[Senate Hearing 109-970]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 109-970
 
  RESPONSIBLE RESOURCE MANAGEMENT AT THE NATION'S HEALTH ACCESS AGENCY 
=======================================================================
                                HEARING

                               before the

                FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
                     INFORMATION, AND INTERNATIONAL
                         SECURITY SUBCOMMITTEE

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 27, 2006

                               __________

        Available via http://www.access.gpo.gov/congress/senate

       Printed for the use of the Committee on Homeland Security
                        and Governmental Affairs

                              -------

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29-758 PDF                 WASHINGTON DC:  2007
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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
TOM COBURN, Oklahoma                 THOMAS R. CARPER, Delaware
LINCOLN D. CHAFEE, Rhode Island      MARK DAYTON, Minnesota
ROBERT F. BENNETT, Utah              FRANK LAUTENBERG, New Jersey
PETE V. DOMENICI, New Mexico         MARK PRYOR, Arkansas
JOHN W. WARNER, Virginia

           Michael D. Bopp, Staff Director and Chief Counsel
             Michael L. Alexander, Minority Staff Director
                  Trina Driessnack Tyrer, Chief Clerk


FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL 
                         SECURITY SUBCOMMITTEE

                     TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska                  THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island      DANIEL K. AKAKA, Hawaii
ROBERT F. BENNETT, Utah              MARK DAYTON, Minnesota
PETE V. DOMENICI, New Mexico         FRANK LAUTENBERG, New Jersey
JOHN W. WARNER, Virginia             MARK PRYOR, Arkansas

                      Katy French, Staff Director
                 Sheila Murphy, Minority Staff Director
            John Kilvington, Minority Deputy Staff Director
                       Liz Scranton, Chief Clerk
















                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Coburn...............................................     1
    Senator Carper...............................................    11

                               WITNESSES
                        Thursday, July 27, 2006

Peter C. Van Dyck, M.D., M.P.H., Associate Administrator, 
  Maternal and Child Health Bureau, Health Resources and Services 
  Administration, U.S. Department of Health and Human Services...     5
Joyce Somsak, M.A., Associate Administrator, Healthcare Sercices 
  Bureau, Health Resources and Services Administration, U.S. 
  Department of Health and Human Services........................     8

                     Alphabetical List of Witnesses

Somsak, Joyce, M.A.:
    Testimony....................................................     8
    Prepared statement...........................................    36
Van Dyck, Peter C., M.D., M.P.H.:
    Testimony....................................................     5
    Prepared statement...........................................    29


  RESPONSIBLE RESOURCE MANAGEMENT AT THE NATION'S HEALTH ACCESS AGENCY

                              ----------                              


                        THURSDAY, JULY 27, 2006

                                     U.S. Senate,  
            Subcommittee on Federal Financial Management,  
        Government Information, and International Security,
                            of the Committee on Homeland Security  
                                          and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 2:32 p.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Tom Coburn, 
Chairman of the Subcommittee, presiding.
    Present: Senators Coburn and Carper.

              OPENING STATEMENT OF CHAIRMAN COBURN

    Senator Coburn. The Subcommittee on Federal Financial 
Management, Government Information, and International Security 
will come to order.
    I want to first thank all of our guests for being here and 
the time they spent. I also want to tell you, regardless of 
what comes through this Subcommittee hearing, we do appreciate 
your service and your dedication to carrying out the charges 
that you have been tasked with.
    The title of our hearing is ``Responsible Resource 
Management at the Nation's Health Access Agency.'' I will 
apologize in advance. I do not think Senator Carper is going to 
be able to make it. The Senate is not in formal session with 
votes, but I will try to cover his areas of concern, as well, 
in the hearing.
    This, I believe, is our 43rd hearing on oversight since 
April 12 of last year. I have a prepared statement that I will 
place into the record, but I want to make a couple of points.
    Six billion dollars goes through the Health Resources and 
Services Administration (HRSA) a year and they have a vision 
statement that is very broad. One of the things that we have 
tried to do is to raise the awareness of metrics, measurement 
of goals, and then evaluation of the metrics as to the goals of 
whether or not we are accomplishing what we want and also using 
that as a tool to help us decide where to direct monies in a 
better way, where do we get the best dollar return in terms of 
accomplishments at HRSA.
    I am a big believer in the Performance Assessment Rating 
Tool (PART) system. I know it has tremendous flaws, but it is 
better than no system. One of the things that is quite evident 
at HRSA is that the failure rate is about one in three programs 
inside HRSA to either identify the goal or perform up to the 
goal.
    So the purpose of this hearing really is to talk about two 
areas, but also just to raise the awareness that we are going 
to be continuing to have hearings in areas in which I do not 
think you would disagree is how do we get the best dollar 
return for what our goals are, and also to give maybe some more 
direction. We recognize we are not the Executive Branch, but we 
do have the power of the purse and the authorization power to 
try to redirect those.
    This is all part of a larger goal, is how do we handle 
health care in America? How do we make it affordable and 
accessible, which you all are keyed into in terms of the 
accessibility, and how do we do that to a degree where people 
can afford it? Part of that problem is the bigger problem of 
prevention, which HRSA is supposed to be associated with, as 
well, and how do we change the format in America from treating 
of disease to investing in health.
    I know that you are both dedicated in those areas. The 
question is do we have the performance measures and the 
guidelines with which to assess the success or failure and the 
objective measurements of whether or not we are successful or 
failing in all the agencies, all the programs run by HRSA.
    Just as an example, we had a hearing 4 months ago on the 
Ryan White and it has taken 4 months to get the answer to 
questions from HRSA. To me, 4 months to answer two or three 
simple questions either means it is not a priority or you do 
not have the capability or organizational skill to answer those 
questions.
    Also, we had a report from GAO, I believe it was, in terms 
of the 340(b) program and what we know is we are wasting at 
least $4 million a month because we are not getting the best 
prices, which was some of the questions we asked, and that is a 
recent GAO report.
    So the point is not to be critical of individuals. Nobody 
doubts your dedication or your desire to do what is in the best 
interests of our country, but rather to have a real frank 
discussion about what we can do better, how do we do it more 
efficiently, and how do we measure what we are doing to see if 
we are accomplishing the goals that were set out to us.
    So I will put my full statement into the record.
    [The prepared statement of Chairman Coburn follows:]
                  PREPARED STATEMENT OF SENATOR COBURN
    We're here to talk about Responsible Resource Management at the 
Nation's Health Access Agency--otherwise known as the Health Resources 
and Services Administration (HRSA). In essence, we're here today for 
nothing more than a routine health checkup.
    As a practicing physician, I have often learned that sometimes you 
treat symptoms in patients because they're a real problem. Other times, 
those symptoms are really alerting you to a much bigger problem in the 
patient. Today we're going to look closely at some programs that aren't 
performing well. And while we expect these programs to make 
improvements, they are only symptoms of a bigger problem at HRSA--a 
universal lack of performance measures and therefore, a lack of 
accountability to the taxpayers for how public funds are being used.
    I recently held a hearing on President Bush's efforts to take a 
multi-trillion dollar government and apply some sort of standardized 
outcome evaluation on it--even if it's a crude instrument--known as the 
Performance Assessment Rating Tool (or (PART). The PART is a tool to 
review the strengths and weaknesses of government programs as agencies 
go through the annual budget process. PART findings, as the agency 
before us today knows, do influence funding and programmatic decisions. 
As we found at that hearing, the Office of Management and Budget has 
reviewed 793 programs, accounting for $1.47 trillion in taxpayer money. 
Almost a third of these programs came up either totally ineffective or 
are ``not demonstrating results.'' One-third of $1.5 trillion is $500 
billion.
    So, how do you manage a multi-trillion dollar Federal Government 
with literally hundreds of agencies and departments? First, you ask 
each agency: ``what are we trying to accomplish?'' You set measurable 
goals that can be tied directly to the outcome you're trying to 
achieve. And then you work diligently to achieve those benchmarks, 
keeping good track of your money and your data along the way.
    An agency's success will in large part depend on its mission being 
realistic, measurable, and whether it has a role appropriate for the 
Federal Government. HRSA is a $6 billion-a-year agency with the stated 
goal to ``provide national leadership, program resources and services 
needed to improve access to high quality, culturally competent health 
care.'' What do you get when you have an unrealistic and unmeasurable 
goal like this? You get seven out of 21 programs that have been 
measured so far failing when it comes to rating program performance--
that's a third of the programs--and those are only the ones that have 
been measured so far.
    When you're talking about healthcare, the results of inadequate 
performance can mean the difference between life and death. We had a 
hearing a few months ago on another HRSA program--the Ryan White CARE 
Act--the Nation's safety net for people infected with HIV/AIDS. Due in 
part to HRSA decisions, some patients are stuck indefinitely on 
waitlists for drugs that could save their lives--some have even died on 
the waitlists. GAO reported that the government is being overcharged 
for those same life-saving drugs by unacceptable amounts. Backing up 
this finding, the HHS Office of the Inspector General released a report 
last week on HRSA's ``340B'' affordable drug pricing program. The 
report found that 14 percent of purchases were made at prices that were 
higher than they should have been--resulting in $3.9 million in 
projected overpayments during just one month last year. HRSA has known 
about the weaknesses in the 340B program but has never corrected the 
problems. In this and other areas, HRSA has not been accountable.
    Let's take another example. HRSA spends $6.2 million on its ``Stop 
Bullying Now'' campaign, an initiative launched in early 2005 that 
occupies quite a bit of ``real estate'' on HRSA's internet home page. 
The recently updated web page includes a ``stop bullying now'' jingle, 
12 games, 12 ``webisodes'' of short animated stories featuring 
characters that ``just might remind you of people you know'' (and a 
promise for new episodes every couple of weeks) as well as quirky 
cartoon ``experts'' that answer questions about bullying. I don't doubt 
that there are good intentions behind this program, that HRSA wants to 
deter violence and stress in schools. But how does this program fit 
into HRSA's goal of ``ensuring access to culturally competent health 
care for all?'' HRSA's own website lists nearly 30 private groups 
addressing the problem, and a host of other programs at HHS, including 
violence prevention at the Centers for Disease Control and Prevention, 
and mental health programs at the Substance Abuse and Mental Health 
Administration, as well as the Departments of Justice and Education are 
working towards the same goal. I wonder why this campaign even belongs 
at HHS. Duplication and priorities that are out of whack are the 
natural results of poorly conceived mission statements and a lack of 
measurable objectives.
    We could go on. But today we'll be examining two programs in 
particular. First, Healthy Start--a program originally conceived to 
reduce infant mortality. The program is currently going through the 
PART process. Healthy Start was first intended in 1991 as a 5-year 
pilot funded at $345.5 million, and today continues to receive large 
sums of money--about $90 million--$100 million a year since 2000. 
Healthy Start was designed to reduce infant mortality, but has 
floundered in achieving results. It is a great shame for our Nation 
that the United States ranks second worst among developed nations in 
infant mortality rates.
    The second program in the spotlight today is HRSA's National 
Bioterrorism Hospital Preparedness program. The program received low 
PART scores, and the Federal Government has poured over $2 billion into 
this program since it was created in 2002 in the Public Health Security 
and Bioterrorism Preparedness and Response Act in answer to the anthrax 
attacks of the fall of 2001. It's also expected to receive another $474 
million in 2007. The primary purpose of the program is to assist 
communities to develop adequate surge capacity to handle a moderate 
bioterrorism or natural health disaster. Building surge capacity is 
hard, and expensive. In the case of a massive epidemic or a disaster 
with catastrophic casualties, it's likely that no community would have 
``adequate'' capacity, but there's a lot that can be done today to make 
us as prepared as possible. However, with poor oversight, the taxpayers 
have poured in billions of dollars to the program, but there remain 
well-documented wide-spread deficiencies in the capacity, 
communication, coordination, and training elements required for 
preparedness and response in the efforts made so far. This is simply 
unacceptable.
    In addition, the Emergency System for Advance Registration of 
Volunteer Healthcare Personnel (ESAR-VHP), as authorized in law in 
2002, is a critical portion of the Hospital Preparedness program. The 
law required the Secretary to directly develop and implement a 
coordinated national database for the advance registration of health 
professionals for Federal use in case of a nationally declared 
emergency. Without this program, in a disaster situation, when 
volunteer doctors and nurses show up and want to volunteer their 
desperately needed services, they will not be able to do so. Despite 
clear need, with the program authorized after 9/11 and addressed by the 
2002 law, the Department has done stunningly little. Finally, even as a 
program which does not match the requirements of the law, is still in 
the design stage. Officials are simply passively sending funds to 
States to develop their own systems--an approach rife with problems 
that we'll address later today with our witnesses.
    I want to thank our witnesses for being here today and for the time 
they spent preparing testimony. I'd like to quote a man whose work I 
admire--Hank McKinnell, Chairman and CEO of Pfizer Inc., who rightly 
points out in his new book that ``the hopes and dreams of grandchildren 
everywhere depend on us today--since the future they will inherit is 
ours to create.''

