tables.htm

5 Bureau of Labor Statistics. Occupational outlook handbook: health care occupations. 2020. Available at: https://www.bls.gov/ooh/healthcare/home.htm#:~:text=Employment%20in%20healthcare%20occupations%20is,about%202.4%20million%20new%20jobs.&text=This%20projected%20growth%20is%20mainly,greater%20demand%20for%20healthcare%20services.

6 Frogner BK. The health care job engine: where do they come from and what do they say about our future? Med Care Res Rev 2018; 75:219-231.

7 Bureau of Labor Statistics. Unemployment rate - leisure and hospitality, private wage and salary workers: unemployment rate (Series LNU04032241). Available at: https://data.bls.gov/pdq/SurveyOutputServlet

8 Bureau of Labor Statistics. Occupational outlook handbook: fastest growing occupations. 2020. Available at: https://www.bls.gov/ooh/fastest-growing.htm

9 Werner A, Schwartz D, Koralek R, Loprest P, Sick N. OPRE Report No. 2018-09: Final report: national implementation evaluation of the first round Health Profession Opportunities Grants (HPOG 1.0). 2018. Available at: https://www.acf.hhs.gov/sites/default/files/documents/opre/final_nie_final_report_1_11_18_clean_v2_b508.pdf

10 Bureau of Labor Statistics. Occupational outlook handbook: home health aides and personal care aides. 2020. Available at: https://www.bls.gov/ooh/healthcare/home-health-aides-and-personal-care-aides.htm

11 Frogner BK, Skillman SM. Pathways to middle-skill allied health care occupations. Issues Sci Tech 2016. Available at: https://issues.org/pathways-to-middle-skill-allied-health-care-occupations/

12 Friedman JL, Neutze D. The financial cost of medical assistant turnover in an academic family medicine center. JABFM 2020; 33:426-430.

13 Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing homes offers important quality information. Health Affairs 2021; 40:384-391.

14 Denny-Brown N, Stone S, Hays B, Gallaghe D. COVID-19 intensifies nursing home workforce challenges. ASPE Report 2020. Available at: https://aspe.hhs.gov/basic-report/covid-19-intensifies-nursing-home-workforce-challenges

15 Willard-Grace R, Knox M, Huang B, Hammer H, Kivlahan C, Grumbach K. Burnout and health care workforce turnover. Ann Fam Med 2019; 17:36-41.

16 Skillman SM, Dahal A, Frogner BK, Andrilla CHA. Frontline workers' career pathways: a detailed look at Washington state's medical assistant workforce. Med Care Res Rev 2020; 77:285-293.

17 Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey. Health Care Management Review 2009; 34:182-190.

18 Fischer SH, McBain RK, Faherty LJ, Sousa JL, Kareddy V, Gittens AD, Martsolf GR. Strengthening the entry-level health care workforce: finding a path. ASPE Report 2020. Available at: https://aspe.hhs.gov/pdf-report/ehcw-finding-a-path 19 Frogner BK, Skillman SM, Patterson DG, Snyder CR. Comparing the socioeconomic status of workers across healthcare occupations. Center for Health Workforce Studies: Seattle, WA. 2016. Available at: https://depts.washington.edu/fammed/chws/wp-content/uploads/sites/5/2016/12/Socioeconomic-Well-Being-of-Workers_FR_2016_Dec_Frogner.pdf

20 Dahal A, Skillman SM, Patterson DG, Frogner BK. What commute patterns can tell us about the supply of allied health workers and registered nurses. Center for Health Workforce Studies: Seattle, WA. 2020. Available at: https://www.familymedicine.uw.edu/chws/wp-content/uploads/sites/5/2020/05/Commute-Patterns-FR-2020.pdf

21 Skillman SM, Patterson DG, Coulthard C, Mroz TM. Access to rural home health services: views from the field. WWAMI Rural Health Research Center: Seattle, WA. 2016. Available at: https://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/02/RHRC_FR152_Skillman.pdf

22 Snyder SR, Frogner BK, Skillman SM. Facilitating race and ethnic diversity in the health workforce. J Allied Health 2018; 47: 58-65.

23 Peck LR, Litwok D, Walton D, Harvill E, Werner A. Health profession opportunity grants (HPOG 1.0) impact study: three-year impacts report. OPRE Report 2019-114. Washington DC: Office of Planning, Research, and Evaluation. Administration for Children and Families, U.S. Department of Health and Human Services. Available at: https://www.acf.hhs.gov/sites/default/files/documents/opre/hpog_three_year_impacts_nov_2019.pdf