HEALTH CARE 

WORKFORCE

Federal Investments in 

Training and the Availability 

of Data for Workforce 

Projections

Statement of Linda T. Kohn

Director, Health Care

Testimony

Before the Subcommittee on Primary 

Health and Aging, Committee on 

Health, Education, Labor, and 

Pensions, U.S. Senate

For Release on Delivery 

Expected at 10:00 a.m. EDT

Wednesday, April 9, 2014

GAO-14-510T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-510T, a testimony 

before the Subcommittee on Primary Health 

and Aging, Committee on Health, Education, 

Labor, and Pensions, U.S. Senate

April 9, 2014

HEALTH CARE WORKFORCE

Federal Investments in Training and the Availability of 

Data for Workforce Projections

Why GAO Did This Study

A well-trained and diverse health care 

workforce is essential for providing 

Americans with access to quality 

health care services, including primary 

care services. To help ensure a 

sufficient supply of physicians, nurses, 

dentists, and other direct care health 

professionals for the nation, the federal 

government has made significant 

investments in health care workforce 

training through various efforts. As 

Congress considers funding existing or 

additional training programs that would 

address any potential shortages of 

health care professionals, timely and 

up-to-date estimates of future supply 

and demand for health care 

professionals are critical.

This statement addresses (1) the 

scope of the federal government’s role 

in health care workforce training and

(2) the availability of data related to 

projecting health care workforce supply 

and demand. It is based on findings 

from two recent GAO reports. The first 

report identified federal programs that 

supported postsecondary training and 

education for direct care health care 

professionals in fiscal year 2012, 

including information about program 

purpose, funding, and targeted health 

professionals. The second report 

examined actions HRSA has taken to 

project the future supply of and 

demand for physicians, physician 

assistants, and advanced practice 

registered nurses (APRN) since 

publishing its 2008 physician workforce 

report. These products used a variety 

of methodologies, which are detailed in 

each report.

What GAO Found

GAO found that there is substantial federal funding for health care workforce 

training programs but that obtaining comprehensive information about the scope 

of such programs is challenging. In GAO’s August 2013 report on the federal role 

in health care workforce training, GAO found that four federal departments—the 

Department of Health and Human Services (HHS), the Department of Veterans 

Affairs (VA), the Department of Defense (DOD), and the Department of 

Education (Education)—administered 91 programs that supported postsecondary 

training or education specifically for direct care health professionals in fiscal year 

2012. All together, the four departments reported obligating about $14.2 billion 

for health care workforce training programs in fiscal year 2012, with HHS funding 

the most programs (69) and having the largest percentage of total reported 

funding (82 percent). The majority of funding for health care workforce training in 

fiscal year 2012—about $11.1 billion, or 78 percent—was invested in seven 

programs that supported postgraduate residency training for physicians, dentists,

and certain other health professionals, called Graduate Medical Education. The 

remaining 84 programs administered by HHS, VA, DOD, and Education

accounted for obligations of about $3.2 billion and provided varying levels of

assistance, ranging from participation in short-term continuing education courses 

to full support for tuition and books and a stipend for living expenses. Compiling 

comprehensive information about the scope of federal support for health care 

workforce training is challenging because multiple federal departments 

administer such programs, and GAO found that the departments did not always 

have comparable program information.

Lack of timely, regularly updated data creates challenges for projecting health 

care workforce supply and demand. The Health Resources and Services 

Administration (HRSA)—an agency within HHS—is responsible for monitoring 

the supply of and demand for health care professionals. At the time of its 

September 2013 report, GAO found that, since publishing a 2008 report on 

physician supply and demand, HRSA had awarded five contracts to research 

organizations to update national health care workforce projections. However, 

HRSA had failed to publish any new workforce projections. While HRSA created 

a timeline in 2012 for publishing a series of new workforce projection reports, the 

agency missed its original goals for publishing them and had to revise its 

publication timeline. HRSA’s report on the primary care workforce was published 

in November 2013, more than 3 years after the contractor originally delivered its 

report to HRSA for review.