    Senator Coburn. I want to thank our guests for being here. 
I would like to recognize Dr. Peter Van Dyck, who is both a 
physician and has a master's in public health. He was appointed 
Associate Administrator for Maternal and Child Health Bureau in 
the U.S. Department of Health and Human Services, Health 
Resources and Services Administration, in 1999. As Associate 
Administrator for HRSA's Maternal and Child Health Bureau, Dr. 
Van Dyck is responsible for a $836 million budget this year. 
The Bureau is charged with promoting and improving the health 
of mothers, children, and families, particularly those that are 
poor who lack access to care. It administers the Maternal and 
Child Health Services Block Grants Programs for the State, the 
Healthy Start Initiative, and the Abstinence Education Program, 
among other programs. Prior to that, he was Senior Medical 
Advisor for 4 years to the Maternal and Child Health and HRSA 
Directors. He is currently Executive Secretary of the 
Secretary's Committee on Infant Mortality.
    Joyce Somsak was appointed Associate Administrator of the 
Healthcare Systems Bureau in the U.S. Department of Health and 
Human Services, Health Resources and Services Administration on 
February 28, 2005. My, that is a long title. As head of HRSA's 
Health Care Systems Bureau, Ms. Somsak oversees $500 million in 
programs and services under the National Bioterrorism and 
Hospital Preparedness Program. The Bureau administers $471 
million in fiscal year 2006 awards to the States to strengthen 
the ability of hospitals and other health care facilities to 
respond to bioterror attacks, infectious disease outbreaks, and 
natural disasters that may cause mass casualties. The Bureau 
also directs programs that oversees the procurement, 
allocation, and transplantation of human organs, tissue and 
bone marrow, manages the Vaccine Injury Compensation Program, 
and administers grants to the States to improve health 
insurance coverage for the uninsured. She served as Acting 
Director for the Vaccine Injury Compensation Program, is 
Director of HRSA's State Planning Grants Program, Acting 
Director of the Division of Transplantation, and is a member of 
the Department of Health and Human Services task force to 
implement the new Medicare Part D drug benefit Medicare 
Advantage legislation.
    I would like to recognize you both in the order in which 
your bios were read. You have no time limit on the amount of 
time. It is just me and you, and so feel free to take off, Dr. 
Van Dyck.

    TESTIMONY OF PETER VAN DYCK, M.D., M.P.H.,\1\ ASSOCIATE 
    ADMINISTRATOR, MATERNAL AND CHILD HEALTH BUREAU, HEALTH 
   RESOURCES AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF 
                   HEALTH AND HUMAN SERVICES

    Dr. Van Dyck. Thank you, Mr. Chairman, and Members of the 
Subcommittee. I am Dr. Peter Van Dyck from the Health Resources 
and Services Administration, the Director for the Maternal and 
Child Health Bureau in the Department of Health and Human 
Services. I want to thank you for the opportunity to testify 
today concerning responsible resource management at HRSA, the 
Nation's health access agency.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Van Dyck appears in the Appendix 
on page 29.
---------------------------------------------------------------------------
    Today, I will concentrate my remarks on the Healthy Start 
Program, one of the programs in the Maternal and Child Health 
Bureau and one about which I am very proud to represent.
    In the late 1980s, a national concern about persistently 
high levels of infant mortality led to a number of efforts to 
address this problem. Although infant mortality rates have 
declined over time, the rate of decline had slowed by the 
middle 1980s, and relative to other developed nations, the 
United States' ranking had slipped. Even more alarming was the 
racial disparity in infant mortality rates. Black infants in 
the 1980s were more than twice as likely to die their first 
year of life than white infants.
    A White House study then recommended the development of a 
major initiative to mobilize and coordinate the resources 
available in selected communities and to demonstrate effective 
approaches to reduce infant mortality. Concerned about this 
persistent high rate of infant mortality, President George H.W. 
Bush created the Healthy Start Initiative to fund 15 projects 
in areas both urban and rural where the infant mortality rates 
were 1.5 to 2.5 times the national average, and so the Healthy 
Start Demonstration Program began as a demonstration program in 
1991.
    Each year in the United States, about four million women 
give birth. Most have safe pregnancies and deliver healthy 
infants, but some women give birth too early, they see their 
babies die soon or after birth, or die themselves in pregnancy-
related deaths. These difficulties continue to occur in greater 
numbers among women who are members of racial and ethnic 
minority.
    According to the most recent available data from CDC's 
National Center for Health Statistics, the national infant 
mortality rate in 2003 was 6.9 deaths per 1,000 live births and 
the racial and ethnic breakdown was 14 deaths per 1,000 live 
births for black infants, 5.9 per 1,000 for Hispanics, and 5.7 
per 1,000 for whites.
    Healthy Start began with a 5-year demonstration phase to 
identify and develop community-based system approaches to 
reducing infant mortality and improve the health and well-being 
of women, infants, children, and their families. Since its 
inception, Healthy Start has been located in HRSA. It was 
originally funded under the authority of Section 301 of the 
Public Health Services Act and most recently authorized as part 
of the Children's Health Act of 2000.
    Healthy Start was founded on the premise that communities 
can best develop and implement the strategies necessary to 
eliminate the factors contributing to infant mortality, low 
birthweight, and other adverse perinatal outcomes among their 
own residents, especially among populations at high risk. 
Healthy Start communities form local coalitions of women, their 
families, health care providers, businesses, various public and 
private organizations, all working together to address 
disparities in perinatal health. Every Healthy Start site is 
guided by its consortium. Local residents are recruited, they 
are trained and employed as case managers and outreach 
providers.
    HRSA provides the Healthy Start communities with national 
leadership in planning, directing, coordinating, monitoring, 
and evaluating the implementation of the various Healthy Start 
programs throughout the country. Specifically, the national 
program collects and analyzes information regarding the Healthy 
Start projects, provides program policy direction, technical 
assistance, and professional consultation on Healthy Start 
activities. It obviously administers the grants and contracts 
and serves as a focal point within the Department for Healthy 
Start.
    The program now reaches 96 communities in 37 States, the 
District of Columbia, and Puerto Rico, and each of these 
vulnerable communities receives funds but has suffered from 
poor perinatal outcomes or an infant mortality rate in one or 
more racial, ethnic, or geographically disparate populations 
that is at least 1.5 times the national average.
    While each Healthy Start project is unique as its community 
setting, there are certain hallmarks of all Healthy Start 
projects. Healthy Start was one of the pioneers in the use of 
women living in the community as outreach workers and home 
visitors. The approach achieves several things. It saves money, 
pregnant women respond better to other community-based women 
who have walked in their shoes, so to speak, and it has 
provided real and meaningful jobs to hundreds of unemployed or 
under-employed women in vulnerable communities.
    Healthy Start communities do not stop helping to build 
healthy families when a healthy baby is born. They stay with 
the mother, the baby, the whole family for 2 years, monitoring 
the baby's growth and development, ensuring the mother's health 
and safety so that each new family is assured a Healthy Start.
    These projects have been forward-thinking in their 
recognition that there can be both physical and psychological 
threats to a mother's health before, during, and after 
pregnancy, and they are particularly focused on identifying and 
treating perinatal depression. Part of what all Healthy Start 
projects are funded to do is to help their communities build 
and strengthen the medical, social, and psycho-social resources 
available to the women and their families. These projects are 
actively engaging mothers, babies, and families through these 
crucially important first 2 years of the child's life. These 
years are critical, as we know, because any difficulty in a 
child's development can be uncovered and addressed early, and 
the child's parents can be most readily engaged in positive 
parenting techniques that will result in optimal development 
and adjustment.
    Just as important, Healthy Start programs begin with a 
fundamental precept that it is important to make sure that the 
mother has a medical home and that she is followed along with 
her infant to improve her health through risk reduction and 
health education. Good interconceptional care for women can 
make a subsequent pregnancy less risky for both mothers and 
babies.
    Throughout the history of this program, it has been 
monitored by an independent council known as the Secretary's 
Advisory Committee on Infant Mortality, and the initial program 
design included a rigorous national evaluation. This 
evaluation, the first one for Healthy Start, was released in 
2000. It used matched comparison communities, Healthy Start 
communities to non-Healthy Start communities, and to the 
original 15 Healthy Start program communities. The evaluation 
revealed several statistically significant differences.
    More than half of the Healthy Start communities had 
improved adequacy of prenatal care. Four Healthy Start 
communities had declines in the pre-term birth rate. Three had 
reductions in the low birthweight rate. And two had declines in 
the infant mortality rate in the first 5 years of greater than 
50 percent. The evaluation also found that Healthy Start 
projects were more effective in enrolling high-risk women into 
prenatal care and that the community-based interventions which 
Healthy Start uses may have longer-term impacts on future 
health and well-being of women and their families that have not 
yet been measured in the first years just surrounding that 
individual birth.
    A major result of the first national evaluation was that 
using its findings, coupled with recommendations from the 
Secretary's Advisory Committee, HRSA was able to reshape the 
Healthy Start program to reflect what had been found to be most 
effective in that first rigorous evaluation.
    Committed to implementing evidence-based practices and 
innovative community-driven interventions, Healthy Start works 
with individual communities to build upon their own local 
assets to improve the quality of health care for women and 
infants at all service levels. At the service level, beginning 
with direct outreach from community health workers to women at 
high risk, Healthy Start projects ensure that the mothers and 
infants have ongoing sources of primary and preventive health 
care and that basic needs--housing needs, nutritional needs, 
psycho-social needs, educational needs, and job skill 
building--are met. Following risk assessments and screening for 
perinatal depression, case management provides linkages with 
needed services and health education for risk reduction and 
prevention.
    Getting women into prenatal care in the first trimester of 
pregnancy, or as early as possible, is critical since we know 
that prenatal care is critical to improving birth outcomes. 
Healthy Start has made proven impacts on participants' access 
to prenatal care. In 1998, participants' first trimester entry 
into prenatal care was only at 42 percent. By 2003, 5 years 
later, this number had risen to 71.4 percent, an increase of 73 
percent across all Healthy Start sites in 5 years.
    One of the first 15 sites, Washington, DC, reported for the 
year 2000 its lowest infant mortality rate ever, and in that 
same year, no babies born to Healthy Start clients died. 
Central Harlem is another example of a Healthy Start success 
story. The infant mortality rate there has dropped 
significantly since its project began in 1991, when in 1991 
there were 27.7 infant deaths per 1,000 live births. By 2003, 
10 or 11 years later, the rate had dropped to 7.3, from 27.7 to 
7.3 per 1,000 births, a 273 percent decline.
    Other locations have had real success in reducing low 
birthweight. In Baltimore, for example, the percentage of very 
low birthweight babies is 2 percent among participants with 
single births enrolled in Healthy Start. Ninety-nine percent of 
those clients are African American. That 2 percent compares to 
a 3.7 percent rate, almost twice, of very low birthweights 
among African American women throughout the rest of the city 
who are not in a Healthy Start site.
    President Bush has asked for $101.5 million for Healthy 
Start in his fiscal year 2007 budget, an amount equal to the 
2006 appropriation.
    I am proud to represent the Healthy Start program. Thank 
you for this opportunity and I will be happy to respond to your 
questions.
    Senator Coburn. Thank you, Dr. Van Dyck. Ms. Somsak.