View GAO-14-510T. For more information, 

contact Linda T. Kohn at (202) 512-7114 or 

kohnl@gao.gov.
 

Page 1 GAO-14-510T Health Care Workforce Training

Chairman Sanders, Ranking Member Burr, and Members of the 

Subcommittee:

I am pleased to be here today to discuss our work on federal investments 

in health care workforce training and the availability of data related to 

projections of supply and demand for health care professionals. A welltrained and diverse health care workforce is essential for providing 

Americans with access to quality health care services, including primary 

care services. A number of reports published by government, academic, 

and health professional organizations have projected national shortages 

of some types of health care professionals, which could result in patients 

experiencing delays in receiving, or a lack of access to, needed care. To 

help ensure a sufficient supply of physicians, nurses, dentists, and other 

direct care health professionals for the nation, the federal government has 

made significant investments in health care workforce training through 

various efforts.1

This statement addresses (1) the scope of the federal government’s role 

in health care workforce training and (2) the availability of data related to 

projected health care workforce supply and demand. It is based on 

findings from two recent GAO reports. The first report, Health Care 

Workforce: Federally Funded Training Programs in Fiscal Year 2012,

identified federal programs that supported postsecondary training and 

education for direct care health care professionals in fiscal year 2012, 

including information about program purpose, funding, and targeted 

These efforts include federal programs that train health 

professionals directly, award grants or make payments to institutions 

training health professionals, and provide financial assistance to health 

professional students through stipends, scholarships, loans, or loan 

reimbursement. In addition, as Congress considers policy options to 

address health care workforce issues—such as funding training programs 

that would address any potential shortages of health care professionals—

timely and up-to-date estimates of future supply and demand for health 

care professionals are critical. The Health Resources and Services 

Administration (HRSA)—an agency within the Department of Health and 

Human Services (HHS)—is responsible for monitoring the supply of and 

demand for health care professionals.

 

1

For the purposes of this statement, direct care health professionals are those who deliver 

clinical or rehabilitative care to patients, such as allopathic and osteopathic physicians, 

nurses, dentists, pharmacists, physician assistants, podiatrists, psychologists, and 

physical or occupational therapists. 
 

Page 2 GAO-14-510T Health Care Workforce Training

health professionals.

2 The second report, Health Care Workforce: HRSA 

Action Needed to Publish Timely National Supply and Demand 

Projections, examined actions HRSA has taken to project the future 

supply of and demand for physicians, physician assistants, and advanced 

practice registered nurses (APRN) since publishing its 2008 physician 

workforce report.

3

Each of the reports cited in this statement provides detailed information 

on our scope and methodology. This statement is based on work that was 

conducted from March 2013 through September 2013 in accordance with 

generally accepted government auditing standards. Those standards

require that we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and conclusions based on 

our audit objectives.

The U.S. health care workforce includes a spectrum of health 

professionals requiring varying levels of postsecondary education and 

training, ranging from diploma programs to graduate degrees and 

postgraduate training.4

To maintain an adequate health care workforce, the future supply of 

health care professionals must be projected and compared to the 

expected demand for health care services to determine whether there will 

be enough providers to meet the demand. Such projections can provide 

advance warning of shortages or surpluses so that health care workforce 

Some professionals who deliver direct health care 

services to patients require clinical training through a health care 

institution—such as internships, residencies, or fellowships—in addition to 

completing graduate-level educational requirements before being eligible 

for full licensure. These professionals include physicians, certain 

pharmacists, podiatrists, clinical psychologists, and dentists seeking a 

dental specialty.

 

2

GAO, Health Care Workforce: Federally Funded Training Programs in Fiscal Year 2012, 

GAO-13-709R (Washington, D.C.: Aug. 15, 2013).

3

GAO, Health Care Workforce: HRSA Action Needed to Publish Timely National Supply 

and Demand Projections, GAO-13-806 (Washington, D.C.: Sept. 30, 2013). 

4

Postsecondary education is education or training beyond the high school level.