 TESTIMONY OF JOYCE SOMSAK, M.A.,\1\ ASSOCIATE ADMINISTRATOR, 
   HEALTHCARE SYSTEMS BUREAU, HEALTH RESOURCES AND SERVICES 
  ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Ms. Somsak. Good afternoon, Dr. Coburn.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Somsak appears in the Appendix on 
page 36.
---------------------------------------------------------------------------
    Senator Coburn. Good afternoon.
    Ms. Somsak. Mr. Chairman, I am Joyce Somsak and I am the 
Associate Administrator of the Healthcare Systems Bureau in the 
Health Resources and Services Administration in the Department 
of Health and Human Services.
    Senator Coburn. Like I said, it is a long title.
    Ms. Somsak. It is a long title. At least I was able to drop 
``acting'' off of one of those.
    Senator Coburn. That helps.
    Ms. Somsak. Thank you for the opportunity to testify today 
concerning responsible resource management at HRSA, which is 
our Nation's health access agency. The specific program that I 
have been asked to talk about today is the Bioterrorism 
Hospital Preparedness Program.
    HRSA recently announced the latest round of grants for this 
program. This is the fifth consecutive year that we provided 
funding for the program, which was created after the terrorist 
attack of September 11.
    Since then, the program has delivered over $2 billion to 
hospitals and health care systems in all 50 States as well as 
five territories, three freely associated States, and four 
large metropolitan areas, New York City, Chicago, L.A. County, 
and Washington, DC. This year, HRSA will be awarding $460 
million to all these jurisdictions to strengthen the ability of 
hospitals and other health care facilities to respond to 
bioterror attacks and other public health emergencies. 
Hospitals play a critical role in both identifying and 
responding to any potential terror attack or infectious disease 
outbreak.
    During the first 4 years of the program, States used grant 
funds to develop surge capacity to deal with mass casualty 
events, such as expanding the number of hospital beds and 
developing isolation capacity at hospitals. Other priorities 
included identifying additional health care personnel who could 
be called into action in the event of an emergency as well as 
establishing hospital-based pharmaceutical caches for hospital 
personnel and associated EMS.
    Recipients also used the funds to increase coordination of 
disease reporting among hospitals, local and State health 
departments, and to improve coordination and communication 
between public health laboratories and hospital-based 
laboratories.
    Jurisdictions were required to improve their ability to 
provide mental health services, to strengthen trauma and burn 
care, and to increase their supplies of personal protective 
equipment and pharmaceuticals. Money could also be used to 
support training, education, drills, and exercises.
    This year, the program's focus is turning to efforts to 
improve the capability of the local and regional health care 
systems to manage mass casualty events and to integrate 
preparedness activities across disciplines and agencies. The 
goal is to ensure that each jurisdiction has a system in place 
that will result in fewer deaths, long-term disabilities, and 
required hospitalizations.
    Progress has been made in getting the funds to local health 
care systems. In the early stages of this program, there were 
some difficulties in quickly expending the large infusion of 
funds because State health departments were not set up quickly 
to establish such large grant programs, and also the capacity 
for the States to pass money on to the hospital systems did not 
exist because this was a new activity.
    States have cited three main reasons for initial delays. 
Some State Governments were either reluctant or found it 
difficult to quickly hire the necessary staff to operate the 
programs. Due to procurement processes at the State level, 
delays were encountered in trying to award contracts to 
hospitals. And before disseminating funds to hospitals, they 
were required to conduct a state-wide needs assessment of their 
ability to respond to a bioterrorist event, infectious disease 
outbreak, or other public health emergency. These three 
barriers have diminished with time and States are now reporting 
greater success at getting funds to their local health care 
systems.
    This program has built upon the needs assessments and 
implementation plans developed by the State grantees during the 
previous years and the updates of these plans from fiscal year 
2003 to fiscal year 2005. Proposals are approved and funded in 
accordance with preparedness priorities developed by the 
States. Information on the improvements in the hospitals' 
capacity to respond to public health emergencies in general and 
to bioterrorism in particular is part of the progress reports 
that are submitted by the States and other grantees.
    Part of this program is the Emergency System for Advance 
Registration of Volunteer Health Professionals, or as that 
wonderful acronym we call ESAR-VHP----
    Senator Carper. Can you say that one again?
    Ms. Somsak. ESAR-VHP. That is one of our more interesting 
acronyms. This program focuses on developing the personnel 
component of medical surge and has provided grant funds to 
States for the purpose of establishing a standardized volunteer 
advance registration system that includes verified information 
on volunteer health professional identity, license status, 
certification, and privileges in hospitals and other health 
care facilities. The establishment of these standardized State 
systems will give each State the ability to quickly identify 
and better utilize health professional volunteers in 
emergencies and disasters and will lead to a virtual national 
system that will allow the easy exchange of volunteers across 
States and through the Federal Government, as necessary. The 
value of these state-based registries was demonstrated in the 
aftermath of Hurricanes Katrina and Rita, when 21 State 
registries deployed over 8,300 health professionals to the 
affected areas.
    The National Bioterrorism Hospital Preparedness Program 
focus this year will be to continue to enhance medical surge 
capacity and capability as well as to develop a response 
structure that allows the implementation of a complex health 
and medical response through a single system. Since the 
inception of the program in fiscal year 2002, the program has 
established and awarded cooperative agreements to 62 States, 
territories, and select cities. These agreements have been 
essential for developing and coordinating health care emergency 
response plans at the State, regional, and local level for the 
management of mass casualty events that might otherwise 
overwhelm the system.
    Significant progress has been made by State awardees in 
establishing the plans, developing partnerships, and assessing 
crucial needs and how to address them. The majority of the 
jurisdictions have in place or are finalizing a system to 
receive and distribute pharmaceuticals made available from 
Federal sources, such as antibiotics and smallpox vaccines.
    States are putting mechanisms in place to address the gaps 
in communications systems among hospital emergency departments 
and outpatient facilities, emergency medical systems, and State 
and local emergency management, public health, and law 
enforcement agencies. They are also developing strategies to 
implement MOUs and mutual aid agreements to foster intrastate 
and interstate collaboration in meeting medical needs. These 
include personnel, equipment, supplies, training, and 
exercising.
    You mentioned the PART program before. A PART review was 
done very early in this program, in fiscal year 2004, and we 
received a rating of ``results not demonstrated.'' The 
assessment did indicate that the program had not demonstrated 
results due to its relative newness and the difficulty in 
measuring preparedness for events that do not regularly occur. 
We developed some new measures that focus on medical surge 
capacity. However, these again were developed early in the 
program and the program has evolved since that time.
    We are currently looking to go beyond capacity and work 
toward capability. We believe the best measures of 
effectiveness of the program will be in capability, not just 
capacity. So we are in the process of developing new medical 
surge capability measures. In January of this year, we had an 
expert panel of awardees, hospitals, State hospital 
associations, and the American Hospital Association, academia, 
and others to develop the measures. We have measures now that 
were cross-checked against others, such as CDC's performance 
measures, our targeted national capabilities list, and JCAHO 
standards. We have a national vetting process that is almost 
complete and we expect these new measures to be final in the 
next month. We think these new measures will be better in terms 
of determining that our Nation's hospitals are prepared to 
handle emergencies.
    Health and Human Services Secretary Mike Leavitt recently 
announced the funding for the preparedness program. His 
statement in the announcement was, ``Improving our Nation's 
response to health care emergencies is an important part of 
securing America. All emergency incidents--whether naturally 
occurring, accidental, or terrorist-induced--begin as local 
matters, and with this program, States and communities will 
build on the preparedness gains they have made over the past 4 
years.''
    Thank you for this opportunity to testify.
    Senator Coburn. Thank you very much. Welcome, Senator 
Carper.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. I have no opening statement. I am just 
delighted that our witnesses are here. I am glad I can stop by 
and join you for a while, and thank you for coming. I would 
like to have a chance in a minute or two to ask a--well, not in 
a minute or two, but later on, I will ask a couple of 
questions. [Laughter.]
    Senator Coburn. Thanks. We are just going to go through 
some things.
    Dr. Van Dyck, how many total women per year are impacted by 
Healthy Start?
    Dr. Van Dyck. Depending on the year, it is in the range of 
16,000 to 18,000 to 20,000 babies born a year in the Healthy 
Start program. There would be a few more women than that 
because it takes 9 months to have a baby and you follow the 
women whether or not they are successful at their pregnancy and 
you follow them for a while after, so the number of pregnant 
women would be somewhat more than the number of births.
    Senator Coburn. So around 20,000 lives impacted plus 
children, so you really have 40,000 lives, is that right?
    Dr. Van Dyck. At least.
    Senator Coburn. Yes.
    Dr. Van Dyck. Correct, and again, we cannot forget if there 
is a sibling that is 1 year old----
    Senator Coburn. That is getting some impact.
    Dr. Van Dyck [continuing]. And when that baby gets care and 
immunizations.
    Senator Coburn. Thank you.
    Dr. Van Dyck. There may be another family member that gets 
care. So we serve more than that.
    Senator Coburn. Just some old housekeeping. I sent you a 
letter--and you probably do not even recall this letter, I 
never got an answer to it--in 2000 on the Ryan White and 
Healthy Start on testing for HIV. What is Healthy Start and 
Maternal Child's position now for neonatal testing of newborns 
whose mother's status is not known?
    Dr. Van Dyck. Healthy Start women, if appropriate, get 
tested for HIV.
    Senator Coburn. What about their children?
    Dr. Van Dyck. The children will also, depending on the 
local sites. It is recommended, but depending on the local 
sites' particular policies.
    Senator Coburn. So we do not condition any grants on a 
totally curable and preventable disease at birth to test 
infants whose mother's status is not known?
    Dr. Van Dyck. The grants are not conditioned on that. There 
are recommendations that are done.
    Senator Coburn. And what percentage of this 20,000 are 
there infants tested or their mother's status known?
    Dr. Van Dyck. I do not know the answer to that.
    Senator Coburn. You do agree with the medical practice. The 
fact is if a child is treated early or treated during the 
intrauterine----
    Dr. Van Dyck. Absolutely.
    Senator Coburn [continuing]. We can eliminate 90 percent of 
it.
    Dr. Van Dyck. Absolutely.
    Senator Coburn. And a mother's status being known, even 
though the child might not test positive, if they are positive, 
breast feeding can lead--which is encouraged in Healthy Start--
can lead to infection in the infant.
    Dr. Van Dyck. Absolutely, and we also know that a negative 
test at the beginning of pregnancy does not mean a negative 
test----
    Senator Coburn. That is right.
    Dr. Van Dyck [continuing]. Later on in pregnancy, either, 
and these are highly recommended----
    Senator Coburn. Interpartum testing is an important aspect 
of pregnancy and delivery, and I was just wondering why we 
would not require that as a part of these grants.
    Dr. Van Dyck. That is a policy we would have to review.
    Senator Coburn. Knowing that one out of every three people 
who is infected with HIV in our country do not know it.
    HRSA has had a PART evaluation, that is true, correct?
    Dr. Van Dyck. Healthy Start?
    Senator Coburn. Yes, Healthy Start and Maternal Child, is 
that correct?
    Dr. Van Dyck. The Maternal and Child Health Block Grant had 
a PART review the first year, 5 years ago. Healthy Start just 
has had a PART review and it is not posted or finished yet.
    Senator Coburn. OK.
    Dr. Van Dyck. We have completed the review.
    Senator Coburn. I am fully supportive of the goals of 
Healthy Start and Maternal Child, so as I question you, it is 
not that I do not support the goals of the program and I want 
you to bear that in mind. What are the metrics that you use in 
Healthy Start for grants? In other words, what are the controls 
and measurements and outcomes to know in the grants that we 
are, in fact, for the amount of money, $5,000 per individual, 
that is the best way to spend the money, and what percentage of 
that $5,000 per individual actually gets to care, to treatment?
    Dr. Van Dyck. First, the $5,000 per individual, that might 
be per birth, but not per individual, if you will allow me----
    Senator Coburn. But the per woman treatment. Let us use it 
as per woman treatment.
    Dr. Van Dyck. Per family unit.
    Senator Coburn. OK.
    Dr. Van Dyck. Just to not understate it. We have a number 
of performance measures that have been used for a number of 
years. The first is to reduce the infant mortality rate among 
the Healthy Start program participants, and our long-term goal 
for 2013 is to reduce it to 4.28 infant deaths. To give you an 
idea, and we have been following this since the beginning of 
the program, in 1991 to 1993 when the program first began in 
those 15 communities, the rate averaged around 20. In 2000, it 
was 13.9. In 2003, it was 11. In 2004, it was 7.65.
    Senator Coburn. So each one of these grantees have to 
return all this data to you?
    Dr. Van Dyck. Yes, sir.
    Senator Coburn. It is a component of the grant?
    Dr. Van Dyck. That is a requirement, and that is infant 
mortality. So not only do they have to return it, but we 
aggregate--we review each Healthy Start project against these 
performance measures----
    Senator Coburn. So what----
    Dr. Van Dyck [continuing]. So aggregate it, as well.
    Senator Coburn. So what happens if somebody is not 
performing right now?
    Dr. Van Dyck. Well, we work with them and we will send out 
technical assistance and we will review the grant again and we 
will review what they are doing.
    Senator Coburn. And so who has lost a grant?
    Dr. Van Dyck. No one has lost a grant that I can remember, 
and I can check on this, from poor performance.
    Senator Coburn. But that does not mean there has not been 
poor performance.
    Dr. Van Dyck. It does not mean there has not been 
performance that needs improvement. But the Healthy Start sites 
have improved.
    Senator Coburn. A key finding from the 2000 mathematical 
review of Healthy Start found that even after the program had 
been around for several years and ``despite considerable 
investment, programs were unsuccessful in developing a 
management information system that would allow for the ongoing 
tracking of service receipt by clients. Client-level data were 
of poor quality and were of limited use for program monitoring 
and for evaluation purposes.'' What has changed since then? 
That is the first part of my question.
    And the second is the independent review that is ongoing 
now, and I understand the close-knitness of holding this close 
to the vest because of a history of people who let things out 
to hurt you in the past that were not necessarily in a balanced 
perspective, but since the early one, there have been two 
reports released in 2000 that came out of the early report. I 
understand there is currently another full independent review 
being conducted by Apt Associates at a cost of around $4 
million for a full 3-year phased study that is in the final 
clearance at HRSA. You all denied us the ability to see that, 
which will necessitate us after we see it having another 
hearing. Can you update us on this particular review? Why was a 
report needed? When is it expected to be released, and what is 
it expected to contain?
    Dr. Van Dyck. This Healthy Start evaluation by Apt 
Associates is a 4-year study. The first 2 years are to get a 
better idea about what are the features of the Healthy Start 
projects across communities, what results have the projects 
achieved, and are there intermediate outcomes that would be 
helpful. Is there an association, then, between what elements 
the Healthy Start programs include in their programs and 
outcomes, and then how does that all fit together in improved 
outcomes.
    There are two phases to the program. The first phase is 
what has just been completed and the document is in clearance, 
and that is an analysis of all 90-plus Healthy Start sites, how 
they serve people, what the elements are in their service 
package. That is in clearance currently as we speak and should 
be, I would hope, cleared within the next several weeks.
    The second phase of the project is on the outcomes, and 
that is a smaller project designed to look at eight to ten 
particular Healthy Start sites against the findings in the 
first half of the evaluation to really tie together the 
practices, features, and elements that the Healthy Start site 
has implemented against the outcomes to see if there is a 
relationship between those elements and the outcomes, but in 
addition, to see if there is any evidence that particular 
elements have a greater impact on the outcome than others, and 
we suspect that may be the case. So this would allow us to 
tailor the programs much more succinctly.
    Some preliminary results, just to give you an idea of the 
type of results that are in this first piece of the outcome, or 
the evaluation, are that 100 percent of the Healthy Start 
projects have elements that include health education and 
training to their participants. Ninety-nine percent of the 
Healthy Start projects have identified strategies for 
addressing the disparities in their particular population. 
Again, these are features of the program, and 97 percent of 
them have implemented these strategies. That gives you a flavor 
for the types of findings, the description of the elements and 
the number of Healthy Start sites that have those elements 
within them.
    Senator Coburn. What about the earlier review where they 
were talking about the data being of poor quality and limited 
use to do any program analysis?
    Dr. Van Dyck. The Healthy Start program began in 1991 and 
there was a real attempt made in the first 15 projects and in 
those early years to develop a data system for those projects 
which was uniform across the projects and would collect 
information such as I described that would allow you to measure 
outcomes. It was not very successful and it was changed to 
rather let us tell the Healthy Start sites what data we want to 
reach which outcomes and let them develop the system that best 
meets those needs for them, because many of them tie into 
universities----
    Senator Coburn. I cannot be critical of that. That is a 
good approach to doing it.
    Dr. Van Dyck. And so now we do have good data and almost 
all Healthy Start sites have a data system that can allow us 
access to individual data.
    Senator Coburn. If you were just divorcing yourself away 
from the importance of what Healthy Start is about and the 
maternal-child function and you sit and say, the $5,000, that 
does not count prenatal care. That does not count delivery 
costs. That is the cost. The question I have for you is how do 
we get more benefit? Instead of having 96 sites, how do we have 
180 sites with the same amount of money accomplishing the same 
thing? In other words, how much money is spent on administering 
Healthy Start versus actually making the difference and how do 
we lessen that so we get this greater coverage with the same 
amount of money?
    Dr. Van Dyck. The Healthy Start legislation has limits on 
both evaluation and administration. Healthy Start law says we 
may spend up to 1 percent of the budget on evaluation. We spend 
a little less than that, but these are important national 
independent evaluations which are the elements that get us a 
decent PART score. I think I can assure you that our PART score 
will be quite positive.
    Senator Coburn. Right. That is what we want.
    Dr. Van Dyck. But OMB requires an independent evaluation 
and that is what this pays for. So up to 1 percent of the money 
each year can be used for an independent evaluation. No more 
than 5 percent can be used for technical assistance, 
administrative kinds of costs, and so we stay under that 5 
percent. So we have somewhere between 94 and 95 percent being 
spent on programs.
    Senator Coburn. OK. Per family unit that you are impacting, 
we are spending $5,000 to impact in terms of postnatal care, 
pediatric care, parental training, diet, prenatal nutrition----
    Dr. Van Dyck. Right.
    Senator Coburn [continuing]. All those things. We are 
spending $5,000 per unit. The question I would ask is, how do 
we get that cost lower so we cover more people?
    Dr. Van Dyck. Well, there are probably several ways. One is 
to look at the results of the evaluations to see which of these 
elements make a difference and which are nice but may not make 
as big a difference and focus more on those.
    Senator Coburn. Let me tell you some personal experience.
    Dr. Van Dyck. Yes.
    Senator Coburn. As you know, I am still delivering children 
on weekends, and routinely when I am in my office, I will get a 
call from somebody from Oklahoma State University and some 
Medicaid patient that I am caring for, they are in their home 
visiting them. They have driven to their home to visit them and 
they are telling me something that I have already told the 
patient that I already know the patient is compliant with, but 
to meet their marker they have to call the physician. That 
makes no sense to me. Now, I do not know if that is in the 
rigors of that particular grant program that is a requirement 
for them to do, but, in fact, if you are given really good 
prenatal care, which I like to think that the group that I was 
formerly associated with did, nutrition is a lot of the 
teaching--what medicines to avoid, what you can take without 
talking to us first. Parenting skills is a part of what you 
talk about. Signs of illness in newborn children, teaching that 