Background
 

Page 3 GAO-14-510T Health Care Workforce Training

policies, such as funding for health care training programs, can be 

adjusted accordingly. In its 2008 physician workforce report, HRSA noted 

that due to the long time needed to train physicians and to make changes 

to the medical education infrastructure, policymakers and others need to 

have information on the adequacy of the physician workforce at least 

10 years in advance.5 We have also previously reported that producing 

supply and demand projections on a regular basis is important so that 

estimates can be updated as circumstances change.6

In our August 2013 report, we found that four federal departments—HHS, 

the Department of Veterans Affairs (VA), the Department of Defense 

(DOD), and the Department of Education (Education)—administered 

91 programs that supported postsecondary training or education 

specifically for direct care health professionals in fiscal year 2012. All 

together, the four departments reported obligating about $14.2 billion for 

health care workforce training programs in fiscal year 2012, with HHS 

funding the most programs (69) and having the largest percentage of total 

reported funding (82 percent).7 See table 1 for additional details about the 

number of health care workforce training programs administered by HHS, 

VA, DOD, and Education and the funds the departments reported 

obligating for them in fiscal year 2012.

 

5

Health Resources and Services Administration, The Physician Workforce: Projections 

and Research into Current Issues Affecting Supply and Demand (Rockville, Md.: 2008).

6

GAO, Health Professions Education Programs: Action Still Needed to Measure Impact, 

GAO-06-55 (Washington, D.C.: Feb. 28, 2006).

7

GAO asked department and agency officials to provide obligations, including those for 

which expenditures have been made, for each program in fiscal year 2012. The term 

obligation refers to a definite commitment by a federal agency that creates a legal liability 

to make payments immediately or in the future. Agencies incur obligations, for example, 

when they award grants or contracts to private entities. An expenditure is the actual 

spending of money by the issuance of checks, disbursement of cash, or electronic transfer 

of funds made to liquidate a federal obligation. The total reported obligations do not 

include amounts obligated in prior years that were expended in fiscal year 2012.

Substantial Federal 

Funding for Health 

Care Workforce 

Training Programs 

Exists, but Obtaining 

Comprehensive 

Information about the 

Scope of Such 

Programs is 

Challenging
 

Page 4 GAO-14-510T Health Care Workforce Training

Table 1: Health Care Workforce Training Programs Administered by Four Federal 

Departments and Funds Obligated for These Programs in Fiscal Year 2012

Department

Number of health care 

workforce training 

programs funded Obligations

Department of Health and Human Services 69 $11.7 billion

Department of Veterans Affairs 12 $1.7 billion

Department of Defense 7 $0.9 billion a

Department of Education 3 $2 million

Source: GAO summary of Department of Defense (DOD), Department of Education (Education), Department of Health and Human 

Services (HHS), and Department of Veterans Affairs (VA) information.

Note: DOD, Education, HHS, and VA obligated a total of about $14.2 billion for health care workforce 

training programs in fiscal year 2012. Amounts listed in this table do not add to $14.2 billion because 

of rounding.

a

In total, across all four departments, the majority (78 percent) of federal 

funding for health care workforce training in fiscal year 2012—about 

$11.1 billion—went to seven programs that supported postgraduate 

residency training for physicians, dentists, and certain other health 

professionals, called Graduate Medical Education (GME) (see fig. 1). Two 

programs administered by HHS’s Centers for Medicare & Medicaid 

Services (CMS)—Medicare payments to teaching hospitals and other 

entities for Direct Graduate Medical Education (DGME) and Medicare 

payments to teaching hospitals for Indirect Medical Education (IME)—

accounted for about 66 percent of total reported health care workforce 

training funding.

One of DOD’s seven programs represents multiple clinical and instructional health professions 

education programs. For the purposes of this statement, we characterized them as a single program 

because DOD could not provide consistent program-level information.

8

 

8

For the purposes of this statement, we considered Medicare DGME payments and 

Medicare IME payments to be separate programs. Medicare DGME payments cover the 

teaching costs of training residents, such as resident stipends, administrative overhead, 

and supervisory physician salaries. Medicare IME payments support the higher patient 

care costs associated with training residents, such as the ordering of more tests and 

increased use of emerging technologies.

CMS’s Medicaid program also made payments to 

teaching hospitals for GME, and HRSA, another agency within HHS, 

administered two programs that supported GME in settings other than 
 

Page 5 GAO-14-510T Health Care Workforce Training

teaching hospitals.9

Figure 1: Proportion of Total Reported Federal Funding Obligated for Health Care 

Workforce Training by Graduate Medical Education (GME) and Other Programs, 

Fiscal Year 2012

VA and DOD also administered GME programs; 

however, the funding information VA provided to us accounted for 

resident salaries and benefits, while the funding information provided by 

DOD accounted for only certain administrative costs to operate its GME 

program.

Note: Percentages do not add to 100 because of rounding.

 

9

Medicaid payments for GME and the two HRSA programs—the Children’s Hospitals 

GME Payment program and the Teaching Health Center GME Payment program—

provided funding for both direct costs of resident training, such as resident salaries and 

benefits, and indirect funding to reflect the higher patient care costs associated with 

resident education.
 

Page 6 GAO-14-510T Health Care Workforce Training

The remaining federal funding for health care workforce training—about 

$3.2 billion—went toward 84 HHS, VA, DOD, and Education programs

that

• provided financial assistance to direct care health professional 

students and professionals,

• provided or supported instruction or clinical training for direct care 

health professionals, or

• provided a combination of these and other training support services. 

Across all 84 non-GME programs, trainees received differing levels of 

assistance, ranging from participation in short-term continuing education 

courses to full support for tuition and books and a stipend for living 

expenses. These 84 programs targeted various types of health 

professionals and eligible individuals. See table 2 for additional

information about the number of non-GME training programs targeting 

various categories of health care professionals.

Table 2: Number of Non-Graduate Medical Education (GME) Training Programs That 

Target Certain Categories of Health Care Professionals

Category of health care professionals targeted 

Number of training 

programs

Students, professionals, or faculty in multiple health professions 47 a

Nurses only 18

Physicians or physician assistants only 8 

Dentists or dental hygienists only 6 

Behavioral health professionals only 4 

Physicians and dentists only 1 

Total 84

Source: GAO summary of Department of Defense, Department of Education, Department of Health and Human Services, and 

Department of Veterans Affairs information.

Note: We included both programs that solely targeted direct care health professionals and programs 

that targeted direct care health professionals among other professionals if the program purpose or 

objectives specifically identified direct care health professionals.

a

Compiling comprehensive information about the scope of federal support 

for health care workforce training is challenging because multiple federal 

departments administer such programs, and we found that the 

departments did not always have comparable program information. For 

example, at the time of our review, we relied on a multitude of sources to 

identify training programs and program information in the absence of a 

These programs targeted three or more types of health professionals. 
 

Page 7 GAO-14-510T Health Care Workforce Training

comprehensive listing of such programs. In some cases, the level of detail 

in the information we obtained from the four departments varied or data 

were not available. For example, HHS and VA were not able to account 

for the number of health professional trainees supported by certain 

programs they administer. In another example, DOD was unable to 

provide information about funds obligated or the number of trainees 

supported by each of its multiple non-GME clinical training and education 

programs for military medical personnel. Therefore, we reported the 

number of trainees supported and amount of funds obligated at an 

aggregate level for these DOD programs. The funding information 

reported by DOD also did not include amounts for salary and benefits of 

residents in its GME programs, whereas other departments included 

these amounts in their reported GME funding.