not just to the mother but to other family members that might 
be there.
    I guess my question is I am somewhat amazed that we are not 
treating more with the same amount of money, that it is costing 
$5,000, or 94 percent of $5,000 to do this. And my question to 
you is in terms of having metrics to measure, can we design a 
metric system where you can take this program and instead of 
approaching 20,000 family units, you can approach 40,000?
    There are a couple of reasons why I am asking it, and it is 
not to be critical of what you are doing. It is hard what you 
are trying to do. If somebody said you were king tomorrow and 
you could make everybody do it, you could do it a lot cheaper, 
I understand that, and you would not have to go through 
different universities and all these other different things. 
But this program is not going to get increased in terms of 
dollars. We are on the downward trend of shrinking every 
program we have just to be able to pay for the major programs 
that are out there and pay the interest.
    So my question really goes and my charge to you is set up 
the metrics in a way where we can become much more efficient 
with the program, so we get two families for $5,000. And in 
terms of infant mortality, what will that mean? If you are 
lowering it 30 or 40 percent in these areas, then you are going 
to lower it 30 or 40 percent in other areas if we do that, and 
so the overall accomplishment of the goal will be that--I will 
stop now because I know Senator Carper has some other time 
constraints and I will come back.
    Dr. Van Dyck. May I respond, please?
    Senator Coburn. You bet.
    Dr. Van Dyck. Yes. So I agree. The evaluation is one way to 
determine which elements are most efficient and effective. But 
we also do other things. We have community well baby clinics, 
where there may be 10 mothers together with their newborn 
babies getting a well baby visit or a well baby educational 
session, making that much more efficient. We use community 
workers or doulas extensively to bring women in to keep their 
appointments, to make sure that they come when they are 
scheduled and the time is not wasted and that they do 
everything that is necessary at that visit--seeing the 
dietician or the nutritionist or the social worker or the 
psychologist and physician or the nurse, so they do not have to 
come back on the interim, or get their lab work at the same 
time.
    So there are many elements like this that I think we really 
do, and as far as the metric, we do have an efficiency measure 
which has been in effect since 2002 which is the number of 
persons served with constant funding. In 2002, it was 289,000. 
In 2004, the baseline was 367,000. And our target for 2008 is 
410,000.
    Senator Coburn. So you are growing the number of 
population.
    Dr. Van Dyck. So this is a metric for Healthy Start of 
efficiency that we worked out with OMB to try to show that we 
can serve progressively more people to a point with the same 
number of dollars.
    Senator Coburn. One final comment before I turn it over. 
There is the case management technique that is being used in 
North Carolina on Medicaid parents. There is case management 
for the severely disabled, where they have an advisor that 
helps them manage it and it is not through the program, it is 
independent. Have you all looked at that to say, maybe we could 
do this better by just assigning case managers and Medicaid to 
accomplish the same goal?
    Dr. Van Dyck. All these women have case managers or care 
coordinators and they work in making the plan for that woman 
and making sure her visits are efficient and timely and go get 
her if she is not there. And so we do use case managers, and in 
fact, some of them might be modeled after the Baby Love Program 
in North Carolina, which is the EPSDT program for case managers 
through EPSDT.
    Senator Coburn. All right, thank you. Senator Carper.
    Senator Carper. Thanks, Mr. Chairman. I want to just follow 
up, if I could. Ms., is it Somsak?
    Senator Coburn. It is a Delaware name. I wanted you to know 
that. [Laughter.]
    Senator Carper. I wanted to ask Dr. Van Dyck a couple more 
questions, if I could, and if time allows it, I would like to 
come back to you for a question.
    Dr. Van Dyck, you were just giving some responses to our 
Chairman with respect to the number of folks served. Would you 
just repeat those again?
    Dr. Van Dyck. In 2002, it was 289,000, rounded. In 2004, 
367,000. So when I said earlier that the number of babies born 
does not truly reflect the number of clients seen in the 
program, this gives an indication of that. There are family 
members, other siblings, fathers who are all involved in this 
process, and there are many women that may come and end up not 
pregnant who still have been seen and evaluated. So, it is a 
significant impact.
    Senator Carper. And the level of funding between 2002 and 
2004, how does one compare it with the other?
    Dr. Van Dyck. Funding in 2002 was $99 million, and the 
funding in 2006 is $101.5 million.
    Senator Carper. So it is basically flat?
    Dr. Van Dyck. So it is basically flat.
    Senator Carper. The quality of the service--you are 
providing service for more people. Are you providing comparable 
service? How do you evaluate the success of the care that you 
are giving, the service you are providing, the quality of the 
service that you are providing for all those people?
    Dr. Van Dyck. Quality is extremely important to us and we 
think if we lower the infant mortality rate, we decrease the 
low birthweight rate, and I might add that Healthy Start has 
decreased the low birthweight percent in Healthy Start clients 
really significantly.
    Senator Carper. How so?
    Dr. Van Dyck. In 1998, it was 12.1 percent of all babies 
born in Healthy Start were low birthweight, and in 2004, it was 
9.3 percent.
    Senator Carper. Say those numbers and dates again.
    Dr. Van Dyck. In 1998, the low birthweight was 12.1 
percent. And in 2004, it was 9.3 percent.
    Senator Coburn. Would you care if I interject?
    Senator Carper. No, go ahead.
    Dr. Van Dyck. In the Nation, the low birthweight percent 
has increased for the last 15 years. We are not being 
successful in the Nation of reducing it, yet in Healthy Start, 
we are.
    Senator Coburn. Those statistics are only important if you 
ferret out pre-term delivery, because the only way you measure 
low birthweight infants is to look at term infants who are low 
birthweight versus pre-term infants, and what are the numbers 
on those?
    Dr. Van Dyck. These are----
    Senator Coburn. That is where you know whether you are 
making a difference.
    Dr. Van Dyck. I do not have that in front of me.
    Senator Coburn. But you will admit, it is important. Pre-
term delivery----
    Dr. Van Dyck. It is important for pre-term birth and low 
birthweight----
    Senator Coburn. You bet, and I understand all the 
ramifications, but if you----
    Dr. Van Dyck. And they run together----
    Senator Coburn [continuing]. Combine the statistics 
together, you cannot measure what you are really doing. We want 
to eliminate pre-term deliveries, which are much greater risk 
for children than a term infant that is low birthweight.
    Dr. Van Dyck. Correct.
    Senator Coburn. And so what we want to try to do is if we 
had to pick which one do we want to excel in, it is pre-term 
deliveries.
    Dr. Van Dyck. Right.
    Senator Coburn. I will not go into all the reasons for 
that, but there are a lot of reasons in our society today why 
we have that.
    Dr. Van Dyck. And that is true, and we have also decreased 
the pre-term delivery rate, and that has also gone up 
nationally.
    Senator Carper. In the State of Delaware, 15 or so years 
ago, there was a time that Mike Castle was our Governor--the 
fellow who served with our Chairman in the House for a while--
but Delaware had maybe the highest rate of infant mortality in 
the country. In his administration, he went to work on it. I 
succeeded him as governor. We worked on it again. We have a new 
Governor who is mindful of this, but we are seeing our infant 
mortality numbers, which had dropped, beginning to rise again 
and they are now at levels that are alarming in our little 
State.
    If you look at, and you mentioned the incidence of low 
birthweight babies being born, we have a lot of those for our 
State, and in a State with a fairly high level of income. We 
are not a poor State by any stretch of the imagination.
    We used to have a Healthy Start program in Delaware and I 
think it went away, I want to say maybe in 2004. Is that 
correct?
    Dr. Van Dyck. Two-thousand-and-one.
    Senator Carper. Two-thousand-and-one. I know the State has 
been interested, and especially as we have seen our incidence 
of low birthweight babies rise and as we have seen infant 
mortality again having dropped to turn around and head back up, 
there is a significant interest in the State of Delaware having 
a Healthy Start program again. Could you give us some guidance 
as to how we ought to proceed to get a program again in our 
State?
    Dr. Van Dyck. Healthy Start has a competitive grant cycle. 
That cycle was competitive this last year, and so these grants 
are awarded for a period of, I believe, 4 years. So there will 
be another competition coming up in about 3 to 4 years, unless 
we get more money. Then we can have a new competition. 
Otherwise, these are the grants that will be in effect for the 
next several years.
    Senator Carper. All right. Can you give us some guidance? I 
do not know how often it is that States or programs are in 
existence and they are not funded or States reapply and they 
are not approved. What are the common reasons why States that 
might have a program do not continue to have a program, why 
they go away?
    Dr. Van Dyck. There is a lot of competition for the Healthy 
Start grants, as you might imagine.
    Senator Carper. You said there is a lot of competition. 
Give me some idea of what----
    Dr. Van Dyck. There may be two to three times as many 
applications as can be funded with the money.
    Senator Carper. OK.
    Dr. Van Dyck. One reason might be that the site has 
improved enough, lowered their infant death rate enough that 
they become ineligible for the grant and allow us to put 
somebody else into the competition or award a grant in an area 
that has worse, or less good, numbers.
    Another might be--and again, these are reviewed by an 
independent review process--may be that the consortium that is 
built with the community folks does not meet the requirements. 
It could be that the partners that have been assembled to 
deliver the care and to provide this seamless network of care 
for the pregnant woman and her baby does not provide enough of 
that network. It could be that the grant just is not written 
well enough for the grants committee to get the essence of 
local communities' needs. It can be any of those or all of 
them.
    Senator Carper. In our State, it sounds like in order for 
us to get back into the game, we have to be ready 3 years from 
now?
    Dr. Van Dyck. Yes.
    Senator Carper. OK.
    Dr. Van Dyck. And we can offer technical assistance to make 
sure that there is an understanding about the guidance and all 
the rest.
    Senator Coburn. Is there a reason that this was not a 
staggered grant process?
    Dr. Van Dyck. Well, the money became available at one 
time----
    Senator Coburn. So you started on----
    Dr. Van Dyck [continuing]. And in order to spend the money, 
you have to start to spend the money----
    Senator Coburn. I have got you.
    Dr. Van Dyck [continuing]. Because the money becomes 
available.
    Senator Carper. The last question I have, if I could, I 
missed your testimony and let me just ask for just one or two 
points you really want us to take away from here in terms of 
what you think are important. Then I am going to ask the same 
question of Ms. Somsak.
    Dr. Van Dyck. Well, there is a real need with an infant 
death rate in the Nation that is twice in African Americans 
what it is in whites--actually, more than twice--a Hispanic 
rate that is higher, and pockets of people who have 
significantly higher infant mortality and low birthweight or 
pre-term birth rates and lack of prenatal care, there are those 
significant areas that Healthy Start seems to be able to make 
an improvement in when they get a grant and they can stay with 
it for 4 or 5 years.
    We just need to make that need known, because there are 
other areas that do not get funding, as you have suggested, 
where we could make a difference in the infant mortality rate. 
Healthy Start has proven successful. We are getting more 
efficient. We are decreasing numbers and we are doing 
independent evaluations and making them public. We could always 
move faster, but we think we are on the right track.
    Senator Carper. Good. Thanks very much.
    Ms. Somsak, just briefly, if you could just summarize one 
or two major points that you want us to take away.
    Ms. Somsak. Sure. I think the goal of the program, of the 
Healthcare Preparedness Program, is to improve the health care 
deliver at the hospital level, at the primary, the health care 
level where patients are likely to be seen. We need to do that, 
to be able to have them respond in emergency situations where 
there is a terrorist attack or an influenza outbreak. That 
capacity has to exist at the hospital level. That is where our 
funds go for the preparation.
    The first few years of the program, we have worked on 
increasing the medical surge capability, the infrastructure, 
creating the equipment, creating the capacity to increase beds 
on short notice, training the personnel to be able to respond. 
Now we are moving towards, in the next few years, moving from 
just a focus on increasing capacity to making sure there is 
demonstrated capability. So that is the thing we have to be 
able to really assure, not just that you have the capacity, but 
when there is an emergency, can you activate the personnel you 
need? Can you demonstrate this in emergencies?
    And we have seen it, not in drills, but we have seen it in 
a situation where there has been a chlorine tanker overturned, 
in South Carolina, and we have seen it in some workers who were 
crop dusted. They were really concerned. They were 
decontaminated in a facility. We have seen it with Hurricane 
Katrina, where we were able to mobilize personnel from across 
States in an emergency situation. So this is the kind of thing 
that this program really does, and it does it at a hospital 
level. It works in coordination with State and local health 
departments, but it is unique in terms of the hospital-level 
capacity that it works on.
    Senator Carper. Good. Thanks, and thank you both.
    Senator Coburn. And we will leave the record open so you 
can ask additional questions if you want.
    Senator Carper. Thank you.
    Dr. Van Dyck. The number of pregnancies remained about the 
same.
    Senator Coburn. So the expansion has not been in pregnant 
women, but in their family members, in those numbers?
    Dr. Van Dyck. It has been in the people surrounding the 
pregnant woman. And we think that is an important element in 
improving the care of that particular pregnant woman.
    Senator Coburn. Well, I would not disagree. Is it more 
important than enrolling more pregnant women, though? That is 
the question to ask, not the other one.
    I also note in the President's budget justification, which 
I assume you were involved in, that your targets are static, 
both in terms of first trimester prenatal care and low 
birthweight, and my question is why? I mean, you are making 
some progress. You have gone from 10.5 to 9.3 percent, but you 
keep a target that is 10.5 percent. Why wouldn't we want to go 
to 8 percent as a target? Why wouldn't we want 95 percent of 
all the women getting first trimester prenatal care? It is page 
370 of the President's justification, and you can answer that 
later, if you would rather.
    Dr. Van Dyck. I do not have the same pages you have. We do 
have additional performance measures other than the infant 
mortality, one being entrance into prenatal care, and our 
target for 2007 is 70 percent. Our target for 2008 is 75 
percent. And so in our performance measurement system, we do 
have an increase in target. The actual number in 2002 was 69. 
In 2003, it was 71.
    Senator Coburn. And in 2004, 73. In 2005, 75. In 2006, 75. 
In 2007, 75. That is what you submitted in the budget 
justifications to Congress.
    Dr. Van Dyck. Right. So in 2008----
    Senator Coburn. Next, on low birthweight babies, it is 10.5 
percent from 2002 to 2007, and you are below that again. The 
question is, why is the target not lower? If we are going to 
use metrics and the input we have just had, your testimony that 
says, in fact, this is one of the things that really changes 
outcomes, and we know it changes perinatal death rates, why 
would we not up the target?
    Dr. Van Dyck. Well, there may be an overlap between when 
that was written and when the data came in for the performance 
measure----
    Senator Coburn. Fair enough.
    Dr. Van Dyck [continuing]. And you point out something we 
will review, because our metric for the performance measures, 
which are our real measurement, are increasing, or decreasing.
    Senator Coburn. OK. Fair enough. The one thing that has 
bothered me, this last year, you gave out three new grants and 
we had something like 233 applications. The only thing that 
bothered me in what you said is your PART score is going to be 
good now. It was not in the past, and yet----
    Dr. Van Dyck. No, I did not say it was not in the past. We 
have not been PART-ed before. This is the first----
    Senator Coburn. Well, your independent reviews from 2000--
let us put it that way, the fact is nobody has lost a grant for 
poor performance, and if that is the case, then somebody has to 
question the evaluation of grants. If somebody who already has 
a grant and they are not performing well and you have 233 
applications of which you are only going to be able to give 
three or four new grants to, there has got to be somebody in 
that group, after this has been going since 1988, ramped up in 
1991 to 1995, is that correct?
    Dr. Van Dyck. Correct.
    Senator Coburn. You really did not get ramped up until 
1995, correct?
    Dr. Van Dyck. During that----
    Senator Coburn. We cannot really judge you before 1995.
    Dr. Van Dyck. That would probably be a fair statement----
    Senator Coburn. OK.
    Dr. Van Dyck [continuing]. Although we have tried to judge 
that period.
    Senator Coburn. I understand. I am not critical of that. I 
am just saying from 1995 to 2006, not one of those grantees had 
such poor performance and not one of those applications showed 
a better need that one of the grantees lost their grant and 
somebody new got it.
    Dr. Van Dyck. No, I did not say that. I said I did not 
remember for sure if anybody lost for poor performance. There 
are--and I can check that. The other thing is whether somebody 
did not get a grant who previously had a grant because they 
could not successfully compete or the numbers in the grant did 
not show enough success. There have been grantees who have not 
been successful subsequently. You heard that case happening in 
Delaware.
    Senator Coburn. Yes.
    Dr. Van Dyck. So there are instances where people----
    Senator Coburn. Have lost their grant?
    Dr. Van Dyck [continuing]. Where they have lost their 
grant, yes.
    Senator Coburn. All right, fair enough.
    Dr. Van Dyck. So there are two ways to look at that. One is 
for poor performance. The other is in a grant competition, they 
may not compete as well as somebody else, then, and we can give 
you those numbers.
    Senator Coburn. You are in good shape.
    Dr. Van Dyck. Thank you for the opportunity, Dr. Coburn.
    Senator Coburn. Thank you, and thanks for your 
pleasantness. And as I told you, if there is any area that you 
want to qualify when we get through that you think our 
assumptions are wrong or inappropriate or inaccurate, please 
bring them up.
    Ms. Somsak, you have a tough job. We will never have the 
surge capacity we need, right? I mean, there is no way we can 
afford to put surge capacity, if we were to have a major 
catastrophic event, that we could have enough ICU beds and 
ventilators. So where do you draw the line? How do you do that, 
and how do you give us the best for the limited amount of money 
that we can go in this direction?
    Ms. Somsak. I think there are two ways that States are 
approaching it that gives us a way to deal with capacity. The 
individual States are working to establish, with the State 
associations and State plans, to come up with ways to handle 
the surge capacity. So within a State, we have a lot of, say, 
how you would do it. Like in New York City, they are working 
with not just hospital by hospital plans, but multiple 
hospitals working together, and I think that is the first way 
you are going to get it, is within a State that the hospitals 
work together so that every hospital is not getting every 
capacity, that you work together to establish and respond.
    The other way you are getting it is across State lines, and 
this is really key. Particularly, for example, in the New 
England region, that whole series of States have come together 
to develop their surge capacity because they do not believe 
individually in their own States they would be able to deal 
with it, particularly if there is one major incident in one 
State and not another. So that is the second way we are seeing 
it, is that regional plans are being worked on to do it, and we 
are really encouraging that and we are seeing that across the 
country, particularly where you have a low population of 
adjacent States and things like that, that you are really going 
to have to have other people come to their help.
    The third way is just in terms of the regional compacts, 
where you could have States that have compacts with other 
States to respond to their needs. So even though they do not 
plan regionally necessarily, they have compacts so they can 
respond to another State's needs. It is a lot easier, 
obviously, in terms of personnel, medical personnel, to be able 
to respond to another State in terms of capacity, but that is 
going on now and we saw it in Katrina, with many of the States 
stepping forward to help Louisiana and Texas.
    Senator Coburn. So there has been $2 billion spent in 
grants on surge capacity.
    Ms. Somsak. Yes.
    Senator Coburn. Where was it spent?
    Ms. Somsak. A lot of it has been on equipment.
    Senator Coburn. How much of the $2 billion was spent on 
equipment and capacity?
    Ms. Somsak. Well, overall, the requirement is that 85 
percent of the money has to go to the hospitals to be spent on 
the requirements of the grant itself.
    Senator Coburn. Has it?
    Ms. Somsak. Of the 85 percent, I would have to find out the 
figures on how much actually was spent on the medical equipment 
component versus pharmaceuticals and storage.
    Senator Coburn. Pharmaceuticals, stockpiling, and things 
like that. But my question is do you have at your fingertips 
the measurement tools to know, out of the $2 billion, the 85 
percent of that--how much of that has actually gone to 
capacity, pharmaceutical stockpiles, ventilators, and beds 
versus how much went for those creating the program to get 
those? What is the percentage? Do you have that at your 
fingertips as a manager, and do you have the ability to measure 
that through the grant process, and if so, what are the 
results, and is every grant recipient spending that money 
appropriately and do you know that?