The scope of our August 2013 review of federal programs that supported 

postsecondary training and education for direct care health care 

professionals had some limitations. For example, we limited our review to 

programs that specifically targeted postsecondary training and education 

for direct care health care professionals in fiscal year 2012. There could 

be additional programs or funding that supported health care workforce 

training that did not specifically target direct care health professionals. For 

instance, in fiscal year 2012, Education administered programs—such as 

the Subsidized and Unsubsidized Stafford Loan Programs, the Direct 

PLUS and Perkins Loan Programs, Pell Grants, and Federal Work 

Study—that support postsecondary training or education for various types 

of students, including direct care health professionals. However, these 

programs do not specifically target health professionals, and we could not 

determine the number of direct care health professionals supported by 

these programs or the total amount of funds from these programs that 

supported such training. Additionally, there may be other programs that 

support health care workforce training but that did not obligate funds in 

fiscal year 2012.
 

Page 8 GAO-14-510T Health Care Workforce Training

In addition to administering 50 health care workforce training programs, 

HRSA is responsible for monitoring the supply of and demand for health 

care professionals and disseminating workforce data and analyses to 

inform policymakers and the public about workforce needs and priorities. 

The Bureau of Health Professions (BHPr) within HRSA has multiple 

responsibilities related to workforce development, including conducting 

and contracting for studies on the supply of and demand for health care 

professionals. In 2006, we found that HRSA had published few national 

workforce projections despite the importance of such assessments to 

setting health care workforce policy, and we recommended that HRSA 

develop a strategy and establish timeframes to more regularly update and 

publish national workforce projections for the health professions.10

At the time of our September 2013 report, we found that HRSA had 

awarded five contracts since 2008 to research organizations to update 

national workforce projections but that HRSA had failed to publish any 

new reports containing projections since those contracts had been 

awarded. While HRSA created a timeline in 2012 for publishing a series 

of new workforce projection reports, the agency missed its original goals 

for publishing these reports and had to revise its timeline for publishing 

them. (See table 3.)

 

10GAO-06-55. 

Lack of Timely, 

Regularly Updated 

Data Creates 

Challenges for 

Projecting Health 

Care Workforce 

Supply and Demand
 

Page 9 GAO-14-510T Health Care Workforce Training

Table 3: Health Resources and Services Administration’s (HRSA) Original and 

Revised Timelines for Publishing Updated Workforce Supply and Demand 

Projections, as of September 2013

Report Description

Original goal 

for publication

Revised goal 

for publication

Primary care Projects supply of and 

demand for the primary 

care workforce to 2020.

No goal date Fall 2013

Clinician specialty Projects supply of and 

demand for physicians, 

physician assistants, and 

certain advanced practice 

registered nursesa

December 2012

 (APRN) 

to 2025.

Summer 2014

Nursing workforce Projects supply of and 

demand for nurses, 

including APRNs, to 2030.

September 2013 Fall 2014

Cross-occupations Projects supply of and 

demand for more than 20 

health professions to 2030.

2013 2014

Source: GAO review of HRSA information.

a

At the time of our September 2013 report, the most recent projections 

from HRSA available to Congress and others to inform health care 

workforce policy decisions—such as distributing physician training slots to 

medical specialties that were projected to experience shortages—were 

from the agency’s 2008 report. That report was based on data that were, 

at that time, more than a decade old.

Includes nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives. 

Clinical nurse specialists are not included.

As of July 2013, HRSA had received some of the contracted reports for 

its review, and others were under development. The first report, which 

included projections for the primary care workforce to 2020, was delivered 

to HRSA in July 2010, but HRSA was still reviewing and revising the draft 

when we released our study in September 2013. We recommended that 

HRSA expedite the review of that report, and the agency published its 

projection in November 2013.11

 

11Health Resources and Services Administration, Projecting the Supply and Demand for 

Primary Care Practitioners through 2020 (Rockville, Md.: 2013). 
 

Page 10 GAO-14-510T Health Care Workforce Training

Chairman Sanders, Ranking Member Burr, and Members of the 

Subcommittee, this completes my prepared statement. I would be 

pleased to respond to any questions that you may have.

If you or your staffs have any questions about this statement, please

contact me at (202) 512-7114 or kohnl@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be 

found on the last page of this statement. GAO staff who made key 

contributions to this statement include Martin T. Gahart, Assistant 

Director; Rebecca Abela; and Alexis MacDonald.

GAO Contact and 

Staff 

Acknowledgments

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