    Ms. Somsak. The States are required to give us yearly 
reports on their progress in meeting their plans and the State 
plans go to what capacity they are going to be building at the 
hospital level. So the State is required to report on where 
they are building the capacity for hospital beds or 
decontamination units. We have targets in their grants that 
they are supposed to meet and then they have to report against 
those grant targets and tell us where they are in meeting the 
goals in terms of surge capacity, in terms of decontamination 
units and things like that.
    Senator Coburn. But you do not have a metric yourself, 
other than self-reporting, that says you know where the money 
is spent? In other words, have you audited one of the grants?
    Ms. Somsak. They are financially accountable for what they 
spend.
    Senator Coburn. I know, but have you all audited the 
grants? Have you audited Oklahoma's money that they have gotten 
under this grant program to see that what they are saying is 
actually where the money went?
    Ms. Somsak. I do not know about Oklahoma's.
    Senator Coburn. Has anybody been audited to see that the 
money that has actually been spent, the $2 billion, actually 
went for what they said it went for?
    Ms. Somsak. Even if they have not been audited to date, 
they will be audited under the financial because all the 
grants, any long-term grant has to be audited. There is an 
audit process that they have to go to. But I cannot tell you at 
this point whether that has occurred because a lot of the 
grants are only 3 years.
    Senator Coburn. OK. Is there any requirement in the grant 
process that X-percentage of the money has to be spent on 
actual capacity, actual ventilators, actual pharmaceutical 
storage, actual units? In other words, if they have 85 percent 
of $200,000----
    Ms. Somsak. Yes.
    Senator Coburn [continuing]. Is there a requirement that 
you cannot consume it in consultants, planning, and 
conferences, but you have got to consume it in actually buying 
the goods?
    Ms. Somsak. I do not know at this point, and I will get 
that information for you, as to what the restrictions are about 
the money that actually goes to the hospitals. I will tell you 
that the hospitals are spending more money, far beyond what we 
give them through the State, because hospital needs are great. 
So the hospitals are actually investing beyond in terms of 
preparing themselves for emergencies, and particularly major 
hospitals.
    Senator Coburn. Let me tell you why I asked this question.
    Ms. Somsak. OK.
    Senator Coburn. HHS's own website, a report responding to 
the IG identified challenges. It established the bioterrorism 
preparedness as management challenge number three. It describes 
issues with both CDC and also surge capacity. One major issue 
that they outlined in that, the grantees failing to comply with 
financial accounting and reporting requirements in HRSA and CDC 
grant programs. Now, you have testified that they are required 
to do that, and here is the IG of your own agency saying they 
are not doing it.
    Ms. Somsak. Yes.
    Senator Coburn. So are they doing it or are they not doing 
it?
    Ms. Somsak. I am not familiar with the IG report, but what 
year was the IG report? Which one are we talking about?
    Senator Coburn. It is the one they filed this year on their 
challenge number three for HHS.
    Ms. Somsak. OK.
    Senator Coburn. OIG has issued 15 audit reports in 2003 on 
State and city monitoring of grantees receiving these, citing 
some States and major cities lacked any appropriate monitoring 
mechanism.
    Ms. Somsak. OK.
    Senator Coburn. So again, my job is not to beat you up on 
this. I am telling you what I am looking for.
    Ms. Somsak. OK.
    Senator Coburn. I am looking for, if they are supposed to 
report and they are not reporting, why are they getting the 
money? That is the question I have for you, and your own IG 
says they are not. So if they are not, then they either 
immediately have to start or they should not be getting 
additional money.
    Ms. Somsak. OK.
    Senator Coburn. And again, the whole purpose of that is for 
you, as an administrator, to make sure the money is going where 
you say it is going, and that is what we want it to do. This is 
a big deal for us. Senator Richard Burr is so concerned about 
are we going to be able to respond, and we are 5 years out and 
we are $2 billion down the road, and if you have grantees that 
are not responding and not reporting according to the 
requirements of the grant, my question for you is why are they 
still getting the money?
    Ms. Somsak. Well, we have reduced--we have put holds on a 
number of grants to States where the State has failed to make 
progress towards it. We have also reduced funding for a number 
of States that have failed to make progress. There are a number 
of other States beyond those that we have worked with to 
increase the performance level. But there are problems with 
some of the States, but we have actually withheld funds or put 
holds on their funds where they have not made adequate progress 
until they have demonstrated additional progress.
    Senator Coburn. But you would agree, as a management 
technique, as a director of this program, that if there are 
requirements in the grant and they do not think you are going 
to hold them to the grant requirements, then not just in terms 
of financial accounting, they may not respond in other areas. 
So the reason I asked you about metrics first is do you have 
that at your fingertips so that you know, and what I would like 
to see is you all to bring that up to date. That is our whole 
problem. It is not just HHS. We have not given you all the 
management tools you need to make measurements to evaluate 
whether or not you are having the performance that you want. 
There are things in the legislation, there are things in the 
management, but to actually say, how do I know this money is 
getting the best deal?
    The other thing--just to clarify, that was challenge number 
three, HHS strategic challenge number three in their audit 
report for 2005. That is where that came from.
    The other thing is all States, every State got some of 
these grant monies, right?
    Ms. Somsak. Last year----
    Senator Coburn. All hospitals got a small amount of money 
instead of a few designated surge centers?
    Ms. Somsak. Not all hospitals in the State received money, 
but a large number of hospitals received money depending on the 
State's plan, working with the hospital association and the 
other hospitals.
    Senator Coburn. But are there hospitals that have received 
this money that will not be strategic surge centers?
    Ms. Somsak. Well, in terms of what the State's plan is, the 
problem is that no one can indicate where the event is going to 
occur and what is going to happen. I think the other issue is 
that it is not just bioterrorism. It is also other activities.
    Senator Coburn. Sure.
    Ms. Somsak. So, for example, with the flu, there is no real 
indication that you may have the capacity across a large number 
of geographic areas to be able to handle that issue. Just being 
in a large metropolitan area may not help you. And so when the 
States are looking in terms of planning for where the capacity 
should be, the feeling is that just concentrating in a few 
areas is not adequate.
    And, for example, with the hurricane, what was the impact 
of the hurricane? As people moved out of the metropolitan area 
into what they called the ring area, and that is one of the 
strategies, too, is that what would happen in an emergency is 
people would not stay in the area. They would move out. So when 
people put together a plan, it is one plan--if you just say, 
well, we should just concentrate the money in one area, then if 
that area is attacked, then where is the capacity for the 
people that move out of that area? So I think that what the 
States are trying to do is come up with multiple scenarios in 
terms of planning for multiple, not just bioterrorism or a 
natural event.
    Senator Coburn. OK. I admitted to you at first that you 
have a tough job, and I think it is a true statement, we do not 
have the amount of money to have the preparedness that we would 
like to have. There is no way we are ever going to have surge 
capacity everywhere. So the question then becomes, how do we 
prioritize this? I would question allowing the hospital 
associations to make that determination rather than strategic 
thinkers here looking at the numbers from CDC's health 
statistics and centers.
    Is it strategic if every hospital, let us say in Oklahoma, 
gets a small amount of money, but much more to the bigger ones 
when, in fact, a hospital that is in Salisaw, Oklahoma, is 60 
miles from a 300-bed hospital in Muskogee, in other words, in 
terms of surge capacity, and they have two ventilators at most 
now. Are we going to put 10 ventilators there in excess or are 
we going to put 50 in excess in a larger regional center that 
has a larger population to draw on?
    So I guess the point I am making is I am not critical of 
what you are doing. I just want to make sure the word 
``strategic'' is there and that we are not trying to please 
States on a political basis of everybody getting some money. It 
is kind of the rest of the grants at Homeland Security. If you 
give it to every State--we ought to do it based on risk, and 
your job is to try to figure out what that risk is. I know that 
is not easy. As a matter of fact, you will be criticized no 
matter what you do in this if we have an event. Everybody will 
say, no matter which way you would have gone, you are going to 
get criticism because you have an unattainable goal of truly 
creating surge capacity.
    Then when we have the PART score that is coming out for 
you, what I would do is ask that you all come back. Maybe we 
can just have a meeting in my office and go through what the 
results are on that so that we do not have to do it so 
formally.
    Our goal is to hold you accountable, to make you better. 
There is no question on your motivation. Please understand 
that. But the biggest problem we have in the Federal Government 
is how do we squeeze more benefit out of the same amount of 
money, because we are in a pinch. In 2016, 81 percent of the 
dollars of this budget of this country, no matter whether we 
raise taxes or not, are going to be consumed by Medicare, 
Medicaid, Social Security, and interest. That means 18, 19 
percent is left for defense, HHS, and everything else. So we 
need to have the metrics with which you can make the best 
decisions to take care of the most people and to supply the 
greatest amount.
    I want to thank you for being here. Do either of you want 
to say anything in closing, a change of opinion or critical of 
the attitude or whatever? I want to give you an opportunity to 
do that. Ms. Somsak, you have got a smile. There is a question 
on whether or not you want to say it or not.
    Ms. Somsak. No. I think when Senator Carper was here, I 
kind of summarized what I would like to point out, is that it 
is critical that we do prepare the hospitals and the primary 
health care. In other words, when the incident occurs, that is 
the people at the ground level that are going to be dealing 
with this situation. But it is important to make sure that we 
have the capacity, strategic capacity to say, and that people 
have the capability to be able to respond to an actual thing. 
We can plan all we want, but it is really important for the 
States to be able to demonstrate that they can actually respond 
to an incident.
    Senator Coburn. You bet. All right. Thank you all very 
much.
    The hearing is adjourned.
    [Whereupon, at 3:51 p.m., the Subcommittee was adjourned.]
                            A P P E N D I X

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